Based on
Module 1: Lecture Materials & Resources
and experience, what are the roles and responsibilities of the advanced nurse practitioners in prescribing?
Chapter 12:
Fungal Infections of the Skin
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Fungal Infections of the Skin
• Tinea
• Tinea versicolor
• Candidiasis
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Types of Tinea Infections
• Tinea capitis: head
• Tinea corporis: body
• Tinea pedis: foot
• Tinea manus: hand
• Tinea unguium (onychomycosis): nails
• Tinea cruris: groin
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Factors Predisposing People to Fungal
Infections
• Warm, moist, occluded environments
• Family history
• Compromised immune system
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Five Species of Fungus Causing Most
Infections
• Trichophyton rubrum
• Trichophyton tonsurans
• Trichophyton mentagrophytes
• Microsporum canis
• Epidermophyton floccosum
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Diagnostic Criteria for Fungal Infections
• Symptoms
– Pruritus, burning, and stinging of the scalp or skin,
possible erythema and vesicles with inflammatory
dermal reactions.
• Diagnostic tests
– Microscopic evaluation of the stratum corneum with
10% potassium hydroxide (KOH) preparation
– Fungal culture
– Wood lamp (identifies only Microsporum)
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Tinea Capitis Presentation
• Inflamed, scaly, alopecic patches, especially in infants
• Diffuse scaling with multiple round areas with alopecia
secondary to broken hair shafts, leaving residual black
stumps
• “Gray patch” type with round, scaly plaques of alopecia
in which the hair shaft is broken off close to the surface
• Tender, pustular nodules
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Tinea Corporis
• Called “ringworm” when it affects the face, limbs, or
trunk but not the groin, hands, or feet
• Presentation: ring-shaped lesion with well-demarcated
margins, central clearing, and a scaly, erythematous
border
• Causes: contact with infected animals, human-to-human
transmission, and from infected mats in wrestling
• Organisms responsible: M. canis, T. rubrum, and T.
mentagrophytes
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Tinea Cruris
• Often referred to a “jock itch.”
• A fungal infection of the groin and inguinal folds, tinea
cruris spares the scrotum.
• Causes are T. rubrum or E. floccosum.
• Symptoms: lesions that are large, erythematous, and
macular, with a central clearing; a hallmark is pruritus or
a burning sensation.
• Often fungal infection of the feet is present.
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Three Types of Tinea Pedis
• Interdigital: scaling, maceration, and fissures between
the toes
• Plantar: diffuse scaling of the soles, usually on the entire
plantar surface
• Acute vesicular: vesicles and bullae on the sole of the
foot, the great toe, and the instep
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Characteristics of Tinea Manus
• Dermatophyte infection of the hand
• Always associated with tinea pedis and usually unilateral
• Lesions marked by mild, diffuse scaling of palmar skin
• Vesicles may be grouped on the palms or fingernails
involved
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Tinea Unguium
• Fungal infection of the nail; typically the toenails.
• Nails become thick and scaly with subungual debris.
• Onycholysis (nail separation from bed) may occur.
• Under the nail, a hyperkeratotic substance accumulates
that lifts the nail up.
• Organisms causing onychomycosis: dermatophytes, E.
floccosum, T. rubrum, T. mentagrophytes, Candida
albicans, Aspergillus, Fusarium, and Scopulariopsis.
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Question
• Upon physical examination, a practitioner notes a ringlike lesion with a scaly, erythematous border on the
trunk of a child. What fungal infection would the
practitioner suspect?
A. Tinea capitis
B. Tinea corporis
C. Tinea cruris
D. Tinea pedis
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Answer
• B. Tinea corporis
• Rationale: Tinea corporis is called “ringworm” when it
affects the face, limbs, or trunk. The typical presentation
of tinea corporis is a ring-shaped lesion with welldemarcated margins, central clearing, and a scaly,
erythematous border. Tinea capitis affects the scalp,
tinea cruris affects the groin, and tinea pedis affects the
feet.
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Initiating Drug Therapy for Fungal
Infections
• Prevention: applying powder containing miconazole
(Monistat) or tolnaftate (Tinactin) to areas prone to
fungal infections after bathing and blow drying on low
temperature
• Goals of drug therapy: directed against the offending
fungus and site of infection; may be topical or systemic
depending on location of lesions
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Topical Azole Antifungals
• Action: work by pairing the synthesis of ergosterol, the
main sterol of fungal cell membranes, allowing for
increased permeability and leakage of cellular
components, resulting in cell death.
