NU-664B Week 13 Assignment 4: APEA Review Content Completion

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

Due: Day 7

Gradebook Category: Other Assignments

Please review the APEA live content for Women’s Health. As a reminder, you may view this content twice. It is recommended that you review it once for this course and once as you prepare for your certification exam. Once you have completed your first viewing, please upload your certificate of completion to this dropbox. You must upload the certificate to receive credit. This assignment does count toward your grade.

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1. Atopic Dermatitis: Atopic dermatitis which is also known as eczema, is a chronic disorder that causes inflammation of the skin that is most commonly seen in children (Howe et al., 2022). Some of the risk factors associated with atopic dermatitis includes family history, asthma, exposure to allergens, very hot or very cold environmental weather, emotional stress, recent illness, and living in urban areas (Howe et al., 2022). Some of the common presentation with atopic dermatitis includes dry skin, scaly grayish lesions, thick skin, severe itchiness, erythematous papules, and vesicles with exudate and pus (Howe et al., 2022). Taumi is presenting with several scaly patches on the skin on the upper and lower extremities that are intensely itching. The itchiness has caused disruption to Taumi’s sleep. The patches are characterized as crust-like with some oozing near the left elbow. Per Taumi’s mothers, the rash has been recurrent in the past few years, the flare-ups happen a few times per year. Some of Taumi’s risk factors includes having recent illness, asthma, environmental allergies, life stressors with school, having a dog as a pet, and having food allergies and sensitivity. Since the patient was adopted, his family history is unknown. Diagnosis is made based on physical examination, medical history, family history, and recurrence of skin rash. Laboratory exams are not always recommended, but skin patch testing, genetic testing, and checking serum immunoglobulin E (IgE) to look at the body’s inflammatory response can be used to rule out other skin conditions (Howe et al., 2022).

2. Scabies: Scabies is an infection associated with an infestation of mites in the skin that can be transmitted through prolonged skin to skin contact (Goldstein et al., 2022). The common pathogen seen with scabies is sarcoptes scabiei (Goldstein et al., 2022). The clinical manifestations includes small, erythematous papules that are very itchy (Goldstein et al., 2022). The itchiness is more severe at night (Goldstein et al., 2022). Most commonly, symptoms start to show after 3-6 weeks after primary infestation (Goldstein et al., 2022). The more common locations for scabies include wrists, outer portion of fingers, knee, elbow, axilla, male genitalia, nipples, waist, and periumbilical areas (Goldstein et al., 2022).  The diagnosis of scabies is less likely to occur with this patient. Even though the patient is having intense itchiness, the characteristics of the skin and lesions are very different. Scabies can be diagnosed by doing a dermoscopic examination where a sample of the skin lesion is collected and looked under the microscope to detect the presence of mites(Goldstein et al., 2022).

3. Psoriasis: Psoriasis is a chronic skin condition that occurs as a result of an inflammation. The body responds to the inflammation by increasing the number of skin cells being produced (Feldman et al., 2022). It is a condition that is mostly seen in adults over the age of 30, but can also occur in children (Feldman et al., 2022). Some of the risk factors associated with psoriasis includes family history, smoking, obesity, alcohol use, viral or bacterial infections, and certain medications such as beta blockers, lithium, and antimalaria medications (Feldman et al., 2022). Some of the clinical presentations includes thick, silvery scale, pigmented skin patches that is mainly located in the scalp, elbows, knees, and gluteal cleft (Feldman et al., 2022). With psoriasis, people can often have itchiness, but necessarily seen in all cases. Even though Taumi is presenting with the dry skin and skin patches, the diagnosis of psoriasis is less likely since the patient is also having crust-like lesions with oozing. Taumi is also suffering from intense itchiness that has been disrupting his sleep. Psoriasis diagnosis is made based on physical examination and family history (Feldman et al., 2022). If the diagnosis of psoriasis is uncertain, a skin biopsy can be collected.

4. Allergic Contact Dermatitis: Allergic contact dermatitis occurs as a response to an exposure to an allergen (Yiannias et al., 2021). Some common allergens associated with allergic contact dermatitis includes metals, fragrances, topical antibiotics, chemicals, glues, and topical corticosteroids (Yiannias et al., 2021). Children are at lower risk than adults for developing allergic contact dermatitis due to less exposure to the different types of allergens (Yiannias et al., 2021). Children can develop allergy to substances inside vaccinations, piercings, topical medications, and cosmetic products. The clinical presentation includes reddened, indurated, and scaly plaques to areas of contact with the allergen (Yiannias et al., 2021). In more severe cases edema to site can be present along with fluid filled blister (Yiannias et al., 2021). Taumi is presenting with scaly patches with some crust and oozing on the upper and lower extremities that are intensely itching. Per Taumi’s mothers, the patient has had similar presentation of these lesion in the past. For these reasons, the diagnosis of allergic contact dermatitis is less likely. Diagnosis can be made by gathering a comprehensive patient history and physical examination (Yiannias et al., 2021). If the allergen is unable to be detected, a skin patch testing can assist with detection (Yiannias et al., 2021).

