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Skin Conditions[endnoteRef:1] [1: References: DermNet NZ http://dermnetnz.org/ eTherapeutics: Minor Ailments MedSask Guidelines for Minor Ailment Prescribing http://medsask.usask.ca/professional/guidelines/index.php Hartman-Adams, H., Banvard, C., Juckett, G. (2014) Impetigo: Diagnosis and Treatment. American Family Physician, 90(4), 229-235. ]

Guidelines for Patient Assessment

For the purposes of this guide, assessing for skin conditions is a means to identify which conditions may be considered minor, and therefore fall within the scope of practice for pharmacists’ assessment versus those conditions that require a referral.

Minor Skin Conditions are those that are included in Table 1. The Differential Assessment section outlines the conditions that may present with similar signs and symptoms that must be ruled out.

Table 1: Minor Skin Conditions

Condition

Location

Description of Lesions

A. Allergic Dermatitis and Mild-Moderate Atopic Dermatitis

Allergic contact dermatitis

Usually confined to area exposed to allergen

Acute onset of itchy vesicles

Eczema

Trunk, face, scalp, limbs

Patches of dry skin, may be red, itchy; may show signs of scratching, skin thickening

B. Mild Urticaria

Can occur anywhere on body

Red patches and wheals (hives), often itchy

C. Impetigo (excluding bullous impetigo)

Usually face and extremities

1 to 2 mm fragile pustules and/or honey-coloured, crusted erosions

D. Fungal Skin Infections: Dermatophyte infections

Tinea corporis (ringworm)

Exposed areas – trunk, limbs, face

Round, red spot that gradually expands with a raised, scaly erythematous border and a clear central area; lesions are 1-10 cm in circumference; itchiness and burning sensation are common

Tinea cruris (jock itch)

Symmetrical, involving the upper inner thigh and groin. Can spread down inner thigh or upwards to stomach and buttock. Does not usually involve penis and scrotum, vulva or anus.

Large round, red well defined patches with bumpy or scaling edges. Burning and itching are common.

Tinea manuum

Palmar surface of the hand more often than the back of the hand; only one hand may be involved if it occurs in conjunction with tinea pedis

Typically dry, mild diffuse scales on an erythematous base

Tinea pedis

(athlete’s foot)

Most commonly between the toes; may spread to instep or sole

Inflamed, blistered and feel itchy, burning, or painful

Fungal Skin Infections: Yeast infections

Pityriasis versicolor/ tinea versicolor

Back, chest, upper arms

Multiple white-pink to brown macules with an overlying fine scale

Cutaneous candidiasis

Moist areas, skin folds, particularly the groin

A “beefy red” edematous area with irregular edges and many small papules outside the borders (satellite lesions)

Differential Assessment

These conditions are assessed based on signs, symptoms and history. Rule out the following conditions that may present with similar signs/symptoms:

· Acne rosacea- pustules, dilated/broken blood vessels; facial flushing including cheeks.

· Acne vulagris- pustules and blackheads, often in other areas of the face as well.

· Alopecia areata- small nonscaly patches of sudden hair loss.

· Bullous impetigo – large, fragile, flaccid bullae that rupture and ooze yellow fluid. Formed in response to the exfoliative toxins produced by Staphylococcus aureus. Typically found on the trunk, axilla, and extremities, and in intertriginous (diaper) areas.

· Burns

· Ecthyma - an ulcerative, deeper infection usually found in the lower leg area following a trauma to the skin such as a cut or scratch.

· Erythrasma- a bacterial infection causing slowly enlarging areas of pink or brown scaling skin in folds in the groin, armpits, or between the toes. Often asymptomatic.

· Folliculitis/boils – infected hair follicles; present as red, often itchy papules and/or pustules at the base of the hair shaft. Subcutaneous folliculitis forms furuncles (boils) – tender red swellings often with a central pustule.

· Ichthyosis vulgaris – severe dry skin with characteristic fish-like scales.

· Lichen simplex chronicus – itchy patches of skin, thickened as a result of chronic scratching or rubbing, maybe covered in small bumps.

· Lupus erythematous- may present as itchy or painful rash – most commonly on face but may occur on chest and back

· Lyme disease- a rash expanding over the course of a few days and resembling a bulls-eye around the site of the tick bite. May be accompanied by flu-like symptoms. If not treated, may progress to severe joint pain and swelling, cardiac arrhythmias and neurological symptoms. Refer for evaluation; antibiotics may be required.

