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Answer the following questions and provide rationales with supporting evidence for your choices using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Jason Ferguson is a 15-year-old boy who weighs 110 pounds. Jason is seeking treatment for a very itchy rash consisting of linear streaks of papules, vesicles, as well as blisters on his arms, legs, and face. He tells you he was hiking in the woods two days ago on trails that were lined with patches of shiny weeds that had three leaves. He tried using calamine lotion and over-the-counter hydrocortisone cream but has had no relief from the itching.
Diagnosis: Contact Dermatitis (Poison Ivy)
List specific goals of treatment for J. F.
What drug therapy would you prescribe? Why?
What are the parameters for monitoring the success of the therapy?
Discuss specific patient education based on the prescribed therapy.
List one or two adverse reactions for the selected agent that would cause you to change therapy.
What would be the choice for second-line therapy?
What over-the-counter and alternative medications would be appropriate for J. F.?
What lifestyle changes would you recommend to J. F.?
Describe one or two drug?drug or drug?food interactions for the selected.
Reply to at least two of your classmates, in a well-developed paragraph (300?350 words) to each peer integrating an evidence-based resource that is different than the one you used for the initial post.
Respectfully agree and disagree with your peers responses and explain your reasoning by including your rationales in your explanation.
classmate 1: Samantha
The case scenario describes a 15-year-old boy who is experiencing the symptoms of allergic contact dermatitis (ACD), which involves skin contact with an allergen producing redness, papules, and/or vesicles (Woo & Robinson, 2020, pp. 984). Common causes of ACD are exposure to metals, topical medications, cosmetics, personal care products, preservatives, and some plants (Brod, 2023). Plants of certain species, such as anacardiaceae, compositae, alliaceae, and myrtaceae, all which contain resins and oils can cause symptoms in sensitized individuals (Brod, 2023). J.F. states that he may have had contact with a three-leaved shiny plant in the woods two days ago. This plant sounds like a description of poison ivy and if J.F. is having a reaction to it 2 days after exposure, this would be a subsequent exposure to the plant as a reaction can only occur after an initial exposure creating sensitization (Prok & McGovern, 2022, Woo & Robinson, 2020). Treatment goals for J.F. should include decrease of inflammation and discomfort including pruritis, treatment of papules, vesicles, and blisters, prevention of secondary bacterial infection, and restoration of skin barrier (Prok & McGovern, 2022).
Since J.Fs case of ACD has extended to his arms, legs, and face, and first-line pharmacological treatment for face and flexural areas is low-medium potency topical corticosteroids 1-2 times daily for 1-2 weeks then tapered dosing over the following two weeks (Brod, 2023). Seeing as J.F. has already used over-the-counter hydrocortisone cream without relief from itching, prescription of a 0.025% topical triamcinolone cream used on affected areas 1-2 times daily for 1-2 weeks is warranted and should be tapered to application every other day for 2 weeks after the first 1-2 weeks os use (Brod, 2023, Lexicomp, n.d.b). An oral antihistamines like Benadryl is not proven to help J.F. as poison ivy ACD is not caused by a histamine response (Brod, 2023). The parameters to monitor success of first-line therapy are resolution of papules, vesicles, and blisters on J.F.s arms, legs, and face, relief from itching, no signs of secondary bacterial infection, and restoration of skin barrier (Prok & McGovern, 2022). Some education that should be shared with J.F. regarding this therapy should include use of therapy as prescribed, avoidance of re-exposure to the allergen poison ivy, avoid scratching, utilization of cold, wet cloths on affected areas, notify provider is rash spreads or severity of rash increases, avoid use of antihistamine creams, numbing products, and antibiotic ointments, as they all can cause an increase in skin or rash irritation (Lexicomp, n.d.b, UpToDate Doctors and Editors, n.d.). Possible drug-drug and drug-food interactions for triamcinolone mainly occur with concurrent use of CYPD4A3 inhibitors including many antifungals, antivirals, macrolides, and grapefruit, all which will increase the serum concentration of triamcinolone (Lexicomp, n.d.b).
If J.F. experienced an adverse reaction to the 0.023% triamcinolone cream such as application site burning, application site irritation, or application site pruritus I would change treatment therapy (Lexicomp, n.d.b). Topical tacrolimus is an alternative therapy to topical corticosteroids and 0.03% tacrolimus ointment can be applied as a thin layer to the affected areas twice daily for ACD (Lexicomp, n.d.a). A systemic corticosteroid can also be prescribed, especially if J.F.s case of ACD worsens (Brod, 2023). An oral prednisone of 50 mg/day should be taken for 5 days, then decreased to 25 mg/day for 5 days, then decreased to 10 mg/day, then discontinued (Prok & McGovern, 2022). Some over-the-counter and alternative treatment options for J.F. include oatmeal baths, cool, wet compresses applied to affected areas, aluminum acetate solution and menthol and phenol containing lotions, however J.F. has already stated that calamine lotion was not helpful for him (Prok & McGovern, 2022). Some lifestyle changes for J.F. include avoidance of poison ivy plants, wearing gloves, long sleeves and pants to avoid risk of contact when working near allergens, washing these clothes and any exposed areas as soon as possible, do not burn poison ivy plants, and use of emollients to maintain skin hydration (Prok & McGovern, 2022).