• Uses: effective against tinea corporis, tinea cruris, and
tinea pedis as well as cutaneous candidiasis.
• Dosage: applied once or twice a day for 2 to 4 weeks.
Therapy should continue for 1 week after the lesions
clear.
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Topical Allylamine Antifungals
• Action: effective against dermatophyte infections but
have limited effectiveness against yeast
• Dosage: shorter treatment period with less likelihood of
relapse; applied twice daily
• Adverse events: burning and irritation
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Griseofulvin
• Action: deposits in keratin precursor cells increasing new
keratin resistance to fungal invasion.
• Adverse events: nausea, vomiting, diarrhea, headache,
or photosensitivity.
• Interactions: increases levels of warfarin (Coumadin) and
decreases levels of barbiturates and cyclosporine
(Sandimmune). It may decrease the efficacy of oral
contraceptives and may cause a serious and unpleasant
reaction with alcohol.
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Systemic Allylamine Antifungals
• Action: inhibits squalene epoxidase, a key enzyme in
fungal biosynthesis, causing a deficiency of ergosterol
causing fungal cell death
• Dosage: fingernail onychomycosis: 250 mg/d for 6
weeks; toenail onychomycosis: 250 mg/d for 12 weeks
• Adverse events: diarrhea, dyspepsia, rash, increase in
liver enzymes, and headache
• Interactions: potentiated by cimetidine (Tagamet) and
antagonized by rifampin (Rifadin)
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Systemic Azole Antifungals
• Action: inhibit cytochrome P-450 (CYP) enzymes and
fungal 14-a-demethylase, inhibiting synthesis of
ergosterol. Systemic therapy is required for tinea capitis
and tinea unguium.
• Dosage: dosage of itraconazole is 200 mg once daily for
12 weeks for toenail infection. For fingernail infection,
the dose is 200 mg twice daily for 1 week, then 3 weeks
off, and repeat dosing with 200 mg twice daily for 1
week.
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Question
• For which fungal infection would the practitioner use as
first-line therapy a systemic fungicide?
A. Tinea capitis
B. Tinea corporis
C. Tinea pedia
D. Tinea cruris
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Answer
• A. Tinea capitis
• Rationale: Topical agents work well for most tineas but
not for tinea capitis and tinea unguium. Topical therapy is
recommended for cases of tinea corporis, pedis, cruris, or
manus when the infection affects a limited area.
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Selecting the Appropriate Agent for Tinea
• Tinea capitis
– First line: griseofulvin (Grifulvin V) minimum 8 weeks
– Second line: terbinafine (Lamisil) or itraconazole
(Sporanox) 4 weeks
• Tinea corporis, tinea cruris, tinea pedia
– First line: topical azole antifungals for 2 to 4 weeks
(1 week past clinical cure), 2 weeks even after rash
is gone
– Second line: systemic therapy: terbinafine (Lamisil)
or fluconazole (Diflucan)
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Selecting the Appropriate Agent for Tinea
(cont.)
• Onychomycosis
– First line: itraconazole (Sporanox) or terbinafine
(Lamisil) 12 weeks with food; not recommended for
children
• Tinea versicolor
– First line: selenium sulfide solution 1% or 2.5%
topical azole cream or spray for localized lesions
– Second line: itraconazole (Sporanox)
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Question
• A clinician treated a patient who has tinea versicolor with
selenium sulfide solution without success. What is the
second line of therapy for this patient?
A. Topical azole
B. Terbinafine (Lamisil)
C. Fluconazole (Diflucan)
D. Itraconazole (Sporanox)
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Answer
• D. Itraconazole (Sporanox)
• Rationale: After trying selenium sulfide solution 1% or
2.5% topical azole cream or spray, the second line of
therapy for tinea versicolor is itraconazole (Sporanox).
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Patient Education for Tinea
• Teach hygiene and ways to avoid transferring fungal
infection to others.
• Complete the full course of treatment and do not stop
treatment when symptoms subside.
• Inform parents and other caregivers that children can
attend school while being treated.
• Dry areas susceptible to fungus with a hair dryer after
bathing.
• Use antifungal powder and sprays for prophylaxis.
