Derm Meds

Question 1

Remember when talking about skin that there are how many layers?

Answer 1

3…this is important for drug absorption (Epidermis, dermis, subcutaneous)

Question 2

What are wet preparations best used for?

Answer 2

Acute inflammation with oozing and vesiculation lesions…have drying effect

Question 3

What are lotions best used for?

Answer 3

Preferred for hairy areas…have a drying effect

Question 4

Creams are best suited for what? Intermediate between drying prep and ointments (high water content)

Answer 4

Acute exudative inflammation, intertriginous areas (good stratum corneum penetration)

Question 5

Penetrates chronic, thickened lesions well and provide protection of skin?

Answer 5

Ointments

Question 6

Direct absorptive effect, reduce friction, absorb moisture, creates more surface area for evaporation?

Answer 6

Powders

Question 7

Best for application to scalp and hairy areas?

Answer 7

Aerosols

Question 8

Best for acne and exudative inflammation?

Answer 8

Gels

Question 9

Do not apply these to weeping lesions or hairy areas?

Answer 9

Pastes

Question 10

Good for application to scalp and hairy areas? Vehicle evaporated quickly

Answer 10

Tinctures

Question 11

Pockets of gas trapped in a liquid, good for application to scalp and hairy areas?

Answer 11

Foam

Question 12

Mild contact dermatitis treatments?

Answer 12

Wet dressings, astringents, colloidal oatmeal bath (aveeno)

Question 13

Moderate contact dermatitis treatments?

Answer 13

Counterirritants (Camphor/Menthol), topical antihistamines, moderate to high potency topical steroid

Question 14

Treatment for severe contact dermatitis (resistant atopic dermatitis)

Answer 14

Systemic corticosteroids

Question 15

Sebrrheic Dermatitis treatments?

Answer 15

Antifugnal agents like ketoconazole shampoo

Anti proliferation agents

Question 16

Atopic dermatitis (Eczema), IgE mediated response of the skin, treatments:

Answer 16

Eliminate allergen
Increase skin hydration (Cetaphil)
Acute weeping lesions: aluminum subacetate or colloidal oatmeal (aveeno)
Corticosteroids (medium-high potency)
Topical immunomodulators (TIMS) - Pimecrolimus cream (Elidel) or tacrolimus ointment
Systemic therapy: oral antihistamines

Question 17

Inhibit T cell activation in inflamed skin by blocking transcription of pro-inflammatory cytokines…used for atopic dermatitis and chronic inflammatory skin disease and as alternatives to topical corticosteroids?

Answer 17

Topical Immunomodulators (TIMs) aka Calcineurin Inhibitors like Pimecrolimus cream (Elidel) and Tacrolimus ointment (Protopic)

*first line steroid sparing agent for atopic dermatitis and psoriasis of the face, flexural, or genital area

Question 18

Which TIM is = low potently steroid and which = medium potency?

Answer 18

Tacrolimus (protopic) = medium

Pimecrolimus (Elidel) = low

Caution w/UV exposure

BB warning for rare cases of lymphoma/skin cancer - use these short term (less than 6 weeks)

Question 19

Topical steroids are NOT used in Impetigo b/c it’s usually staph or strep caused, what do we treat with?

Answer 19

Mupirocin (Bactroban) = topical Abx of choice

System Abx = Dicloxacillin or Cephalexin (more effective than topical but more systemic effects)

Question 20

Treatment of acne rosacea

Answer 20

Topical metronidazole is the DOC for papulopustular rosacea

Can use Azelaic Acid, sodium sulfacetamide and sulfur, brimonidine, and ivermectin cream also

Question 21

Acne drug w/dual mode of action…releases oxygen; Letha to the P.acnes (anaerobe) and increases turnover rate of epithelial cells?

Answer 21

Benzoyl Peroxide…effective for both inflammatory and non-inflammatory acne vulgaris…especially effective when combine with topical erythromycin

Question 22

Topical Abx for acne?

Answer 22

Clindamycin

Erythromycin

Combos of both of those with Benzoyl peroxide

Question 23

Systemic Abx for acne?

Answer 23

Tetracycline and Erythromycin rarely used due to resistance and GI issues

Minocylcline or Doxycycline are the MC used

Sulfamethoxazole and Trimethoprim are used in pts resistant to erythromycin/tetracyclines…but minocycline or doxy are preferred over this due to SEs

Question 24

Vitamin A analogs that reduce the production of sebum which is required by P. Acnes and reduce inflammation by inhibiting neutrophil and monocyte chemotaxis, used for acne after benzoyl trial and topic Abx failure, but can be first line

Answer 24

Retinoids…AEs: drying, redness, peeling skin, pustular flare may occur and may darker skin

NOT RECOMMENDED IN PREGNANCY AND DEGRADED BY UV LIGHT SO APPLY AT NIGHT

Question 25

Three topical retinoids?

Answer 25

Tretinoin, Adapalene (better tolerated/faster), and Tazarotene (best efficacy, preg cat X, INDICATED FOR PSORIASIS TOO)

Question 26

Oral Retinoids that’s the only effective one for severe cystic acne, but so bad for pregnancy that provider, pt, and pharmacy have to register to get it? CAT X

Answer 26

Isotretinoin PO...two forms of contraception MUST be used during therapy and for one month after treatment AEs: Depresison and SIs

Question 27

Acne med with unknown MoA used for rosacea or acne, comparable efficacy to other acne meds w/minimal toxicity?

