NU-664B Week 12 Assignment 2: AAD Dermatology Modules

Value: Complete/Incomplete (100 points is Complete and 0 is Incomplete)

Due: Day 7

Grading Category: Other Assignments

Instructions

Complete the following quizzes for the following modules and upload the certificate of completion. All quizzes are located at the end of each of the listed modules from the American Academy of Dermatology. Students can upload a document indicating completion or screenshot a .jpg and upload.

To access each quiz:

• Access each AAD module listed in the assignment instructions.
• Select Access the Module. Use your personal AAD login information to log in to the AAD website. You should have created this while reviewing resources in this week’s Instructional Materials. If you have not already done so, create this account now.
• Review each learning module and complete the associated quiz:
  • Acne and Rosacea (Module: Acne and Rosacea)
  • Atopic Dermatitis (Module: Two-week rotation: General dermatology)
  • Contact Dermatitis (Module: Two-week rotation: General dermatology)
  • Pediatric Fungal Infections (Module: Two-week rotation: General dermatology)
  • Dermatologic Therapies (Module: Two-week rotation: General dermatology)
  • Dermatoses in Pregnancy (Module: Four-week rotation: General dermatology—Week 4)
  • Newborn skin disease: Rashes (Module: Three-week rotation: General dermatology for pediatricians—Week 2)

Students can take the quizzes more than once and must achieve a grade of 80% or higher, but have multiple attempts.

Study Tip: These are the required modules, but every single module on the ADD is helpful. If you have time to complete more, please complete The Four-Week rotation: General Dermatology.

Please refer to the Grading Rubric for details on how this activity will be graded.

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Submission status

Submission status	Submitted for grading
Grading status	Graded
Time remaining	Assignment was submitted 1 day 7 hours early
Last modified	Saturday, 25 March 2023, 4:39 PM
File submissions	9 files
Submission comments	Comments (1)

Differential Diagnoses

1.       Atopic dermatitis (eczema)

a.       The most likely diagnosis for the patient due to presenting signs and symptoms. The patient’s symptoms of atopic dermatitis began when he was 4 years old and has begun to worsen as he has turned 9 years old; atopic dermatitis severity typically increases during childhood (Dunphy et al., 2019). The patient exhibits symptoms of pruritis and extensive redness in the popliteal and antecubital fossae, abdomen, and arms, which are common locations for atopic dermatitis (Dunphy et al., 2019). The patient has a history of asthma, and the patient’s family history is significant for the potential risk factor of developing atopic dermatitis. The patient’s father has asthma, and the patient’s sister has allergic rhinitis and an allergy to cow’s milk (Dunphy et al., 2019). The patient’s mother noted that the rash becomes worse in dry weather, and atopic dermatitis typically flares during the fall and the winter (Dunphy et al., 2019). The patient’s mother smokes in the home, and smoking is a trigger for the atopic dermatitis  (Dunphy et al., 2019). Additionally, the patient’s clothes are being washed in a new detergent, which may be irritating and precipitating the prolonged exacerbation (Dunphy et al., 2019). The patient’s current treatment regimen of hydrocortisone 2% QID and Aquaphor QID, along with diphenhydramine and Zyrtec are insufficient for management his symptoms, as antihistamines do not typically reduce the rash itself (Dunphy et al., 2019). Other treatment options of higher potency are available to the patient due to the severity of the atopic dermatitis and are worth considering to relieve the rash and associated pruritis (Dunphy et al., 2019).

2.       Plaque psoriasis

a.       A potential diagnosis for the patient due to presenting symptoms. The patient has patches present along his bilateral upper and lower extremities, which is commonly seen in patients with plaque psoriasis (Dunphy et al., 2019). Additionally, the rash is pruritic, a common symptom of plaque psoriasis (Dunphy et al., 2019), and has not resolved with treatments that have worked previously. The patient also has scales present on the rash itself, which is common with plaque psoriasis (Dunphy et al., 2019). However, the patches are absent in additional common areas where plaque psoriasis is present, such as the elbows, knees, intergluteal cleft, and umbilicus (Dunphy et al., 2019). Additionally, the patient’s past medical history must be taken into consideration. The patient has a past history of asthma, and both asthma and allergic rhinitis are present within his immediate family, which are commonly seen in patients who develop atopic dermatitis (Dunphy et al., 2019).

3.       Contact dermatitis

a.       The patient could potentially be experiencing widespread contact dermatitis, though this is not as likely. The patient is experiencing an erythematous, pruritic rash, which is a hallmark symptom of contact dermatitis (Dunphy et al., 2019). The patient does have a one weeping lesion on his left elbow, which is characteristic of contact dermatitis; however, the rash lacks vesicles and a sensation of burning and/or stinging (Dunphy et al., 2019). It is important to note that the patients’ mother did state a new detergent has been used, which could be causing the rash, as it is present on his upper and lower extremities; however, the rash is not present in other areas where clothes would contact, such as the axilla and waist (Dunphy et al., 2019). Considering the rash has been reported as consistently present over the past few weeks, typically papules may be present at this stage, along with minimal erythema, which is not the case in the patient (Dunphy et al., 2019). Until the patient undergoes further allergy testing, it would be uncertain whether certain products are resulting in allergic contact dermatitis, as common causes could include fragrances, nickel, and preservatives found in soaps and shampoos (Levy, 2022).