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Tinea Versicolor (Pityriasis Versicolor)
• An opportunistic superficial yeast infection
• Causes: overgrowth of the hyphal form of Pityrosporum
ovale; occurs mostly in subtropical and tropical areas
• Action: an enzyme oxidizes fatty acids in the skin surface
lipids, forming dicarboxylic acids, which inhibit tyrosinase
in epidermal melanocytes and cause hypomelanosis
• Diagnostic criteria: well-defined skin lesions, round or
oval macules with an overlay of scales forming on the
trunk, upper arms, and neck with mild itching; confirmed
by positive KOH test
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Candidiasis
• Superficial fungal infection of the skin and mucous
membranes.
• Causes: C. albicans occurs on moist cutaneous sites in
people with infection or diabetes, or using systemic and
topical corticosteroids, and with immunosuppression.
• Action: C. albicans invades the epidermis when warm,
moist conditions prevail.
• Diagnostic criteria: red, moist papules, or pustules found
in the axillae, inframammary areas, groin, and between
the fingers and toes.
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Order of Treatment for Candidiasis
• First line: cool soaks with Burow solution, topical azole
for 10 days, oral nystatin
• Second line: itraconazole (Sporanox) or fluconazole
(Diflucan)
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Complementary and Alternative Medicine
• Apple cider vinegar
• Palin yogurt
• Tea tree oil
• Tea
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Summary
• Fungi live in the dead, horny outer layer of the skin.
• The organisms penetrate only the stratum corneum—the
surface layer of the skin.
• Fungi infect the skin, hair, and nails and cause tinea,
tinea versicolor, and candidiasis.
• An important role of the practitioner is to teach the
patient about hygiene and ways to avoid transferring
fungal infection to others.
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Chapter 13:
Viral Infections of the Skin
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Three Groups of Viruses Producing Skin
Lesions
• Herpes viruses: replicate their own polymerase, along
with several of their own enzymes
• Papilloma viruses: contribute to the initiation of DNA
replication
• Pox viruses: replicate entirely in the cytoplasm
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Viruses
• Viruses are obligate intracellular parasites consisting of a
nucleic acid core surrounded by one or more proteins.
• A host cell is required for viral replication.
• Several mechanisms exist for viral replication, and
different DNA viruses replicate by their own specific
mechanism.
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Seven Types of Herpes Virus Infections
• Herpes simplex type 1 (HSV-1): involves the face and
skin above the waist
• Herpes simplex type 2 (HSV-2): involves genitals and
skin below the waist
• Varicella-zoster virus (VZV): causes varicella
(chickenpox) and herpes zoster (shingles)
• Epstein-Barr virus: associated with infectious
mononucleosis
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Seven Types of Herpes Virus Infections
(cont.)
• Cytomegalovirus: causes mononucleosis and pneumonia
• Human herpesvirus type 6 (HHV-6): associated with
roseola
• Human herpesvirus type 8 (HHV-8): associated with
Kaposi sarcoma, especially in patients with HIV infections
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Question
• A patient presents with painful vesicular eruptions located
on his genitals. What herpes infection would the
practitioner suspect?
A. Herpes simplex type 1 (HSV-1)
B. Herpes simplex type 2 (HSV-2)
C. Varicella-zoster virus (VZV)
D. Epstein-Barr virus
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Answer
• B. Herpes simplex type 2 (HSV-2)
• Rationale: Herpes simplex type 2 (HSV-2) involves
genitals and skin below the waist. Herpes simplex type 1
(HSV-1) involves the face and skin above the waist.
Varicella-zoster virus (VZV) causes varicella (chickenpox)
and herpes zoster (shingles). Epstein-Barr virus is
associated with infectious mononucleosis.
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Herpes Viruses
• Action:
– Herpes viruses replicate their own polymerase along
with several of their own enzymes.
– After primary infection, the virus becomes dormant
until reactivated by triggers.
– The virus is highly contagious and spread by direct
contact with skin or mucous membrane.
• Diagnostic criteria: vesicular eruptions that are painful
and often recurrent.
