Welcome to PNP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for 90 students studying to pass their PNP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

You see a 17-year-old woman with a long-standing history of eczema and allergic rhinitis. Today she presents with worsening symptoms of skin lesions with itch for the past 2 months, now affecting the antecubital fossa of both arms, she states, “I get like this every winter, but I am much better during warm weather.” She is otherwise healthy. The most important aspects of skin care for this scenario is: 
 
A. Daily use of medium to higher potency topical corticosteroids. 
 
B. Twice-daily application of an antifungal cream. 
 
C. Use of a topical antibiotic until skin lesions are clear. 
 
D. Maintaining skin lubrication.

E. The use of low to medium potency topical corticosteroids to treat flares.

And where do you start? I'm not actually going to give you the answer to this one yet, which I usually do. But what I want to do is walk you through the process because of course, this is a different kind of exam question design.  

Where do you start? First, you should determine what kind of a question this is. It is a plan question. We're provided with the diagnosis, then directed to choose the most important components of treatment and not just a single correct option. Questions with more than one correct answer do show up occasionally on boards, but you're always directed as to the number of responses to pick.  

So very clearly here, five answers to we're told and we have to choose two of them. There are no all of the above or none of the above questions on the NP boards. Yeah. First of all, they're not considered to be terribly valid questions and that people get quite confused by them. But now let's get back to basics and take a look at the background information in this scenario. 

We're told she has eczema, which is a type of atopic dermatitis. It is one of a number of manifestations of type one hypersensitivity reaction. Other examples of atopic disease include asthma and allergic rhinitis. And of course, the latter is reported in this patient. It is not one bit uncommon to see a patient who has eczema, allergic rhinitis, and asthma. And the commonality there is that type one hypersensitivity reaction. Atopic diseases have a very strong familial component and tend to cause localized rather than systemic reactions. Eczema is a chronic condition that can come and go for years throughout life and can overlap with other kinds of eczema. This eczema in and of itself is a clinical diagnosis where no special testing is required. And just a reminder, what's a clinical diagnosis? This is a diagnosis you make by looking at the health history, history of present illness, and the clinical exam. Most of what we diagnose in derm we do as clinical diagnosis.  

 This patient is reporting a common pattern where symptoms are worse during the drier, colder months of the year, but better during the summer when the climate is typically warmer and the air is more humid. I appreciate that in some parts of the United States there isn't much of a winter. But, you know, even in parts of like the southeast, in the southwest U.S., I will hear from people who spend part of their year there who in the southwest U.S. where it doesn't get as cold as it does where I am in southern New England, to be sure they'll still tell me when I'm there, my eczema is worse just because it's a little cooler and a little less humid.  

She also reports one of the most common locations for eczema in the antecubital fossa. The other common location of the popliteal space. But eczema can be found in the adult population on really almost any part of the body. Though the face is typically spared. Children, younger children in particular, like under the age of four or five can get eczema on the face, but usually once they get beyond that age, the face is not a big, big place for this condition. The skin lesions are typically reddened, thickened, and nearly always itchy. Xerosis, a fancy word for dry skin is usually noted. With severe flares the lesions often weep. Onset of initial signs and symptoms of eczema usually start in childhood and actually often improve significantly in adulthood. Obviously, we haven't been told this about this 17-year-old, but if you dug further into her history, I would be willing to say that she's going to tell you my eczema was much worse when I was a younger kid, and it's getting better now. So, let's look at the question and the options offered. 

You see a 17-year-old with a longstanding history of eczema and allergic rhinitis. Today, she presents with worsening symptoms of skin lesions with itch for the past few months now affecting the antecubital fossa and stating, I get like this every winter, but I'm much better during the warm weather. She's otherwise healthy. The two most important aspects of skin care in this scenario is: 
 
A. Daily use of a medium to higher potency topical corticosteroids.  

This is incorrect and I really hesitate to say the words this will almost always be incorrect on the more common dermatologic conditions that we use a topical corticosteroids to treat. But I'm going to go way out on a limb and say this will almost always be incorrect for the more common conditions we see in the primary care setting. And that protracted use of medium to high potency topical corticosteroids can lead to subcutaneous tissue atrophy, striae, rosacea, telangiectasia, which are little blood vessels running through the skin, purpura, and other cutaneous and systemic reactions. 

One more time. Read what the question says: daily use of medium to higher potency topical corticosteroids. Eczema is characterized as a disease of flares, where the topical corticosteroids are typically not used daily.  

B. The twice daily application of any antifungal cream. Given that fungal infection is not part of the pathophysiology of eczema and does not contribute to flares, this answer is also not correct.  

We got rid of A, we got rid of B, we have three options left and we're going to choose two. C the use of a topical antibiotic until the skin lesions are clear. Well, superimposed bacterial infection can occur during an eczema flare. At the same time, the use of topical antibiotic is not routinely used for eczema treatment, and there's nothing in this scenario that makes me think she has a superimposed bacterial infection.  

Now we got rid of A, B and C. It looks like D and E will be our correct answers.  

D. Maintaining skin lubrication. This is one of the correct answers. Eczema is sometimes called the itch that sometimes rashes. In other words, not a rash that itches, but an itch that sometimes rashes. And this owing to the xerosis that is at the core of the disease. Minimal use of soap on the skin, the consistent use of a skin lubricant, even petroleum jelly Vaseline will work beautifully on this. This is really like the backbone of treating eczema because what you're trying to do is help the patient avoid the flares. 

And option E, the use of low to medium potency topical corticosteroids to treat flares. This is our other correct answer. Owing to the atopic ideology of the disease, the use of low to medium potency topical corticosteroids limited to flares is one of the first line therapies, and it's typically very helpful in milder disease. She has disease limited to two smaller areas of her body, the antecubital fossa spaces. And so she does not have widespread eczema. Select immunomodulators and biologics are often used to treat more recalcitrant disease.  

Key takeaway recalling a disease's pathophysiology not only helps to direct its clinical presentation, but also the choice of therapies.  

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