Dermatology, Insect Bites/Stings, Pediculosis IRAT

Appropriate self-care plan for insect bites -Diphenhydramine

0.5 - 2% Generally, not absorbed in sufficient quantities to cause systemic AEs. Don't apply to a large area.

Appropriate self-care plan for insect bites. - Hydrocortisone 1% cream

1st choice. Antipruritic and anti-inflammatory. Avoid prolonged use. Avoid in scabies, fungal or bacterial infections, candidiasis. Apply up to 4 times a day

State when follow-up should occur - Lice

Follow-up of lice infestations should occur within 10 days

Recommend an appropriate insect repellant and describe how to use. - DEET

For kids recommend products which have less than 30% deet Children less than 2 - less than 10% Less than 2 months old don't use repellant Typically recommend less than 50% concentration for adults Applied to package and is recommended 4-8 hours applied (but this depends on the concentration)

Describe nonpharmacologic therapy for treatment of lice.

Nondrug methods, specifically combing and vacuuming, combing with an FDA-approved nit comb, such as the LiceMeister comb; removal of nits is helpful in treating and controlling head lice The AirAllé (formerly called the LouseBuster) is a machine that applies heat to the hair and scalp to dehydrate and kill lice and nits. Direct physical contact with an infested individual should be avoided and articles such as combs, brushes, towels, caps, and hats should not be shared however protective head gear should not be avoided due to fear of transmission

Describe the general approach to self-care of insect stings

OTC Product containing topical anesthetic or skin protectants. OR OTC product with counterirritant, topical AH, skin protectant, hydrocortisone. - Symptoms should resolve after 7 days

Recommend an appropriate insect repellant and describe how to use. - Citronella

Olfactory repellent. Candles less effective than if applied topically

Describe the mechanism of action of permethrin.

Permethrin acts on the nerve cell membrane of lice. It disrupts the sodium channel, delaying repolarization and causing paralysis and death of the parasite

List the contraindications for permethrin.

Permethrin is contraindicated in patients who are sensitive to pyrethrins or chrysanthemums. Permethrin should not be used on infants younger than 2 months

Cyst

When pus originated from lower in skin and then pushes skin up Semisolid or fluid-filled mass, encapsulated in deeper layers of skin

Compare the effectiveness of permethrin and pyrethrins

When treatment involves a single application of a pediculicide, permethrin is more effective than the pyrethrin and piperonyl butoxide combination. However, to date, no significant difference exists in effectiveness of these agents when treatment consists of two applications.

Scaling Fissures

White dry skin linear breaks in the skin

Scaling

White dry skin - A lot of erythema

Scaling

White flakes- -seeing individual cells which slough off and clump together and dries out to get white appearance

Pustule and Erosion

Yellow lesions are raised and filled with pus

Appropriate self-care plan for insect bites -Skin protectant

Zinc oxide. Calamine Reduce inflammation and irritation Absorb fluids from weeping lesions

Crust

a lesion where fluid is broken up on surface of skin (yellow so probably once a pustule) - dried on skin

Describe complications that may occur from insect bites - Ticks

rocky mountain spotted fever and Lyme disease (rare in WV)

State the exclusions to self-treatment of insect bites

•Hypersensitivity to insect bites •< 2 years old •History of tick bite and systemic effects indicating possible infection •Suspected spider bite requiring medical attention. - Brown recluse (ulceration) •Signs of secondary infection (scratching complication)

State when to seek medical attention.- Lice

•Significant skin irritation or excessive exposure of eyes or mucous membranes to pediculicides warrants medical intervention. •Seek medical attention if symptoms of lice infestation persist after the second treatment. •Seek medical attention if resistance to pyrethrins or permethrin has been reported in the region.

