Dermatology Pharm

106問 • 1年前

問題一覧

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

Epidermis

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

Dermis

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

Use ointment for excoriation

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

Pathophysiology of acne

-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]

Acne Vulgaris

-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

Retinoids

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

Isotretinoin (Accutane)

Retinoid that is 1st generation agent for acne

Tretinoin

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

Adapalene / Tazorac

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

Benzyl Peroxide

-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

Salicylic Acid

-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

Azelaic Acid

-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

Antibiotic use for acne

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

Topical Dapsone

Moderate to severe acne requires these ORAL antibiotics

Doxycycline [preferred] or Minocycline

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

-Reverse excess desquamation -Improve penetration of other drugs -Work best with antibiotics -Reduce all acne lesions by 50% in 12 weeks of therapy

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

Topical retinoid

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

Topical retinoid + benzoyl peroxide [BPO] OR topical retinoid + BPO/antibiotic combination

Treatment for moderate acne (papular/pustular disease):

topical retinoid + oral antibiotic & BPO [can add OCP in ⧬ ]

Treatment for moderate acne (nodular disease):

topical retinoid + oral antibiotic & BPO [or BPO/antibiotic]

Alternative treatment for moderate nodular acne

Isotretinoin orally

Treatment for severe acne (nodular):

oral antibiotic and topical retinoid + BPO [can add OCP in ⧬]

Alternative treatment for severe acne (nodular):

Isotretinoin oral

Treatment for severe acne (cystic/pustular):

oral Isotretinoin [Accutane]

Alternative treatment for severe acne (cystic/pustular):

high dose oral antibiotic and topical retinoid + BPO [+ OCP in ⧬]

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

UVB

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

UVA

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

SPFs of >16

Compare and contrast Sunscreen vs Sunblock

Sunscreen filters the sun's ultraviolet (UV) rays, while sunblock reflects the sun's rays away from the skin.

What are the active ingredients in sunscreen?

zinc oxide titanium dioxide

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

Use 3 tablespoons [to cover all BSA] every 120 minutes

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

Use small amounts of SPF 15 or less sparingly

When does sunscreen expire?

36 months after date manufactured date

-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

Description of psoriasis

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

Etiology of psoriasis

Important non-drug therapies for psoriasis

Avoid rubbing/scratching; healthy diet, exercise and lose weight, stop smoking

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

Topicals—retinoids, Vitamin D analogues, keratolytics, topical steroids

For severe psoriasis diseas use these systemic therapies

Methotrexate, cyclosporine, immune modulators

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

Phototherapy [Methoxsalen + UVA [PUVA] OR UVB alone]

-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

Tazarotene [Tazorac]

2nd generation retinoid; given PO for pustular psoriasis

Acitretin [Soriatane]

Vit D Analogues - These agents inhibit growth of keratinocytes

Calcipotriene and Calcitriol

-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

Vit D Analogues

Keratolytic Agents

-Coal tar—inhibits excessive skin cell proliferation -Salicylic acid -Both used on scalp to remove scale and improve steroid penetration -These agents have largely been replaced in psoriatic care by the newer topical 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

Corticosteroids and immune modulators—suppress the dysregulated immune response

Calcineurin Inhibitors

Tacrolimus [Protopic] and Pimecrolimus [Elidel]

-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

Calcineurin Inhibitors

Systemic Therapies

-If unresponsive to topicals or BSA >5% -Apremilast [Otezla]

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

Phosphodiesterase 4 inhibitor

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

TNF Alpha Blockers

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

Phototherapy

Usually prescribed as a daily wash for Rosacea

Sodium Sulfacetamide [10%] with Sulfur 5%

This agent is considered DOC for Rosacea and safe in pregancy

Topical Metronidazole [MetroGel]

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

Azelaic acid [Finacea] or Topical Metronidazole [MetroGel]

Oral drugs used for Rosacea

Doxycycline and Erythromycin

BID Topicals for Rosacea

-Metronidazole 0.75% -Erythromycin 2% -Clindamycin gel

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

BID oral therapy for Rosacea

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

Efudex [5-flourouracil]

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

Aldara [Imiquimod]

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

Efudex [5-flourouracil]

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

Aldara [Imiquimod]

-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

Tacrolimus ointment [.1%, .03%] [Protopic] and Pimecrolimus cream [Elidel]

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]

OTC treatment for Verruca

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

Podophyllin 0.5% solution for Verruca

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

Imiquimod [Aldara] 5% cream for Verruca

-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

Minoxidil

-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

Finasteride

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

Bacitracin

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

Mupirocin

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

Retapamulin

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

Polymyxin B

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

Gentamycin

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

Augmentin

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

Augmentin

-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

Doxycycline

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

Clindamycin

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

Fluoroquinolones

Prototype drug for Onychomycosis

Terbinafine [Lamisil]

-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

Terbinafine [Lamisil]

-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

Terbinafine [Lamisil]

-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

Naftifine [Naftin]

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

Butenafine [Lotrimin Ultra]

-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

AE of Glucocorticoids

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

It is contraindicated in pregnancy

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?

Metronidazole

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?

Methotrexate

Which of the following is correct regarding trichogenic agents?

Finasteride inhibits the 5-alpha-reductase enzyme that controls the production of DHT from testosterone

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

Ectoparasitic Infections

Treatment of Ectoparasitic Infections

Lindane, Permethrin, Synergized pyrethrins with piperonyl butoxide

Lindane, Permethrin, Ivermectin, and piperonyl butoxide

Anti-parasitc Agents

DOC for pediculosis

Piperonyl butoxide

Yeast vs Non-yeast infections

Candidia is yeast vs dermatophytes [tinea] "ringworm" are non-yeast

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

Dermatophytosis

-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

Candidiasis

Contrast lice vs mites

Lice causes pediculosis and mites cause scabies

Never put fluoronated steroids on?

Perineum or face

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

20 mins

Water resistant sunscreen is good for?

80 mins

What drugs help put Rosacea in remission?

Doxycycline or Erythromycin

100

What are the treatments for Actinic Keratosis?

Efudex and Aldara

Patho Renal

Two Clean Queens · 100問 · 2年前

Patho Renal