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#2 Derm > 24 - Antifungals and Corticosteroids > Flashcards

24 - Antifungals and Corticosteroids Flashcards

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1
Q

What drug variables determine percutaneous absorption?

A

o Concentration (concentration more important than volume)
o Lipophilicity
o Molecular size (most effective topical meds have a molecular weight of

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2
Q

What vehicle variables determine percutaneous absorption?

A 
o	Lipid content (ointment strongest vehicle, solution typically the weakest)
o	Irritancy (irritating vehicles will alter skin barrier function)
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3
Q

What skin variables determine percutaneous absorption?

A

o Stratum corneum thickness
o Cutaneous vasculature
o Inflamed skin (will have increased absorption)
o Ulceration (can get systemic effects)

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4
Q

What other variables determine percutaneous absorption?

A 
o	Skin hydration (hydrating skin prior, increases absorption)
o	Occlusion (applying topical, then wrapping in impervious material, ex – lotion on feet, then wrap in saran wrap)
o	Age (children have increased total body surface to body volume ratio)
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5
Q

What are the risk factors for systemic toxicity?

A
  • Time
  • Surface area
  • Body site
  • Skin barrier function
  • Use of occlusion
  • Inappropriate use
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6
Q

What are the consequences of systemic toxicity in corticosteroids, silver products and antibiotics?

A

Corticosteroids
o Altered HPA axis

Silver products
o Renal or hepatic problems

Antibiotics
o GI effects, renal effects

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7
Q

Describe the spectrum of inflammation and the cooresponding spectrum of dermatologic vehicles

A

INFLAMMATION

Acute inflammation
o Erythema, edema, vesiculation, oozing, crusting, infection, puritus

Chronic inflammation
o Erythema, scaling lichenification, dryness, puritus

TREATMENT

Appropriate treatments
o	Wet dressing (solutions) 
o	Powders, lotions, aerosols, sprays
o	Creams (oil-in-water emulsions), gels
o	Ointments (water-in-oil emulsions, inert bases)

This means that with acute inflammation, wet dressings and powders/lotions are more appropriate, but as you progress to chronic inflammation, creams and ointments will be needed

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8
Q

What are the general treatment axioms

A
  • If wound is wet, dry it
  • If wound is dry, wet it
  • If wound is inflamed/irritated, soothe it
  • If chronic wound is stagnant, irritate/turn into chronic wound
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9
Q

What are the types of topical medications and vehicles we can use?

A
  • Open Wet Dressings
  • Closed wet dressings
  • Powders
  • Lotions
  • Cream
  • Gel
  • Ointment
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10
Q

Describe open wet dressings and closed wet dressings

A

Open Wet Dressings
o Causes vasoconstriction and decreased inflammation
o Cleanse wound of exudates, crusts, and debris
o Indication: acute inflammatory conditions, erosions, and ulcers

Closed wet dressings
o Can cause maceration

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11
Q

Describe powders, lotions, creams, gels and ointments

A

Powders
o Used to reduce moisture, maceration, and friction

Lotions
o Suspension of powder in water (can be a little too drying for some skin)
Cream
o Semisolid emulsion of oil in water (much more hydrating than a lotion)
Gel
o Semisolid emulsion that liquefies on contact, leaving thin film
Ointment
o Water droplets suspended in oil or petroleum

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12
Q

Describe the relative potency, hydration/drying properties, stage of dermatitis treated, sites to avoid and sensitization risk for OINTMENTS

A
  • Relative potency = strong
  • Hydration/drying properties = hydrating
  • Stage of dermatitis treated = chronic
  • Sites to avoid = sites with maceration
  • Sensitization risk = very low
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13
Q

Describe the relative potency, hydration/drying properties, stage of dermatitis treated, sites to avoid and sensitization risk for CREAMS

A
  • Relative potency = moderate
  • Hydration/drying properties = some hydration
  • Stage of dermatitis treated = acute to subacute
  • Sites to avoid = sites with maceration
  • Sensitization risk = significant
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14
Q

Describe the relative potency, hydration/drying properties, stage of dermatitis treated, sites to avoid and sensitization risk for GELS

A
  • Relative potency = stong
  • Hydration/drying properties = drying
  • Stage of dermatitis treated = acute to subacute
  • Sites to avoid = fissures, erosions
  • Sensitization risk = significant
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15
Q

Describe the relative potency, hydration/drying properties, stage of dermatitis treated, sites to avoid and sensitization risk for LOTION/SOLUTION

A
  • Relative potency = low
  • Hydration/drying properties = variable
  • Stage of dermatitis treated = acute
  • Sites to avoid = fissures, erosions
  • Sensitization risk = significant
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16
Q