Discuss patient education for pediculosis - Non-prescription measures

•Treatment of other family members should be determined on the basis of presence of lice or nits and the family members' level of contact with the infested individual; unnecessary treatment should be avoided. •Application steps for a pyrethrin shampoo include the following: oApply sufficient quantity to wet the dry hair and scalp. (Foams should also be applied to dry hair.) oAllow the treatment to remain for 10 minutes. oWork the shampoo into a lather and then rinse thoroughly. (Remove foams with shampoo or soap and water.) oUse a nit comb to remove dead lice and eggs as described previously. •Application steps for a permethrin cream rinse include the following. oShampoo with regular shampoo, rinse, and towel dry hair. oApply sufficient cream rinse to wet hair and scalp. oAllow the treatment to remain for 10 minutes; then rinse and towel dry. oUse a nit comb as described previously. •Avoid contact of the pediculicide with eyes and mucous membranes. •The pediculicide can cause temporary irritation, erythema, itching, swelling, and numbness of the scalp; itching should be relieved in a few days. •For pyrethrin products, repeat entire process in 7-10 days; permethrin products can be used again in 7-10 days if lice or nits are detected. Because of treatment resistance, proper use of these products is required and overuse must be avoided. •If desired, contact the National Pediculosis Association at www.headlice.org or 1-617-905-0176 for information about treatment of lice infestations. •If pediculicides are ruled out as a treatment option, alternative products such as citronella, lemon eucalyptus oil, soybean oil, cedar oil, lavender oil, tea tree oil, garlic, and scented moisturizers in mineral oil (e.g., Skin-So-Soft) may be tried.

Macules

Non raised areas with small discoloration - less than 5 mm

Describe how to use permethrin for treatment of head lice.- a. State when treatment should be repeated.

The rinse has residual effects for up to 10 days; therefore, retreatment in 7-10 days is not required unless active lice are detected.

How to use pyrethrins for treatment of lice.- State when treatment should be repeated.

The treatment is repeated in 7-10 days to kill any remaining nits that have since hatched. The drug should not be applied more than twice in 24 hours

Fissures Excoriation

This is linear type lesions are not deep. This is scratching and broken surface scabbing

Describe how to use permethrin for treatment of head lice.- State how long the product should be left on the affected area

1% cream rinse is applied in sufficient quantities to cover or saturate washed hair and scalp. It is left on the hair for 10 minutes before rinsing; the hair is then combed with a lice comb

Summarize information about lice resistance to pediculicides

25 states in the United States had lice with genetic mutations indicating resistance to nonprescription pediculicides; with lice in California, Texas, Florida, and Maine being the most resistant

Crust Vesicle Macule

3 o'clock - lesion which is broken open and some dryness 9 clock- raised lesion filled with clear fluid and is small 12 o'clock- red lesion, small and not raised

Recommend an appropriate insect repellant and describe how to use. - Permethrin

Applied to clothing, shoes, bed nets, and camping gear. NOT to be applied to skin - outdoor places Repels and kills - ticks, mosquitos and other arthropods Works for weeks, even after laundering

Fissures Excoriation Scaling

Area of breaks in skin - linear Surface of skin scabbing over Skin flaking off in white areas

Recommend an appropriate insect repellant and describe how to use. - Oil of Lemon Eucalyptus

Biopesticide Effective against mosquitoes, biting flies, and gnats NOT ticks Not safe in those under 3 (30% is comparable to 20% DEET but needs applied more)

Recommend an appropriate insect repellant and describe how to use. - Avon Skin So Soft Bug Guard

Biopesticide. IR3535 or picaridin. Short duration - average protection time of 23 minutes. Less effective than DEET

Describe the signs and symptoms of insect bites.- Fleas

Bites occur on lower legs and ankles and multiple bites are grouped together

Ecchymoses/Bruise

Blood under skin caused by trauma. - this > 5 mm in diameter

Vesicle Pustule Cyst

Bottom left raised lesion with clear fluid on surface of skin Upper right- filled lesion on surface of skin with yellowing and pus Upper left - originating from deeper levels

Appropriate self-care plan for insect bites -Counter irritants

Camphor menthol, ammonia Afterbite- may cause more stinging Ammonia and mink oil StingEze Benzocaine, phenol, camphor. Phenol - avoid in kids

Telangiectasia

Capillaries permanently evident on surface of skin

Describe how to clean carpets, rugs, and furniture.

