dermatologic disorders Flashcards
(140 cards)
1
Q
when to refer to MD
A
multiple or extensive burns Human or animal bites Multiple or extensive cuts, bruises, or abrasions Rash that is extensive, weeping, or infected Tumors or growths Yellow skin Deep infection (cellulitis) Large blisters of unknown origins Exposed deep tissue, muscle, or bone
2
Q
anatomy of the skin
A
epidermis
dermis
subQ
3
Q
primary skin lesions
A
flat, nonpalpable changes in skin color: macule, patch
elevation formed by a fluid in a cavity: vesicle, bulla, pustule
elevated, palpable solis masses: papule, plaque, nodule, tumor, wheal
4
Q
secondary skin lesions
A
material on skin surface: scale, crust, keloid
loss of skin surface: erosion, ulcer, excoriation, fissure
5
Q
vascular skin lesions
A
cherry angioma, telangiectasia, petechiae, eccyhmosis
6
Q
basic vehicles for derm products
A
ointment, cream, lotion, gel, soln/spray
very important to realize basic properties
7
Q
ointments
A
Semi-solid preparations intended for external application to skin and mucous membranes.
Four classes: Hydrocarbon, Absorption, Water-removable, Water-soluble
Advantages: Hydrates, Removes scales, Greatest bioavailability of active ingredient
Disadvantages: Greasy
Preferred Area of Use: Smooth skin with short or sparse hair
8
Q
properties of ointments
A
Occlusive: promotes retention of water in the skin, forms a hydrophobic barrier that prevents moisture in the skin from evaporating.
Humectant: causes water to be retained because of its hygroscopic properties.
Emollient: Softens the skin, Soothes irritation in skin or mucous membranes
Protective: Protects injured or exposed skin surfaces from harmful or annoying stimuli
9
Q
application of creams/ointments
A
finger tip units - 1/2 gram of cream/ointment
amount needed depends on area of patient, area being applied to, how often and how long
10
Q
creams and lotions
A
Ointment bases of the water-removable class Consisting of oil-in-water emulsions or aqueous microcrystalline dispersions of long fatty acids or alcohols Water washable and more cosmetically and aesthetically acceptable than ointments*** LOTIONS are basically watered-down creams
11
Q
lotions solutions or sprays
A
Advantages: Easy to apply to hairy areas, scalp, High patient acceptance
Disadvantages: Drying, Lower bioavailability
Preferred Area of Use: Intertriginois and hair-bearing skin, face
12
Q
cream properties
A
Advantages: Good cosmetic appearance, High patient acceptance
Disadvantages: Not as hydrating as ointments
Preferred Area of Use: Smooth or hair-bearing skin, Intertriginous areas
13
Q
gels
A
semi-solid systems consisting of either suspensions made up of small inorganic particles or large organic molecules interpenetrated by a liquid
Advantages: Non-greasy, Easy to apply to hairy areas, High patient acceptance
Disadvantages: Drying
14
Q
gels/lotions/solution/foam preferred area of use
A
hair bearing skin
15
Q
oleaginous bases
A
white petrolatum, vaseline, plastibase
absorbs NO water, not water washable - soap is required
16
Q
absorption bases
A
aquaphor, aquabase, polysorb
can absorb* several times it;s weight of water*
not water washable
17
Q
water-in-oil emulsion bases
A
nivea, eucerin, hydrocerin
absorbs less water than absorption bases
not water washable
18
Q
oil-in-water emulsion bases
A
hydrophilic ointment, dermabase, hydrocerin, unibase, cetaphil lotion, vanicream
water washable***
add water = lotion
19
Q
water soluble base
A
polyethylene glycol ointment
water washable
minimal therapeutic effect
primarily used for drug delivery
20
Q
choice of bases
A
Condition of the skin - Desired effect** from the base
Area of application
Patient acceptability
The nature of the incorporated medication - Bioavailability, Stability, Compatibility
21
Q
drug-induced skin disorders
A
Hypersensitivity/allergic rxn - rash, hives, scarlet fever
Photosensitivity
Toxic Reaction: Erythema multiforme, Stevens-Johnson Syndrome, toxic Epidermal Necrolysis
22
Q
treatment of ADRs
A
stop the drug!