Diagnosis: Atopic Dermatitis with Impetigo on the Left Elbow

Labs: No diagnostic test is needed to diagnose atopic dermatitis. Following tests can be done to rule out body’s inflammatory response: Serum immunoglobulin E (IgE) (Howe et al., 2022). 

Diagnostic exam: No diagnostic test is needed to diagnose atopic dermatitis. Following tests can be done to rule out other skin conditions: Skin patch testing (Howe et al., 2022). 

Pharmacology:

-Start Triamcinolone Acetonide 0.1% ointment, apply a thin layer to the affected areas 2 times per day for 14 days (Spergel et al., 2022). It is recommended that wet wraps be performed with each application of the ointment. The wet wraps consists of applying a thin layer of the ointment on the affected areas and two layers of cotton clothing on top. Ointment should be left on the skin for two or more hours if tolerated (Spergel et al., 2022).

-Start Crisaborole 2% ointment, apply a thin layer to affected areas 2 times per day for 28 days (Howe et al., 2023). Avoid areas such as the mouth and eyes.

-Start Mupirocin 2% ointment, apply a thin layer to left elbow 3 times per day for 10 days. If no improvement after 5 days of treatment, contact provider for reevaluation (Baddour et al., 2022).

-Continue Diphenhydramine 25 mg every 6 to 8 hours as needed for itchiness relief. Be mindful when taking medication, the medication can cause sedation.

-Stop Hydrocortisone 2% ointment.

-Stop Zyrtec 10 mg daily.

Non-pharmacology:

1.     Take a shower or bath daily (Howe et al., 2023). Can add bath emollient such as oils with or without emulsifiers and colloidal oatmeal to help with skin hydration (Howe et al., 2023).

2.     Keep skin well moisturized with emollients. Thick creams and ointments are preferred and should be used two times per day (Howe et al., 2023). It is best to apply after bathing when skin is well hydrated (Howe et al., 2023).

3.     Stress management with engaging in sports, play time, and other recreational activities. 

4.     Having a good night sleep.

5.     Avoid foods that cause an allergic reaction. For you those food would include strawberry, pineapple, and dairy.

6.     Avoid being outside during high pollen season.

7.     Avoid environments that are very cold or very hot.

Referrals: Referral to an allergen and dermatologist is indicated to assist with better managing atopic dermatitis and reduce the number of flare-ups (Spergel et al., 2022).

Patient education:

1. Triamcinolone Acetonide 0.1% ointment, is a topical corticosteroid that will assist with management of skin inflammation. Apply a thin layer to the affected areas 2 times per day for 14 days (Spergel et al., 2022). It is recommended that wet wraps be performed with each application of the ointment. The wet wraps consist of applying a thin layer of the ointment on the affected areas and two layers of cotton clothing on top. Ointment should be left on the skin for two or more hours if tolerated (Spergel et al., 2022).

2. Apply a thick layer of emollient moisturizing thick creams or ointments on a daily basis. If skin is very dry, apply emollient creams with more frequency during the day. Keeping the skin moisturized will help prevent flare-ups and decrease itchiness related to dry skin (Howe et al., 2023). Some good over the counter emollient includes Vaseline, petrolatum jelly, and Aquaphor. If child does not like the greasy feeling from ointments, some other thick moisturizing creams that can be used includes Vanicream, CeraVe, and Cataphil (Garzon et al., 2019).  

3. It is best to apply topical corticosteroid ointments in combination with emollient moisturizers for best absorption.

4. Diphenhydramine is an antihistamine that is recommended to help relief symptoms associated with allergic reaction, such as excessive itchiness (Howe et al., 2023). It is good to take before going to bed at night to assist with having a better night of sleep, free of intense itchiness. 

5. Animal dander, dust mites, molds, pollen, and food allergies can be related to atopic dermatitis flare ups (Howe et al., 2023). It is recommended that you see an allergen, allergy specialist, to get tested and identify the possible triggers. Important to keep house clean and free of dust mites and washing bedding weekly is highly recommended (Garzon et al., 2019).  

