In addition to wet dressings and soaks, topical solutions can be applied to large areas
of the body through bathing. In using this type of treatment, the bath should be about
half full. Soothing and antipruritic colloidal bath additives may be used to treat
widespread eruptions. Colloidal oatmeal, in the form of 1 cup of oatmeal (e.g.,
Aveeno) mixed with 2 cups of cold tap water and poured into 6 inches of a lukewarm
bath, produces a pleasing and soothing bath. Alternatively, a starch bath using two
cups of hydrolyzed starch (e.g., Linit, a mixture of equal parts baking soda and
hydrolyzed starch) may also be used. Epsom salt baths, made by dissolving three
cups of magnesium sulfate in 6 inches of lukewarm water in a tub, are useful in
treating pyodermas, furuncles, and necrotic acne (especially when the back,
shoulders, and buttocks are affected).
Many different bath oils are available: Alpha-Keri, Domol, Lubriderm, and
Nutraderm. Adding the oil directly to the bath is not recommended because it makes
the tub slippery and potentially dangerous. The concentration of the oil in the water
becomes almost insignificant anyway (5–10 mL in 20–40 gallons). Approximately 5
to 10 mL of bath oil may be applied directly to wet skin on leaving a bath and patted
dry with a towel for a more significant effect. This is most useful in preventing and
treating mild cases of xerosis (dry skin). With moderate-to-severe cases of xerosis,
additional topical oleaginous products are generally required to improve the
Powders are drying and cooling, absorbing moisture and creating more surface area
for evaporation. They are used mainly in intertriginous areas (e.g., groin, under the
breasts, or in skin folds) to decrease friction, which can cause mechanical irritation.
The liberal use of powders on bedridden patients helps prevent pressure ulcers
(bedsores). They also are useful in the treatment of chafing, tinea pedis (athlete’s
foot), tinea cruris (jock itch), and diaper dermatitis (diaper rash).
Powders can be applied with a cotton puff or shaker. Care should be taken to
minimize breathing the powder because this can lead to respiratory tract irritation,
particularly in infants. Powders that contain starch or cellulose (which are
hygroscopic) should be washed off before reapplication, because continued buildup
can produce mechanical irritation. Corn starch-containing powders should not be
used for intertrigo (inflammation of body folds—thighs, armpits, under breasts, or
enlarged abdomen; aggravated by heat, moisture, and maceration) because starch can
serve as a substrate for Candida albicans. Powders should not be applied to oozing
lesions because they tend to cake into hard granules, making them difficult and
painful to remove, and promoting maceration. The most commonly used powder is
Lotions are suspensions or solutions of powder in a water vehicle. They are usually
cooling and drying, but may provide some lubrication, depending on the formulation.
treat superficial dermatoses, especially if there is slight oozing. They are useful if
large or intertriginous areas are affected, and they are especially advantageous in the
treatment of conditions characterized by significant inflammation and tenderness. In
these situations, creams or ointments may cause pain on application. Lotions are also
useful for hairy areas of the body and scalp. Generally, lotions not containing
corticosteroids are applied 3 or 4 times daily, with each fresh application placed
over previous application, unless there is significant oozing present, which could
promote caking of dried solid ingredients. If this is the case, the area should be
cleansed before repeat application. Because many lotions are suspensions, it is
advisable to shake the lotion well before application. Generally, 6 ounces of lotion
covers the entire body of an average adult.
ointments are water-in-oil emulsions. Because the fraction of oil increases, the
viscosity of the emulsion will also increase.
The indications for liquid oil-in-water emulsions (e.g., Keri Lotion, Cetaphil) are
similar to those for lotions and creams, except that this dosage form provides greater
occlusion and is more useful in conditions in which dry skin predominates. Liquid
water-in-oil emulsions (e.g., Nivea, Eucerin, or Lubriderm) have similar indications
to ointments, except they can be applied more easily than ointments. Water-in-oil
emulsions are most useful in conditions in which dry skin predominates; application
to hairy or intertriginous areas should be avoided. As with lotions, 6 ounces of a
liquid emulsion will cover all exposed skin on an average adult.
Gels are a form of ointment (semisolid emulsion) that contain propylene glycol and
carboxypolymethylene. They are clear, nongreasy, nonstaining, nonocclusive, and
quick drying. They are thixotropic (i.e., become thinner with rubbing and may sting
on application). Gels are most useful when applied to hairy areas or other areas such
as the face or scalp, where it is considered cosmetically unacceptable to have the
residue of a vehicle remain on the skin. Because of their ingredients, gels tend to be
Creams are the most commonly used vehicle in dermatology. Most are oil-in-water
emulsions and are intended to be rubbed in well until they vanish (vanishing creams).
Because creams are drying and do not provide much occlusiveness, they are most
often recommended for subacute lesions and occasionally for chronic lesions without
significant lichenification. The most common mistake made by patients when
applying creams is that they use too much or do not rub them in fully. Generally, if the
cream can be seen on the skin after application, the patient has made one or both of
these application mistakes and the preparation is wasted or the patient is not getting
the full therapeutic benefits.
