Is the protective layer—its outer most surface—the stratum corneum contains lipids & keratin

Lies between the epidermis and SQ fat layer—it is composed of connective tissue and contains sweat glands, sebaceous glands, hair follicles and vessels

Compare and contrast the importance of the vehicle chosen to apply a dermatological medicine—ointment versus lotion

-Excess sebum -Comedones (small, flesh-colored, white, or dark bumps that give skin a rough texture) (2 types) -Propionibacterium acnes overgrowth -Inflammation

-Disease classified as -Comedones, pustular/papular and nodular -Disease further subdivided as→ Mild—comedonal, pustular/papular -Moderate—pustular/papular, small nodules [up to 1 cm] -Severe—nodular, cystic/pustular [also called acne conglobate]

-Derivatives of Vitamin D -Influence cell proliferation, immune function, inflammation & sebum production [3rd generation agents, do not ↓ sebum production]; these agents are comedolytic and anti-inflammatory; MOA mediated through nucleic retinoic acid receptors -Adverse effects—irritation, dryness, skin peeling, photosensitivity, dry MM, dry eyes

Retinoid that is 1st generation agent for acne—category X agent—must be prescribed by licensed providers—I Pledge

Retinoid that is 1st generation agent for acne

-Retinoid that is 3rd generation agent—less irritating -1st line for comedonal and inflammatory acne

-1st line for mild to moderate acne with NO inflammation -MOA—antiseptic against P acnes and opens pores -Adverse effects—dry skin, peeling, irritation

-A Beta hydroxy acid, penetrates pilosebaceous unit -MOA—exfoliates to clear comedones; mild anti-inflammatory activity and is keratolytic at high concentrations for mild disease -Adverse effects—peeling, dryness, local irritation

-Antibacterial against P acnes and it has anti-inflammatory actions -Normalizes keratinization and it anti-comedogenic -Used in mild to moderate inflammatory acne -Adverse effects include skin irritation

-Propionibacterium acnes is a gram + rod associated acne -For moderate to severe acne—with inflammatory lesions, topical or oral antibiotics can inhibit this bacteria’s growth—Erythromycin and Clindamycin [preferred] are available and used -Topical antibiotics best when combined with BPO or retinoids

A Sulfa drug for acne is available—MOA is unknown—side effects have been reported—methylhemaglobinemia

Moderate to severe acne requires these ORAL antibiotics

In the treatment of acne, topical retinoids play a critical role in therapy—these agents:

For mild acne, if presentation is mainly comedones—treatment of choice is:

For mild acne, if presentation is papular/pustular—treatment of choice is:

Treatment for moderate acne (papular/pustular disease):

Treatment for moderate acne (nodular disease):

Alternative treatment for moderate nodular acne

Treatment for severe acne (nodular):

Alternative treatment for severe acne (nodular):

Treatment for severe acne (cystic/pustular):

Alternative treatment for severe acne (cystic/pustular):

Are the rays that burn us, cause wrinkling and skin cancers

Can cause some wrinkling and with many decades of “lead time” may manifest itself as BCC later in life

Use of sunscreens with _______ for 5 years will decrease malignant melanoma risk by 50%

Compare and contrast Sunscreen vs Sunblock

What are the active ingredients in sunscreen?

How much sunscreen do you need and how often is it applied?

For infants less than 6 months, how much sunscreen should you use?

When does sunscreen expire?

-Chronic, scaling papules and plaques -Characteristic distribution is knees, elbows, scalp -Skin lesions occur insidiously [on occasion may be acute] +/- pruritus; may be associated with acute systemic illness with fever and malaise

Alteration in cell kinetics of keratinocytes with shortening of cell turnover rate, resulting in increased production of epidermal cells

Important non-drug therapies for psoriasis

Patients with mild to moderate psoriasis [<5% of BSA and not involving palms or soles] can be managed with?

