Acute Otitis Externa

what is it?

Inflammation of the ear canal

Etiology (causes) of Acute Externa Otitis (AOE)

90% Baterial

10% Fungal

How can you get AOE

1. Swimming

2. Trauma (Q-tips in ears)

3. Eczema

4.Use of hearing aids

5. Immunocompromized Individuals

6. Use of Antibiotics containing Neomycin

Cortisporin

is?

Neomycin

an antibiotic

The appearance of a resistance to Neomycin might be

a __________ ____________.

Neomycin Sensitivity

In AOE the physical exam of the ear will show the

following:

1._____________

2._____________

3._____________

4._____________

5._____________

1. Pressing on the Pinna may cause pain

2. Pulling on the Tragus nearly always causes pain

3. Inserting Otoscope causes pain

4. Canal maybe so occluded otoscope maybe difficult to insert.

5. Otorrhea

What is Otorrhea?

Discharge from the external ear

To cure AOE you must create an ___________

environment in the External ear canal or by

______________ the _______________.

acidic environment

eradicate the pathogen

For a Mild case of AOE the use of ____ _____ ____ and ________ may clear the infection.

2% acetic acid

and

alcohol

If you suspect that the tempanic membrane is

perforated or if there are tubes present

What medications are safe to use in treating

Acute Otitis Externa?

Ciproflaxacin and Ofloxacin

If the treatment for AOE fails what are the two things

you should consider?

1. Neomycin toxicity (if using cortisporin drops)

2. Fungal Infection (occurs in 10% of pts)

If you find that the AOE is a fungal infection

but it has not responded to topical antifungals

what should you do next?

An oral antifungal such as

itraconazole or fluconazole

might be needed.

Necrotizing Otitis Externa is when?

The bacteria enters the mastoid or temporal bones

What should you do for Necrotizing Otitis Externa?

Immediately consult an ENT

and refer the patient to the ENT

Or send patient to the emergency room immediately

When treating Otitis Externa are oral

antibiotics given and why?

Oral antibiotics are rarely given because they

are less effective than topical antibiotics.

What medication can be used for pain

control in Otitis Externa?

If there is no tympanic membrane perforation

Antipyrine/Benzocaine drops can be used

Acetaminophen or Ibuprofen

can be used either way.

What would you tell your patient to educate them

about using drops for Otitis Externa?

Drops should be at room temperature before using.

For Adults pull the Tragus up to put drops in

remember (grown up)

For Children pull the Tragus down to put drops in

No swimming until infection is clear (approx. 7 days)

How would you educate your patient in preventing Otits Externa Infections?

Use Acetic Acid/Alcohol combination

(ratio of 1:3)

before and after swimming but not in children

less than 3 yrs old

Do not put anything in your ear that is smaller

than your elbow.

What is the first line drug prescibed for Otitis Externa?

Fluoroquinolones

What is frequently added to ear drops to

decrease inflammation and reduce pain?

Steroids

What is one of the second line drugs prescribed to

treat Otitis Externa?

Cortisporin

Fluoroquinolones are used in Otitis Externa

because?

A. They cover Pseudomonal Activity

B. The Clinical Cure Rate is 84-96%

C. Less stinging than Cortisporin applications

D. Dosing is once to two times a day

Why would Cortisporin be a better choice

than prescribing Fluoroquinolones?

It is less expensive

($4.00 on list at Walmart)

What is the second line drug prescibed in

treating Otitis Externa?

Aminoglycoside antibiotics

(neomycin sulfate/polymixin B/ hydrocortisone sulfate)

What are some of the drawbacks in using the

second line drug when treating

Otitis Externa?

 A. Risk for hypersensitivity reactions are high

B. Ototoxicity is (rare) but possible with Neomycin

C. Dosing is three to four times a day

D. It stings when applied

What is the most common infection in children

where antibiotics are prescribed?

Acute Otitis Media

How is Acute Otitis Media caused? 

Bacteria entering the eustachian tube

by way of the respiratory tract

What is the most common age for

Acute Otitis Meda?

6 months to 2 years of age

What is it called when you have a presence

of fluid but no signs of infection.

It effects hearing and therefore

speech development.

Otitis Media with Effusion

What is the etiology of Acute Otitis Media?

Bacterial and Viral

What are three of the most common

pathogens for Acute Otitis Media?