Carpets, rugs, and furniture should be vacuumed thoroughly and regularly.

Describe how infestations of head lice are spread

Commonly spread through direct head-to-head contact with an infected person.

Role of the pharmacist - Dermatology

Communicate with other health care professionals using common/descriptive terms Understand what they are reading Triage those in need of self care counseling

Describe common symptoms of insect stings

Most people will complain of pain, itching, and irritation at the site following an insect sting, but they generally will have no systemic symptoms

Describe how dimethicone works for treatment of pediculosis.

Dimethicone 100% gel also has been shown to cure pediculosis while causing less irritation than traditional therapy. Furthermore, dimethicone works by coating the lice and irreversibly immobilizing them within 5 minutes of application

external products that can be used to treat insect stings. -topical antihistamines

Diphenhydramine hydrochloride in concentrations of 0.5%-2%

Papules

Multiple discrete raised lesions which are less than 1 cm filled with solid material

Nodule

Growth coming from under the skin Pushing up from under the skin Solid, elevated lesion or mass, 5 mm to 5 cm in diameter

State where hair inspection should be focused

Hair inspections should focus on the crown of the head, near ears, and at the base of the neck.

Describe the clinical presentation of head lice.

Head lice usually infest the head and live on the scalp The bites of a louse causes an immediate wheal to develop around the bite, with a local papule appearing within 24 hours. Itching and subsequent scratching may result in secondary infection. Adult lice, which are about the size of a sesame seed, often are difficult to locate, because they move when the hair is moved during inspection of the scalp

List exclusions for self-treatment.- insect stings

Hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing Significant allergic response away from the site of the sting Previous sting by honeybee, wasp, or hornet (need to evaluate possibility development of hypersensitivity.) Previous severe reaction to insect bites Personal of family history of significant allergic reactions (hay fever) <2 years of age

external products that can be used to treat insect stings. -hydrocortisone

Hydrocortisone 1%

List the exclusions to self-treatment.- Lice

Hypersensitivity to chrysanthemums, ragweed, pediculicide ingredients Presence of secondary skin infection <2 years of age for pyrethrins <2 months of age for pemethrins Lice infestation of eyelids or eyebrows Pregnancy or breast feeding Presence of active tumors Regional resistance to pediculicides

Recommend an appropriate insect repellant and describe how to use. - Picaridin

If patient has gotten skin irritation from deet products this might be a good alternative, or someone who wants a deet free product. Duration can last 2-8 hours Odorless, nongreasy, and less likely to irritate skin

Explain when to seek medical attention - Insect sting

If you have experienced previous severe reactions to insect stings, seek emergency medical care immediately. If a primary care provider has prescribed epinephrine or an oral antihistamine and you have it on your person, administer it according to the provider's instructions. Seek medical attention if you develop symptoms of an allergic reaction, such as hives, excessive swelling, dizziness, vomiting, or difficulty breathing. Seek medical attention if the pain and itching worsen during treatment or if they do not improve after 7 days of topical treatment.

State when pyrethrins should not be used.

Individuals allergic to pyrethrins or chrysanthemums should not use this agent; ragweed-sensitive individuals risk cross-sensitivity.

Patch

Large area - discolored/white.

Wheal

Lesion different in not symmetrical - raised lesion - not small, multiple regions raised region filled with fluid which changes shape over time 1cm in diameter Transient, irregular pink elevation with surrounding edema

Pustule

Lesions raised above surface of skin with yellow fluid - not broken open on right On the left it is broken open but not in a dried state - it is still liquid

Describe general self-care of pediculosis

Lice in pubic area or on scalp Pediculicide containing pyrethrins. symptoms should resolve in 2 treatments.

Describe the signs and symptoms of insect bites - Ticks

Local reaction from tick bite can be an itchy papule appearing within a week (Lyme disease - bullseye lesion associated with Lyme's disease)

List the adverse effects associated with pyrethrins.