6. Use bath soaps and clothing detergent that has fragrance (Garzon et al., 2019). Use fragrance free soaps with less chemicals. Chemicals can be harsh on the skin. Also avoid fabric softeners, chlorine, and bleach (Garzon et al., 2019).  

7. Stress can be a major contributor to atopic dermatitis flare-ups. It is important to recognize stressful situations and incorporate methods to help manage stress. For children some methods can include exercising, playing, being outside in the nature, and meeting with a therapist.

8. Avoid being in very hot or cold environments (Howe et al., 2023).

9. Avoid clothes that are made of wool (Garzon et al., 2019).  

10. It is recommended to keep the fingernails cut short to avoid trauma to the skin, especially when itching (Garzon et al., 2019).  

Follow-up:

-Contact provider if you continue to have itchiness that is interfering with sleep and daily activities after 5 days of initiating treatment.

-Follow-up in 2 weeks to assess skin rash.

-Monitor for signs of eczema, which includes dry skin, patches of skin that look lighter than regular skin, itchiness, yellow scabs, and pus (Howe et al., 2022).  If you notice any of these changes, contact provider for further advice.

-Seek medical help right away by calling 911 if you experience any trouble breathing, wheezing, dizziness, unusual puffiness of face, eyelids, ears, mouth, tongue, hands or feet (Howe et al., 2023).

Health Maintenance:

A secondary prevention for Taumi would include identifying the triggers that cause the atopic dermatitis flares and assist in methods to help prevent recurrence in the future. Some of the common triggers can include teaching the mothers the importance of daily baths and finding the appropriate skin care for the patient. Keeping the skin clean and moisturizes will help prevent flare-ups.

Social Determinant:

Atopic dermatitis is a chronic condition and can involve life-long treatments. It is important to consider cost of treatment and medication whenever prescribing. It is good to work with patient’s parents and pharmacy to find an affordable and realistic treatment.

References

Baddour, L. M., Sexton, D. J., Kaplan, S. L., Rosen, T., Ofori, A. O. (2022). Impetigo. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/impetigo?search=impetigo%20treatment%20children&source=search_result&selectedTitle=1~142&usage_type=default&display_rank=1

Feldman, S. R., Dellavalle, R. P., Duffin, K. C., Ofori, A. O. (2022). Psoriasis: Epidemiology, clinical manifestations, and diagnosis. UpToDate.  https://www-uptodate-com.regiscollege.idm.oclc.org/contents/psoriasis-epidemiology-clinical-manifestations-and-diagnosis?search=eczema%20children&topicRef=1729&source=see_link

Garzon, D., Starr, N., Brady, M., Gaylord, N., Driessnack, M., & Duderstadt, K. (2019). Burn’s pediatric primary care. (7^th ed.). Elsevier Publishing Company.

Goldstein, B. G., Goldstein, A. O., Dellavalle, R. P., Levy, M. L., Rosen, T., Ofori, A. O. (2022). Scabies: Epidemiology, clinical features, and diagnosis. UpToDate.  https://www-uptodate-com.regiscollege.idm.oclc.org/contents/scabies-epidemiology-clinical-features-and-diagnosis?search=eczema%20children&topicRef=1729&source=see_link

Howe, W., Dellavalle, R. P., Levy, M. L., Fowler, J., Corona, R. (2022). Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/atopic-dermatitis-eczema-pathogenesis-clinical-manifestations-and-diagnosis?search=eczema%20children&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=2#H13

Howe, W., Dellavalle, R. P., Levy, M. L., Fowler, J., Corona, R. (2023). Treatment of atopic dermatitis (eczema). UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/treatment-of-atopic-dermatitis-eczema?search=eczema%20children&topicRef=1726&source=see_link

Spergel, J. M., Lio, P. A., Dellavalle, R. P., Levy, M L., Fowler, J., & Corona, R. (2022). Management of severe atopic dermatitis (eczema) in children. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/management-of-severe-atopic-dermatitis-eczema-in-children?search=eczema%20children&topicRef=1729&source=see_link

Yiannias, J., Fowler, J., & Corona, R. (2021). Clinical features and diagnosis of allergic contact dermatitis. UpToDate. https://www-uptodate-com.regiscollege.idm.oclc.org/contents/clinical-features-and-diagnosis-of-allergic-contact-dermatitis?search=eczema%20children&topicRef=1729&source=see_link