a clinical triad: treating the weekend warrior€¦ · a clinical triad: treating the weekend...
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A Clinical Triad: Treating the Weekend Warrior
ACP Virginia Chapter- Annual Meeting and Clinical Update
March 8, 2019
Kimberly S. Salkey, MD
Associate ProfessorDepartment of Dermatology
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Bumps, Burns and Bites… Oh my!ACP Virginia Chapter- Annual Meeting and Clinical Update
March 8, 2019
Kimberly S. Salkey, MD
Associate ProfessorDepartment of Dermatology
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Kimberly S. Salkey, MD
A Clinical Triad: Treating the Weekend Warrior
DISCLOSURES
I do not have any relevant relationships with industry.
DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY
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Identify this plant
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Poison Ivy
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Poison Plants: Ivy, Oak and Sumac
• Most common type of allergic contact dermatitis in the US
• Culprit: Urushiol (oleoresin)
• Founds in all continental United States
JW Pine (Ed.) Fisher’s contact dermatitis.; Williams & Wilkins, Baltimore (1995), pp 469-472
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www.AAD.org
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Poison Ivy Quiz• Scratching poison ivy
blisters will spread the rash
• Poison ivy is contagious
• Dead poison ivy plants are no longer toxic
• Rubbing weeds on the skin can help
• FALSE
• FALSE
• FALSE
• FALSE
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Urushiol
• Irritant and allergen
• Combines with skin proteins
• Fomite friendly
- Bound resin cannot be spread
- Rash takes 12-72 hours to appear
- Resolves without treatment in 2-3 weeks
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Poison Ivy
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Poison Ivy
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Poison Ivy
J Am Acad Dermatol 2001;45:246-9.
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• Requires concentrated sap
• Spots peel and skin heals
• Fomites can cause dermatitis indefinitely
J Am Acad Dermatol 2001;45:246-9.
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Poison Ivy Treatment
• Wash all exposed areas with cold running water ASAP
• Wash clothing in a washing machine with detergent
• Wash contaminated equipment
• Cool showers, hydrocortisone cream
• Severe reaction
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Severe Poison Ivy
• Dry it
– Domeboro soaks
• High potency topical corticosteroids
– Clobetasol
– Betamethasone diproprionate
• Systemic steroid
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Journal article title• Severe poison ivy:
– Known exposure AND andone of:
– >20% BSA
– Hands, feet, face or genitals
– Involvement of 2 or more body areas
• Treatment regimen:
• Short course:– Prednisone 40mg qd x 5 days
• Long course: – Prednisone 40mg x 5 days
– 30mg x 2 days
– 20mg x 2 days
– 10mg x 2 days
– 5mg x 4 days
J Clin Med Res. 2014 Dec; 6(6): 429-434
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J Clin Med Res. 2014 Dec; 6(6): 429-434
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Poison Ivy Prevention
• Recognition and avoidance
• Wear long clothing
• Keep pets away from wooded areas
• Do not burn poison plants
• Barrier skin creams
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Poison Ivy Prevention
AAD.org
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But my TV doctor told me I need Vitamin D!!
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Sunburn
• Radiation burn
• Risk factors
– Time and intensity of UV rays
• Other factors
– Medications, ozone, altitude, skin phototype
Sunburn. [Updated 2018 Nov 23]. In StatPearls [Internet]. www.ncbi.nlm.nig.gov
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Sunburn• Differential Diagnosis:
– Autoimmune disease- SLE
– Infection- staph scalded skin
– Solar reactions-phytophotodermatitis, photoallergic, phototoxic
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Sunburn Management
✓Dry it
✓Cool compresses
✓NSAIDs
✓Time
ₓ Topical anesthetics
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Journal of Investigative Dermatology (2017) 137, 2078e2086
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• Increased risk of melanoma with increasing number of sunburns during all life-periods, not just childhood
Ann Epidemiol. 2008 Aug; 18(8): 614-627
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AAD position statement on Vitamin D
“There is no scientifically validated, safe threshold level of UV exposure from the sun or indoor tanning devices that allows for maximal vitamin D synthesis without increasing skin cancer risk”
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AAD position statement on Vitamin D
• “adequate amount of vit D should be obtained from a healthy diet… and/or vitamin D supplements”
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Photoaging
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Sun Protection
• Shade and sun avoidance
• Protective clothing with UPF rating
– Solumbra, Coolibar, etc
• Sunscreens
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Choosing Sunscreen
• Broad spectrum
• Water resistant
• SPF 30 or greater
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SPF 100+ sunscreen is more protective against sunburn than SPF 50+ in actual use
• Natural sunlight, split face, double-blind evaluation
• Less sunburn on SPF 100 side
• Higher SPF compensates for typical sunscreen use behavior
J Am Acad Dermatol. 2018 May; 78(5):902-910
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SPF 100+ sunscreen is more protective against sunburn than SPF 50+ in actual use
J Am Acad Dermatol. 2018 May; 78(5):902-910
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Bites
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Mosquitoes
• Multiple factors for attraction
• Saliva induces histamine release
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Mosquito Bite Treatment
• Cool compresses
• Anti-histamine
• Topical corticosteroids
• PREVENTION!
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Bug Repellant• DEET
– Effective against mosquitoes, biting flies, gnats, chiggers, ticks but NOT stinging insects
• Picaridin– Same efficacy as DEET
• Citronella• Permethrin
– Used in fabrics or applied to clothing
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• 32yo boy scout troop leader
• Recently back from a camping trip
• All of the other campers in his cabin developed similar findings
Diagnosis?Bed Bug bites
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Bedbugs
• Nocturnal, blood-sucking, ectoparasites
• Cimex lectularius
• Do not transmit disease– Secondary infection
– Asthma exacerbation
• Bites are painless and may not appear for several days
www.cdc.gov
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Gothamist.com
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Bedbugs
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Bedbugs
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Bed Bug Treatment• Remove bugs
– Barriers to removal• Good hiders• Fast movers
• Other– Diatomaceous earth → dessication– Pyrethroids, dichlorvos, malathion– Steam/Heat (45oC or greater)– Cold
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Bed Bug TreatmentWhat NOT to do:
• Abandoning rooms or even a whole facility
– Adult bugs can live 1 year without blood meal
• “Bug bombs” or total release foggers
– Only hit exposed surfaces
– Bugs have a chance to “run for cover”
• Simply discarding beds and beddingGuidelines for Prevention and Management of Bed Bugs in Shelters and Group Living
Facilities- New York State Integrated Pest Management Program
www.nysipm.cornell.edu
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A Clinical Triad: Treating the Weekend Warrior
ACP Virginia Chapter- Annual Meeting and Clinical Update
March 8, 2019
Kimberly S. Salkey, MD
Associate ProfessorDepartment of Dermatology