Most adverse reactions are cutaneous and include irritation, erythema, itching, and swelling

Petechiae

Pinpoint areas of redness, non-blanching (did not turn white) - press on areas and never go to white - blood leaked out under skin so under skin you can see areas where blood is pooling. pinpoint size to < 3 mm

Describe the mechanism of action of pyrethrins.

Pyrethrins block nerve impulse transmission, causing the insect's paralysis and death. Addition of piperonyl butoxide to pyrethrins synergizes their insecticidal effect through inhibition of pyrethrin breakdown, increasing insecticide levels within the louse

Vesicle

Raised lesion filled with fluid - clear fluid - fairly small less than 1CM

Hemorrhagic bulla

Raised lesion which is no longer filled with clear fluid filled with blood

Describe the first steps in treating insect stings

Removal of the stinger followed by application of an ice pack in 10-minute intervals is the first step in treating insect stings.

State when peak outbreaks of head lice occur

Sharing personal items such as caps, hairbrushes, and combs is unlikely to cause spreading. Outbreaks usually peak after the opening of schools each year, between August and November.

Desquamation

Skin coming off and not in small piecing - this is upper layer of skin coming off in sheets. Shedding or loss of debris on skin surface

Describe the signs and symptoms of insect bites -Bed bugs

Small grouping of bites and can occur any place

Tumor

Solid mass, larger than 5 cm in diameter; usually extends to dermis Lesion above surface and not symmetrical

Annular plaques

Tiny bumps which are round/circular and all come together to form what looks like flat tops.

Appropriate self-care plan for insect bites - OTHER

Systemic Antihistamines - Sedating and non-sedating - itching for bug bites (bitten by fleas, multiple bites) NSAIDs Ice pack

Describe the Nuvo method for treatment of head lice, including what product is used and how.

The Nuvo method, which uses Cetaphil Gentle Skin Cleanser, the first DSP product to be tested, is a nontoxic lotion that "shrink-wraps" lice It is applied to hair and dried with a hairdryer to form a shrink-wrap film over hair and lice. The lotion covers breathing holes, suffocating the louse. One study suggests suffocation products may be more effective than pyrethrins/piperonyl butoxide; however, additional research is needed.

How to use pyrethrins for treatment of lice.- State how long the product should be left on the affected area

The medication is applied to the affected area for 10 minutes; then the treated area is rinsed or shampooed as recommended.

Describe how to remove the honeybee's stinger

The patient should not use tweezers or squeeze the sac, because rubbing, scratching, or grasping it releases more venom. Scraping away the stinger with a fingernail or the edge of a credit card minimizes the venom flow. After the stinger is removed, an antiseptic, such as hydrogen peroxide or alcohol, should be applied.

Describe the signs and symptoms of insect bites -Mosquitos

a welt and itching which is due to the salivary secretion which is injected during feeding

Describe allergic symptoms of insect stings

allergic to insect stings may experience hives, itching, swelling, and burning sensations of the skin. Although anaphylaxis is rare, those with severe allergies may experience a fall in blood pressure, light-headedness, chest tightness, dyspnea, and even loss of consciousness

Ecchymosis

blood under vessels rupture and breakdown over a large area

Fissures Excoriation

also occur on the mucus membrane classic example - chapped lips licking lips and cycle of wet and dry causes skin to crack Epidermal erosion usually caused by scratching - on bottom left causes teeth scrapping bottom of lip off

State an alternative to washing clothing, bedding, or other items that may have been contaminated with lice.

an alternative to washing would be to seal contaminated items in a plastic bag for 2 weeks.

Plaque

and bunch of little bumps making up the large region - all little bumps coalesce together to form what looks like a flat top

State the approved indications for synergized pyrethrins

approved for the treatment of head and pubic lice.

