Summer Is Near and Skin Issues Are Here

Home , Amorolfine, Efinaconazole, Hand eczema, Tavaborole

3/16/2021

DISCLOSURES

• I have no disclosures • Off-label use of medications will be clearly labeled

SUMMER IS NEAR AND SKIN ISSUES ARE HERE

TANDY S. REPASS, MD

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CLINICAL IMAGES CLINICAL IMAGES

• DermNet New Zealand • www.dermnetnz.org • Unmodified images • https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

• Bolognia 3rd Edition • Edwards L. Genital Dermatology Atlas. Philadelphia: Lippincott Williams & Wilkins; 2004. 3 4

OBJECTIVES OBJECTIVES

• Explore evidence-based practices related to • Explore evidence-based practices related to management of contact dermatitis, insect and management of contact dermatitis, insect and animal bites, and insect stings. animal bites, and insect stings.

• Formulate effective strategies for managing • Formulate effective strategies for managing sunburns, burns, abrasions, abscesses, and fungal sunburns, burns, abrasions, abscesses, and fungal infections. infections.

• Analyze management strategies for lacerations • Analyze management strategies for lacerations (suturing, Dermabond, medications, and follow-up). (suturing, Dermabond, medications, and follow-up).

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MANAGEMENT MANAGEMENT

• Contact dermatitis • Contact dermatitis

• Insect and animal bites • Insect and animal bites

• Insect stings • Insect stings

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CONTACT DERMATITIS CONTACT DERMATITIS

• Irritant vs. allergic contact dermatitis • Irritant vs. allergic contact dermatitis • Allergic contact dermatitis • Allergic contact dermatitis • Poison ivy (urushiol) • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Nickel (chronic vs. acute) • Balsam of Peru • Balsam of Peru • Neomycin • Neomycin • Formaldehyde • Formaldehyde • Special types of allergic contact dermatitis • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Stasis dermatitis • Hand dermatitis • Hand dermatitis • Management • Management

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IRRITANT VS. ALLERGIC CONTACT IRRITANT CONTACT DERMATITIS DERMATITIS

• Irritant contact dermatitis • Hand dermatitis • Non-immune-modulated • Note finger web spaces • Skin injury, direct cytotoxic effects, or cutaneous • Often from occupational exposures inflammation from contact with an irritant • Chemical irritants (solvents and cutting fluids) account for most cases

• Allergic contact dermatitis • Type IV, T-cell mediated, delayed hypersensitivity response • Occurs with re-exposure • Common examples: Poison ivy, nickel, and fragrances

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55.

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IRRITANT CONTACT DERMATITIS CONTACT DERMATITIS

• Lip licker’s dermatitis • Irritant diaper dermatitis • Allergic contact dermatitis • Irritant contact dermatitis • Wipes, lidocaine, male condoms, • Over-washing • Excessive lip licking spermicide, soap

Edwards. Genital Dermatology Atlas. 2004 13 14

ALLERGIC CONTACT DERMATITIS CONTACT DERMATITIS

• Eyelid dermatitis • Lip dermatitis • Irritant vs. allergic contact dermatitis • Allergic contact dermatitis • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Balsam of Peru • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management

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URUSHIOL POISON IVY DERMATITIS

• Sap of rhus plants • Wash off immediately before it is absorbed • Poison ivy, oak, and sumac • 50% can be removed at 10 minutes, 25% at 15 • Plants brush across skin minutes, and 10% at 30 minutes causing linear streaks of • After 30 minutes, sufficient penetration of urushiol erythema and vesicles has occurred • Lack of definitive preventative therapy besides avoidance

Kim Y, Flamm A, ElSohly MA, Kaplan DH, Hage RJ Jr, Hamann CP, Usatine RP, Riojas M. Diagnosis and management of contact Kim Y, Flamm A, ElSohly MA, Kaplan DH, Hage RJ Jr, Hamann CP, Marks JG Jr. Poison Ivy, Oak, and Sumac Dermatitis: What is Marks JG Jr. Poison Ivy, Oak, and Sumac Dermatitis: What is dermatitis. Am Fam Physician 2010;82(3):249-55. Known and What is New? Dermatitis 2019;30(3): 183-190. Known and What is New? Dermatitis 2019;30(3): 183-190. 17 18

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NICKEL DERMATITIS NICKEL DERMATITIS

• Component of many metals • White gold, German silver, gold plating, solder, stainless steel

• Hairdressers using nickel- containing scissors

• Crochet hooks

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55.

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ALLERGIC CONTACT DERMATITIS: NICKEL DERMATITIS: CHRONIC ACUTE

BALSAM OF PERU NEOMYCIN

• In personal care products and cosmetics • Over-the-counter • Fragrance topical antibiotic • Fragrance masker in products labeled “unscented” • Balsam of Peru diet • Vesicles • Avoid: Spices, ketchup, chili sauce, barbecue sauce, citrus products, colas, beers, wines, bakery items, candy, ice cream, chocolate, and tomatoes • Geometric • Improve systemic contact dermatitis in patients with contact allergy • Important to distinguish from infection

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55.

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NEOMYCIN FORMALDEHYDE SENSITIVITY

• Diffuse truncal rash • Permanent press/wrinkle-resistant fabrics release formaldehyde • Formaldehyde in the clothing could be contributing

Mowad CM, Anderson B, Scheinman P, Pootongkam S, Nedorost S, Brod B. Allergic contact dermatitis: Patient management and education. J Am Acad Dermtol. 2016;24(6): 1043-54. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55.

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SPECIAL TYPES OF ALLERGIC CONTACT CONTACT DERMATITIS DERMATITIS

• Irritant vs. allergic contact dermatitis • Photoallergic contact dermatitis • Allergic contact dermatitis • Airborne contact dermatitis • Poison ivy (urushiol) • Stasis dermatitis • Nickel (chronic vs. acute) • Balsam of Peru • Hand dermatitis • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management

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PHOTOALLERGIC CONTACT AIRBORNE CONTACT DERMATITIS DERMATITIS

• Sun-exposed areas • Sparing behind the ear, under • Allergic contact dermatitis the chin, and under clothing • Irritant contact dermatitis • Areas on the skin with maximal exposure to sunlight • Most common causative • Type IV hypersensitivity agent is plants

• Requires chemical exposed to Bolognia. Dermatology. 3rd ed. 2012. UV radiation • Photopatch testing Chrysanthemum allergy • Sunscreens (most frequently)

Mowad CM, Anderson B, Scheinman P, Pootongkam S, Nedorost S, Brod B. Allergic contact dermatitis: Patient management and education. J Am Acad Dermtol. 2016;24(6): 1043-54.

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STASIS DERMATITIS CHRONIC HAND ECZEMA

• Irritant contact dermatitis • Avoid latex gloves • Wound secretions • Wear nonlatex gloves • Allergic contact dermatitis when working with from various topicals solvents, soaps, and • Topical antibiotics detergents • Lanolin derivatives • Use cotton liners under • Fragrances gloves • Preservatives • Contact sensitization leads to secondary dissemination • Note the eruption on the arms • Id Reaction

Bolognia. Dermatology. 3rd ed. 2012. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 31 32

CHRONIC HAND ECZEMA CONTACT DERMATITIS

• Patch testing positive to • Irritant vs. allergic contact dermatitis potassium dichromate • Allergic contact dermatitis and a piece of his glove • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Balsam of Peru • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management

Bolognia. Dermatology. 3rd ed. 2012. 33 34

MANAGEMENT CONTACT DERMATITIS: MANAGEMENT

• Education • Identify and avoid causative • Self-management substance • Education • Topical treatment • Self-management • Dimethylglyoxime test (nickel • Systemic treatment spot test) for nickel allergy • Widely available online • Patch testing/TRUE Test • Pink color change indicates presence of nickel

• Example: Nickel Dermatitis • Cover metal tabs on jeans with iron-on patches or coats of clear nail polish Bolognia. Dermatology. 3rd ed. 2012.