1. Strep Pneumoniae 38%

20% resolve spontaneously

2. Haemophilus Influenza 27%

50% resolve spontaneously

3. Moraxella Catarrhalis 10%

Not all cases of Acute Otitis Media need to be treated;

those that are treated must ______ ______ ______,

except if they are _______________.

Meet Diagnostic Criteria

Less than 6 months old

What is the first line medication to be prescribed?

A. High Dose Amoxicillin

for intermediate-resistant Strep Pneumoniae

B. If Allergy to PCN (non type I hypersensitivity reaction such as a rash) give Cephalosporin as alternative to second or third generation.

C. If severe Illness give Amoxicillin-Clavulanate for beta lactamase resistant bacteria.

When giving Amoxicillin-Clavulante why is the

ES and XR formulations recommended?

To limit the excess exsposure to clavulanate and

to reduce the incidence of diarrhea.

What is the second line medication prescribed

for Acute Otitis Media?

A. Macrolides - 5 days of Azithromycin or

10 days of Clarithromycin (high incidence

of RX failure is rationale for 2nd line choice).

B. Cllindamycin - lacks activity to H. Influenzae or

H. Cattarrhalis

(which is 37% of bacterial cases)

What are the risk factors for developing

an antibiotice resistance?

A. Winter and Spring Season

B. Exposure to antibiotics in the prior 1-3 months

C. Age less than 2 years old

D. Attending Day Care

Some response to treatment shoud be noted

within _____ hours after first dose.

72 hours

What are three causes of treatment failure?

A. Resistant Organism

B. Viral Infection

C. Nonadherence to treatment regimen`

For Ophthalmic problems what should you do?

Why should you avoid using a

cortisone in the eye?

It may mask an infection

Extreme caution should be taken when treating eye problems.

Never take chances.

For which problems should you seek and immediate referral?

A. Vision Loss

B. Blurred vision that does not clear with blinking

C. Foreign body unable to dislodge

D. The lack of improvement with treatment

Should you choose a solution or ointment

when treating the eyes?

A. It is the patient's preference

B. For infants and young children and patient's

who have and aversion to drops

ointment is preferred

Inflammation of the eyelids by bacteria,

hypersecretion, or seborrhea

is known as?

Blepharitis

Blepharitis is typically ______ in nature.  

Chronic

When treating Blepharitis the goal of therapy is?

To eradicate the pathogen causing the

infection

When treating Blepharitis the first line medications

prescribed are _____________ and ______________

for infection.

Bacitracin and Erythromycin Ointment

both are topical antibiotics

When treating Blepharitis (Seborrhea)

what do you use? 

Wash eyelids regularly with baby shampoo

Inflammation of the Bulbar or

Palpebral Conjunctivae

is known as?

Conjunctivitis

The etiology of Conjunctivitis is

Bacterial and Viral

Bacterial Conjunctivitis

has ___________ dischage

Purulent

Viral Conjunctivitis

has __________ discharge

Watery

What are the bacteria found in

Bacterial Conjunctivitis?

1. Gram + Staph and Strep

2. Gram - Moraxella and Haemophilus

3. Less Common - N. Gonorrhea and C. Trachomatis

Conjunctivitis in children is found to be

about ________% ___________.

50%  Bacterial

What other things besides Viruses and Bacteria

can cause Conjunctivitis?

A. Allergens - IgE mediated release of mast cells

B. Atopic

C. Mechanical or Chemical Irritants

For Conjunctivitis Antibiotics

__________ the course of the disease.

Shortens

Which antibiotics are used when treating

conjunctivitis?

A. E-mycin or Bacitracin-polymyxin solution or ointment

B. Aminoglycosides - good gram - coverage

incomplete coverage for strep and staph

C. Fluoroquinolones - all have gram - coverage

newer ones have gram - and improved gram +

N. Gonorrhea - Rocephin Injection : C. Trachmatis - Erythromycin Ointment (silver nitrate not used)

What year did the recommendation change for using

silver nitrate for C. Trachomatis?

2009

What medications should be used for

Allergic Conjunctivitis?

1. Antihistamines - ophthalmic drops & oral Emedastine blocks histamine response in blood vessels.

2. Mast Cell Stabilizers - inhibit hypersensitivity reactions & prevents increase in vascular permeability; takes 3-4 weeks to see improvement.

3. NSAIDS - Ketorolac helps control itch. Inhibits biosynthesis of protaglandin by decreasing activity of enzyme cyclooxygenase.