State the approved indication for permethrin

available as a nonprescription cream rinse for treating head lice only

List measures that help avoid attracting stinging insects.

avoid wearing perfume, scented lotions, and brightly colored clothes; control odors in picnic and garbage areas; change children's clothing if it becomes contaminated with summer foods such as fruits; wear shoes when outdoors and destroy nests of stinging insects near homes.

external products that can be used to treat insect stings. - Local anesthetics

benzocaine, pramoxine, benzyl alcohol, lidocaine, dibucaine, and phenol

external products that can be used to treat insect stings. -Counterirritants

camphor and menthol

Describe the signs and symptoms of insect bites - Black widow

delayed and intense pain, stiffness and joint pain, abdominal disturbances, fever, chills, shortness of breath

Red surrounding skin NOT caused by blood pooling from capillaries

erythema

Fissures Excoriation

lesion - lines going horizontally - linear lesions which on surface of skin do not go very deep Scratching skin and broken skin and scab over-epidermal erosion usually caused by scratching

Crust

looks like lesions broken up and whatever was in those lesions have dried on the surface of the skin

Describe complications that may occur from insect bites - Mosquitos

malaria and West Nile virus (fatigue which can progress to muscle weakness, encephalitis and meningitis)

Plaque

multiple lesions coming together to make a larger lesion can be any shape

Ulceration

not above the surface of skin- deep within skin and starting to become infected

Appropriate self-care plan for insect bites. -Local anesthetics

not in kids under 2. Allergic to benzocaine or related anesthetics you can use Pramoxine or benzyl alcohol Gold bond - pramoxine Lanacane - benzocaine Dibucaine and phenol most potential for AE - phenol is best to avoid in pregnancy and children

List the adverse effects associated with permethrin.

occur in up to 10% of the patient population, include transient pruritus, burning, stinging, and irritation of the scalp

Purpura

push color does not go away not macules and non blanching because the color does not go away - bigger than pinpoint lesions

Bulla

raised lesion filled with clear fluid - bigger than few millimeters - also a Blister larger than 1.0 cm

Describe the signs and symptoms of insect bites - Brown Recluse

spreading ulcerated wound

State systemic agents that can be used to treat itching associated with insect stings.

systemic antihistamines

Describe the signs and symptoms of insect bites - Chigger

they inject fluid under skin and hardens and forms a tube where they continue to feed

Describe complications that may occur from insect bites -Fleas

transmit bubonic plague and typhus

Describe complications that may occur from insect bites Brown Recluse

ulceration in wound could need surgery

Recommend an appropriate insect repellant and describe how to use. - DEET Polymer formulations

use longer with less concentration - toxic if ingested Can provide up to 12 hours with a lower concentration

Describe complications that may occur from insect bites - Black widow

very young and very old can die

External products that can be used to treat insect stings. -Skin protectants

zinc oxide calamine and titanium dioxide

Describe appropriate measures to avoid insects. - things NOT to do

•Go barefoot •Wear perfume or fragrant lotions •Yellow clothing •Wear wool, leather, or suede - smell like a cow

Discuss patient education for pediculosis - Non-Drug measures

•Wash hairbrushes, combs, and toys of infested patients in water at a temperature of 130°F (39.4°C) or higher for 10 minutes. •Use water at a temperature of 130°F (39.4°C) or higher to wash the clothes, bedding, and towels of infested patients. Dry the items on the hottest dryer setting that the fabric permits. •Objects or clothing that cannot be washed should be sealed in plastic bags for the length of the louse's life cycle (2 weeks) so that it is unable to feed on a host. •Avoid close physical contact with an infested patient; do not share articles such as combs, brushes, towels, caps, and hats. Vacuum living areas thoroughly and regularly during treatment period. •Visually inspect the hair and scalp before, during, and after treatment for evidence of lice or nits. oUse a nit comb diligently to remove nits. oPart hair into segments and comb the hair in each segment. (Individual hairs can be trimmed if nit removal proves difficult.)

Describe appropriate measures to avoid insects. - things to do

•White clothing •Smooth clothing •Cover as much skin as possible •Cuff clothes - Cuff clothes around ankles, wrists and neck •Avoid swamps and dense woods •Remove standing water