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EDUCATION SELF-MANAGEMENT

• Education on reading labels • Advise on how to test a new skin care product • “Fragrance-free” • Repeat Open Application Test • “Sensitive skin” • Apply a small amount of product to the volar aspect of the • “Dermatologist-tested” forearm twice a day for 1-2 weeks • “For baby” • If any eczematous reaction occurs they should avoid the • These products can still contain fragrance product • If ingredients are not used ”solely to impart an odor to a product” it is legal for a “fragrance-free” product to contain a fragrance

Mowad CM, Anderson B, Scheinman P, Pootongkam S, Nedorost S, Brod B. Allergic contact dermatitis: Patient management and education. J Am Acad Dermtol. 2016;24(6): 1043-54. Rashid RS, Shim TN. Contact dermatitis. BMJ 2016; 353.

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CONTACT DERMATITIS: SELF-MANAGEMENT TOPICAL TREATMENT

• Avoidance of fragrances and his cologne • Bland emollients [petroleum jelly] • Soaking before applying topicals to improve penetration “soak and smear method” • Topical corticosteroids • Steroid ointment (avoiding preservatives) vs. cream

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55.

Amazon.com • AVOID IRRITANTS • Fragranced bath products • Soap • Medicated wipes • Excessive washing • Heat

Bolognia. Dermatology. 3rd ed. 2012. 39 40

CONTACT DERMATITIS: CONTACT DERMATITIS: TOPICAL TOPICAL TREATMENT TREATMENT

• Localized • Topical calcineurin inhibitors (off-label use) • Mid- or high-potency topical steroid • Currently licensed for 2nd line treatment of atopic dermatitis • Triamcinolone 0.1% or clobetasol 0.05% when topical steroids have failed or there is serious risk of adverse effects (skin atrophy) • Thinner skin (flexural, periorbital, facial, and anogenital) • These principles are applied to the treatment of contact • Lower potency steroid (minimize risk of atrophy) dermatitis • Desonide 0.05% ointment • Sites: Face and neck • I often use Hydrocortisone 2.5% ointment in these locations • Topical antifungal or antibiotic if needed

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. Rashid RS, Shim TN. Contact dermatitis. BMJ 2016; 353.

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CONTACT DERMATITIS: CONTACT DERMATITIS: SYSTEMIC TREATMENT SYSTEMIC TREATMENT

• Extensive areas of skin (>20% body surface area) • Other options mentioned in the literature • Systemic corticosteroids • Psoralen combined with ultraviolet A light (PUVA) treatment • Often offers relief in 12-24 hours • Narrow band ultraviolet B treatment • Immunomodulators (methotrexate, cyclosporine, or azathioprine) • Severe rhus dermatitis • Alitretinoin (licensed for severe chronic hand eczema) • Taper over 2-3 weeks to avoid rebound dermatitis • Steroid dose pack • Insufficient dosing and duration • Should not be prescribed for contact dermatitis

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. Rashid RS, Shim TN. Contact dermatitis. BMJ 2016; 353.

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CHRONIC CONTACT DERMATITIS: RULE OUT SYSTEMIC TREATMENT

• Off-label use of dupilumab • Bacterial superinfection • Example of rubber accelerator allergy • Tinea (do a KOH preparation and fungal culture if KOH negative) • Candida • Scabies

Marked involvement under the patient’s bra elastic

Goldminz AM, Scheiman PL. A case series of dupilumab-treated allergic contact dermatitis patients. Dermatol Ther. 2018;31(6): e12701.https://doi.org/10.1111/dth.12701. Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55. 45 46

NEXT STEPS FOR FOLLOW-UP PATCH TESTING

• If avoidance and empiric treatment do not resolve • If unable to taper off steroid despite avoidance of the dermatitis, consider patch testing soap, wipes, etc. • Allergic contact dermatitis: patch testing is the • Contact avoidance of positive allergens via an app gold standard for diagnosis that provides the patient with a list of safe products • Irritant contact dermatitis: diagnosis of exclusion to use for 8-12 weeks

Rashid RS, Shim TN. Contact dermatitis. BMJ 2016; 353. www.dermnetnz.org 47 48

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TRUE TEST PATCH TESTING

• Thin-layer Rapid Use Epicutaneous Test • Customized patch testing • 3 panels • Personal products (cosmetics, lotions) can be diluted for testing • 29 allergens • Extended patch testing • Reimbursement compensates for the cost of the test • Sunscreen series • Most relevant allergens detected using the TRUE test • Textile series • Nickel • Shoe series • Thimerosal (preservative) • Metal series • Cobalt (metal) • Hairdressing series • Fragrance mix • Dental series • Balsam of Peru

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician 2010;82(3):249-55.

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SUMMARY: CONTACT DERMATITIS SUMMARY: CONTACT DERMATITIS

• Irritant vs. allergic contact dermatitis • Irritant vs. allergic contact dermatitis • Allergic contact dermatitis • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Balsam of Peru • Neomycin • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management

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SUMMARY: CONTACT DERMATITIS SUMMARY: CONTACT DERMATITIS

• Irritant vs. allergic contact dermatitis • Irritant vs. allergic contact dermatitis • Allergic contact dermatitis • Allergic contact dermatitis • Poison ivy (urushiol) • Poison ivy (urushiol) • Nickel (chronic vs. acute) • Nickel (chronic vs. acute) • Balsam of Peru • Balsam of Peru • Neomycin • Neomycin • Formaldehyde • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis

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SUMMARY: CONTACT DERMATITIS SUMMARY: CONTACT DERMATITIS

• Irritant vs. allergic contact dermatitis • Management • Allergic contact dermatitis • Education • Poison ivy (urushiol) • Self-management • Nickel (chronic vs. acute) • Balsam of Peru • Topical treatment • Neomycin • Systemic treatment • Formaldehyde • Special types of allergic contact dermatitis • Photoallergic contact dermatitis • Patch testing/TRUE Test • Airborne allergic contact dermatitis • Stasis dermatitis • Hand dermatitis • Management

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MANAGEMENT MANAGEMENT

• Contact dermatitis • Contact dermatitis

• Insect and animal bites • Insect and animal bites

• Insect stings • Insect stings

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INSECT BITES INSECT BITES

• Bedbugs • Scabies • Spiders • Ticks • Mosquitos

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BEDBUGS BEDBUGS: CASE

• Pruritic papules on the bilateral posterior arms x 3 months • Biopsy showed findings suggestive of arthropod exposure • Insects emanating from the mesh backing of his office chair at work • Arthropods confirmed to be bedbugs • Treated with clobetasol and eradication of the workplace

Chittoor J, Wilison BD, McNally BW. What’s eating you? Bedbugs. Cutis. 2019;103(1): 31-33. 61 62