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Drug Therapy for Herpes Virus
• Primarily treated with topical agents
– Soaks with Burow solution
– Viscous lidocaine (Xylocaine) 2%
– Diphenhydramine (Benadryl) elixir and aluminum
hydroxide/magnesium hydroxide (Maalox)
• Systemic drug therapy in case of severe infection in
immunocompromised patient
• Antiviral treatment for herpes zoster
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Topical Antiviral Agents
• Types: acyclovir 5%, penciclovir (Denavir)
• Action: inhibiting viral DNA synthesis; decrease healing
time
• Dosage: apply topical acyclovir every 3 hours, six times
per day, for 7 days; apply penciclovir every 2 hours,
during waking hours, for 4 days
• Adverse effects: mild skin irritation and pruritus
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Systemic Antiviral Agents
• Types: acyclovir (Zovirax), famciclovir (Famvir),
valacyclovir (Valtrex)
• Contraindications: patients with renal disease
• Adverse events: headache vertigo depression, tremors
• Interactions: effect increase in patients taking
probenecid; patients taking zidovudine (Retrovir) may
experience drowsiness
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Dosing Acylovir
• Immunocompetent host: initial episode: 200 mg orally
five times per day for 7 to 10 days; recurrent episodes:
200 mg five times per day for 5 days
• Immunocompromised host: 400 mg five times per day
for 7 to 10 days: suppression therapy, 400 mg twice a
day is the dosage
• Children: 5 mg/kg/d in five divided doses for 7 days
• VZV infections: children 20 mg/kg four times per day for
5 days; adults: 800 mg five times per day for 7 to 10
days
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Famciclovir
• Action: diacetyl ester prodrug of penciclovir that is an
acyclic guanosine analog; oral bioavailability ranges from
5% to 75%
• Dosage: initial episode: 250 mg three times per day for 7
to 10 days; recurrent episodes: 1,000 mg twice daily for
1 day and 250 mg twice a day for suppression therapy
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Valacyclovir
• Action: prodrug of acyclovir that is converted rapidly with
50% bioavailability
• Dosage: initial infection: 1,000 mg three times a day for
7 to 10 days; recurrent infection: 2,000 mg two times a
day for 1 day; suppression therapy: 1,000 mg daily
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Recommended Order of Treatment for
HSV-1 Infection
• First line
– Topical therapy with acyclovir 5% (Zovirax) or
penciclovir 1% (Denavir); treating at earliest signs of
outbreak
• Second line
– Systemic therapy with acyclovir (Zovirax),
famciclovir (Famvir), or valacyclovir (Valtrex)
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First-Line Therapy: Varicella-Zoster Virus
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First-Line Therapy: Herpes Zoster
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Question
• An adolescent patient who is taking steroids is diagnosed
with varicella-zoster virus and is manifesting fever and
vesicular lesions on an erythematous base. What is an
appropriate first-line therapy for this patient?
A. Treat symptomatically
B. Begin systemic therapy with acyclovir for 7 days
C. Topical acyclovir 5% every 3 hours six times a day
for 7 days
D. Oral analgesics only
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Answer
• B. Begin systemic therapy with acyclovir for 7 days
• Rationale: The first line of therapy for an adolescent with
varicella-zoster who is immunocompromised is systemic
acyclovir at a dosage of 20 mg/kg four times a day for 5
days. If the patient was not taking steroids, the disease
could be treated symptomatically. Topical acyclovir 5%
every 3 hours six times a day for 7 days is appropriate
for herpes virus infections, and analgesics are used to
control pain associated with the virus.
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Patient Education
• Hygiene
• Precipitating factors
• Prevention methods
• Zostavax vaccine for herpes zoster
• Safe sex practices for patients with HSV-2 infection
• Wearing gloves when applying medication and careful
hand washing
• Avoiding skin-to-skin contact
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Types of Warts (Verrucae)
• Verruca vulgaris—common warts: infection with HPV-2;
occur on the fingers or toes at sites of trauma
• Plantar warts—HPV-1: occur on the soles of the feet and
the palms of the hands; flesh-colored to brown,
hyperkeratotic papules
• Flat warts—HPV-3: located on the face, neck, and chest
or flexor regions of the forearms and legs
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Factors Predisposing to HPV
• Infection with HIV
• Intake of drugs that decrease cell-mediated immunity
(prednisone, cyclosporin)
• Chemotherapeutic agents
• Pregnancy (may cause proliferation)
• Handling raw meat, fish, or other animal matter
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Warts
• Action: HPV proteins contribute to the initiation of DNA
replication; incubation period is usually 4 to 6 months
with transmission by direct contact or by fomite
• Diagnostic criteria:
– Papillomatous, corrugated, hyperkeratotic growths
found only on the epidermis, especially in areas
subjected to repeated trauma
– Can be solitary, multiple, or clustered
– Named for clinical appearance, location, or both
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Initiating Drug Therapy for Warts
• Choice of medication depends on age of the patient,
whether pain is involved, and the location of the wart.