Ointments are made of inert bases such as petrolatum or may consist of droplets of
water suspended in a continuous phase of oleaginous material (i.e., water-in-oil
emulsions such as Aquaphor or Polysorb). Ointments are most useful on chronic
lesions, relieving dryness, brittleness, and protecting fissures owing to their
occlusive properties. They should not be used on acutely inflamed lesions. Ointments
should not be applied to intertriginous, burns, or hairy areas because they tend to trap
heat and promote maceration. Ointments are greasy and may be cosmetically
Appropriate Dermatologic Vehicle Selection Across the Range of Dermatologic
Range of Lesions Range of Vehicles
Oozing, weeping, vesication, edema, pruritus
Crusting, less oozing, pruritus
Lichenification, dryness, erythema, pruritus, scaling
Aqueous vehicles and water, and then powder
solutions, lotions, sprays, and aerosols
Aerosols are the most expensive and inefficient way to apply dermatologic
medications. Their only advantage over other dosage forms is that they do not require
direct mechanical contact with the skin and may be useful if application causes
intolerable pain for the patient. If an aerosol is used, it should be shaken well before
use, and the patient should be cautioned not to spray the product around the face
where it could get into the eyes or nose or be inhaled. Generally, aerosols should be
sprayed from approximately 6 inches above the skin in bursts of 1 to 3 seconds.
Aerosols are also useful for application to hairy areas if a special application nozzle
is used. Aerosols have a drying effect and should not be used for a long period.
Selection of a Delivery System
Dermatologic vehicles should be matched to the type of lesion for which they will be
used. Acute lesions require aqueous vehicles until the lesions become dry. Subacute
lesions also benefit from aqueous vehicles, but for shorter periods before switching
to creams or gels. Chronic lesions usually require ointments because of their dry,
lichenified characteristics. Although there are exceptions, usually due to patient
preferences, these principles are depicted in Table 39-2.
ASSESSING THE DERMATOLOGIC PATIENT
be asked to help determine the appropriate diagnosis and treatment?
The diagnosis of dermatologic conditions can be simplified by considering six
primary factors: appearance (what the lesions look like, pattern of the lesions);
location or distribution of the lesions on the body; symptoms, both local and
systemic; history of the present condition as well as related conditions; age of the
patient; and patient sex. Direct observation of the skin lesion, plus C.B.’s responses
to questions about these factors, will allow an appropriate diagnosis and treatment
Dermatologic Lesions, Definitions, and Clinical Examples
Macule Nonpalpable, flat, change in color, <1 cm Freckles, flat moles
Patch Nonpalpable, flat, change in color, >1 cm Vitiligo, “café au lait” spots,
Papule Palpable, solid mass, may have change in color, <1 cm Verrucae, noninflammatory
Nodule Palpable, solid mass, most often below the plane of the
Tumor Palpable, solid mass, >2 cm, most often above and
Plaque Flat, elevated, superficial papule with surface area
Psoriasis, seborrheic keratosis
Wheal Superficial area of cutaneous edema, fluid not confined
Urticaria (hives), insect bite
Vesicle Palpable, fluid-filled cavity, <1 cm, filled with serous
Herpes simples, herpes zoster,
Bulla Palpable, fluid-filled cavity, >1 cm, filled with serous
Pemphigus vulgaris, seconddegree burn
Pustule Similar to vesicle, but filled with purulent fluid Acne, impetigo, folliculitis
Comedone Plugged opening of sebaceous gland Acne, blackhead, whitehead
Cyst Palpable lesion filled with semiliquid material or fluid Sebaceous cyst
Abscess Accumulation of purulent material in dermis or
subcutaneous layers of skin; purulent material not
Furuncle Inflammatory nodule involving a hair follicle, following
Carbuncle A coalescence of several furuncles Large boil
Erosion Loss of part or all the epidermis Ecthyma
Ulcer Loss of epidermis and dermis Stasis ulcer
Fissure Linear crack from epidermis into dermis Tinea pedis
Excoriation Self-induced linear, traumatized area caused by intense
Atrophy Thinning of skin with loss of dermal tissue Striae
Crusts Dried residue of pus, serum, or blood from a wound,
Lichenification Thickening of epidermis, accentuated skin markings,
usually induced by scratching or chronic inflammation
Table 39-3 provides a listing of common dermatologic lesions, their respective
definitions, and some well-known clinical examples. Lesions may also be classified
as either primary or secondary. Primary lesions are lesions because they first appear
on the skin, whereas secondary lesions develop from primary lesions. The ability to
recognize and describe specific lesions is critical to a successful diagnosis and
communication regarding response to therapy.
In addition, many lesions present in a particular distribution or pattern. Poison ivy
lesions are commonly distributed linearly. Herpetic lesions are so typical that the
patient’s condition. Dermatologic terms related to lesion distribution or pattern are
shown in Table 39-4. The lesion’s consistency (firm vs. soft), borders, and color are
also important diagnostic considerations.