BEDBUGS BEDBUGS: CLASSIC EXAM

• Cimex lectularius • Erythematous papule with hemorrhagic punctum • Clues from one bite • Atypical dermatoses not responding to therapy • Histology suggests arthropod exposure Chittoor J, Wilison BD, McNally BW. What’s eating you? Bedbugs. Cutis. 2019;103(1): 31-33.

www.dermnetnz.org/topics/bed-bug Bolognia. Dermatology. 3rd ed. 2012. 63 64

BEDBUGS BEDBUGS

• Some individuals have little or no reaction to • Symptom control bedbug bites • Oral antihistamines, topical steroids, and wound care • Common for only one or a few family members • Treat with antibiotics for secondary bacterial infection (even among those sleeping in the same bed) to • Pest management experts to eradicate bedbugs report lesions • Professional exterminators (trained dogs sniff for bed • Bites can be in linear groups of three (breakfast, bugs) lunch, and dinner) • Soft items must be washed at hot setting for 30 min • Bedding can be frozen in bags in a freezer • Permethrin 5% cream or DEET 40% before bed is reasonable while waiting for complete deinfestation • Monitor for signs of depression, anxiety, and stress

McMenaman KS, Gausche-Hill M. Cimex lectularius (“Bed Bugs”): Recognition, Management, and Eradication. Pediatr Emerg rd Bolognia. Dermatology. 3 ed. 2012. Care. 2016;32(11): 801-806. 65 66

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SCABIES SCABIES

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SCABIES SCABIES: BURROW

• Don’t forget to check the penis, scrotum, areolae, and nipples • Do a FULL skin exam

Bolognia. Dermatology. 3rd ed. 2012.

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SCABIES: SPECIAL CONSIDERATIONS SCABIES: SPECIAL CONSIDERATIONS

• Crusted scabies: hyperkeratosis and fissures • Infants, elderly, immunocompromised can have • Debilitated, elderly, and immunocompromised scalp and face involvement • Increased risk of secondary infection and sepsis • Keep in mind when treating

Bolognia. Dermatology. 3rd ed. 2012. © DermNet New Zealand. Photo by Dr Mashihul Hossain

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SCABIES: DIAGNOSIS SCABIES

• Oil prep: mites, eggs, and/or scybala • Scalpel (no. 15 blade) • Biopsy: incidental mite if present • Dermoscopy: delta shape • Triangular shape showing the head of the mite in the burrow

Photo by Tandy S. Repass, MD Bolognia. Dermatology. 3rd ed. 2012.

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SCABIES: PATIENT QUESTIONS SCABIES: TREATMENT

• “Where did I get this?” Topical Permethrin 5% cream: first line • Pregnancy category B • Close personal contact • Alternatives: Topical Sulfur or Benzyl Benzoate (compounding • Clothing, linens, furniture, and towels pharmacy) • Common in chronic care facilities • Dispense ~30g for each application • “How long have I had this?” • Other topical options available but not more effective • Takes 2-6 weeks for the immune system to be sensitized enough to cause pruritus and lesions Oral Ivermectin (off-label) • 200-400 mcg/kg two doses one week apart • Repeat infestations can be noticed in 24-48 hours • “Did I get this from my dog?” Children • Animal mites do not cause infestation in humans (but can • Children as young as 2 months old: Permethrin cream cause bites) • < 2 months: Topical Sulfur • Oral Ivermectin not for children <15 kg

Wolverton SE. Comprehensive Dermatologic Drug Therapy. 3rd ed. Philadelphia: Elsevier Saunders. 2013. 75 76

SCABIES: TREATMENT SCABIES: EDUCATION

• Apply from the neck down • Treat all family members living together and sexual • Include scalp and face (infants and immunocompromised) partners • Special focus on hands and fingernails • Asymptomatic scabies-infested family members are “carriers” • Leave on overnight and wash off in the morning • Even if no signs or symptoms • Repeat in 7 days • You do not have to treat pets • Decreases reinfestation from fomites • One application of permethrin is sufficient • Kills nymphs that might have survived in their protective egg • Set expectations • Return to school/work the day after 1st treatment • Pruritus and lesions can last 4 weeks or longer • Wash linens, clothing, and towels in hot water and • Dead mites should slough off in 2 weeks dry in high heat • Symptomatic relief • Store in a bag for 10 days • Topical steroids • Vacuum • Oral antihistamines

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SUMMARY: SCABIES SPIDERS

• Do a complete exam and don’t miss the genitalia • Black widow (Latrodectus mactans) for clues • Brown recluse (Loxosceles reclusa) • Practice doing oil preps, it’s a rewarding diagnosis • Permethrin cream is treatment of choice • If you plan to treat be sure to complete two applications 1 week apart • Treat all household contacts • Be prepared to be patient and educate on treatment compliance

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BLACK WIDOW SPIDER BLACK WIDOW SPIDER

• Black with red hourglass mark on ventral abdomen • Bite on upper extremity crampy muscle spasms in • Venom: ⍺-latrotoxin  massive presynaptic release chest (mimic myocardial infarction) of acetylcholine • Bite on lower extremity  crampy muscle spasms of • Usually an outdoor bite the abdomen (mimic acute abdomen) • Resolves in 48-72 hours • IV benzodiazepines for muscle spasms and narcotics for pain

Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. 81 82

BLACK WIDOW SPIDER ANTIVENOM BROWN RECLUSE SPIDER

• Grade 3 bites may warrant antivenom • Inverted violin-shaped marking on the dorsal thorax • May be considered up to 48 hours after the bite • Bites usually occur indoors • Tender erythematous halo develops after a bite

Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7.

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BROWN RECLUSE SPIDER BROWN RECLUSE SPIDER

• Central necrosis in 40% • Systemic symptoms are rare • Venom: sphingomyelinase D  neutrophil • Hemolysis activation and skin necrosis • Coagulopathy Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. • Measles-like toxic erythema rash (responds to prednisone) • Antivenom is not available in the United States

Bolognia. Dermatology. 3rd ed. 2012. Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. 85 86

BROWN RECLUSE SPIDER TICKS

• Management is controversial (no published clinical trials to guide therapy) • Good wound care • Minor debridement • Anti-histamines • Consider Dapsone 50-100 mg bid x 10 days for severe bites • Theoretical prevention of neutrophil degranulation/necrosis • Test for G6PD prior to treating to avoid hemolysis in G6PD deficiency

Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7.

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TICKS TICK BITE PROPHYLAXIS: PER CDC

• Deer tick or black-legged tick • In highly endemic areas for Lyme disease • Ixodes scapularis • Single prophylactic dose of doxycycline • Both nymph and adults can • 200 mg for adults transmit Lyme disease • 4.4 mg/kg for children of any age weighing < 45 kg • Bull’s eye rash (erythema migrans) • Babesiosis (malaria-like protozoal • Antibiotic treatment following a tick bite is not illness) recommended to prevent • Human granulocytic anaplasmosis • Anaplasmosis • Babesiosis • Ehrlichiosis • Rocky Mountain spotted fever • Other rickettsial diseases

https://www.cdc.gov/ticks/tickbornediseases/tick-bite-prophylaxis.html Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. 89 90

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TICK BITE PROPHYLAXIS: PER CDC TICKS