For severe psoriasis diseas use these systemic therapies

If patient not a candidate for systemic psoriasis therapy then do this

-Topical retinoid for plaque psoriasis -½ life of 120 days; ETOH contraindicated as it increases potency and prolongs ½ life -Teratogenic and women must avoid pregnancy for at least 3 years after using Acitretin -Adverse effects—cheilitis, pruritus, peeling skin, hyperlipidemia

2nd generation retinoid; given PO for pustular psoriasis

Vit D Analogues - These agents inhibit growth of keratinocytes

-Synthetic Vitamin D3 derivatives used topically to treat plaque psoriasis -These agents inhibit keratinocyte production -These agents can cause hypercalcemia -Adverse effects—itching, dryness, burning irritation and erythema

Keratolytic Agents

Topicals for Psoriasis -High potency topical steroids BID for 2-3 weeks; then, use in pulse fashion BID for 2 d/week -Intralesional steroids -Avoid oral steroids which can cause rebound flares -May control mild disease but may be irritating or messy -Long term use of topical corticosteroids is limited by cutaneous atrophy

Calcineurin Inhibitors

-These agents suppress T-cell activation/proliferation; they block calcineurin phosphatase & prevent dephosphorylation of activated T cells, causing inhibition of these activated cells & production of proinflammatory cytokines—TNF-α, IFN-γ and IL-2 [key cytokines in a ramped-up T-cell response] -Steroid sparing agents; used in flexural and facial psoriasis

Systemic Therapies

-Methotrexate With Folic acid 1-5 mg/d -Cyclosporine

-Adalimumab [Humira] -Etanercept [Enbrel] -Infliximab [Remicade] -Interleukin IL-12 & IL 23 Blocker -Ustekinumab [Stelara] -Interleukin IL-17A Blocker -Secukinumab [Cosentyx]

-Can be uses with topicals -PUVA [Psoralen with UVA light] -Narrow band UVB therapy

Usually prescribed as a daily wash for Rosacea

This agent is considered DOC for Rosacea and safe in pregancy

Effective for papules, pustules, erythema in Rosacea, and safe in pregnancy

Oral drugs used for Rosacea

BID Topicals for Rosacea

-Response usually seen in 4 weeks, maximum response from one regimen may take up to 9 weeks -Requires long term maintenance treatment

-Twice daily for 3-4 weeks for Actinic keratosis -Side effects—redness, crusting, intense stinging

-3 to 5 applications per week for 1-2 months for Actinic keratosis -Side effects— redness, crusting, intense stinging

-5% cream or 2%/5% solution for Actinic keratosis -Apply to affected area BID for 2-4 weeks -MOA—inhibits DNA & RNA synthesis

-5% cream for Actinic keratosis; apply 3 times per week @ hs for up to 16 weeks -MOA is unknown—immune modulator

-Used as steroid sparing agents in chronic eczema -Both agents have BB for skin malignancies and lymphoma -Neither to be used in children under the age of 3 years

Salicylic acid topically—many OTC formulations [Compound W; DuoFilm, others]; Virasal [27.5% Rx required—topical ]; 50% can be compounded as a paste [Rx required]

Apply BID for 3 days; off 4 days; can repeat until cleared [MOA is unknown; inhibits cell mitosis]

Apply 3 times per week @ hs for up to 16 weeks [MOA is unknown—immunomodulator]

-Used for Alopecia - originally used as an antihypertensive—used to halt hair loss in both men & women -MOA unknown; thought to act by shortening the rest phase of the hair cycle; must be used continuously

-Used for Alopecia - 5 alpha reductase inhibitor that blocks conversion of testosterone to 5 alpha dihydrotestosterone [DHT] -High levels of DHT cause the hair follicle to atrophy; this agent lowers scalp and serum DHT levels [in large doses this agent is used to treat BPH] -Adverse effects—decreased libido, decreased ejaculation, ED -Approved for men, should no be used or handled in pregnancy as it can cause hypospadius in the male fetus

Used most often for prevention of skin in Gram + infections after burns and scrapes