4.       Impetigo

a.       The patient does have a report of crust-like lesions with oozing serum to this left elbow. The patient has a scaly, red rash that is larger in size, which is a common finding with impetigo (Dunphy et al., 2019). The patient’s primary complaint is how severely pruritic the rash is, which is the most common symptom seen with impetigo (Dunphy et al., 2019). The patient’s rash is present on his extremities, which can be noted with impetigo (Dunphy et al., 2019). Because the area to the left elbow is the only area with crusting and is oozing, it is less likely the patient has impetigo (Dunphy et al., 2019). Additionally, there were no reports of the rash beginning as a vesicle-type rash, and bullae is not present on examination (Dunphy et al., 2019). Since this is a nonbullous rash, it is important to note if the rash contains yellow, thick crusting (Dunphy et al., 2019). The patient’s rash is not characteristic of this, thus making the diagnosis less likely, but still important to consider since it is bacterial in nature.

Diagnosis: Atopic dermatitis

Pharmacological management:

–          Discontinue the use of low potency hydrocortisone 2% QID (Dunphy et al., 2019).

–          Due to the acute flare, begin a high potency topical corticosteroid, such as betamethasone dipropionate, augmented 0.05% BID (Howe, 2023)

o   Apply a thin layer of betamethasone dipropionate, augmented 0.05% to rash in the morning and evening daily for two weeks; must not exceed two weeks

–          Regarding the localized crusting and oozing lesions to left elbow, it is appropriate to begin topical mupirocin, as universal colonization of Staphylococcus aureus is common with routine atopic dermatitis (Howe, 2023).

o   Apply a thin layer of mupirocin 2% cream to left elbow rash twice daily for two weeks (Howe, 2023)

–          To combat extreme pruritis, use of a weak coal tar preparation to apply over the topical corticosteroid at nighttime (Dunphy et al., 2023)

–          Continue diphenhydramine 25 mg PO PRN at bedtime to combat pruritis and aid in sleep (Howe, 2023)

–          Discontinue use of Zyrtec 10 mg QD, as there is limited benefit to combating pruritis and treating atopic dermatitis, and the patient does not have symptoms of allergic rhinitis or significant seasonal allergies (Howe, 2023)

Non-pharmacological management:

–          Use of soak baths for bathing, followed by generous application of moisturizer to prevent excessive dryness (Dunphy et al., 2019).

–          Continue with use of use of ointment to prevent excessive skin dryness and water loss (Dunphy et al., 2019). A recommended ointment includes Eucerin to apply onto skin daily (Dunphy et al., 2019).

–          Products with fragrance-containing oils should be avoiding, including soaps, deodorants, and detergents (Dunphy et al., 2019).

–          The patient should be more aware of products that contain lactic acid and glycolic acids/alpha-hydroxy, which can aggravate atopic dermatitis (Dunphy et al., 2019).

–          The patient should utilize a humidifier to lessen dry climates and promote skin hydration (Dunphy et al., 2019).

Labs/diagnostics:

Diagnostics:

–          RAST testing to identify antigen-specific IgE to allergens such as tree pollen, animal dander, mold, dust mites (Dunphy et al., 2019)

–          In the near future (must be off of antihistamines for 2 weeks), allergen skin prick testing with an allergist to assess for potential allergens that are triggering the patient’s hypersensitivity response (Dunphy et al., 2019)

–          A wound culture of the patient’s left elbow prior to initiation of mupirocin to identify the causative organism (Dunphy et al., 2019).

Labs:

–          Serum IgE level to assess for atopy, though this is non-specific (Dunphy et al., 2019)

Referrals/Interprofessional communications:

–          The patient should be referred to both an allergist and a dermatologist due to 5 years of exacerbations of asthma (Dunphy et al., 2019). The patient should obtain allergy testing with the allergist to determine if an underlying allergen(s) is worsening the patient’s exacerbations. The patient should be referred to a dermatologist for potential monitoring if the current treatment regimen has not alleviated his symptoms, as more aggressive treatment options can be offered by the dermatologist (Dunphy et al., 2019).