systemic antihistamines, systemic or topical CSs, soothing baths or soaks
23
Q
derm SEs
A
photosensitivity,
24
Q
treatment of photosensitivity
A
Prevention*** with sunscreens/clothing - SPF ≥ 30 Systemic analgesics Systemic antihistamines for itching Prevent infection Moisturizers Cooling creams and gels (Aloe)
25
drug-induced skin disorders
Toxic Skin Reactions: Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis
Characteristics: Epidermal detachment, Erosive mucosal lesions
Underlying mechanism: Drug protein complex reaction leads to T-cell activation which migrates to the dermis and releases cytokines
26
drugs associated with SJS/TEN
Sulfonamides, Cephalosporins, Penicillins, Fluoroquinolones, Anticonvulsants***, Allopurinol, NSAIDs, Others…
27
features of SJS/TEN
Usually occurs within first 4 weeks of tx
Prodromal NVD, myalgias, sore throat, arthralgias - Flu-like symptoms
Involvement of mucous membranes
Widespread blisters and lesions
Full thickness epidermal detachment - Risk of infection
28
treatment of SJS/TEN
Stop offending agent***, IV fluids / nutrition, Pain control, Eye carem, Nasal saline, Oral hygiene and anesthetics, Topical antiseptics, Wound care
29
questions to ask a patient who presents with a skin rash or lesion
Onset, duration, getting better or worse
Parts of body involved
Symptoms
Exposure to new drugs or irritants
30
cellulitis
infection near break in skin
Red, warm, swollen
Refer to PCP**
Tx with… Oral antibiotics, IV antibiotics in severe cases
31
imeptigo
```
Topical Staph skin infection
Most common in children
Direct spread
Refer to PCP**
Tx with… Topical or oral antibiotics
```
32
topical candida infection
Common in moist areas in humid conditions
| Tx with… Topical antifungals, Dry affected areas
33
tinea pedis
Often spread in pools/showers
Moist environments promote growth
Dermatophyte infection
Tx with… Topical antifungals
34
tinea corporis
```
body ring worm
Commonly transmitted in day-care
Hot/humid environments promote growth
Small, circular, red scaly areas
Tx with… Topical antifungals
```
35
head lice
Children 3-12 yo
Scalp redness and scaling
Pruritus
Refer to PCP
tx with... Permethrin 1%, Malathion (Ovide), Oral Ivermectin (Stromectol), Spinosad (Natroba), Topical Ivermectin (Sklice)
Other considerations! Somewhat expensive OTC medications (Make sure patient knows how to use); Prevention! (Others in house, Washing everything!)
36
scabies
Sarcoptes scabiei infestation
Primarily in children and adolescents (LTCF)
Raised lines caused by mites burrowing under skin***
Extreme pruritus
Refer to PCP
Tx with… Permethrin 5%, Crotamiton (Eurax Cream), Oral Ivermectin (Stromectol)
37
herpes zoster (shingles)
Adults > 40 yo
Especially in pts who previously had chicken pox
Potentially contagious while blisters are present
Triggered by stress, old age, immunosuppression
Extreme pain along dermatome
Tender red papules - progresses to scabs
Refer to PCP
Tx with…
-Oral valacyclovir or famciclovir
-Manage acute pain and postherpetic neuralgia - Oral opioids for acute pain, Gabapentin for PHN, Lidoderm patches - once lesion have healed
38
skin cancer
```
Better screening tests means its becoming more “prevalent”
Patients becoming more aware of it
Lots of prevention education available
Basal cell carcinoma (most common)
Squamous cell carcinoma (sun-exposed)
Melanoma (most deadly)
Caucasians w/ light eye and hair color
Refer to PCP
Tx with… Removal of lesion, Chemotherapy, Radiation
```
39
xerosis
dry skin
Common features: Fall and winter, Feet, lower legs, Hands, elbows, face, Rough, dry, scales, cracks, Itching is common Sx
who is at risk - elderly (decreased activity of sweat and sebaceous glands; very warm, dry environments) and frequent bathing
treatment options: emollients (first line for itching, restores barrier and skin function), agents for itching, alter bathing habits (no more than 3 times/week, tepid water (3-5 degrees above body temp), for 3-5 minutes, pat dry, apply copious amounts of emollients within 3 minutes, apply at least 3 times daily)