• Filiform and flat warts are removed by a dermatologist.
• Topical treatment with salicylic acid (DuoFilm) is usually
the starting point for all other warts.
• The goal of therapy is eradication of the virus and lesion,
although there is no way to actually kill HPV.
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First-Line Therapy for Warts
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Summary
• Viruses producing skin lesions may be categorized into
three groups: herpes viruses, papilloma viruses, and pox
viruses.
• Viruses are further classified by family—either the
ribonucleic acid family or the deoxyribonucleic acid (DNA)
family.
• To prevent the spread of these viruses, it is important to
educate the patient about hygiene, precipitating factors,
and prevention.
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Chapter 14:
Bacterial Infections of the Skin
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Common Primary Bacterial Skin Infections
• Impetigo
• Bullous impetigo
• Folliculitis
• Felons
• Paronychias
• Cellulitis
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Causes of Bacterial Skin Infections
• Staphylococcus aureus
• Beta-hemolytic forms of streptococci such as
Streptococcus pyogenes (group A Streptococcus, or GAS)
• Streptococcus agalactiae (group B Streptococcus)
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Impetigo and Ecthyma
• Cause: due primarily to S. aureus
• Diagnostic criteria: scattered, discrete macules that itch
and spread and develop into vesicles and pustules on an
erythematous base; honey-colored crust occurs
• Ecthyma: chronic form of impetigo affecting deeper
layers of the skin; vesicles form that then develop into
shallow ulcerations often causing scarring
• Contributing factors: person-to-person contact in schools
or day care centers; poor hygiene, crowded living
conditions
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Cellulitis
• Infection involving the skin and subcutaneous layers,
with the potential to spread systemically and cause
serious illness
– Causes: GAS or S. aureus; insect bite or wound
• Methicillin-resistant S. aureus (CA-MRSA):
– S. aureus organisms that are resistant to commonly
used antibiotics; major cause of community-acquired
skin infections; furuncle with necrotic center
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Erysipelas
• Superficial form of cellulitis; most common in children,
especially infants and the elderly, but it can occur in
healthy individuals who have sustained only minor
wounds.
• Most commonly found on the lower extremities but can
also be present on the face and scalp.
• Begins as an area of sharply demarcated erythema that
spreads rapidly in minutes to hours. The affected area is
slightly raised, firm, warm, and tender to the touch
(classic orange peel appearance).
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Pustular Infections
• Folliculitis
– Superficial infection of the hair follicle commonly
caused by S. aureus
• Furunculosis and carbunculosis
– Pustular infections usually caused by S. aureus. Both
conditions involve deeper areas of the skin and can
develop from unresolved cases of folliculitis.
– Manifests as pus-filled nodule that encircles a hair
follicle found in hairy areas.
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Paronychia and Felon
• Paronychia
– Infection of tissue surrounding a nail bed
– Associated with nail biting, hangnails, or finger
sucking
• Felon
– Fingertip wound of the pulp space in the tip of a
digit, which is erythematous, edematous, and tender
– If left untreated, abscess/tissue necrosis can occur
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Necrotizing Fasciitis
• An extremely serious infection of the subcutaneous
tissues that can be life threatening if not diagnosed early
and treated appropriately
• Management: often requires emergent surgical
interventions to remove infected tissue in combination
with antibiotic therapy
• Occurrence: middle-aged, elderly, or seriously debilitated
patients
• Treatment: IV antibiotic, surgical debridement
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Necrotizing Fasciitis/Diagnostic Criteria
• Initial lesion is often minor.
• Infection may initially appear similar to cellulitis,
although severe pain, erythema, and edema are
commonly present.
• May be differentiated from cellulitis by its rapid spread,
tissue destruction, and lack of response to usual
antibiotic therapy.
• Symptoms: high fever (102°F to 105°F [38.9°C to
40.6°C]), intense pain and tenderness at the site,
swelling of the affected extremity.
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Risk Factors for Skin Infections
• Diabetes
• Immune system disorders
• Malnutrition from alcoholism
• Circulatory compromise of arterial, venous, or lymphatic
system
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Question
• A patient presents with a lesion on his arm that is
causing intense pain, swelling of the arm, high fever, and
drainage. What condition would the practitioner suspect?