• Benefits may outweigh risks when all of the following • American dog tick (Dermacentor variabilis) circumstances are present • Rocky mountain spotted fever • Doxycycline is not contraindicated • Tularemia • Tick can be identified as an adult or nymphal I. scapularis • Estimated time of attachment is ≥36 h (based on engorgement with blood or likely time of exposure) • Can be started within 72 h of tick removal • Lone star tick (Amblyomma americanum) • Lyme disease is common in the county or state where the • White spot on it’s shield tick bite occurred (CT, DE, DC, MA, MD, ME, MN, NH, NJ, NY, PA, RI, VA, VT, WI, WV) • Human monocytic ehrlichiosis • Tularemia • Q fever • Southern tick-associated rash illness (Lyme-like disease)

https://www.cdc.gov/ticks/tickbornediseases/tick-bite-prophylaxis.html Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. 91 92

ALPHA-GAL ALLERGY

• Lone star tick bites • Persistent allergy to red meat (and cetuximab) • IgE antibody to galactose- alpha-1,3-galactose (alpha-gal) • Hives, anaphylaxis after eating beef, pork, and lamb

Bolognia. Dermatology. 3rd ed. 2012. Steinke JW, Platts-Mills TA, Commins SP. The alpha-gal story: lessons learned from connecting the dots. J Allergy Clin Immunol. 2015; 135(3): 589-96. Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. 93 94

TICKS: MANAGEMENT TICK MANAGEMENT

• Prevent bites by spraying clothing with permethrin • Remove with forceps (“Tick Nipper™”) • Diethyltoluamide (DEET) to exposed skin • Grasp as close to the skin as possible • Tuck pants into socks • Pull perpendicular to the skin (not twisting) • Wear hats • Daily tick checks

Juckett G. Arthropod bites. Am Fam Physician. 2013 88;(12): 841-7. https://www.wildearth.com.au/buy/amk-tick-nipper-tick-removal-tool/155-0661 95 96

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MOSQUITOS MOSQUITO-BORNE DISEASE

• Treatment for most is supportive • Rest • Hydration to prevent dehydration • Acetaminophen • NSAIDs (avoid until dengue has been ruled out) • Emphasis is on reducing risk and local spread • Use mosquito repellant on exposed skin • Mosquito netting sprayed with repellant • Wear long-sleeved shirts and pants (consider permethrin treated clothing)

Lee H, Halverson S, Ezinwa N. Mosquito-Borne Diseases. Prim Care. 2018;45(3): 393-497.

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ARBOVIRAL RASHES ZIKA

Dengue Dengue Chikungunya • Pruritic maculopapular rash (including palms and soles) • Nonpurulent conjunctivitis • Low-grade fever • Joint pain

Lee H, Halverson S, Ezinwa N. Mosquito-Borne Diseases. Prim Care. 2018;45(3): 393-497. Lee H, Halverson S, Ezinwa N. Mosquito-Borne Diseases. Prim Care. 2018;45(3): 393-497.

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OTHER INSECT BITES AVIAN MITE BITES

• We are often able to diagnose bites in the office • Etiologic agent can be more challenging to identify • Example of avian mites from birds nesting in the patient’s house • Check attic, crawl spaces, etc.

Bolognia. Dermatology. 3rd ed. 2012.

101 102

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SQUIRREL MITES ANIMAL BITES

• 5 year old female patient presented with 1 week of vesiculated, pruritic, and crusted papules • No one else in the house was affected • She was not improving on prednisone

• Detailed history taking revealed a new sound in the attic that the father thought was possibly squirrels

• She changed rooms for a short time • He eventually had 5 squirrels removed from his attic and she subsequently improved

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ANIMAL BITES: CHECK LIST ANIMAL BITES: MANAGEMENT

• How the bite occurred? • Early, aggressive irrigation • Time elapsed since the bite? • 0.9% sodium chloride solution or povidone-iodine solution • Was the animal provoked? • 250-500 ml • Has the animal ever bitten • Careful examination someone before? • Radiographic and orthopedic evaluation for • Vaccination status of the animal? fractures, broken teeth, and foreign bodies • Is the patient up-to-date on tetanus • Primary closure is appropriate for wounds with immunization? • No underlying injury, immunocompetent patient, and • Patient will need a tetanus vaccination location is face or scalp if it has been more than 5 years since • Secondary intention they were last immunized • Cat bites should never be closed

Hurt JB, Maday KR. Management and treatment of animal bites. JAAPA. 2018;31(4): 27-31. Hurt JB, Maday KR. Management and treatment of animal bites. JAAPA. 2018;31(4): 27-31. 105 106

ANIMAL BITES: ANTIBIOTICS RABIES POSTEXPOSURE PROPHYLAXIS

• Polymicrobial: anaerobic and aerobic • Only evidence-based benefit for prophylactic antibiotics is for bites to the hand • High-risk bites: cat bites and bites to the hand • Cat bites: risk of osteomyelitis and septic arthritis • First-line: Amoxicillin-clavulanate • If penicillin allergic: Doxycycline or clindamycin + fluroquinolone

Hurt JB, Maday KR. Management and treatment of animal bites. JAAPA. 2018;31(4): 27-31. Hurt JB, Maday KR. Management and treatment of animal bites. JAAPA. 2018;31(4): 27-31.

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RABIES POSTEXPOSURE PROPHYLAXIS MANAGEMENT

• Rabies Vaccine + Rabies immune globulin • Contact dermatitis • Rabies Vaccine day 0, 3, 7 and 14 for a total of 4 injections • Rabies immune globulin injected around the borders of the wound using 20 IU/kg (remainder IM • Insect and animal bites distal to the bite) • If already vaccinated they do not need the immunoglobulin, only the vaccine booster on day 0 and 3 • Insect stings

Hurt JB, Maday KR. Management and treatment of animal bites. JAAPA. 2018;31(4): 27-31. 109 110

THE GUÊPE STINGS

• French for wasp • Remove stinger • Gordes, France • Sac can continue to exude venom into the skin • Sweeping the dull blade of a butter knife or edge of a credit card across the skin at an angle • Localized pain/edema • Cold compresses, oral antihistamines, and mild analgesics • Extensive, disabling local edema • Systemic steroids • Anaphylaxis • Start with subcutaneous epinephrine 1:1,000 • 1 mg/ml; 0.01 ml/kg body weight up to 0.3 ml in adults and 0.5 ml in children • Proceed to nearest ER

Steen CJ, Janniger CK, Schutzer SE, Schwarts RA. Insect sting reactions to bees, wasps, and ants. Int J Dermatol. Photo by Tandy S. Repass, MD 2005;44(2): 91-4. 111 112

STINGS FIRE ANTS

• Common wasp • Local reaction from • Clusters of sterile pustules from the stings multiple wasp stings around the eye

Steen CJ, Janniger CK, Schutzer SE, Schwarts RA. Insect sting reactions to bees, wasps, and ants. Int J Dermatol. rd 2005;44(2): 91-4. Bolognia. Dermatology. 3 ed. 2012. 113 114

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BULLOUS BUG BITE REACTION CASE

• Bullae on the lower legs is a common chief • Exaggerated insect bite-like complaint reaction • Lesions can be lanced with sterile needle or blade • This patient with CLL had no • Local wound care with vinegar water and Vaseline history of arthropod bites or mupirocin is often my plan • Can occur before diagnosis of CLL or after end of chemotherapy • CBC with diff? • Association with chronic lymphocytic leukemia (CLL)

Kim JE, Kim SC. Insect Bite-Like Reaction with Bullous Lesions Mimicking Bullous Pemphigoid in a Patient with Chronic Bolognia. Dermatology. 3rd ed. 2012. Lymphocytic Leukemia. Ann Dermatol. 2018;30(4): 468-472. 115 116

INSECT BITE DIFFERENTIAL QUESTIONS?