40
emollients for xerosis
Vaseline, Nivea, Keri, Lubriderm, AmLactin, Eucerin
| Ointments vs. Creams vs. Lotions
41
agents to reduce itching for xerosis
Menthol and camphor - ½ to 1%, Create a sensation of cooling
Pramoxine - 1%, Local anesthetic
Aluminum Acetate - 0.2%, Alter C-fiber nerve transmission
Hydrocortisone - 0.5% and 1%, Anti-inflammatory
42
acute dermatitis
red patches or plaques
Pebbly surface or blisters (vesicles)
Itching is common
43
subacute dermatitis
dry, less red than acute, crusting, oozing, mild thickening
Red scaling, fissured, patches or plaques
Slight to moderate pruritis, pain, stinging or burning
44
chronic dermatitis
```
Epidermal thickening
Exaggerated skin markings
lichenification
Scaling
Less itching
Well demarcated, lichenified, thichened plaques
Excoriations, fissures, scaling
Itching predominates - Minor irritations or trauma worsens itching
Treatment – same as subacute
Use emollients (ointments for dry lesions)
Avoid long-term corticosteroids
UV light
```
45
acute contact dermatitis
Look at pattern
Look at part of body involved
Main symptom is itching
Two types: Allergic and Irritant
46
acute contact dermatitis - irritant
Non-immunologic reaction to frequent contact with everyday substances
Reaction within a few hours
Common irritants ???
More common than allergic
47
poison ivy
example of acute dermatitis
Direct exposure: Broken plant, Resin – 2 weeks
Indirect exposure: Clothing, dog, smoke, Does not spread from lesions
Prevention is the key: Ivy-Block (Protectant; barrier, Re-apply every 4 hours)
Dermatitis occurs 24 to 48 hrs after exposure.
Pruritis is intense - secondary infections, cool water
Wash skin and nails within 10 minutes. - wash clothing as well
Topical therapy OK if less than 10% BSA involved.
treatment options: Remove source, Soaks, Calamine Lotion, Topical antihistamines, Oral Antihistamines, Topical Corticosteroids, Oral Corticosteroids
48
soaks for treating acute dermatits
For oozing, weeping, crusting lesions
| Wet dressings useful for drying acutely inflammed, wet areas
49
treatment of acute dermatits
Domeboro (5% aluminum acetate) - Packets in cool water
Acetic Acid: 60 ml vinegar in 1 qt warm water
Saline: 1 tsp salt in 2 cups water
Water
Apply linen or cheesecloth for 30 minutes bid – qid; remove when dry
50
topical corticosteroids for treatment of acute dermatitis
MOA: Anti-inflammatory, Anti-pruritic, Suppress immune response
***Apply bid to qid x 3 – 14 days
choice of vehicle based upon: Location of lesions, Type of lesion, Severity of lesion/degree of inflammation, Degree of skin penetration desired
Classified according to potency which corresponds to anti-inflammatory activity and vasoconstrictive potency
-Very-high - High – Mid – Low (Grades I to VII)
Vehicle impacts delivery and potency of corticosteroids
Only 1% is absorbed when applied to normal intact*** skin
Occlusion enhances penetration** - Plastic wrap + T-shirt / bandage, Increases penetration 10X, Leave on for six hours
51
topical corticosteroids side effects
```
Thinning of skin
Dilated blood vessels
Bruising
Skin color changes
Risk of HPA suppression with long-term use of high-potency agents
Development of tolerance (tachyphylaxis)
```
52
low potency topical CSs
```
grades 5 - 7
Examples: Hydrocortisone; Desonide
Use on face, groin, genitals, axilla
Mild anti-inflammatory effect
Safest for long-term maintenance use
```
53
mid-potency topical CSs
Grades 3 - 5
Examples: Betamethasone, Triamcinolone, Mometasone
Used on most skin surfaces for exacerbations
Moderate anti-inflammatory effect
Safer for longer usage than high potency
54
high/very-high potency topical CSs
Grades 1 -2
Examples: Fluocinolide, Halobetasol, Clobetasol
Used for very severe lesions and on thicken skin when maximum penetration is needed - Psoriasis
Do NOT use on face.