Classmate 2: Sara
1. List specific goals of treatment for J. F.
From the description of the plant Jason came into contact with recently, it sounds as though he is suffering from contact dermatitis from poison ivy. Poison ivy is a type IV hypersensitivity allergic reaction caused by penetration of the epidermis by the plants oleoresin urushiol that causes symptoms within 12-18 hours after contact (Prok et al., 2022). Specific goals for Jasons treatment would be quick reduction of symptoms including the severe pruritis. Itching the rash puts Jason at a higher risk for infection so appropriate and effective treatment options should be initiated in a timely manner. Treatment goals also include resolution of the papules, vesicles, and blisters, no signs of a secondary infection, and complete restoration of the skin barrier.
2. What drug therapy would you prescribe? Why?
An oral corticosteroid is recommended for widespread cases of dermatitis especially when involving the face or genital area. Dermatitis that covers 20 percent or more of the skin surface and/or involving the face, oral steroids are preferred (Levy et al., 2022). To treat Jasons contact dermatitis related to poison ivy exposure, I would prescribe prednisone which should be initiated at 1mg/kg/day then tapered over 2-3 weeks (Prok et al., 2022). Jason weights 110 pounds which means his dosage of prednisone should be 50mg po daily; however, 40mg/day is the maximum amount recommended for children (Woo & Robinson, 2020). Jason would be prescribed 40mg po daily x5 days, then 20mg po daily x5 days, then 10mg po daily x5 days, then discontinue the medication. Patients placed on short courses of oral steroids, such as a week or less, have a higher risk of rebound dermatitis; therefore, treatment over 2-3 weeks is suggested.
3. What are the parameters for monitoring the success of the therapy?
Parameters for monitoring the success of the therapy include assessing the effectiveness of the medical treatment. Lessening of symptoms, healing of the lesions, and absence of secondary infection are signs of successful therapy (Prok et al., 2022). Jasons ability to tolerate the prednisone, lessening of a need for adjunctive treatments, and a lack of adverse side effects are also signs of successful treatment (Levy et al., 2022).
4. Discuss specific patient education based on the prescribed therapy.
Jason and his guardian(s) should be educated on the treatment plan concerning prednisone and the importance of adhering to the prescription as directed. Jason should not stop the medication abruptly even if symptoms and the rash have resolved before finishing the medication course. This could result in rebound dermatitis (Lexicomp, n.d.). It should be explained that prednisone needs to be taken with food or milk to decrease gastrointestinal disturbances. Side effects including behavioral changes, weight gain, gastrointestinal disturbances, infections, or visual disturbances warrants contact of the health care provider.
5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
One adverse reaction of prednisone that may cause a change in therapy for Jason would be psychiatric disturbances such as anxiety, agitation, fear, insomnia, mania, restlessness, or tearfulness (Lexicomp, n.d.). If these mood changes are severe and interfering with Jasons daily activities, a change in therapy would be recommended. Most cases of adverse behavioral reactions occur early on in treatment (usually within the first week), with an average of 11.5 days.
6. What would be the choice for second-line therapy?
Second-line therapy for Jason would include a low-mid potency topical corticosteroid. Triamcinolone acetonide ointment 0.025% applied 3-4 times a day until healing is complete would be another option for Jason if he is unable to take oral prednisone (Lexicomp, n.d.). This ointment will allow for enhanced medication absorption and is semi-occlusive; however, adherence to this treatment may be low as the ointments are greasy and sticky. Jasons rash is on his arms, legs, and face so using the ointment on larger surface areas could be difficult and should be used with caution on the face.
7. What over-the-counter and alternative medications would be appropriate for J. F.?
Over-the-counter and alternative medications that would be appropriate for Jason would include the topical astringent aluminum acetate (Burows solution) which can be used to dry up the lesions caused by the poison ivy exposure (Prok et al., 2022). Utilization of an oral antihistamine at night, such as Benadryl 25 to 50mg po qhs, can be beneficial for increased pruritis in the evening and can be helpful allowing for sleep to occur undisturbed. Application of cool, wet dressings can help soothe the itching, decrease the erythema, debride the dried discharge from weeping lesions, and provide a skin barrier (Levy et al., 2022). Oatmeal baths can also provide soothing relief for pruritis.
8. What lifestyle changes would you recommend to J. F.?
Lifestyle change for Jason would include identification of poisonous plants to avoid while hiking (Prok et al., 2022). Wearing protective clothing while hiking such as long sleeve tops, pants, and boots. Minimizing skin exposure while in areas of toxic plants is a smart decision to avoid allergy potential. Jason should also know that urushiol can be on clothing and pets for days; therefore, washing clothing and giving pets a bath should be performed as soon as possible after hiking. If there is a known exposure, washing of contaminated clothing with hot water should be done as soon as possible, and showering the entire body with mild soap and hot water while wiping in one direction should be done immediately.
9. Describe one or two drug?drug or drug?food interactions for the selected agent.
Triamcinolone and CYP3A4 inhibitors may cause the concentration of the steroid to be increased (Lexicomp, n.d.). Therefore, avoidance of CYP3A4 inhibitors such as many antifungals, antivirals, and macrolides should be considered. Systemic effects of steroids such as Cushing syndrome or adrenal suppression can be initiated through coadministration of CYP3A4 inhibitors and triamcinolone. Alternative corticosteroids should be considered if long-term use of triamcinolone is expected.
Requirements: 3-4 pages
Requirements: NEED IN 2 HOURS
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