McMenaman KS, Gausche-Hill M. Cimex lectularius (“Bed Bugs”): Recognition, Management, and Eradication. Pediatr Emerg Care. 2016;32(11): 801-806. 117 118

OBJECTIVES MANAGEMENT OF

• Explore evidence-based practices related to • Sunburns, Burns, and Abrasions management of contact dermatitis, insect and animal bites, and insect stings.

• Formulate effective strategies for managing • Abscesses sunburns, burns, abrasions, abscesses, and fungal infections.

• Analyze management strategies for lacerations (suturing, Dermabond, medications, and follow-up). • Fungal infections

119 120

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MANAGEMENT OF SUNBURN

• Sunburns, Burns, and Abrasions • Principle cause is UV irradiation wavelengths of 290-320 (ultraviolet B) • Sunburn is observable 3-5 • Abscesses hours after exposure, reaches maximum intensity at 12-24 hours, and fades over 72 hours

Bolognia. Dermatology. 3rd ed. 2012. • Fungal infections

Driscoll MS, Wagner RF. Clinical management of the acute sunburn. Cutis 2000; 66: 53-8.

121 122

SUNBURN SUNBURN

• Typically a self-limited condition • Systemic and topical corticosteroids have little or no • The majority of studies conclude that treatments are clinically important effect on the sunburn reaction ineffective at decreasing recovery time from • NSAIDs only result in an early and mild reduction of sunburn UVB-induced erythema

Driscoll MS, Wagner RF. Clinical management of the acute sunburn. Cutis 2000; 66: 53-8. Driscoll MS, Wagner RF. Clinical management of the acute sunburn. Cutis 2000; 66: 53-8. 123 124

SUNBURN: SUNBURN: PREVENTION IS KEY LITERATURE RECOMMENDATIONS

• Conservative local symptomatic relief of sunburn- • Physical protection induced pain or pruritus • Hats, sun protective clothing, umbrellas • Bland emollients • Sunscreen • Cool compresses • Lack of sunburn in • Oatmeal soaks in cool water areas of sunscreen • Pain control application • NSAIDs • Acetaminophen • Diphenhydramine • Hydrocortisone • Aloe vera • Treat secondary infection with antibiotics

Han A, Maibach HI. Management of Acute Sunburn. Am J Clin Dermatol 2004; 5(1); 39-47. Bolognia. Dermatology. 3rd ed. 2012.

125 126

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AAD STATEMENT AAD RECOMMENDATIONS

• “Recent accounts of the Food and Drug Administration’s • To protect your skin and reduce your risk of skin proposed sunscreen rule incorrectly suggest that many cancer, the AAD recommends that everyone sunscreens currently on the market do not meet safety requirements of the FDA. In fact, only two ingredients • Seek shade were proposed to be unsafe — PABA and trolamine • Wear protective clothing (including a lightweight, long- salicylate — and these are no longer available in the sleeved shirt, pants, a wide-brimmed hat, and sunglasses) U.S.” • Generously apply a broad-spectrum, water-resistant • “The AAD is reminding the public that sunscreen remains sunscreen with an SPF of 30 or higher to exposed skin an important way to protect yourself from the sun’s harmful ultraviolet rays." • “Scientific evidence supports the benefits of sunscreen to prevent sunburn and reduce the risk of skin cancer, the most common cancer in the U.S. “

Statement attributable to AAD/AADA President George J. Hruza, MD, MBA, FAAD Statement attributable to AAD/AADA President George J. Hruza, MD, MBA, FAAD May 22, 2019 May 22, 2019 www.aad.org/news/aad-safety-of-sunscreens www.aad.org/news/aad-safety-of-sunscreens 127 128

BURNS BURNS

• Goal of management: limiting progression of tissue necrosis • Initially unburned tissue contiguous to the burn wound undergoes progressive necrosis after the actual insult has ceased • Jackson Burn Wound Model: zone of stasis • Preservation is critical in limiting the progression of burn depth

Harish V, Tiwari N, Fisher OM, Li Z, Maitz P KM. First aid improves clinical outcomes in burn injuries: Evidence from a cohort study of 4918 patients. Burns 2019; 45: 433-439.

129 130

BURNS: FIRST AID BURNS: FIRST AID

• Extinguishing the flames “stop, drop, and roll” • 20 mins of cool, running water onto the burn • Significantly improved • Even if there is delay, this first aid may still be effective within 3 clinical outcomes in burn hours of the burn injury injuries with these practices • Avoiding hypothermia: which can deepen the burn • Reduction in burn wound depth as a result of vasoconstriction • Faster healing • • Cold tap water 12-18℃ minimized depth of injury Decreased skin grafting requirements • Iced water 1-8℃ caused further necrosis

Harish V, Tiwari N, Fisher OM, Li Z, Maitz P KM. First aid improves clinical outcomes in burn injuries: Evidence from a Kim LK, Martin HC, Holland AJ. Medical management of paediatric burn injuries: Best practice. J Paediatric Child Health cohort study of 4918 patients. Burns 2019; 45: 433-439. 2012; 48(4); 290-5. 131 132

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ABRASIONS MANAGEMENT OF

• In my practice I recommend • Sunburns, Burns, and Abrasions • Vinegar water soaks once to twice daily • 1 tablespoon of vinegar to one pint of water • Vaseline jelly (mupirocin ointment if there is concern for increased risk of infection) • Abscesses • Avoid “double-dipping” and contaminating the cleaning solution and ointment • Keep the abrasion covered

• Fungal infections

133 134

ABSCESS ABSCESS

• Defined as a purulent skin and soft tissue infection

Fitch MT, Manthey DE, McGinnins HD, Nicks BA, Pariyadath M. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Videos in clinical medicine. Abscess incision and drainage. N Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Engl J Med. 2007; 357(19):e20. Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):10-52. 135 136

ABSCESS ABSCESS

Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):10-52. Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):10-52. 137 138

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ABSCESS ABSCESS

• Incision and drainage is the recommended • Obtain gram stain and culture of pus treatment for abscesses

Fitch MT, Manthey DE, McGinnins HD, Nicks BA, Pariyadath M. Videos in clinical medicine. Abscess incision and Fitch MT, Manthey DE, McGinnins HD, Nicks BA, Pariyadath M. Videos in clinical medicine. Abscess incision and drainage. N Engl J Med. 2007; 357(19):e20. drainage. N Engl J Med. 2007; 357(19):e20.