-Protein synthesis inhibitor for Gram + infections -Useful for treating impetigo and other serious gram + skin infections—including MRSA Staph aureus

Newer protein synthesis inhibitor for Gram + infections approved for the treatment of impetigo

-Cyclic hydrophobic peptide that disrupts the bacterial cell membrane of gram - pathogens -Commonly combined with Neomycin & Bacitracin in triple antibiotic [TAO] products

Can be used to treat skin infections caused by gram - infections such as Pseudomonas, E. coli and Klebsiella species

-Systemic therapy for Cellulitis -Dosing: 875 mg BID for 7 days [or high dose Amoxicillin]

-Systemic therapy for Cellulitis -Dosing: 250-500 mg QID for 7 days

-Systemic therapy for Cellulitis -Dosing: 100 mg BID for 7 days [Sanford, 2013]; If MRSA suspected—Trimethoprim/Sulfa DS [2] BID or Doxycycline 100 mg BID

-Systemic therapy for Cellulitis -300 mg q6h or Rifampin if infection severe

-Systemic therapy for Cellulitis -Levofloxacin 500 mg QD or Moxifloxacin 400mg QD

Prototype drug for Onychomycosis

-Active against most all strains of dermatophytes [including Scopulariopsis—a fungus responsible for deep fungal and fungus ball infections in the immunosuppressed] & near 50% of candida infections -Comes in oral, cream, gel and solution

-Oral form is DOC for onychomycosis [250 mg daily for 3 months] and tinea capitis [250 mg daily for 1-2 weeks] -Topical [cream usually] treats tinea pedis, corporis, cruris BID for 1-6 weeks [depending on severity] -Highly protein bound; concentrates in breast milk [don’t prescribe to breast feeding mums] -½ life in tissues is 200-400 hours -Metabolized in liver and excreted in liver -Avoid in patients with liver dysfunction -Adverse Effects—diarrhea, dyspepsia, nausea, headache, elevated LFTs

-Active against Trichophyton Microsporum, Epidermophyton -Available in 1% cream and gel -Used to treat tinea corporis, cruris, and pedis—must dose BID for at least 2 weeks

-Active against Trichophyton, Epidermophyton, Malassezia -Same indications as Naftin; 1% cream BID for 2 weeks

-Skin atrophy, striae, purpura -Acneiform eruptions, dermatitis, local infections, hypopigmentation -In children, applying potent steroids to large body surface area [BSA] can cause systemic toxicity—depression of HPA axis and growth retardation

Which of the following is correct regarding the use of isotretinoin in the treatment of acne?

A 32-year old woman with papulopustular rosacea prefers to use topical agent, rather than an oral agent, to treat her lesions. Which of the following agents is the most appropriate recommendation?

Which of the following drugs used for more severe forms of psoriasis works by reducing DNA synthesis in cells of the immune system and is noted for its long-term risk of liver damage?

Which of the following is correct regarding trichogenic agents?

-Parasites that live on animal skin [where they obtain their nutrition] and can jump “species” and infect the human -Pediculosis—lice -Scabies—mite

Treatment of Ectoparasitic Infections

Lindane, Permethrin, Ivermectin, and piperonyl butoxide

DOC for pediculosis

Yeast vs Non-yeast infections

-Classically presents with red annular scaly plaques central clearing and a serpiginous border -Do not invade dermis because of keratin dependency

-Characterized by pruritic, bright red, macerated plaques with surrounding ‘satellite’ vesiculopustules -Predilection for skin folds—axillary, inframammary, genitocrural -More common in patients with comorbidities—obesity, diabetes, recent antibiotics -Also affects the mucous membranes and can cause systemic disease in the immunosuppressed

Contrast lice vs mites

Never put fluoronated steroids on?

If you go out in the sun and burn in 2 mins, and SPF of 10 will provide coverage for?

Water resistant sunscreen is good for?

What drugs help put Rosacea in remission?

What are the treatments for Actinic Keratosis?