A. Impetigo
B. Carbuncle
C. Paronychia
D. Necrotizing fasciitis
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Answer
• D. Necrotizing fasciitis
• Rationale: Necrotizing fasciitis may initially appear similar
to cellulitis, although severe pain, erythema, and edema
are commonly present with high fever, intense pain,
swelling of the extremity, and drainage. Impetigo
manifests as vesicles and pustules on an erythematous
base with a honey-colored crust. A carbuncle is a pusfilled nodule that encircles a hair follicle found in hairy
areas, and a paronychia is an infection of the tissue
surrounding a nail bed.
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Strategies to Prevent Skin Infections
• Wash hands frequently to prevent spread of infecting
organisms.
• Clean skin twice daily with soap and water or
antibacterial soap (e.g., Hibiclens, Lever 2000).
• Avoid scratching.
• Use warm soaks to promote drainage of pustular matter.
• Avoid irritants, including tight clothing, shaving,
sunscreens, and occlusive cosmetics and deodorants.
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Recommended Order of Treatment for
Impetigo and Ecthyma
• First-line therapy
– Oral antibiotic for 7 to 10 days
• Second-line therapy
– Alternate oral antibiotic for 7 to 10 days or refer
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Recommended Order of Treatment for
Cellulitis and Erysipelas
• First-line therapy
– Oral antibiotic for 7 to 10 days
• Second-line therapy
– Admit for intravenous antibiotic treatment or refer
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Recommended Order of Treatment for
Furuncles and Carbuncles
• First-line therapy
– Oral antibiotic for 7 to 10 days or refer
• Second-line therapy
– Alternate oral antibiotic for 7 to 10 days or refer
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Recommended Order of Treatment for
Paronychias
• First-line therapy
– Tetanus prophylaxis, as appropriate, and oral
antibiotic for 7 to 10 days
• Second-line therapy
– Alternate oral antibiotic for 7 to 10 days or refer
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Recommended Order of Treatment for
Felon and Puncture Wound
• First-line therapy
– Tetanus prophylaxis, as appropriate, and oral
antibiotic for 7 to 10 days
• Second-line therapy
– Continue oral antibiotic if infection continues;
alternate oral antibiotic for 7 to 10 days or refer
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Question
• A practitioner is treating a patient who has a paronychia.
What is the appropriate first-line therapy for this patient?
A. Oral antibiotic for 7 to 10 days
B. Admit for IV antibiotic treatment
C. Tetanus prophylaxis and oral antibiotic for 7 to 10
days
D. Topical antibiotic treatment
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Answer
• C. Tetanus prophylaxis and oral antibiotic for 7 to 10 days
• Rationale: The first-line therapy for paronychias is
tetanus prophylaxis and oral antibiotic for 7 to 10 days.
Oral antibiotic alone for 7 to 10 days is appropriate firstline therapy for impetigo, ecthyma, cellulitis, and
erysipelas. IV antibiotic treatment is second-line
treatment for cellulitis and erysipelas. Topical
preparations do not penetrate the nail bed well and
generally are not indicated for treatment of paronychias.
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Common Adverse Effects of Antibiotics
• Nausea
• Vomiting
• Diarrhea
• Rashes, allergic reactions
• Urticaria
• Fungal infections
• Pseudomembranous colitis
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Drugs Used to Treat Bacterial Infections
• Broad-spectrum penicillins
• First-, second-, and third-generation cephalosporins
• Clindamycin
• Fluoroquinolones
• Vancomycin, daptomycin, telavancin, dalbavancin,
oritavancin, linezolid, tedizolid, and tigecycline
• Trimethoprim/sulfamethoxazole
• Topical agents: mupirocin ointment, gentamicin
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Monitoring Patient Response
• Emphasis should be placed on controlling aggravating
factors and promoting good hygiene measures.
• Follow-up or referral is required if the condition spreads
or does not resolve.
• Secondary infection such as osteomyelitis or endocarditis
is a risk in carbunculosis. For this reason, systemic
antibiotics are always given after lesions are drained.
• Patients with cellulitis and erysipelas should be followed
closely because of the potential for a serious systemic
infection.
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Patient Education
• Take medication around the clock to sustain the proper
blood level and don’t discontinue until prescribed length
of time is up.
• Know common side effects of medications including
predisposition to fungal infections.
• Report signs of allergic reactions, unusual bleeding, or
bruising.
• Avoid smoking due to flammable nature of some
antibiotics.
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Summary
• Although most bacterial skin infections are self-limiting
and resolve quickly with treatment, some have the
potential to become much more serious.