Avoid using super-potent agents for > 2 wks.
Limit to no more than 50 grams per week.
55
topical calcineurin inhibitors
```
MOA: blocks pro-inflammatory cytokine genes
Can be used on any area
Equivalent to mid-potency corts
No risk of atrophy
Few side effects - burning
$$$$$
Now considered 2nd-line tx
Intermittent use only**
Recent concern regarding long -term use - Risk of malignancies, Risk of resp infect in children under 2 yrs
```
56
crisaborole 2% ointment
```
Phosphodiesterase-4 Inhibitor (non-steroidal)
Alternative to TCS and TCIs
Mild or moderate AD
BID for 28 days
$$$
```
57
treatment of acute dermatitis - systemic
CSs
-avoid dose packs (not long enough)
-start at prednisone 40-60 mg QD; taper q 3 days
-minimum of 10-14 days
non-sedating antihistamines - loratadine, desloratadine, fexofenadine
sedating antihistamines - diphenhydramine, cetirizine, hydroxyzine, doxepin
58
atopic dermatitis
```
Most common form of eczema
Usually presents in infancy
1 in 5 children
1 in 12 adults
80% mild; 80% mod-severe
Pruritis
Red papules or plaques
Scaling excoriations
Overall dryness of skin
Redness and inflammation
Prone to infections due
to scratching
Usually Staph aureus
Tx with antibiotics
Bleach baths
```
59
atopic triad
atopic dermatitis - asthma - allergic rhinitis
Atopic march – Often first disease of atopic/allergic triad to be observed
50%-75% also develop allergic rhinitis and/or asthma
Unknown if early intervention in infants or children might halt or slow atopic march
60
atopic dermatitis - infant
Red, papular skin rash on cheeks and skin.
Lesions often crust over time.
Lesions later appear on neck, trunk and groin.
Itching often results in irritability.
61
atopic dermatitis - child
Face, neck, flexural creases of arms and legs.
Skin often appears dry, flaky, rough, cracked, and may bleed from scratching.
Sleep disturbance is common.
Greater risk of secondary skin infections
62
atopic dermatitis - adult
Hands and neck.
Flexor surfaces of the arms and legs.
Excoriation and lichenification from chronic scratching.
Sleep disturbance; Altered QOL; depression
63
triggers of atopic dermatitis
Allergens, Chemicals, Bathing, Detergents, Smoke, Dust, Infections
64
stepwise management of AD
non-pcol: lukewarm or tepid baths; emollients, ellimination of irritants, modify environment, consider bleach baths, fingernails, clothing
topical: CSs, calcineurin inhibitor therapy, strength/duration of use based on severity
systemic: phototherapy, oral immunosuppressant therapy, injectable biologic agents
65
dupilumab
Dupixent
First biologic indicated for mod-severe AD.
300 mg SC q 2 weeks.
$37,000 per year
66
stasis dermatitis
```
Patients > 50 years
Poor circulation
Most common around ankles
Aching, swellings, discomfort
Red, scaly, crusted plaques
Swelling; edema
Secondary infection and ulcers common
Hyperpigmentation - Retention of Fe++ in skin
```
67
treatment of stasis dermatitis
Topical corticosteroids: for itching
Emollients: for all pts
Oral antihistamines: ???
Oral antibiotics for local infections - Cephalexin 250-500 mg TID; Bandage any weeping lesions until healed
To relieve edema… Elevate feet and legs, Support stockings, Compressive bandages
68
cost considerations
low cost: oral CS, antihistamines
medium cost: topical CSs (typically price increases by potency)
high cost: calcineurin inhibitors
69
patients at risk for topical fungal infections
```
Infants
Elderly
Immunosuppressed
Incontinent; Inc freq of BM
Obese**
Warm and humid climates
```
70
treat or refer topical fungal infections
most can be treated with OTC, refer if any systemic sxs, refer if patients is immunocomp
slow to grow - slow to go - treat 4 weeks or longer
71
treatment options for topical fungal infections
Hygeine !!!
