-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

-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

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

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

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

This agent is considered DOC for Rosacea and safe in pregancy

-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

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

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

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

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

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

What are the treatments for Actinic Keratosis?

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

Treatment for severe acne (nodular):

-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

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

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

Treatment for severe acne (cystic/pustular):

Retinoid that is 1st generation agent for acne

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

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

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

What are the active ingredients in sunscreen?

When does sunscreen expire?

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

Water resistant sunscreen is good for?

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

-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

-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

Important non-drug therapies for psoriasis

Never put fluoronated steroids on?

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

Systemic Therapies

Alternative treatment for severe acne (cystic/pustular):

What drugs help put Rosacea in remission?

-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

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

-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

Vit D Analogues - These agents inhibit growth of keratinocytes

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

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

-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]

Prototype drug for Onychomycosis

Treatment of Ectoparasitic Infections

For severe psoriasis diseas use these systemic therapies

-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

-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

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

-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

Contrast lice vs mites

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

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

What drugs treat Gram + Skin Infections

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

Calcineurin Inhibitors

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?

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

Which of the following is correct regarding trichogenic agents?

Oral drugs used for Rosacea

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

Treatment for Vitiligo

Keratolytic Agents

Treatment for Plantar Warts

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

DOC for pediculosis

-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

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

What drugs treat Gram + Skin Infections?

Treatment for moderate acne (nodular disease):

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

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

Drugs that treat Freckles/Melasma

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]

Moderate to severe acne requires these ORAL antibiotics

What do we use for Atpoic Dermatitis?

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

Alternative treatment for moderate nodular acne

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

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

Compare and contrast Sunscreen vs Sunblock

-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

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

Alternative treatment for severe acne (nodular):

BID Topicals for Rosacea

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

-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

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?

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

-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

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

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

Usually prescribed as a daily wash for Rosacea

Lindane, Permethrin, Ivermectin, and piperonyl butoxide

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

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

Treatment for moderate acne (papular/pustular disease):

2nd generation retinoid; given PO for pustular psoriasis

Yeast vs Non-yeast infections