• Patients should be taught to report symptoms such as
fever, increased erythema or streaking, chills, or malaise
that may indicate a worsening of their condition.
• The chronic nature of some skin infections, such as
folliculitis, should be emphasized so that patients
understand that treatment may be long term and
recurrent.
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Chapter 15:
Psoriasis
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Psoriasis
• Debilitating disease characterized by recurrent
exacerbations and remissions
• Symptoms: element of physical discomfort, with pain,
itching, stinging, cracking, and bleeding of the lesions
• Causes: abnormal epidermal cell cycle, hereditary
factors, and trigger factors, including trauma, infection,
endocrine imbalance, climate, and emotional stress
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Drugs Known to Exacerbate Psoriasis
• Systemic corticosteroids (when dose is decreased or
stopped)
• Lithium carbonate
• Antimalarials
• Beta-blockers
• Systemic interferon
• Alcohol
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Pathophysiology of Psoriasis
• Autoimmune-mediated process are driven by abnormally
activated helper T cells.
• APC activation requires costimulatory signals.
• Once activated, psoriatic T cells produce a type 1 helper
T cell–dominant cytokine profile that includes interleukin2 (IL-2), tumor necrosis factor-alpha (TNF-α), interferonγ, and IL-8.
• These cytokines act to attract and activate neutrophils,
which are responsible for much of the inflammation seen
in psoriasis.
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Psoriasis/Diagnostic Criteria
• Observation of characteristic, well-demarcated,
erythematous papules or plaques surrounded by silvery
or whitish scales.
• Lesions are symmetric and usually found on the face,
extensor joints, anogenital area, palms and soles,
intertriginous areas (known as inverse psoriasis), trunk,
scalp, ears, and nails.
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Types of Psoriasis
• Plaque: sharply demarcated, erythematous papules, and
plaques with marked silvery-white scales
• Guttate: small, scattered, teardrop-shaped papules, and
plaques
• Erythrodermic: generalized intense erythema and
shedding of scales
• Pustular: three forms: generalized, localized, and
palmar-plantar with similar characteristic: 2- to 3-mm
sterile pustules on specific body regions
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Question
• A patient presents with a rash manifesting small,
scattered, teardrop-shaped papules and plaques. What
type of psoriasis would the practitioner suspect?
A. Plaque
B. Guttate
C. Erythrodermic
D. Pustular
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Answer
• B. Guttate
• Rationale: The guttate type of psoriasis is characterized
by small, scattered, teardrop-shaped papules and
plaques. The plaque type produces sharply demarcated,
erythematous papules and plaques with marked silverywhite scales. The erythrodermic form is characterized by
generalized intense erythema and shedding of scales.
The pustular type manifests as 2- to 3-mm sterile
pustules on specific body regions.
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Initiating Drug Therapy for Psoriasis
• First counsel to avoid precipitating factors.
• Discourage cigarette smoking.
• Determine whether psoriasis is localized or general to
choose from three treatment modalities:
– Topical agents: 10% or less of body involvement
– Phototherapy: greater than 10% BSA
– Systemic agents: greater than 10% BSA
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Goals of Drug Therapy
• Decrease size and thickness of the plaque
• Decrease pruritus
• Improve emotional well-being and quality of life
• Put the patient in remission
• Have minimal side effects from treatment
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Drug Therapy for Psoriasis/Emollients
and Topical Corticosteroids
• Emollients (adjunct therapy)
– Eucerin cream/lotion, Lubriderm, and Moisturel
– Hydrate the stratum corneum, decrease water
evaporation, and soften the scales of plaque
• Topical corticosteroids
– Decrease erythema, pruritus, and scaling
– Low-potency corticosteroids
– Medium- or high-potent agent
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Drug Therapy for Psoriasis/Coal Tars
• Coal tars (polycyclic hydrocarbon compounds of coal)
– Depress DNA synthesis and have anti-inflammatory
and antipruritic properties
– Available in ointment, gel preparation, bath
preparation, and shampoo
• Anthralin
– Inhibits DNA synthesis and decreases epidermal
proliferation
– Good therapy for limited number of lesions
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Drug Therapy for Psoriasis/Vitamin D
Analogs
• Vitamin D analogs (calcipotriene [Dovonex] and
Calcipotriol)
– Supplied in creams, ointments, and topical foam
– Reduction of cell proliferation by binding to receptors
in epidermal keratinocytes; anti-inflammatory effect
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Drug Therapy for Psoriasis/Retinoid
• Retinoid (vitamin A derivative)
– Tazarotene (Tazorac): mild to moderate psoriasis
– Clear, nonstaining gel and cream (0.05% and 0.1%)
applied in a thin layer once a day at bedtime
• Systemic retinoids
– Acitretin (Soriatane) used for long-term therapy
– Diminishes cell hyperproliferation and inflammation
– Contraindicated in pregnancy, lactation, and alcohol
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Drug Therapy for Psoriasis/Methotrexate
• Inhibits folic acid reductase, resulting in the inhibition of
cellular replication and selection of the most rapidly
dividing cells
• Initial dose is 2.5 mg a week administered in three doses
over a 24-hour period; then titrated to a dose of 12.5 to
25 mg a week
• Contraindicated in pregnancy and lactation; used with
caution in patients with renal and hepatic disorders and
leukopenia
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Question
• A practitioner is considering drug therapy for a patient
who has psoriasis and is pregnant. What drug would be
safe for this patient?