OTC Products: Miconazole (Micatin; Lotromin), Clotrimazole (Lotrimin; Cruex; Desenex), Terbinafine (Lamisil)
Rx Products: Nystatin (Mycostatin), Ciclopirox (Loprox), Ketoconazole (Nizoral)
72
diaper rashes treatment options
```
Remove irritant (freq diaper changes)
Air dry
Keep clean (mild soap and water)
Antifungal agents +/- corticosteroid
Apply protectants !!! - Zinc oxide, Destin™, Aveeno™, A&D Ointment™, Butt Paste, can be applied over anti-fungal, if necessary
```
73
seborrhic dermatitis
Erythema with greasy yellow scaling
Hairline, scalp, nose, neck, ears, back
Itching
Cradle cap in infants - Baby oil to soften, Baby shampoo, No drug tx usually required
treatment options:
-medicated shampoo: Scalp and hair line, Use 2-3 times per week, then weekly to control, pyrithione zinc; selenium; ketoconazole (Try OTC first, Rx strengths (2X), Removes scales, Reduces cell turnover)
-Topical corticosteroid - Low strength: Reduces inflammation and itching, Ideal for lesions on face and ears**, Use BID, then prn
74
acne - definition
A chronic inflammatory disease of the sebaceous glands and hair follicles of the skin characterized by comedones, papules, and pustules
75
pathophys of acne
Keratinous obstruction of sebaceous follicle outlet
Traps sebum
Comedone** – hair follicle plugged with sebum, keratin & dead skin
Bacterial colonization in trapped sebum**
Bacteria
-Propionibacterium acnes** naturally colonize the skin and sebaceous glands
-proliferates in sebum environment
-Bacteria converts TG to FFA which irritates local cell resulting in inflammation
can be non-inflam (whiteheads, blackheads) or inflammatory (pupules, pastules, ruptures contents)
76
non-inflammatory acne
whitehead - trapped contents
| blackhead - trapped contents, dilated opening, melanin accumulates
77
inflammatory acne
papules - red, inflammed
pustules - yellow, inflammed
ruptured contents
78
secondary ance
excoriations, erythematous macules, hyperpigmented macules, scars
79
treating complications
dermabrasion, chemical peels, laser resurfacing, $$$
80
goals of therapy of acne
long-term control, prevent scars
81
MOAs of acne agents
antimicrobial, antiiflammatory, decreased serum production, keratolytic/comedolytic
82
treatment of acne - ALL patients
follow a regular skin cleansing regimen using a mild facial soap BID
minimize* the use of products that cause irritation or stinging (aftershave, alcohol-based cleansers)
Use tepid, not hot*, water to clean affected areas
No quick fix - weeks to months
83
treatment of comedonal, noninflammatory acne (mild)
topical retinoids (adapalene)
84
treatment of mild-moderate papulopustular inflammatory acne
adapalene + benzoyl perozide (BP) or
| clindamycin + BP
85
treatment of severe papulopustular OR moderate nodular acne
oral isotretinoin
86
treatment of nodular or conglobate acne
oral isotretinoin
87
Maintenance therapy of acne
adapalene*
88
adapalene
Formulation: gel, cream, solution
MOA: retinoid
daily at HS, burning/stinging
89
tazorotene
formulation: cream, gel
MOA: retinoid
daily, start with lower strength, very drying, category X
90
tretinoin
formulation: cream, gel, solution
MOA: retinoid
daily at hs, sting, burn, dryness, photosensitivity, 4-6 weeks until improvement
91
azelaic acid
formulation: cream
MOA: antibacterial, keratolytic
adjunct, well tolerated
92
benzoyl peroxide
formulation: cream, gel, lotion
MOA: antiseptic, comedolytic/keratolytic, anti-inflammatory
BID, dry skin/irritation, can bleach skin/hair, start w lower strength, avoid contact with clothing
93
clindamycin
formulation: gel, solution, lotion
MOA: antibiotic
daily or BID
94
erythromycin
formulation: gel, solution
MOA: antibiotic
BID, expires in 30 days
95
clindamycin + BP
formulation: cream
MOA: antibiotic
limits resistance
96
oral antibiotics for acne