139 140

ABSCESS “SEVERE INFECTION” DEFINED AS

• Mild infection: Incision and drainage • Patients who have failed incision and drainage plus oral antibiotics or those with systemic signs of • Moderate infection: purulent infection + systemic infection such as signs of infection • Temperature >38°C • Tachycardia (heart rate >90 beats per minute) • Incision and drainage • Tachypnea (respiratory rate >24 breaths per minute) • Culture and sensitivity • Abnormal white blood cell count (>12,000 or <4,000 cells/μL) • Antibiotic • Empiric: trimethoprim-sulfamethoxazole or doxycycline • Immunocompromised patients • MRSA: trimethoprim-sulfamethoxazole • MSSA: dicloxacillin or cephalexin

“SEVERE INFECTION” DECOLONIZATION

• Incision and drainage • Nasal decolonization: Mupirocin twice daily 5-10 days • Culture and sensitivity • Body decolonization • • Antibiotic Skin antiseptic (Chlorhexidine) 5-14 days • Dilute bleach bath (¼ cup bleach in ¼ tub) 15 min 2x/week • Empiric: vancomycin, daptomycin, linezolid, telavancin, or for 3 months ceftaroline • Oral antimicrobial therapy • MRSA: trimethoprim-sulfamethoxazole • For active infection only, not for decolonization • MSSA: nafcillin, cefazolin, or clindamycin • Household transmission? • Consider nasal and topical body decolonization • If prior infection documented as MRSA, screening culture not recommended • Subsequent surveillance cultures not recommended Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF. Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):10-52. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of Methicillin-resistant Staphylococcus Aureus infections in adults and children: Executive Summary. Clin Infect Dis 2011 Feb 1;52(3):285-92. 143 144

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MANAGEMENT OF FUNGAL INFECTIONS

• Sunburns, Burns, and Abrasions • Tinea corporis • Tinea faciei • Tinea cruris Can be treated • Tinea manuum topically • Abscesses • Tinea pedis • Tinea versicolor (pityriasis versicolor)

• Tinea unguium/onychomycosis • Fungal infections Requires oral • Tinea capitis treatment

145 146

TINEA CORPORIS TINEA FACIEI

• Annular scaly patches • Steroid use can decrease scale • Tinea “incognito”

Bolognia. Dermatology. 3rd ed. 2012.

Bolognia. Dermatology. 3rd ed. 2012. 147 148

TINEA CRURIS CANDIDIASIS

• Scrotum involved with satellite lesions

Bolognia. Dermatology. 3rd ed. 2012. Bolognia. Dermatology. 3rd ed. 2012. 149 150

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TWO FEET AND ONE HAND SYNDROME TINEA PEDIS

Bolognia. Dermatology. 3rd ed. 2012.

151 152

TINEA PEDIS VS. SECONDARY SYPHILIS FUNGAL INFECTIONS

• Tinea corporis, tinea cruris, and tinea pedis • Tinea capitis • Tinea versicolor (pityriasis versicolor) • Tinea unguium (onychomycosis)

• Confirm suspected fungal infection with potassium hydroxide preparation or culture

Bolognia. Dermatology. 3rd ed. 2012. 153 154

DIAGNOSIS: KOH & CULTURE HOW TO DO A KOH PREPARATION

• KOH preparation of dermatophytes • No. 15 scalpel blade • All species look the same • Scrape scale from leading • Cost effective edge • Done at the bedside • Apply to glass slide • If suspicious and KOH preparation negative, then • KOH 10-20% + coverslip send for culture • Gentle heating • Culture (swab, plucked hair, or clipped nails) • Scan at 4X, then evaluate • Can identify species at 10X, 20X, and 40X • Utilize if not responding to therapy • Nails: subungual debris, • More important when thinking about using oral antifungal overlying superficial scale, or proximal portion of the • Biopsy of skin or nail clipping nail plate Photo by Tandy S. Repass, MD • PAS or silver stain of skin, follicles, and nails

155 156

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TINEA CORPORIS, CRURIS, AND PEDIS TINEA CORPORIS, CRURIS, AND PEDIS

• Generally responds to • Oral antifungal if extensive disease, failed topical inexpensive topical agents treatment, immunocompromised, or severe [terbinafine cream, moccasin-type tinea pedis butenafine cream] • Worsens after empiric treatment with a topical • First-line topical: terbinafine steroid 1% cream qd to bid for 1-2 • Do not use nystatin to treat tinea (dermatophytes weeks are resistant) • Do not use combination products (betamethasone + clotrimazole) because they can aggravate fungal infections and cause atrophy

Ely JW, Rosenfeld S, Sebury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. 2014; 90(10): Ely JW, Rosenfeld S, Sebury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. 2014; 90(10): 702-10. 702-10. 157 158

TINEA VERSICOLOR A NOTE ABOUT COMBO CREAMS (PITYRIASIS VERSICOLOR)

• Not recommended

• Start with either a pure antifungal cream or pure steroid cream

• Adjust accordingly based on clinical improvement or lack thereof

Erbagci, Z. Topical therapy for dermatophytoses: should corticosteroids be included? Am J Clin Dermatol. 2004;5(6):375-84.

159 160

TINEA VERSICOLOR TINEA VERSICOLOR (PITYRIASIS VERSICOLOR) (PITYRIASIS VERSICOLOR)

• Caused by Malassezia yeast • KOH prep reveals ”spaghetti and meatball” pattern • Favors chest and back (areas of high sebum) of the round yeast and mycelial forms • Typically there is associated scale  KOH prep

Bolognia. Dermatology. 3rd ed. 2012.

161 162

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TINEA VERSICOLOR TINEA CAPITIS (PITYRIASIS VERSICOLOR): TREATMENT

• Selenium sulfide 2.5% shampoo and 2% ketoconazole shampoo twice weekly for 2-4 weeks • Leave on 10-15 minutes before rinsing • Oral fluconazole, ketoconazole, and itraconazole can be used off-label for severe cases

• I try to avoid oral therapy as relapses are common • Ketoconazole shampoo weekly can help prevent recurrence

• Repigmentation can take weeks to months to occur once treatment has been successful

Bolognia. Dermatology. 3rd ed. 2012. 163 164

TINEA CAPITIS TINEA CAPITIS

• Alopecia with or without scale • Mostly children, predilection for African decent

• Endothrix: “black dot,” hair breakage near the scalp • Non-inflammatory scaling (like seborrheic dermatitis) • T. tonsurans – treat with Terbinafine • Ectothrix: “gray patch,” dry scaly patches • M. audouinii – treat with Griseofulvin

• Look for posterior cervical and posterior auricular

Bolognia. Dermatology. 3rd ed. 2012. lymphadenopathy

Bolognia. Dermatology. 3rd ed. 2012. 165 166

TINEA CAPITIS TINEA CAPITIS: ORAL THERAPY

• Requires systemic antifungal • Griseofulvin and terbinafine are FDA-approved • Combine oral therapy with sporicidal shampoos • Fluconazole is used off-label (selenium sulfide shampoo or 2% ketoconazole shampoo) • Apply for 5-10 minutes three times a week for 2-4 weeks • Terbinafine may be superior for Trichophyton species • 95% of tinea capitis in the US is caused by Trichophyton (terbinafine is a reasonable first choice) • Treat for 6 weeks (longer for Microsporum) • Baseline ALT, AST • CBC at 6 weeks for courses > 6 weeks

167 168

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TINEA CAPITIS KERION

• Griseofulvin may be superior for Microsporum • Host response • Treat for 6-12 weeks (continue 2 weeks after symptoms • Boggy, purulent plaques with abscess formation resolve) • Alopecia • No baseline labs in absence of liver disease • If needed >8 weeks: ALT, AST, bilirubin, Cr, and CBC every 8 • Treat as soon as possible to prevent permanent weeks alopecia • Bitter tasting • Take with whole milk or peanut butter to improve absorption • Cross-sensitivity with penicillin allergy may occur

Ely JW, Rosenfeld S, Sebury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. 2014; 90(10): 702-10. Bolognia. Dermatology. 3rd ed. 2012. 169 170

KERION TINEA CAPITIS

• Treat kerion with griseofulvin unless proven • Patient should avoid sharing combs, brushes, Trichophyton, in which case use terbinafine helmets, hats, or pillowcases for 14 days after • Failure to treat promptly can lead to scarring and starting oral therapy permanent hair loss • Consider empiric treatment of asymptomatic household contacts of children with tinea capitis with sporicidal shampoos (selenium sulfide or 2% ketoconazole)

TINEA CAPITIS TINEA UNGUIUM/ONYCHOMYCOSIS

“Carrier state”: T. tonsurans no si/sx of scalp infection • Can shed and be contagious • Examine family members • Patient and household contacts • Every other day antifungal shampoo (2% ketoconazole shampoo or 2.5% selenium sulfide) - sporicidal • Combs, brushes, and headwear should be disinfected

Bolognia. Dermatology. 3rd ed. 2012. 173 174

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TINEA UNGUIUM/ONYCHOMYCOSIS CANDIDIASIS

Bolognia. Dermatology. 3rd ed. 2012.