Describe “fingertip unit” prescription amounts

A

Ointment expressed from tube from index finger MPJ to tip of finger

  • Approximately 0.5 grams
  • 1 FTU Should cover plantar aspects of 1 or both feet
  • Need 2 FTU to cover one foot
  • If just doing interspaces, should only need 0.25-0.5 FTU or 0.1-0.25 grams

For most podiatric applications a 15 gram tube will last 1 month
- If prescribing for several months, use 60 gram tube because it is less expensive

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17
Q

Common topicals used in podiatry

A

Most common
o Antibiotics
o Antifungals
o Corticosteroids

Less common
o Antivirals
o Pain medications

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18
Q

Topical antibiotics

A
  • Most commonly in cream or ointment form
  • Solutions occasionally used for soaking (Dakin’s, acetic acid, Burrow’s)
  • Antiseptics (for surgical preparation and scrub)
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19
Q

Topical antibiotics - creams and ointments

A
  • Bacitracin
  • Polysporin
  • Neosporin
  • Mupirocin (bactroban)
  • Gentamicin
  • Silvadene
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20
Q

Bacitracin cream/ointment

A

Contains one abx – bacitracin

Coverage

  • Good Gram (+) coverage, minimal to no gram (-) coverage
  • Can cause sensitivity reaction, particularly with stasis dermatitis
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21
Q

Polysporin cream/ointment

A

Contains 2 abx – bacitracin and polymyxin B

PolymyXin B effective against gram (–)

  • Including pseudomonas
  • Contact allergy rare

This is her number one choice – don’t need the third one because of problems (below)

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22
Q

Neosporin cream/ointment

A

Contains 3 abx – bacitracin, polymyxin B, and neomycin

Neomycin – covers gram (+) and (-)

  • Good S. aureus coverage
  • Does not cover Pseudomonas, or Bacteroides
  • Weak Strep activity
  • 1% of population has contact allergic sensitivity, rate can increase to almost 10% in patients with prolonged use
  • Bacitracin causes coreaction with neomycin
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23
Q