Decreases bacteria and inflammation** - Weeks are required to see improvement
Most effective when inflammation is present.****
Risk of allergy, photosensitivity, GI upset, thrush
Risk of resistance developing - Limit tx to 6-8 weeks, if possible
After inflammation is controlled, acne can often be controlled with topical retinoids and/or benzoyl peroxide for long periods
97
options for oral antibiotics for acne
```
Minocycline 50-100 mg daily - BID - 20 mg dose – only anti-inflammatory activity
Doxycycline 50-100 mg daily - BID
Erythromycin 250 mg QID
Azithromycin 250 mg 3 times a week
TMP/ SMZ (Bactrim) - 1 DS tab daily
```
98
oral tetracyclines for acne
Risk of photosensitivity
Interaction with OCs
Do not take with dairy products or antacids
Minocycline is most lipophillic** Dizziness; Hyperpimentation (scars)
Discoloration of teeth
Avoid in children and during pregnancy*
99
oral anti-androgens for acne
Hormone Treatment
-Estrogens and anti-androgens
-Generally NOT used in males
-Ideal for females who’s acne flares during menstral cycle***
Decreases androgen production (reduces sebum & comedone formation)
Low-dose Oral Contraceptives: Ortho-Tri-Cyclen®, Estrostep®; Contain non-androgenic progestins, Any OC is likely to be effective, 6 month trial may be necessary, Risk vs. benefit
Spironolactone - 50-200 mg per day
Intra-lesion corticosteroids
Oral corticosteroids - Short course for highly inflammatory acne
100
isotretinin for severe acne
vitamin A derivative
provides resolution in up to 80% of cases
reduces sebum production and shrinks sebaceous glands
Used when patients have failed other treatments or when it relapses soon after discontinuing other therapies****
Very expensive
10mg, 20 mg, 40 mg capsules
dosing: 0.5 - 2 mg/kg/day in 2 doses (with food) for 15 - 20 weeks - Some dermatologists recommend a cumulative dose of 120-150 mg/kg, Acne will get worse before it gets better***, If acne flares after > 2 months off tx, a 2nd course may be used, Effectiveness increases with higher doses*
counseling tips: avoid pregnancy / proper use of contraceptives, adverse effects, do not take vitamin A supp (includes nutr supp), use moisturizer, lip balm, and artificial tears, use a sunscreen, take with food
101
ipledge program
isotretinoin
Patients, physicians, and pharmacies must register with a centralized clearinghouse
Dispensing occurs only after the pharmacist has received an authorization code.
Can only dispense a 30 day* supply with no refills
Pharmacists will get a “do not dispense after date” - 7 days past office visit
Females must have a negative pregnancy test every month while on therapy
102
rosacea
A common, chronic, progressive inflammatory dermatosis based upon vascular instability.
Primarily affects the central part of the face.
Characterized by facial flushing/blushing, facial erythema, papules, pustules, and telangiectasia
Ages of 25 and 70 years
People with fair complexions.
women > men
Rosacea is chronic, persisting for years with periods of exacerbation and remission.
103
telangiectatic rosacea
Visibly dilated blood vessels*
| Very red skin
104
papulopustular rosacea
Resembles acne*
| Often referred to as “adult acne”
105
phytmatous rosacea
Enlarges sebaceous glands
Especially the nose*
More common in males
106
ocular rosacea
Watery eyes
| Bloodshot eyes
107
trigger factors for rosacea
```
Foods
Temperature**
Weather
Beverages
Medical conditions
Emotional influences
Physical exertion
Skin products
drugs: vasodilators, topical CSs, nicotinic acid, ACEI, CCB, statins
```
108
lifestyle mods to treat rosacea
```
Avoid triggers* known to exacerbate.
Avoid excessive exposure to the sun.
Use mild soaps and cleansers.
Stress adherence to topical meds.
Topical meds should be allowed to penetrate the skin for 5-10 min before applying make-up.