Certain lesions or conditions usually occur in specific body locations, usually due to
physiologic reasons. Table 39-5 provides a list of anatomic sites with common
dermatoses occurring in those locations. For example, diseases of the sebaceous
glands (e.g., acne, seborrheic dermatitis, rosacea) occur only in sites with high
concentrations of sebaceous glands, such as the scalp, head, neck, chest, and
umbilicus. Atopic dermatitis shows a predilection for the flexor surfaces of the body
(i.e., antecubital and popliteal fossae).
Most skin conditions have only localized symptoms with the most common symptom
being pruritus. Occasionally, localized burning or pain is the predominant symptom.
Descriptive Dermatologic Terms
Acneiform Acne-like Acne vulgaris
Arcuate Shaped like an arc Syphilis
Confluent Lesions run together Psoriasis, tinea
Discrete Lesions remain separate Psoriasis, tinea
Eczematous General term for dry, red flaky, or
lichenified skin without clear border
Chronic allergic contact dermatitis, atopic
Geographic Shaped like islands or continents; map-like Generalized psoriasis
Grouped Lesions clustered together Herpes
Herpetiform Appears like herpes simplex Herpes simplex
Intertrigo Irritant dermatitis in skin folds Diaper dermatitis
Iris Looks like a bull’s-eye, lesion within a
Keratotic Horny thickening Psoriasis, corn, callus
Linear Shaped in lines Poison ivy
Multiform More than one type or shape of lesion Erythema multiforme
Papulosquamous Papules with desquamation Psoriasis
Serpiginous Snake-like lesions Cutaneous larva migrans
Zosteriform Appears like herpes zoster Herpes zoster
Common Skin Diseases by Body Location
Scalp Seborrheic dermatitis, dandruff
Face Acne, rosacea, seborrheic dermatitis, perioral dermatitis, impetigo, herpes
Chest or abdomen Tinea versicolor, tinea corporis, pityriasis rosea, acne, herpes zoster
Back Tinea versicolor, tinea corporis, pityriasis rosea
Genital area Tinea cruris, scabies, pediculosis, condyloma acuminate (venereal warts)
Extremities Atopic dermatitis (cubital and popliteal fossa)
Hands Tinea manuum, scabies, primary irritant contact dermatitis, warts
Feet Tinea pedis, contact dermatitis, onychomycosis
Generalized or localized Primary irritant or contact dermatitis, photodermatitis
Although a diagnosis may often be made from morphology, location, and symptoms,
the patient history provides useful diagnostic and therapeutic information. Similar to
the historical information obtained for any acute medical problem, the following
questions should always be asked:
When and how did the problem start?
How has it progressed or changed since its onset? How have the lesions changed in
size, color, appearance, or severity?
What is the patient’s past and current medical history? What other symptoms might
indicate that this is a dermatologic manifestation of a systemic disease?
What are the patient’s other symptoms?
What kind of allergies does the patient have?
What makes the condition worse or better?
What events or happenings have occurred with the onset or worsening of the
condition (e.g., increased stress, exposure to new products, recent travel, and
What have you used to treat the condition, and how have the treatments worked?
How did the patient use any previous therapy, and for how long did they use it?
Many conditions occur predominantly in certain age groups, such as acne in neonates
and those ages 11 to 20 years, seborrheic dermatitis in neonates and those ages 11 to
12 years, rosacea in those older than 30 years, and atopic dermatitis primarily in
children younger than 6 years. In fact, atopic dermatitis begins and ends before 6
years of age in 95% of patients. It is equally important to realize that many
conditions, such as primary irritant and allergic contact dermatitis, occur independent
of age. In addition, the skin of children and patients older than 65 years is more
penetrable, thus more responsive and more susceptible to adverse effects from
therapy with topical agents. Topical therapeutic agent potency and delivery systems
must be carefully evaluated before usage.
Although most dermatologic conditions occur in both sexes, sometimes frequency and
severity are sex dependent. Rosacea
occurs more frequently in women, but is often more serious in men.
“arthritis.” How would you advise C.R. to manage this condition?
C.R.’s complaints represent a common problem of the elderly, xerosis (dry skin).
The seasonal cycle described is frequently called “winter itch.” Most cases of dry
skin are caused by dehydration of the stratum corneum.
7,8 Cold temperatures decrease
the indoor humidity because of increased use of central heating, or living in a low
humidity climate, such as in Arizona, dry out the outer layers of the skin. Given fact
that bathing (moisture) provides temporary relief points to xerosis as the most likely
7,8 The location of the itching, the lack of a visible rash, the relief with bathing,
and no chronic diseases rule out most other causes of xerosis (e.g., atopic dermatitis,
diabetes mellitus). However, given her age and sex, hypothyroidism remains a
possibility. Table 39-6 gives general recommendations for the treatment of dry skin.
Table 39-7 lists the most common topical corticosteroid preparations by their degree
of potency according to the Stoughton–Cornell classification system.
A topical corticosteroid is often the drug of choice for many inflammatory and
pruritic eruptions. In addition, topical corticosteroids are useful with hyperplastic
and infiltrative disorders. The following conditions generally respond well to topical
corticosteroids: allergic contact dermatitis, atopic dermatitis, psoriasis, and
The following conditions (predominantly infectious etiologies) are worsened by
topical corticosteroids: acne vulgaris, ulcers, scabies, warts, molluscum
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