A. Tazarotene
B. Acitretin
C. Methotrexate
D. Calcipotriene
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Answer
• D. Calcipotriene
•Rationale: Calcipotriene is a topical vitamin D analog used
for treating mild to moderate psoriasis. It is not
contraindicated in pregnancy. Tazarotene can cause fetal
harm, and acitretin and methotrexate are both
contraindicated in pregnancy and lactation.
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Drug Therapy for Psoriasis/Cyclosporine
• Action: suppresses cell-mediated immune reactions and
humoral immunity; inhibits production of IL-2, which is
responsible for producing T-cell proliferation
• Dosage: maximum dose is 2 to 5 mg/kg/d
• Contraindications: pregnancy and lactation; cautioned
with impaired renal function and malabsorption
• Interactions: nephrotoxic agents, digoxin, lovastatin
(Mevacor), diltiazem (Cardizem), and ketoconazole
(Nizoral), hydantoin (Dilantin), rifampin (Rifadin), and
sulfonamide use
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Phosphodiesterase 4
Inhibitors/Apremilast
• Action: oral small molecule specific to cyclic adenosine
monophosphate (cAMP)
• Dosage: 30 mg twice daily
• Contraindications: hypersensitivity to apremilast
• Adverse event: GI distress and diarrhea
• Interactions: Otezla coadministered with strong CYP450
inducers (i.e., rifampin)
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Drug Therapy for Psoriasis/Etanercept
(Enbrel)
• Action: contains human TNF receptor; binds and inhibits
TNF, the cytokine that helps regulate the body’s immune
response to inflammation
• Dosage: initial: 50 mg sq twice a week for 3 months.
Maintenance: 50 mg sq weekly, with a maximum of 25
mg given at one site
• Contraindications: live vaccine, active infection
• Adverse events: infection, injection site pain, localized
erythema, rash, URIs, abdominal pain, vomiting
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Drug Therapy for Psoriasis/Infliximab and
Adalimumab
• Infliximab
– Action: monoclonal antibody that targets TNF-α and
inhibits its activity
– Dosage: 5 mg/kg at week 0, week 2, and week 6,
and then once every 8 weeks via IV infusion over 2
hours
• Adalimumab
– Action: recombinant humanized immunoglobulin G1
monoclonal antibody that binds to TNF-α
– Dosage: 80 mg followed by 40 mg every other week
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Factors Affecting Selection of Agent
• Patient’s age
• Type of lesion
• Site and involvement
• Previous treatments
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Recommended Order of Therapy for
Psoriasis
• First-line therapy: moisturizers and topical steroids
– For 2 weeks, a high-potency or very–high-potency
topical steroid is applied twice a day and covered by
an occlusive dressing of plastic wrap.
• Second-line therapy
– 1-week rest from the topical corticosteroids; 2 weeks
of therapy with same agent for two more times
– Taper high-potency topical corticosteroid use to once
or twice a week; add a vitamin D analog twice a day
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Recommended Order of Therapy for
Psoriasis (cont.)
• Third-line therapy:
– Refer to a dermatologist
– Dermatologist may use ultraviolet B light treatments,
antimetabolites, etanercept, or psoralens plus
ultraviolet A light therapy
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Summary
• In patients with psoriasis, education regarding stress
monitoring and control is important, as is education
regarding the disease process and treatment goals.
• The patient should understand that psoriasis is not
contagious.
• Symptom control, rather than cure, is the goal of therapy
for psoriasis.
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