4. Vasoconstrictors - available OTC contraindicated in Glaucoma causes rebound congestion.

5. Topical Corticosteriods - reduce inflammation; long term can cause ocular hypertension, cataract formation, glaucoma & infection.

What is the first line treatment for

Primary Open Angle Glaucoma?

Topical Medication to decrease aqueous formation use

1. Beta Blockers - can cause bradycardia

2. Adrenergic Agonists

3. Carbonic Anhydrase Inhibitors

To Increase Outflow use

1. Prostaglandins - usually first line due to fewer side effects.

Caution: there are many commonly prescribed drugs that are contraindicated in persons with glaucoma. Be sure to check for this contraindication when prescribing any drug.

What are the ABCDE's of preventing

Skin Cancer?

A. Asymmetry

B. Borders are irregular

C. Color changes - from one area to

another (tan, brown, black, white, red or blue)

D. Diameter (usually larger than 6mm diameter)

E. Evolution - Keeps changing appearance

How many cases of Skin Cancer are diagnosed

in the U. S. each year?

3.5 Million

When applying Sunscreen what

SPF should it be?

15 SPF or Higher

If you are going to be in the sun for 20 minutes or longer

How long before you go outside should you

apply sunscreen?

How often should you reapply?

30 minutes before going out

reapply every 2 hours

By increasing the SPF do you significantly

increase your protection?

NO!!

SPF 15 protects 93%

While SPF 34 only protects 97%

What does a Broad Spectrum Sunscreen

protect against?

UVA and UVB rays

Gel sunscreens are not recommended

if you _______ because they are

__________ ________ _________.

Sweat, because they

are sweated off easily

Can sunscreens be labled as Waterproof?

No - because it does come off in the water after

a certain amount of time.

What must Water Resistant Sunscreens

show on their labels?

They must show how long they last in

water exposure. (ex: 40mins or 80mins)

How much sunscreen should you

apply each time?

About 1 ounce each time

Typically how long are sunscreens good?

Do they have an expiration date?

Yes Sunscreens have an expiration date

and are typically good for 3 years.

Does altitude have anything to do

with exposure?

Yes, the higher the altitude the greater the

exposure.

What SPF should a lip balm

contain?

SPF 15 or higher

What is Contact Dermatitis?

It is when the skin breaks out due to an exposure

of an irritant or allergin.

What is an irritant in Contact Dermatitis?

It is exposure to an agent that is toxic to the skin.

What is an allergen in Contact Dermatitis?

Exposure to an antigen

The most common atopic dermatitis is Eczema

which is a chronic condition.

What are the factors to determine type of treatment

for Contact Dermatitis?

A. Protection/Barrier Function

B. Delivery of Drug to Skin

C. Cosmetic Appearance with Treatment

What are some ways to handle

Contact Dermatitis?

1. Prevent coming in contact with the allergen.

2. Determine severity which determines treatment.

3. Mild Cases - cool compresses, colloidal ointments, baking soda in bath water,

Burrow's solution to dry vesicles

Drug Therapy

1. Ointment and Emollients?

2. Creams?

3. Lotions?

4. Solutions?

5. Barrier Creams and Moisturizers do?

1. Ointment & Emollients - best delivery and protection most potent and most lubricating.

2. Creams - less greasy less effective, cosmetically most desirable, water based causes more drying.

3. Lotions - are diluted creams.

4. Solutions- alcohol based liquids to treat scalp.

5. Barrier Creams and Moisturizers - increase skin hydration.

What are the goals of drug therapy for

treating Dermatitis?

A. Restoration of a normal epidermal barrier.

B. Treatment of the inflammed skin.

C. Control itching.

What medications are available for treating

Contact Dermatitis?

A. Topical Corticosteriods

B. Immunosuppressant (used for chronic atopic dermatitis but takes several weeks and associated with skin cancer and lymphoma.

C. Systemic Corticosteriods

D. Antihistamines

Topical Corticosteriods are used

how and for how long?

Twice a day and

for no more than two weeks for adults

one week for children.

Why should you avoid permeable areas

such as the face, groin and axillae

with high potency topical

steriods?

It can lead to skin thinning and breakdown

if used for long periods of time.

Should a high or low potency

topical steriod be used

on the face, groin, or axilla?

Low potency

Where should a high potency

topical steriod be used?

The extremities and torso

Applying an occlusive dressing does what?

It increases the absorption and penatration

of the topical steriod by increasing

hydration.

What are the adverse effects of using

Topical Steroids for

prolonged periods?