```
109
treatment overview of mild rosacea
Avoid triggers
Topical antibiotics
Topical retinoids
110
treatment overview of moderate rosacea
Oral antibiotics
| Topical retinoids
111
treatment overview of severe rosacea
Oral Isotretinoin
| Laser treatments
112
metronidazole for rosacea
Treatment of choice of topical antibiotics
Apply BID
Some burning/stinging
113
azelaic acid for rosacea
Finacea® Gel 15%
antibacterial, comedolytic, and antiinflammatory effects
less acidic / better absorbed than acne formulation
$$$
114
oral antibiotics for rosacea
For patients with moderate to severe rosacea
Doses vary depending on severity
Used alone or in combination with topical agents
115
brimonidine for rosacea
```
new treatment
Mirvasco® 0.33% gel-Alpha-2 adrenergic agonist
-Tx for persistent facial erythema
-Insurance coverage?
Ophthalmic drops for ocular rosacea
```
116
oral antibiotic options for rosacea
```
doxycycline 50-100 mg daily or BID
Minocyclcine 50-100 mg BID
For pts with moderate to severe cases
Doses vary depending severity
Used alone or in combination with topical antibiotics
```
117
tretinoin for rosacea
Used for more severe cases
| May worsen erythema and telangiectasias
118
isotretinoin for rosacea
Only used for most severe cases
| Weigh risks vs. potential benefits
119
laser therapy for rosacea
Used to remove blood vessels and reduce excessive redness
A minimum of 3 treatments is usually required
May also be used in more severe cases* to retard build up or remove unwanted tissue and reshape the nose
120
psoriasis basic information and clinical presentation
Chronic autoimmune inflammatory skin disorder
T-lymphocyte mediated disease
Keratinocyte proliferation
Thickened, red patches covered by silvery-white scales
Results from a rapid skin growth - 7 X faster than normal
2% of US population
Onset usually prior to 40yo
Usually a series of exacerbations/remissions
Not curable !!! - Long remissions are possible
121
major types of psoriasis
```
Plaque psoriasis
Palmoplantar psoriasis
Scalp / nail / pubic psoriasis
Inverse psoriasis
Pustular psoriasis
Guttate psoriasis
Erythrodermic psoriasis
Psoriatic arthritis
```
122
psoriasis classification
```
Limited - under 5% BSA
Generalized
-Moderate 5-10% BSA
-Severe >10% BSA
80% of pts have mild to moderate
20% have severe disease
```
123
psoriasis comorbidities
Psoriatic arthritis
Crohn’s Disease
Psychiatric disorders
Metabolic Syndrome - CV disease / stroke
124
psoriasis triggers
```
Stress
Environment (cold)
Injury
Infection
Smoking
Drugs (NSAIDs, ACE, Lithium…)
Diet
```
125
goals of therapy for psoriasis
Reduce inflammation and slow down rapid skin cell division
Achieve clearing of lesions
Use topical therapy over systemic therapy whenever possible (treatment is based on patient’s health, age, lifestyle, and severity of psoriasis)
Prolong periods between exacerbations
126
PASI
Psoriasis Area Severity Index
- Used in most clinical trials
- Very subjective
- PASI-75 is standard for efficacy - over 75% reduction from baseline PASI; Some pts still not satisfied w/results
127
general measures of psoriasis treatment
Sun
Baths
Emollients
Keratolytics
128
treatment overview of psoriatic arthritis
anti-TNF +/- MTX
129
treatment overview of mild-moderate psoriasis
topical
topical + phototherapy
topical + systemic
130
topical therapy for psoriasis
Most effective when used to treat localized plaques psoriasis covering under 20% of BSA
70% of patient receive only topical therapy
emollients - used for all patients with psoriasis
CSs - decreases scaling, erythema, pruritis; Economical; Shampoo available for scalp; High potency ointment preferred for scaly lesions; Risk of tachyphylaxis
calipotriene/calcitrol - Inhibit proliferation of lesions, Potency equivalent to mid potency corts, Well tolerated; No tachyphylaxis
Cort + Vit D analog - Calcipotriene + Betamethasone (Taclonex™); Ointment + Topical Suspension
Cort + tazarotene - CS sparing effect
calcineurin inhibitor - For areas not suitable for corts; Face and flexures
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topical corticosteroids for psoriasis
Development of tolerance to the anti-inflammatory activity with repeated use (tachyphylaxis)
May alternate with other topical medications to avoid tolerance
Occlusion enhances penetration**
-Plastic wrap + T-shirt
-Increases penetration 10X
-Leave on for six hours
High / Very-High Potency
Used for very severe lesions and on thicken skin when maximum penetration is needed.