Patient education: (1) The patient’s parents and the patient should be educated on being aware of signs of a secondary bacterial infection and to report any potential infection to the provider immediately (Dunphy et al., 2019). The skin is at risk for bacterial and viral infections, and thus the parents must be aware of eczema herpeticum, which is life threatening (Dunphy et al., 2019). (2) The patient’s parents and the patient should be require education about avoidance of environmental allergens and triggers that may exacerbate the patient’s atopic dermatitis. Triggers and potential allergens include smoking/air pollutants, pollen, animal dander, and dust mites (Dunphy et al., 2019). (3) The patient’s parents and the patient should be educated on the option for allergy testing via skin prick testing with an allergist, to further determine any potential allergens that may be exacerbating the atopic dermatitis (Dunphy et al., 2019). (4) The patient and parents should be educated on how to apply topical corticosteroids, and the importance of daily compliance to optimize treatment success (Dunphy et al., 2019). (5) Education on potential side effects of topical corticosteroids should be discussed, such as prolonged use can lead to striae and skin atrophy, and there is a potential for a rebound affect which can worsen existing symptoms (Dunphy et al., 2019). (6) The patient and parents must be educated on the importance of following up in two weeks, as the patient is on high-potency topical corticosteroid treatment, and this must be adjusted after two weeks (Howe, 2023). (7) Bathing education should be provided, such as avoiding prolonged hot baths, and using tepid water to soothe the skin (Howe, 2023). (8) Post-bathing education should be provided, such as thoroughly patting the skin dry and applying a generous amount of fragrance-free (along with lactic acid and glycolic acid/alpha-hydroxy-free) moisturizer to prevent excessive skin dryness (Dunphy et al., 2019). (9) The parents and patient must be educated on using ointment such as Eucerin daily to prevent skin dryness and water loss (Dunphy et al., 2019). (10) It is important the patient avoids using fragrance containing products (Dunphy et al., 2019). The detergent the parents are using must be switched back to a fragrance free, sensitive skin detergent (Dunphy et al., 2019). (11) The soap the patient uses must be a mild-soap or use a soap-free cleanser (Howe, 2023). (12) While symptoms are currently troublesome and more severe, wet wraps can be utilized to soothe the patient’s skin and reduce irritation and pruritis (Howe, 2023). (13) The parents and patient should be educated on how use of a humidifier can help lessen the dryness of the air in the home and help hydrate the skin (Dunphy et al., 2019). (14) The parents and patient should be instructed that as needed use of diphenhydramine is appropriate to control pruritis, though it is best taken during the night due to sedative effects and can help with sleeping issues caused by pruritis (Howe, 2023). (15) The patient and parents should be educated to not apply the high-potency topical corticosteroid to the face or neck if atopic dermatitis develops there (Dunphy et al., 2019).  (16) The patient and family must be educated on the potential side effects of the high-potency steroid, including skin atrophy, telangiectasis, and striae (Dunphy et al., 2019). (17) The family requires education that to enhance absorption of topical corticosteroids, they are best applied after a brief bath or shower (Dunphy et al., 2019).

Follow-up:

The patient should follow-up in 2 weeks to determine the effectiveness of the new regimen, and to decrease the potency of the topical corticosteroid, and potentially switch treatments if ineffective (Dunphy et al., 2019).

Health maintenance: Avoidance of triggers is critical for the extent of exacerbations of atopic dermatitis (Dunphy et al., 2019). The patient’s mother smokes cigarettes, and this is a common trigger for atopic dermatitis, and thus exposure should be avoided (Dunphy et al., 2019). To further identify the underlying causes of frequent flare-ups, the patient should undergo allergy testing with an allergist (Dunphy et al., 2019). This can help the patient avoid the known allergens and reduce the severity and frequency of flare-ups. Staying proactive with skin care with the use of hydrating moisturizers and emollients is necessary to prevent overly dry skin and risk of worsening atopic dermatitis (Dunphy et al., 2019). It is important to avoid direct sun exposure (wear SPF and sun hats) to prevent worsening of symptoms and the development of further skin conditions in the future, such as skin cancer (Dunphy et al., 2019). Ensuring proper and consistent use of prescription medications is key to reducing the extent of the flare-up and potential for needing alternative treatments, such as immunomodulating calcineurin inhibitors, cyclosporine A, or even a potential immunotherapeutic biologic (Dunphy et al., 2019).

Social determinant of health obstacle:  

The patient is a pediatric patient, which is considered a vulnerable population. The underlying difficulty with the patient’s age is his care is very dependent on his parents’ support and compliance. The patient must rely on the parents to grow, which involves being submerged in their lifestyle. The patient is exposed to allergens, specifically smoking, which causes air pollution and risk for worsening health in the patient (Cook et al., 2021). The environmental factors that are surrounding the vulnerable patient directly impacts health of the child and can yield immune dysregulation (Cook et al., 2021). To help the child in this situation, the provider should educate the mother on the importance of being proactive with eliminating potential allergens from the household, including the cessation of smoking.

References

Cook, Q., Argenio, K., & Lovinisky-Desir, S. (2021). The impact of environmental injustice and social determinants of health on the role of air pollution in asthma and allergic disease in the United States. Journal of Allergy and Clinical Immunology, 148(5), 1089-1101. https://doi.org/10.1016/j.jaci.2021.09.018

Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2019). Primary care: Art and science    of advanced practice nursing – An interprofessional approach. (5th ed.). F.A. Davis.

Howe, D. (2023). Treatment of atopic dermatitis (eczema). UpToDate. Retrieved March 17, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/treatment-of-atopic-dermatitis-eczema?search=eczema%20treatment%20children&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1063295835

Levy, M. (2022). Contact dermatitis in children. UpToDate. Retrieved March 17, 2023, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/contact-dermatitis-in-children?search=contact%20dermatits&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2