Mupirocin (bactroban) cream/ointment

A

o Effective against MRSA

o Can be used in nasal passages for MRSA carriers

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24
Q

Gentamicin cream/ointment

A

o Good gram (-) coverage, notably Pseudomonas

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25
Silvadene cream/ointment
o Effective against Gram (+) and (-) o ***Shouldn’t use in patients allergic to sulfonamides*** o If using in large area over long time period, can get significant absorption of silver o Can occasionally cause brown/gray hyperpigmentation of skin with use o Commonly used with burn patients
26
Topical antibiotic solutions
- Dakin's solution | - Acetic acid solution
27
Dakin's solution
o Sodium hypochlorite solution – AKA bleach | o Comes in 0.5%, 0.25%, or 0.125% strengths
28
Acetic acid solution
o 5% solution (pretty much just vinegar) o Effective against superficial pseudomonas infections o Also has drying effect – Good for wet tinea pedis infection
29
Astringent solutions
- Burow's solution | - Epsom salt
30
Burrow's solution
o 1:40 mixture or 0.14% aluminum acetate solution | o Used to dry out wounds – i.e. macerated tinea pedis or wet dermatitis
31
Epsom salt solution
o Magnesium sulfate o 2 Tbsp./pint of H2O o Also used for drying effect
32
Topical antiseptics
Used for presurgical scrub for surgeon and/or patient o Chlorhexidine o Povidone-Iodine Over the counter antibacterial soaps - Triclosan
33
Chlorohexidine antiseptic
- Broad spectrum coverage - S. aureus, P. aeruginosa, S. marcescens, and facultative anaerobes - Low rate of sensitization
34
Povidone-Iodine antiseptic
- Broad spectrum against gram (+) and (-) - High incidence of dermatitis - Can also be used as a topical to help dry wounds
35
Triclosan antibacterial soap
- Most common abx soap ingredient | - Broad spectrum activity
36
Antifungal classes
- Polyenes (not used much in podiatry) - Azoles (older class, mostly fungistatic) - Allylamines/benzylamines (newer class, better potency/efficacy, fungicidal, can actually kill fungus) - Others (ciclopirox (loprox))
37
Polyenes
Nystatin o Effective against Candida albicans o Not highly effective against dermatophytes, bacteria, or viruses Remember - not commonly used in podiatry
38
General characteristics of azoles
o Azoles are effective against dermatophytes o We are not responsible for dosing information, but just from a clinical perspective, some agents will be more effective if they only need to apply it once a day, just from the compliance perspective
39
List of azoles
- Miconazole (Monostat-Derm, Micatin) - Clotrimazole (Lotramin) - Econazole (Spectazole) - Ketoconazole (Nizoral) - Sertaconazole (Ertaczo) - Oxiconazole (Oxistat) - Efinaconazole topical (Jublia)
40
Miconazole (Monostat-Derm, Micatin)
o Good activity against T. rubrum, T. mentagrophytes | o Has mild effectiveness against some Gram (+)
41
Clotrimazole (Lotramin)
o Broad spectrum against, Trichophyton, Epidermophyton, and Microsporum o Also active against Gram (+) and Candida
42
Econazole (Spectazole)
o Broad spectrum against Trichopyton, Microsporum, Epidermophyton, C. albicans, and M. furfur o Shows some gram (+) and (-) coverage
43
Ketoconazole (Nizoral)
o Broad spectrum activity against dermatophytes
44
Sertaconazole (Ertaczo)
o Relatively lipophilic o Effective against T. rubrum, T. mentagrophytes, E. floccusum, Candida o Moderate activity against Gram (+) bacteria
45
Oxiconazole (Oxistat)
o Good absorption into stratum corneum, will stay for several days after treatment
46
Efinaconazole topical (Jublia)
o 10% solution o Used for onychomycosis o Needs to be used QD for 48 weeks (LONG time)
47
List of allylamines and benzylamines
- Naftifine (Naftin) - Terbinafine (Lamasil) - Butenafine (Mentax)
48
Naftifine (Naftin)
o Highly lipophilic, allows good penetration and high concentration in stratum corneum o Expensive o Earlier symptomatic relief than Lotramin
49
Terbinafine (Lamasil)
o Highly lipophilic and binds well to stratum corneum o Broad spectrum against dermatophytes, molds, C. albicans o Effective against chronic tinea pedis
50
Butenafine (Mentax)
o Broad spectrum against dermatophyes and dimorphic fungi
51
Other antifungals
Ciclopirox Olamine (Loprox, Penlac Nail Lacquer)
52
Ciclopirox Olamine (Loprox, Penlac Nail Lacquer)
o Used for tinea pedis or onychomycosis o Has Gram (-) and (+) activity as well as anti-inflammatory properties (good for tinea pedis with secondary bacterial infection) o Lacquer shown to have 40% clinical and mycological efficacy (have to use daily for several months)
53
Anti-dermatophyte potnecy
From MOST to LEAST potent 1. Butenafine (Mentax) = Terbinafine (Lamasil) 2. Ciclopirox (Loprox) 3. Naftifine (Naftin) 4. Azoles
54
Propylene glycol content in topical antifungals
- If there is irritation, maybe switch to something that is propylene and glycol free - Note that the more potent ones have the propylene and glycol in them Antifungas WITHOUT propylene glycol - Miconazole (Micatin) - Clotrimazole (Lotrimin) - Econazole (Spectazole) - Naftifine (Naftin) - Ciclopirox (Loprox) Antifungals WITH propylene glycol - Terbinafine (Lamasil) - Butenafine (Mentax) - Ketoconazole (Nizoral) - Oxiconazole (Oxistat)
55
Mechanism of action/anti-inflammatory effects of topical corticosteroids
