PREVENTION

Patients should recognize that sun safety guidelines include sun avoidance (especially during
the midday hours), protective clothing, and sunscreen. Advise the patient on ways to avoid the
damaging effects of the sun, such as wearing a large-brimmed hat, sunglasses, and a long-
sleeved shirt of a lightly woven fabric or carrying an umbrella. Patients need to know that the
rays of the sun are most dangerous between 10:00 AM and 2:00 PM standard time or 11:00 AM
and 3:00 PM daylight saving time, regardless of the latitude. Even on overcast days, serious
sunburn can occur because up to 80% of the sun’s UV rays can penetrate the clouds.

PHYSIOLOGIC CHANGES IN THE BODY:

● Cyanosis - Grayish blue tone, especially in nail beds, earlobes, lips, mucous
membranes, palms, and soles
● Ecchymosis - Dark red, purple, yellow, or green color, depending on age of bruise
● Erythema - Reddish tone, possibly accompanied by increased skin temperature
secondary to localized inflammation
● Jaundice - Yellowish color of skin, sclera, fingernails, palms, and oral mucosa
● Pallor - Pale skin color that may appear white or ashen; also evident on lips, nail beds,
and mucous membranes
● Petechiae - Lesions appearing as small, reddish purple pinpoints, best observed on
abdomen and buttocks
● Rash - May be visualized and felt with light palpation
● Scar - Generally heals, showing narrow scar line

LABORATORY / DIAGNOSTIC TESTS:

● Dermatoscopy - The main diagnostic techniques related to skin problems are

inspection of an individual lesion and a careful history related to the problem. If a
definitive diagnosis cannot be made by these techniques, additional tests may be
indicated, such as dermatoscopy (examination of the skin through a lighted instrument
with optical magnification).

● Biopsy (punch, incisional, excisional, and shave biopsies) - Biopsy is one of the most
common diagnostic tests used to evaluate a skin lesion. A biopsy is indicated in all
conditions in which a malignancy is suspected or a specific diagnosis is questionable.
Techniques include punch, incisional, excisional, and shave biopsies. The method used
is related to factors such as the site of the biopsy, the cosmetic result desired, and the
type of tissue to be obtained.
- Punch - Special punch biopsy instrument of appropriate size used. Instrument
rotated to appropriate level to include dermis and some fat. Suturing may or may
not be done. Provides full-thickness skin for diagnostic purposes.
- Excisional - Used when good cosmetic results and/or entire lesion removal
desired. Skin closed with subcutaneous and skin sutures.
 - Incisional- Wedge-shaped incision made in lesion too large for excisional
biopsy. Useful when larger specimens than shave or punch biopsy is needed.
- Shave - Single-edged razor blade used to shave off superficial lesions or small
samples of a large lesion. Provides thin specimens for diagnostic purposes.

● Stains and Cultures for fungal, bacterial, and viral infections - Test identifies fungal,
bacterial, and viral organisms. For fungi, scraping or swab of skin performed. For
bacteria, material obtained from intact pustules, bullae, or abscesses. For viruses,
vesicle or bulla and exudate taken from base of lesion.

● Direct immunofluorescence/Indirect immunofluorescence - Direct immunofluorescence is

a special diagnostic technique used on biopsy specimens and may be indicated in
certain conditions such as bullous diseases and systemic lupus erythematosus. Indirect
immunofluorescence is performed on a sample of blood. Some skin diseases have
specific, abnormal antibody proteins that can be identified by fluorescent studies. Both
skin tissue and serum can be examined.

● Patch Testing and Photo Patch Testing - . Patch testing and photopatch testing may be
used to evaluate allergic dermatitis and photoallergic reactions. Used to determine
whether patient is allergic to specific testing material. Small amount of potentially
allergenic material applied, usually to skin on back.

PHARMACOLOGY

● Antibiotics - Antibiotics are used both topically and systemically to treat

dermatologic problems, and are often used in combination. When using topical
antibiotics, apply a thin film lightly to clean skin. Common OTC topical antibiotics
include bacitracin-neomycin-polymyxin (Neosporin), bacitracin, and polymyxin B.
Many health care providers do not recommend Neosporin because it often
causes allergic contact dermatitis. Prescription topical antibiotics include
mupirocin (for superficial Staphylococcus infections such as impetigo),
gentamicin (used for Staphylococcus and most gram-negative organisms), and
erythromycin (used for gram-positive cocci [staphylococci and streptococci] and
gram-negative cocci and bacilli). Topical erythromycin and clindamycin (Cleocin
solutions or gels) are used in the treatment of acne vulgaris. Topical
metronidazole is used to treat rosacea and bacterial vaginosis. Many of the more
popular systemic antibiotics are not used topically because of the danger of
allergic contact dermatitis. If there are manifestations of systemic infection, a
systemic antibiotic should be used. Systemic antibiotics are useful in the
treatment of bacterial infections and acne vulgaris. The most frequently used are
synthetic sulfur, penicillin, minocycline, erythromycin, and tetracycline (or
 doxycycline). These drugs are particularly useful for erysipelas, cellulitis,
carbuncles, and severe infected eczema. Culture and sensitivity of the lesion can
guide the choice of antibiotic. Patients require drug-specific instructions on the
proper technique of taking or applying antibiotics. For instance, oral tetracycline
must be taken on an empty stomach. It should never be taken within 1 hour
before consuming a dairy product or 2 hours after, since this would interfere with
its absorption