175 176

TINEA UNGUIUM (ONYCHOMYCOSIS) TINEA UNGUIUM (ONYCHOMYCOSIS)

• Don’t prescribe oral antifungal therapy for • Oral terbinafine is first-line suspected nail fungus without confirmation of • 250 mg daily: 6 weeks for fingernails and 12 weeks for fungal infection toenails • Treatment is long, failure rates are high, and • Itraconazole is also FDA-approved, but terbinafine recurrence is common preferred • Less than 50% of dystrophic toenails resulted in a • 200 mg daily: 12 weeks for toenails positive fungal culture • 2 treatment pulses of 200 mg bid x 1 week separated by 3 • Most sensitive test is a PAS stain (send nail clipping weeks of no treatment to the pathology laboratory) • Fluconazole (off-label) • Culture has poor sensitivity, but good specificity • 150 mg weekly: 6-9 months for fingernails and 12-18 months • False-negative rate of 30% for nail samples for toenails

Ely JW, Rosenfeld S, Sebury Stone M. Diagnosis and management of tinea infections. Am Fam Physician. 2014; 90(10): Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol. 2019; 80(4): 702-10. 853-867.

177 178

TINEA UNGUIUM (ONYCHOMYCOSIS) TINEA UNGUIUM (ONYCHOMYCOSIS)

• Topical ciclopirox nail lacquer • Other FDA-approved topical treatments • If systemic therapy is contraindicated • Efinaconazole 10% solution • Daily for 9-12 months • Tavaborole 5% solution • In addition to debridement of the hyperkeratotic nails • Prevention • Topical ciclopirox, amorolfine, bifonazole, and terbinafine • Apply weekly as prophylaxis • Found to lower recurrence in a retrospective study

Lipner SR, Scher RK. Onychomycosis: Treatment and prevention of recurrence. J Am Acad Dermatol. 2019; 80(4): Kovitwanichkanont T, Chong AH. Superficial fungal infections. Aust J Gen Pract. 2019; 48(10): 706-711. 853-867.

179 180

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OBJECTIVES LACERATIONS

• Explore evidence-based practices related to • Suturing management of contact dermatitis, insect and animal bites, and insect stings.

• Formulate effective strategies for managing sunburns, burns, abrasions, abscesses, and fungal • Dermabond infections.

• Analyze management strategies for lacerations (suturing, Dermabond, medications, and follow-up). • Medications

• Follow-up

181 182

LACERATIONS LACERATIONS

• Suturing • Document tetanus vaccination status

• Patients with contaminated or high-risk wounds • Who have not had a tetanus booster for more than 5 years should receive a tetanus vaccine • Who have not had at least three doses of a tetanus • Dermabond vaccine or an unknown tetanus vaccine history should also receive a tetanus immune globulin

• Patients with clean and minor wounds • Who have not had a tetanus vaccine for more than 10 years should receive a tetanus vaccine • Medications • Tetanus immune globulin is not indicated

• Follow-up Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. 183 184

LACERATIONS

• Evaluation of the wound • Obtain hemostasis • Devitalized and necrotic tissue should be identified and removed • Imaging might be needed to rule out presence of foreign body • Noninfected wounds caused by clean objects may undergo primary closure up to 18 hours after injury (head wounds up to 24 hours)

Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. 185 186

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MANAGEMENT OF ACUTE LACERATIONS

LACERATIONS LOCAL ANESTHESIA

• Achieve hemostasis • Lidocaine • Irrigation • Bupivacaine • 50-100 mL of irrigation solution per 1 cm of wound length • Procaine (Novocain) • 19-gauge needle with 35 mL syringe • Epinephrine • Under a running faucet • Fears of using epinephrine in fingers, toes, penis, ears and nose have not been supported by evidence • Series of 10,201 surgical procedures using lidocaine with epinephrine in the ear and nose showed not a single ischemic complication

Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. Mankowitz SL. Laceration Management. J Emerg Med. 2017;53(3): 369-382. 189 190

WOUND CLOSURE LACERATIONS: SUTURING

• Provides rapid healing • Expedite healing with optimal hemostasis and • Prevents infection cosmesis • Promotes better cosmetic appearance • Eversion of wound edges • Ragged wound edges require scalpel debridement • Techniques include • Suture • Staples • Tissue adhesive • Porous tape

Bolognia. Dermatology. 3rd ed. 2012. Hoyt KS, Flarity K, Shea SS. Wound care and laceration repair for nurse practitioners in emergency care: part II. Adv Emerg Nurs J. 2011;33(1): 84-99. Turner RC. Surgical management of acute lacerations. Aust J Gen Pract. 2019; 48(9): 600-603. 191 192

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LACERATIONS: SUTURING LACERATIONS: SUTURING

• Interrupted sutures • Continuous (running) suture • Simple interrupted • Subcutaneous interrupted • Cutaneous continuous

• Figure-of-eight • Vertical mattress • Subcuticular

Turner RC. Surgical management of acute lacerations. Aust J Gen Pract. 2019; 48(9): 600-603. Turner RC. Surgical management of acute lacerations. Aust J Gen Pract. 2019; 48(9): 600-603. 193 194

MANAGEMENT OF ACUTE LACERATIONS

LACERATIONS: SUTURING LACERATIONS: SUTURING

• Absorbable suture does not require a separate visit • Use finest suture caliber possible for optimal for suture removal cosmesis • In several studies, there has been no cosmetic • Face: 5-0 or 6-0 difference when absorbable suture has been • Limbs/scalp: 4-0 or 5-0 compared to nonabsorbable suture • Torso: 3-0 or 4-0 • Remove sutures as soon as the scar can withstand the tensile force (avoid ‘tram-track’ appearance) • Face: 3-5 days • Arms: 7-10 days • Torso: 10-14 days • Staples: stainless steel

Mankowitz SL. Laceration Management. J Emerg Med. 2017;53(3): 369-382. Turner RC. Surgical management of acute lacerations. Aust J Gen Pract. 2019; 48(9): 600-603. 197 198

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CASE: FACIAL LACERATION 6-0 NYLON

199 200

7 DAY SUTURE REMOVAL PEARLS FOR PEDIATRIC PATIENTS

201 202

PEARLS FOR PEDIATRIC PATIENTS PEARLS FOR PEDIATRIC PATIENTS

• If a parent is squeamish, give them the option to • If positioning allows, the stay behind the curtain (allowing participation patient can be placed in through verbal encouragement) their comforting adult caregiver’s arms • Distraction diverts attention from painful stimuli • Keep surgical tray, sharps, • Most effective in children younger than 7 years old needle, and syringe out of • Smart devices (iPhones, DVD players, and handheld full view gaming devices) can distract from anticipating pain

• Negotiated rewards should be easily accessible and/or visible

Agim NG, Shah KM. Pearls for Dermatologic Surgery in Pediatric Patients. Dermatol Clin. 2019; 37(3): 387-395. Agim NG, Shah KM. Pearls for Dermatologic Surgery in Pediatric Patients. Dermatol Clin. 2019; 37(3): 387-395.