1. Atrophy of the skin

2. Ecchymosis - large purpura or bruising

3. Stiae - lines on the skin

4. Telangiectasia - spider vessels appear on face

5. Acne like eruptions on face

6. Hypertrichosis - strange hair growth on face

7. Cataract formation or glaucoma with prolonged use around the eyes.

What kind of dosing regimen is there

for Systemic Corticosteriods?

Burst and Tapered Dosing

What are the actions of

Systemic Corticosteriods?

A. Inhibit cytokine and mediator release

B. Attenuate mucus secretion

C. Up regulate beta-adrenergic receptors

inhibit IgE synthesis

decrease microvascular permeability

D. Suppress influx of inflammatory cells

What are contraindications for taking

Systemic Corticosteriods?

Patients receiving vaccinations

Patients with systemic mycosis

Fungal Skin Infection

What is Tinea Capitis?

Fungus of the Scalp

Fungal Skin Infection

What is Tinea Pedis?

Fungus of the foot

Athlete's Foot

Fungal Skin Infections

What is Tinea Unguium?

Fungus of the Nails

Onychomycosis

Fungal Skin Infections

What is Tinea Corporis?

Fungus of the Face, Limbs or Trunk

Ringworm

Fungal Skin Infections

What is Tinea Cruris?

Fungus of the Inguinal Area

Jock Itch

Fungal Skin Infections

What is Tinea Manus?

Fungus of the Hand

When Treating a Fungal Infection

should you use topical or oral medication?

Tropical treatment should be the first line for most skin infections unless there is a resistance.

Systemic Oral Treatment should be first line for

Tinea Capitis and Tinea Unguium (nails).

How do the Topical Azole Antifungals Work?

It impairs synthesis of erosterol allowing for increased permeability and leakage of cellular components resulting in cell death.

When is an Antifungal Contraindicated?

During Pregnancy and Lactation

How long do you use a Topical Antifungal?

Usually treat for 2-4 weeks and then continue treatment for one week after the lesions disappear.

When selecting a Systemic Azoles

what should you keep in mind?

A. The Cost

B. Patient Adherence

C. Age and Health of Patient

D. Drug Interactions

What are the Adverse Effects to

using Systemic Azoles?

GI Upset, Headache,

 Urticaria (rash), Pruritus (itching),

Hepatic Dysfunction, Edema, Hypokalemia

and Numerous Drug Interactions

Can Systemic Azoles be used

During Pregnancy?

They should not be used during pregnancy.

However it might be used if the benefits

outweigh the risks.

Not Very Often!!

How would you Educate your patient

about preventing fungus

or a reinfection?

A. Keep affected areas dry -

can use a hair dryer on low setting.

B. Antifungal powders and sprays -

can be used prophylaxtically.

C. Good Hygiene will prevent spread

D. Recommend a clean towel being laid on

the bench prior to lying down for

weight lifting.

What is the definition of Candidiasis?

It is a superficial fungal infection

of the skin and mucous membranes

What causes Candidiasis?

It is caused be Candida Albicans

a yeast like fungus that thrives in

moist and cutaneous sites.

Where is Candidiasis Found?

It is found in the diaper area, oral cavity,

occluded areas, intertriginous areas

(where folds of skin meet, get warm and sweat),

nails, vagina and male genitalia. 

Seen in diabetes, in chronic use of topical and systemic steroids and in the immunosuppressed.

What is the recommended treatment for

Candidiasis?

Keep skin areas dry by powdering, drying and

exposing to air.

Apply Ketoconazole or Clotrimazole

to the effected areas.

For Oral Candidiasis use Oral Nystatin

Viral Infections of the Skin

Include

A. HSV-1 Simplex type 1 (fever blisters) 

B. HSV-2 (typically found in Genitalia)

C. VZV  Varicella (Herpes) Zoster Virus

E. EBV Ebsteen Barr Virus

F. HSV-6 Found in patients with Multiple Sclerosis

G. HSV-8 (Karposi's Sarcoma)

What is the treatment for

HSV-1 (oral)

Viscous Lidocaine for pain control

or solution of Benadryl & Maalox (1:1)

oral rinse once a day

What is the treatment for

HSV-1 (Labialis)

Topical Antivirals can be used such as

Doconosal (Abreva)

Acyclovir

Penciclovir

and may give

Acyclovir Orally

What is the treatment for

VZV (Herpes Zoster)

Start oral therapy within 72 hours

1. Acyclovir (Zovirax) the least expensive

but must take 5 times a day

2. Famciclor (Famvir)

3. Valacyclovir (Valtrex)

What are the contraindications in

using Oral Antivirals?