· Perioral dermatitis- papules and pustules around moth and chin; often includes a history of topical steroid use.

· Photosensitivity rash- ask about recent sun exposure; consider medication history and drugs associated with photosensitivity.

· Pityriasis rosea- appears as small, scaly lesions on the trunk in an evergreen tree pattern. It starts as a single patch which may be mistaken for tinea corporis.

· Psoriasis – well-defined, red papules coalescing into plaques (patches of slightly thickened skin); typically appears as silvery scales on red plaques.

· Scabies – generalized, severe itching, burrows in finger webs and sides of fingers.

· Scalded Skin Syndrome - starts with a localized infection caused by toxins produced by certain strains of S.aureus. When the blisters break, the top layer of skin peels and becomes inflamed, resembling a burn. This most often affects infants and children under 5 years old.

· Seborrheic dermatitis – minimal itch; patches of red, greasy, scaling rash with indistinct margins on scalp, eyebrows, around ears, nose folds, on forehead, chest, or upper back.

· Stevens-Johnson syndrome - involves fever, severe rash and skin-peeling in reaction to a drug.

· Venomous spider bites - may cause increased body temperature and blood pressure, profuse sweating, dizziness, blurred vision, nausea, pain and swelling around the bite within 1 to 8 hours.

· Viral skin diseases such as cold sores, shingles or chickenpox, which may blister, but have a clear exudate. Herpes simplex or herpes zoster may resemble impetigo; however, the lesions are not honey-coloured.

· Cold sores usually occur singly around the border of the lip.

· Chickenpox lesions usually develop over the trunk and extremities as well as the face.

· Vitiligo- nonscaly, chalk-white lesions

When to Refer

Patients with minor skin conditions often do not require further investigation; however, consider further assessment in the following situations:

· Symptoms are severe or large areas of the skin are involved.

· Secondary infection is present, e.g., fever, excessive swelling, redness, tenderness, discharge, and folliculitis.

· Symptoms are not relieved after a course of treatment of an appropriate duration.

· Anaphylactic reactions

· May appear as:

· Trouble breathing or swallowing

· Swelling of the lips or throat

· Fainting or dizziness

· Confusion

· Rapid heart rate

· Nausea and cramps

· Patients presenting with severe or systemic reactions should receive emergency treatment (911; hospital emergency department). Epinephrine injection may be indicated.

· Refer to physician for testing, assessment and epinephrine injection device.

· Systemic symptoms are present, e.g., fever, swollen lymph glands, fatigue, painful joints or nausea.

· Allergy testing is desired.

· Suspected adverse reaction to a prescription drug – treat and refer because alternate drug may be required.

· Patients with underlying diseases or drug regimens that may cause them to be immunocompromised.

· Area of inflammation around lesion expands rapidly over a few hours with or without systemic symptoms (fever, chills) – may be cellulitis or erysipelas.

· Suspected MRSA (methicillin-resistant S. aureus):

· It is not possible to distinguish MRSA from methicillin-sensitive S. aureus except by culture. However, risk factors should be examined, such as: recurrent boils or abscesses, previous MRSA infection and underlying medical conditions, close contact with others with the infection and also skin trauma such as scrapes, tattoos, injection drug use, shaving and/or sharing equipment that is not sterilized. Many people who get MRSA have no risk factors.

· MRSA infections usually involve the skin, but can cause more serious bone infections or rarely pneumonia. This is more common in children who also have influenza.

· Previous infection that did not fully resolve despite appropriate treatment, or frequent recurrences

· Onychomycosis (fungal nail infection)

· Unable to confirm patient assessment or a more serious condition is suspected (see differential assessment above).

A. Contact Allergic Dermatitis and Mild to Moderate Eczema

(Atopic Dermatitis)

Description

Contact Allergic Dermatitis

· Typically first appears in early childhood (i.e. in the first year of life) and subsides with advancing age. In general, the skin of people over 65 years of age is less reactive to allergens.

· It is a delayed or T cell-driven hypersensitivity reaction.

· Predisposition to develop allergic contact dermatitis is genetic.

· All