● Corticosteroids - Corticosteroids are particularly effective in treating a wide

variety of dermatologic conditions and can be used topically, intralesionally, or
systemically. Topical corticosteroids are used for their local antiinflammatory and
antipruritic effects. Attempts to diagnose a skin problem should be made before a
corticosteroid preparation is applied, since corticosteroids may alter the clinical
manifestations. Once a sufficient amount of medication is dispensed, limits
should be set on the duration and frequency of application. The potency of a
particular preparation is related to the concentration of active drug. With
prolonged use, more potent corticosteroid formulations can cause adrenal
suppression, especially if a large surface area is covered and occlusive
dressings are used. Over time, high-potency corticosteroids may produce side
effects, including atrophy of the skin resulting from impaired cell mitosis, capillary
fragility, and susceptibility to bruising. In general, dermal and epidermal atrophy
does not occur until a corticosteroid has been used for 2 to 3 weeks. If drug use
is discontinued at the first sign of atrophy, recovery usually occurs in several
weeks. Rosacea eruptions and severe exacerbations of acne vulgaris may also
occur. Rebound dermatitis is not uncommon when therapy is stopped. This can
be reduced by tapering the use of high-potency topical corticosteroids when
improvement is noted. Low-potency corticosteroids such as hydrocortisone act
more slowly but can be used for a longer time without producing serious side
effects. Low-potency corticosteroids are safe to use on the face and intertriginous
areas, such as the axillae and groin. The most potent delivery system for a
topical corticosteroid is an ointment form. Creams and ointments should be
applied in thin layers and slowly massaged into the site one to three times a day
as prescribed. Accurate and adequate topical therapy is often the key to a
successful outcome. Intralesional corticosteroids are injected directly into or just
beneath the lesion. This method provides a reservoir of medication with an effect
lasting several weeks to months. Intralesional injection is commonly used in the
treatment of psoriasis, alopecia areata (patchy hair loss), cystic acne,
hypertrophic scars, and keloids. Triamcinolone acetonide (Kenalog) is the most
common drug used for intralesional injection. Systemic corticosteroids can have
remarkable results in the treatment of dermatologic conditions. However, they
often have undesirable systemic effects. Corticosteroids can be administered as
short-term therapy for acute conditions such as contact dermatitis caused by
poison ivy. Long-term corticosteroid therapy for dermatologic conditions is
reserved for severe disease such as bullous (blistering) disorders
● Antihistamines - Oral antihistamines are used to treat conditions that exhibit
urticaria, angioedema, and pruritus.14 Dermatologic problems such as atopic
dermatitis, allergic dermatitis, and other allergic cutaneous reactions can be
reduced with the use of histamine blockers. Antihistamines compete with
histamine for the receptor site, thus preventing its effect. Antihistamines may
have anticholinergic and/or sedative effects. Several different antihistamines may
have to be tried before the satisfactory therapeutic effect is achieved. Sedating
antihistamines, such as hydroxyzine (Atarax) and diphenhydramine (Benadryl),
are often preferred for pruritic conditions because the tranquilizing and sedative
effects offer symptomatic relief. Warn the patient about sedative effects, a
particular problem when driving or operating heavy machinery. Antihistamines
such as loratadine (Claritin), fexofenadine (Allegra), and cetirizine (Zyrtec) bind to
peripheral histamine receptors, providing antihistamine action without sedation.
These nonsedating antihistamines are not effective for controlling pruritus.
Antihistamines should be used with particular caution in older adults because of
their long half-life and their anticholinergic effects

● Topical Fluorouracil.  Fluorouracil (5-FU) is a topical cytotoxic agent with

selective toxicity for sun-damaged cells. 5-FU is available in four strengths (0.5%,
1%, 2%, and 5%) and is used for the treatment of premalignant (especially
actinic keratosis) and some malignant skin diseases. Because systemic
absorption of the drug is minimal, systemic side effects are virtually nonexistent.
Patient compliance is a consideration in the use of 5-FU. The medication
produces erythema and pruritus within 3 to 5 days and painful, eroded areas over
the damaged skin within 1 to 3 weeks, depending on skin thickness at the site.
Low-potency topical corticosteroids are often prescribed to be applied 20 minutes
after 5-FU to reduce erythema and pruritus and increase patient adherence with
therapy. Treatment must continue with applications one (only in the 0.5%
strength) or two times a day for 2 to 6 weeks. Healing may take up to 4 weeks
after medication is stopped. Because 5-FU is a photosensitizing drug, instruct the
patient to avoid sunlight during treatment. Teach patients about the effect of the
medication and that they will look worse before they look better. Adherence
depends on thoroughness of your instruction, which should include a written
handout. After effective treatment, treated skin is smooth and free of actinic
keratosis. Actinic keratosis may recur in treated areas, and multiple courses of
chemotherapy may be necessary over the years for individuals with severely
sun-damaged skin

● Immunomodulators.  Topical immunomodulators, such as pimecrolimus (Elidel)

and tacrolimus (Protopic), are used to treat atopic dermatitis. They work by
suppressing an overreactive immune system. The side effects are minimal and
may include a transient burning or feeling of heat at the application site. An
increased risk of skin cancer and precancerous lesions may be associated with
 these drugs. Another topical immunomodulator, imiquimod, acts to stimulate the
production of α-interferon and other cytokines to enhance cell-mediated
immunity. It boosts the immune response only where applied and is safe for
transplant patients. This medication is used for external genital warts, actinic
keratoses, and superficial BCC. Most patients using this cream experience skin
reactions, including redness, swelling, blistering, excoriations, peeling, itching,
and burning.