They should not be given to patients

with Renal Disease, Congestive Heart Failure

or while Lactating

What would you educate your patients

about these viruses?

1. Educate the patients about the presipatating factors.

2. Educate about preventing the spread of infection

3. Followup for post herpatic neuralgia in those

with Herpes Zoster (Shingles)

4. A person with shingles can transmit chicken pox to individuals who have never had them before.

With both Acne Vulgaris and Rosacea your first line

treatment should be what?

Skin care is very important,

Avoid Cosmetics and

 Moisturizers should be water based and

 perfume free.

With both Acne Vulgaris and Rosacea

the Goals of Therapy are what?

Minimize Scarring

and

Improve Appearance

How long does it take to show

significant improvement in

Acne Vulgaris and Rosacea?

4-6 Weeks

What are the Topical Treatments for

Acne?

1. Retinoic Acid (Tretinoin)

2. Adapalene Gel

3. Benzoyl Peroxide

4. Topical Antibiotics

Retnoic Acid

What is it and what does it do

in an Acne Treatment?

It is the Acid form of Vitamin A

and

it causes peeling of the skin and erthema

Why use Adapalene Gel

when treating Acne?

It is less Irritating the Retinoic Acid

Why use Benzoyl Peroxide in

treating Acne?

It is very effective against

Propionibacterium Acnes or P. Acnes

(a slowing growing, typically aerotolerant

anaerobic and gram positive)

It is Category C and should not be used in pregnancy

When Topical Antibiotics are combined

with _________ ___________ it

reduces ________ ___________.

Benzoyl Peroxide

it reduces bacterial resistance

What is the Systemic Drugs used to

treat Acne?

Isotretinoin (Accutane)

Ethinyl Estradiol with Norgestimate

Ortho Tri-cyclen, Estrostep, Yaz

What are the problems found with

the medication Accutane?

It is reserved for very severe nodulocycstic acne when other treatments have failed.

It's given over 15-20 weeks

Pregnancy Category X

It's a teratogen so only prescribers registered in the iPledge program can prescribe Accutane.

Women must have 2 negative pregnancy test prior to starting and must be on two forms of contraception and must aviod pregnancy for a month after completing the therapy.

Ethinyl Estradiol with Norgestimate

maybe taken up to ____ ______

to see improvement.

6 Months

What are the common names of

birth control used for

Acne?

A. Ortho Tri-Cyclen

B. Estrocep

C. Yaz

What are the requirements for

using birth control to treat

Acne?

1. Females Only

2. Should be at least 15 years old

3. Must have started menarche

4. Is the third line after trying topical keratolytic agents first, combined antibiotic with benzyl peroxide second.

What is Rosacea?

It is a condition seen in adults that mimics acne

Triggered by spicy foods, stress, alcohol

Causes sunburn appearance to cheeks, across bridge of nose with papules

Chronic condition

What is the medication used

to treat Rosacea?

Metronidazole

cream, gel or lotion

benefit seen in 3 weeks with full effect in 9 weeks

can be used indefinitely for chronic cases

What is the name of the medication

used in the treatment of

Scabies?

Permethrine 5%

(Elimite)

How would you educate your patient

in treating Scabies?

1. Apply the permethrine cream over the entire body starting at the neck down and cover the soles of the feet.

2. Wash all clothing, linens, and towels in very hot water.

3. Treat all household contacts at the same time.

4. Tell them that itching may persist after the treatment is completed because the medication is very irritating.

What is the first line treatment for

Pediculosis (Lice)?

OTC Pediculicides & nit combing

What is the second line treatment

for Lice?

Malathion Lotion (Ovide)

If a parent does not want to use

pediculicides what would you

prescribe?

Ulesfia

but it is not as effective as

malation, so it may have to be used more than once.

What off label medication can be

used for the treatment

of Lice?

Oral Ivermectin

(Stromectol)

What medication that was successful

is rarely used because it is neurotoxic?

Lindane

Definitely do not use with history of

seizure disorder.

True or False

An effective home remedy for treatment of

Lice is Mayonnaise, olive oil, or tea tree oil.

False

What are the reasons for failure in

the treatment of Lice?

1. Insufficient product to saturate hair.

2. Resistance of Lice to Pediculicide.

3. Reinfestation.