Do NOT use on face.**
Avoid using super-potent agents for > 2 wks.
Limit to no more than 50 grams per week.
Mid-potency products used after initial tx
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patient education on topicals for psoriasis
Apply a small amount. - just enough to cover the affected area**
Gently apply - do not rub aggressively.**
Wash hands before and after applying.
Leave on only for the prescribed length of time.
Protect clothing and bed linens.
Stress adherence!**
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if topical therapy fails for psoriasis
1st line if UV tx available: UVB Phototherapy Alone, UVB + Acritretin, PUVA, UVB + Methotrexate
1st line if UV tx not available: Acritretin, Biologic Agent, Methotrexate, Cyclosporine
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role of phototherapy in psoriasis treatment
Targeted phototherapy for limited* and resistant* plaques
For patients with mild-moderate* disease who do not completely respond to topical agents
Used in combination with systemic/biologic tx for pts with severe* disease
Role in maintenance* therapy
Overall role has increased in recent years**
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immunomodulatory effect of phototherapy for psoriasis treatment
UVA - Penetrates thicker lesions better than UVB; Very effective
NB-UVB (BB-UVB – out of favor) - Tx of choice for initial therapy – thinner lesions; 20-25 tx given 2-3 per week; Cost-effective
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phototherapy overview
```
Risks: UVA > UVB
Side effects: skin aging, skin cancer - Squamous cell
Coal Tar + UVB light therapy
Light enhances the activity of coal tar
Goeckerman therapy – all day occlusive coal tar followed by light therapy
PUVA: Psoralen + UVA
Methoxsalen
-0.6-0.8 mg/kg PO 2 hours before UVA tx
-2 – 3 tx per week
-Photosensitizer
-Controls 90% of patients - Superior to UVB alone
-Potentially more risks; skin damage
```
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treatment overview of mod-severe psoriasis
systemic agent +/- topical agent or phototherapy; consider BRM esp if comorbidities exist
more potent systemic agent or (less commonly) 2 or more systemic agents in rotation +/- topical agent
biological response modifier (BRM) +/- other agents (can also consider BRM earlier - even as first line, but costly)
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tx for severe psoriasis
```
Phototherapy: PUVA + psoralen*
Biologic Therapy: First-Line**
-Tumor Necrosis Factor Inhibitors
-T-Cell Activation Inhibitors
Systemic Therapy: Second-Line**
-Oral retinoids
-Cyclosporine
-Methotrexate
```
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biologic/systemic tx for severe psoriasis
Patients with recalcitrant, widespread, plaque psoriasis or patients with comorbidities
Patients with psoriatic arthritis
12 week courses of therapy
May induce long-term remissions
Often very expensive $$$$$ - $20 K to $30K per year
Risk of long term side effects may be significant - May be life threatening, Rotation of therapies may minimize side effects
adalimumab, infliximab, etanercept, golimumab (psoriac artritis only), alefacept, eflizumab, ustekinumab, secukinumab
Comparison of ADRs and risks
-Common: HA, nausea, fatigue, chills, flu-like Sx, Injection site discomfort
-Activation of infections: TB
-Long-term concerns: risk of malignancies, MS in pts with FH
Monitor: Signs and symptoms of infection or bleeding
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systemic therapy for severe psoriasis
acritretin - oral retinoid, 3-6 mo until max effect, SE similar to accutane, cat X
MTX - immunosuppressant, reasonable cost, monitor CBC, LFTs, oral, cat X
cyclosporine - Calcineurin inhibitor, Avoid grapefruit juice, Max tx: 2 yrs, Renal toxicity
apremilast: Start at 10mg and titrate up over 5 days, PDE-4 inhibitor, Psoriatic arthritis, Specialty Rx