Answer 27

Azelaic Acid (Azelex for acne and Finacea fo rosacea) Mild skin effects and hypopigmentation possible w/dark complexion

Question 28

A-2 agonist that may reduce erythema through direct vasoconstriction...used to topical treatment of persistent erythema of Rosacea in 18y/o and older

Answer 28

Brimonidine Intermittent flushing and systemic BP lowering effects reported

Question 29

First line for mild to moderate psoriasis? But efficacy only goes up as potency increases -> can lead to skin atrophy/changes

Answer 29

Topical CSs

Question 30

Drug that carcinogenic to animals, bad smelling, not used much anymore, for poor people for mild/moderate plaque psoriasis...but less effective than topical CSs?

Answer 30

Coal Tar

Question 31

These are used for psoriasis in a way that’s not known, regulates the concentration of calcium and phosphate in the blood and promotes healthy growth and remodeling of bone...

Answer 31

Vitamin D3 Analogs (Calcitriol, Calcipotriol, Calcipotriene and Betamethasone dipropionate)

Question 32

Adjunct to topical CSs, often used in combo, more for maintenance because onset is slower, for mild psoriasis as monotherapy or moderate to severe in combo...

Answer 32

Vitamin D3 Analogs...AEs = skin discomfort, calcium monitoring, can’t use calcipotriene/betamethasone dipropionate on face, flexures, or genital areas

Question 33

Topical retinoid (vitamin A derivative) that reduces inflammation by inhibiting neutrophil/monocyte chemotaxis?

Answer 33

Tazarotene gel, cream, foam

Question 34

Tazarotene can be used for mild plaque psoriasis w/topical CS and for acne, but what are the three main AEs?

Answer 34

CAN NOT be used on genitals or skin folds Photosensitivity (use sunscreen) Teratogenic risk

Question 35

Oral retinoid that reduces inflammation by inhibiting neutrophil and monocyte chemotaxis?

Answer 35

Acitretin (Soriatane) PO

Question 36

Acitretin can be used as monotherapy or adjunct to other treatments...less risk of organ toxicity than methotrexate or cyclosporine, but what main AEs?

Answer 36

High teratogenic (no pregnancy for 3 years post use) And mucocutaneous dryness, alopecia, hypertiglyceridemia, hepatotoxicity, premature closure of epiphyseal closure in kids

Question 37

Pimecrolimus and Tacrolimus are two drugs of this category (aka calcineurin inhibitors) that inhibit T cell activation in inflamed skin by blocking transcription of pro-inflammatory cytokines

Answer 37

Topical Immunomodulators (TIMs)

Question 38

TIMs are a first-line steroid sparing agent for atopic dermatitis and psoriasis of the face, flexural, or genital area...caution with UV exposure due to possible cancer risk, what are the two drugs we talked about?

Answer 38

Tacrolimus (protopic) | Pimecrolimus (Elidel)

Question 39

Cyclosporine PO is used mainly for what?

Answer 39

Disease that is too severe, refractory, or extensive for topicals Lots of AEs/interactions, less effective than biologics, but these are cheaper

Question 40

Apremilast is a PDE4 inhibitor, reduces inflammatory mediators, used for what?

Answer 40

Moderate to severe psoriasis in pts who are candidates for phototherapy or systemic therapy Less effective than cyclosporine but fewer AEs (and less severe AEs) DI: CYP3A4 inducers like rifampin, carbamazepine

Question 41

Folic acid antagonist that inhibits purine synthesis by acting on dihydrofolate dehydrogenase used for disease that is too severe, refractory, or extensive for topicals (palms, soles, scalp, more than 10% body) Less efficacious than biologics, but much cheaper

Answer 41

Methotrexate

Question 42

Methotrexate you worry about stomatitis risk, but reduce that with folic acid supplements, need CBC monitoring, pulm function monitoring, liver function monitoring and preg cat X (at least one menstrual cycle for women, 3 months for men), what’s the reversal agent?

Answer 42

Leucovorin (Folinic Acid)

Question 43

Biologics MoA?

Answer 43

Block pro-inflammatory cytokines or bind to T-cells to prevent stimulation

Question 44

What are the 4 biologics we talk about?

Answer 44

Adalimumab (Humira): Human IgG Ab to TNF-a Infliximab (Remicade): Chimeric ab to TNF-a (most effective*****) Etanercept (Enbrel): TNF-a antagonist Ustekinumab (Stelara): Human ab to IL-12/23

Question 45

Biologics are for moderate to severe psoriasis, can be combined with methotrexate/acitretin, but risks are what?

Answer 45

Infections: TB, lupus, cancers, etc Less toxic to some organs though compared to methotrexate, acitretin, and cyclosporine

Question 46

To physically destroy affected wart tissue we use?

Answer 46

Keratolytic agents (salicylic acid, podofilox, podophyllum resin, imiquimod)

Question 47

Wart med that is a topical immunomodulator that induces local cytokine induction?

Answer 47

Imiquimod cream used for cutaneous, genital, perinatal (external) warts Or for actinic keratosis on face/scalp Superficial basal cell carcinomas Don’t use in pregnancy

Question 48

Wart meds for external warts that cause necrosis of tissue used on, CI in pregnancy?

Answer 48

Podofilox or Podophyllum resin

Question 49

Med derived from green tea leaves that upregulates apoptosis-associated genes and to modulate and downregulate genes involved in proinflammatory response to HPV infection, applied for 16 weeks, expensive?

Answer 49

Sinecatechins ointment