203 204

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PEARLS FOR PEDIATRIC PATIENTS LACERATIONS

• Eutectic mixture of lidocaine and prilocaine (EMLA) • Suturing with or without occlusion can initiate pain relief before the procedure • Avoided in infants (risk of methemoglobinemia) • Generally safe after age 1 • Area of application should not exceed 5x5 cm • Dermabond • Ideal time of application is 15-60 minutes before the procedure

• Medications

Agim NG, Shah KM. Pearls for Dermatologic Surgery in Pediatric Patients. Dermatol Clin. 2019; 37(3): 387-395. • Follow-up 205 206

DERMABOND DERMABOND (2-OCTYL CYANOACRYLATE) (2-OCTYL CYANOACRYLATE)

• Irrigate and cleanse the wound normally • Works well for clean, linear wounds that are • Be sure to obtain good hemostasis not under tension • Wound must be approximated manually and evenly

• Not generally used for hair-bearing areas

• Slightly higher likelihood of dehiscence

Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. Bruns TB, Worthington JM. Using tissue adhesive for wound repair. Am Fam Physician. 2000;61(5):1383–1388. 207 208

DERMABOND DERMABOND (2-OCTYL CYANOACRYLATE) (2-OCTYL CYANOACRYLATE)

• Single-use vial • Do not apply into the wound • Outside plastic casing • If placed in the wound cavity it can cause an inflammatory and an inner glass response and prevent healing ampule containing the adhesive • If misapplied, wipe off with dry gauze or if dry, use • Vial is crushed and as petroleum-based ointment and wipe away after 30 the adhesive moves min through the applicator www.usamedicalsurgical.com tip, it mixes with an initiator that begins the chemical change from monomer to polymer

Bruns TB, Worthington JM. Using tissue adhesive for wound repair. Am Fam Physician. 2000;61(5):1383–1388. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. 209 210

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DERMABOND DERMABOND (2-OCTYL CYANOACRYLATE) (2-OCTYL CYANOACRYLATE) • Apply 5-10 mm either side of the wound • Wait 5-10 seconds before applying another coat (3 coats are required) • Do not apply any ointment • It will peel off in 5-8 days Tran V, Turner RC. Acute lacerations: Assessment and non-surgical management. Aust J Gen Pract. 2019;48(9): 585-588.

https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Skin-glue-Dermabond Bruns TB, Worthington JM. Using tissue adhesive for wound repair. Am Fam Physician. 2000;61(5):1383–1388. 211 212

TISSUE ADHESIVE HAIR APPOSITION COMPARISON: TECHNIQUE SUTURES/STAPLES/ADHESIVE STRIPS

• Useful for closing scalp • Tissue adhesives are an acceptable alternative to wounds sutures/staples/adhesive strips • Best for • No significant difference in cosmetic scores • Non-actively bleeding wounds • Tissue adhesive lowered time for the procedure and • Less than 10 cm long levels of pain • Scalp hair longer than 3 cm • Tissue adhesive had a significant increase in the • Bring together opposing rate of dehiscence strands of hair with a twist • Secure with a drop of tissue adhesive

Fairon KJ, Osmond MH, Hartling L, Russell KF, Klassen TP, Crumley E, Wiebe N. Tissue adhesives for traumatic lacerations: Forsch RT. Essentials of skin laceration repair. Am Fam Physician. 2008; 78(8): 945-51. a systematic review of randomized controlled trails. Acad Emerg Med. 2003;10(2): 110-8. 213 214

DERMABOND AND ALLERGIC DERMABOND AND ALLERGIC CONTACT DERMATITIS CONTACT DERMATITIS

• Erythematous, partly • Positive patch test • Eruption restricted to the adhesive sites urticarial and vesicular reaction to 2-octyl- • Rule out infection rash around a surgical site cyanoacrylate • Dermabond has a low reported rate of sensitization closed with Dermabond • Rapid polymerization upon contact with keratin • Once polymerized, cyanoacrylates degrade and release formaldehyde • Contact allergy to cyanoacrylate may be attributable to the formation of free formaldehyde • Both 2-octyl cyanoacrylate and formaldehyde should be patch tested • Inform patients of the risk of an allergic reaction

Sachse MM, Junghans T, Rose C, Wagner G. Allergic contact dermatitis caused by topical 2-octyl-cyanoacrylate. Sachse MM, Junghans T, Rose C, Wagner G. Allergic contact dermatitis caused by topical 2-octyl-cyanoacrylate. Contact Dermatitis. 2013;68(5): 317-9. Contact Dermatitis. 2013;68(5): 317-9. 215 216

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POROUS PAPER TAPE POROUS PAPER TAPE

• This closure method can be useful for low tension, superficial wounds • Good for ”thin skin” lacerations • Can improve cosmetic outcome and reduce spread of scar if kept in place for several weeks after suture removal

Hoyt KS, Flarity K, Shea SS. Wound care and laceration repair for nurse practitioners in emergency care: part II. Adv Emerg Nurs J. 2011;33(1): 84-99.

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LACERATIONS: AFTERCARE LACERATIONS INSTRUCTIONS

• Suturing • Provide verbal and written wound aftercare instructions • Elevation of the injured body part • Local cold packs or ice • Gentle pressure dressing for wounds in highly • Dermabond vascular areas • Return to the emergency care setting immediately if they have a fever or signs of infection

• Medications

Hoyt KS, Flarity K, Shea SS. Wound care and laceration repair for nurse practitioners in emergency care: part II. Adv • Follow-up Emerg Nurs J. 2011;33(1): 84-99.

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LACERATIONS: MEDICATIONS LACERATIONS: FOLLOW UP

• Aftercare • Patients with high-risk wounds should have a wound • Keep covered and dry for 24 hours check within 2 days to detect early infection • Lightweight occlusive or semi-occlusive dressing with a non- Mankowitz SL. Laceration Management. J Emerg Med. 2017;53(3): 369-382. stick pad • Goal is to maintain a moist wound environment • Follow up for suture removal • The routine use of prophylactic oral antibiotics has been studied and found to be non-beneficial • Silicone-based products (sheets and gels) are the

Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. 2017;95(10): 628-636. recommended gold standard, first-line, non-invasive option for both the prevention and treatment of • Antibiotic ointment or white petroleum jelly? scars • Studies have failed to show a benefit of topical antibiotics • Advise sun protection of the wound • Some argue the moist environment rather than the antibiotic itself promotes wound healing Meaume S, Le Pillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines Mankowitz SL. Laceration Management. J Emerg Med. 2017;53(3): 369-382. and use of silicones. Eur J Dermatol. 2014;24(4): 435-43.

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OBJECTIVES OBJECTIVES

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OBJECTIVES QUESTIONS?

• Explore evidence-based practices related to management of contact dermatitis, insect and animal bites, and insect stings.

• Formulate effective strategies for managing sunburns, burns, abrasions, abscesses, and fungal infections.

• Analyze management strategies for lacerations (suturing, Dermabond, medications, and follow-up).

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