Reduces number and function of inflammatory cells and chemical mediators o Reduced inflammation and immune response Reduces keratinocyte proliferation, fibroblast activity, and dermal volume(due to decreased H2O content) o Thinning of the skin o Prolonged use causes skin atrophy
56
Indications for topical steroids
- Inflamed or irritated skin, non infectious in nature* | - Examples: dermatitis, eczema, psoriasis, lichen planus
57
Contraindications for topical steroids
Absolute o Hypersensitivity to the topical corticosteriod or vehicle Relative o Bacterial, fugal, or viral infection o Ulceration (higher chance of systemic effect of steroids)
58
Systemic adverse effects of topical corticosteroids
o Suppression of HPA axis o Iatrogenic Cushing’s syndrome o Growth retardation in infants and children
59
Local adverse effects of topical corticosteroids
``` o Epidermal atrophy o Steroid rebound o Allergic or contact dermatitis o Exacerbation or increased susceptibility to bacterial, fungal and viral infections o Reactivation of Kaposi’s sarcoma o Delayed wound healing o Tachyphylaxis (tolerance to med) ```
60
Risk factors for systemic effects of topical corticosteroids
``` o Infant or child o Liver or renal disease o Amount applied o Potency o Use of occlusion o Lack of physician supervision ```
61
Risk factors for local atrophy due to topical corticosteroids
``` o Infant or child o Potency o Duration of treatment o Use of occlusion o Location (face, neck, axilla, groin, upper inner thighs, pretibial location) ```
62
Absorption of topical corticosteroids
- About 1% of TCS will be absorbed on normal forearm skin (less on thick skin like sole of foot) - This will increase if skin irritated, inflamed, or thinned - Placing under occlusion dramatically increases absorption (Increases skin surface area by 40%)
63
Choosing a topical corticosteroid - factors to consider
- TCS potency - Vehicle - Brand name vs Generic - Price and cost-effectiveness considerations - Proper amount to dispense - NOTE: ***Choose the least potent topical that will still be affective, or quickly taper down***
64
Potency classes of topical corticosteroids
- Very High (I) - High (II &III) - Medium (IV & V) - Low (VI &VII)
65
Very high (I) potency of topical corticosteroids
o Short term use only | o Best for thick, lichenified or hypertrophic skin resistant to high potency topical steroids
66
High (II &III) potency of topical corticosteroids
o Severe dermatitis, thick, lichenified, or hypertrophic skin o Short term use only
67
Medium (IV & V) potency of topical corticosteroids
o Moderate dermatitis | o Good for extremities as long as not on extremely thickened skin
68
Low (VI &VII) potency of topical corticosteroids
o Mild dermatitis o Preferred treatment for large areas o Best if long term treatment required o Best for thin skin
69
List of very high (I) potency corticosteroids
o Amcinonide ointment 0.1% (Cyclocort) o *Betamethasone dipropionate ointment 0.05% (Diprosone) o *Desoximethasone cream 0.25% (Topicort) o *Desoximethasone gel 0.05% (Topicort) o Diflorasone diacetate ointment 0.05% (Florone) o Fluocinonide 0.06% (Lidex) o Halcinonide cream 0.1% (Halog)
70
List of potent (II) corticosteroids
o *Betamethasone benzoate gel 0.025% (Benisone) o *Betamethasone dipropionate cream 0.05% (Diprosone) o *Betamethasone valerate ointment 0.1% (Valisone) o Diflorasone diacetate cream 0.05% (Florone) o Triamcinolone acetonide cream 0.5% (Aristocort)
71
List of mid-potency (III) corticosteroids
These are a lot of LOTIONS (change of vehicle = change of potency) o Amcinonide cream 0.1% (Cyclocort) o Betamethasone valerate lotion 0.1% (Valisone) o Flucinolone acetonide cream 0.2%, ointment 0.025% (Fluonid, Synalar) o Hydrocortisone valerate cream 0.2% (Westcort) o *Triamcinolone acetonide ointment 0.1% (Aristocort, Kenalog) - Still a prescription, but a lower potency for those who need to apply over a large area – comes in a large jar (not tiny tube)
72
List of low potency (IV) corticosteroids
o Aclometasone dipropionate cream 0.05% (Aclovate) o Betamethasone valerate cream 0.1% (Valisone) o Clocortolone pivalate cream 0.1% (Cloderm) o Fluocinolone acetonide cream 0.025% (Fluonid, Synalar) o Flurandrenolide 0.05% (Cordran) o Hydrocortisone valerate cream 0.2% (Westcort) o Triamcinolone acetonide cream 0.01%, lotion 0.025% (Kenalog, Aristocort)
73
List of mild (V) corticosteroids
Mostly OTC o Desonide cream 0.05% (Tridesilon) o Flumethasone pivalate cream 0.03% (Locorten) o Fluocinolone acetonide solution 0.01% (Fluonid, Synalar
74
List of least potent (VI) corticosteroids
OTC o Prednisolone 0.5% (Meti-derm) o Methylprednisolone 1% (Medrol) o Fluorometholone 0.025% (Oxylone) o Dexamethasone 0.1% (Decadron Phosphate) o *Hydrocortisone 0.25, 0.5, 1.0, 2.5% (Hytone, Nutraderm, Synacort)
75
Combination therapy options
- Corticosporin | - Lotrisone
76
Corticosporin
o Neomycin + Polymyxin + Hydrocortisone | o Corticosteroid-responsive dermatoses with secondary infection
77
Lotrisone
o Clotrimazole + Betamethasone | o Inflamed tinea pedis
78
Anti-hyperkaratotics
- Used for patients with severe chronic hyperkaratosis - Helps to hydrate, soften and debride thickened skin Lactic acid o Lac-Hydrin, Amlactin o 12% Cream or Lotion o May cause irritation in non-intact skin Urea o Carmol 40 o 40% urea cream, lotion, gel

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