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Advanced Pharmacology > Drugs to skin disorders > Flashcards

Drugs to skin disorders Flashcards

1
Q

epidermis

A

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

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2
Q

dermis

A

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

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3
Q

What does sunlight do?

A

 One of the main effects is maintaining the body’s
supply of Vitamin D—this effect is positive
 The photoreceptors on the skin [forearms/legs],
when uncovered [and not coated with sunscreen]
absorb Vitamin D2 from the sun rays
 This form of Vitamin D is converted to Vitamin D3 in the
kidney and then to its active form in a second renal
conversion—1, 25 dihydroxyvitamin D3

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4
Q

What are the 2 types of UV?

A

 UVB [bad] are the rays that burn us, cause wrinkling
and skin cancers
 UVA can cause some wrinkling and with many decades
of “lead time” may manifest itself as BCC later in life

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5
Q

MED is?

A

minimal erythemal dose—minimum amount of UV radiation that produces clearly evident erythema
after one exposure

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6
Q

SPF is?

A

amount of UVB protection provided by a sunscreen [MED on protected skin ÷ MED on
unprotected skin]; gives direction for how long one will
be protected before burning

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7
Q

Broad spectrum is

A

effective against both UVA & UVB radiation; these protect against sunburn, skin cancer
and photoaging

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8
Q

Water resistant is

A

—sunscreen is effective for 40-80

minutes while a person is swimming [or is sweating]

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9
Q

How long should you apply insect repellant after you apply sunscreen

A

30 minutes

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10
Q

When does sunscreen expire

A

36 months after manufactured date

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11
Q

Effects of Sun exposure

A

 Photoaging refers to damage done to the skin from
prolonged exposure to UV radiation—throughout one’s
lifetime
 Normal skin changes of aging are exacerbated by sun
exposure
 Photoaging includes—dark spots, wrinkles, droopy
skin, yellowish tint to the skin, blood vessels that are
fragile and break easily, leathery skin, skin cancers

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12
Q

skin phototype I

A

-Pale white skin; blue/hazel eyes; blonde
or red hair

-Always burns; does not
tan

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13
Q

skin phototype II

A
  • Fair skin with blue eyes

- burns easily, tans rarely

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14
Q

skin phototype III

A
  • darker white skin

- tans after initial burn

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15
Q

skin phototype IV

A
  • light brown skin

- burns minimally, tans easily

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16
Q

skin phototype V

A
  • brown skin

- rarely burns, tans darkly with ease

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17
Q

skin phototype VI

A
  • dark brown or black

- never burns; tans darkly

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18
Q

Glucocorticoid Prescribing

A

 Steroids work via intracellular receptors; they
initiate several transcriptions—inhibition of
arachidonic acid cascade, decrease production of
many cytokines and inflammatory cells
 Potency is based on vasoconstriction—most potent
[VII] to least potent [I]

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19
Q

Tachyphylaxis

A

Decrease in response with repetitive use or recurrance
of s/s when drug stopped; giving drug holiday can
reduce chance of this phenomenon

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20
Q

Adverse effects of glucocorticoids

A

 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

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21
Q

Low potency glucocorticoids

A 
-Alclometasone dipropionate
.05% [C, O]
-Clocortolone pivalate .1%
[C
-Flucinolone acetonide .01%
[S]
-Hydrocortisone base or
acetate .25-2.5% [O, C]
-Triamcinolone acetonide
.025% [C, L, O]
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22
Q

Intermediate potency glucocorticoids

A 
-Betamethasone
dipropionate .05% [C]
-Desonide .05% [C, L, O] H
-Desoximetasone .05% [C]
-Fluocinolone acetonide .025% [C, O]
-Flurandrenolide .025% - .5% [C, O]
-Fluticasone propionate .005%- .05% [O, C]
-Hydrocortisone butyrate .1%
[C, O, S]
-Hydrocortisone valerate .2% [C, O]
-Mometasone furoate .1% [C,O, L]
-Triamcinolone acetonide .1-
.2% [C, O]
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23
Q

High Potency glucocorticoids

A

-Amcinonide .1% [C, L, O]
-Betamethasone dipropionate
augmented .05% [C, L]
-Desoximetasone .05% [O]
-Diflorasone diacetate .05% [O, C]
-Halcinonide .1% [C, O]
-Triamcinolone acetonide .5% [C, O]
-Fluocinonide .05% [C, G, O, S]

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24
Q

High potency glucocorticoids

A
  • Betamethasone dipropionate .05% [O, G]
  • Clobetasol prionate .05% [C, G, O]
  • Diflorasone diacetate .05% [O]
  • Fluocinonide .1% [C]
  • Flurandrenolide .05% [L]
  • Halobetasol .05% [C, O]
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25
Q

Patho of acne vulgaris

A

 Excess sebum
 Comedones
 Propionibacterium acnes overgrowth
 Inflammation

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26
Q

How is acne vulgaris classified

A

 Disease classified as
-Comedones, pustular/papular and nodular

 Disease further subdivided as→

  • Mild—comedonal, pustular/papular
  • Moderate—pustular/papular, small nodules [up to1 cm]
  • Severe—nodular, cystic/pustular [also called acne conglobate]
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27
Q

Retinoids

A

 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

 Prototype Drug
» Tretinoin—1st generation agent

 Other agents
>>Isotretinoin—1st generation
agent—category X agent—must be prescribed by licensed providers—I Pledge
-Oral agent
- Used in scarring acne and in
severe disease

Adapalene / Tazorac—3rd generation agent—less irritating
 1st line for comedonal and inflammatory acne

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28
Q

Benzoyl Peroxide

A

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

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29
Q

Salicylic Acid

A

 A Beta hydroxy acid, penetrates pilosebaceous unit
 MOA—exfoliates to clear comedones; mild antiinflammatory activity and is keratolytic at high concentrations
 For mild disease
 Adverse effects—peeling, dryness, local irritation

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30
Q

Azelaic Acid

A

 Antibacterial against P acnes and it has antiinflammatory actioins
 Normalizes keratinization and it anticomedogenic
 Used in mild to moderate inflammatory acne
 Adverse effects include skin irritation

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31
Q

Antibiotics

A

 P acnes is a gram + rod associated acne

 For moderate to sever 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

 Topical Dapsone [a sulfonamide] is available

> > MOA is unknown—side effects have been reported— methylhemaglobinemia

 Moderate to severe acne requires ORAL antibiotics— Doxycycline [preferred] or Minocycline

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32
Q

Treatment of Acne

A

 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

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33
Q

Selection of agents for mild acne vulgaris

A

 If presentation is mainly comedones—treatment of
choice is topical retinoid
 If presentation is papular/pustular—treatment of
choice is topical retinoid + benzoyl peroxide [BPO] OR
topical retinoid + BPO/antibiotic combination

34
Q

Selection of agents for moderate disease

A

 For Moderate Disease
 For papular/pustular disease—topical retinoid
+ oral antibiotic & BPO [can add OCP in ⧬ ]
 For nodular disease— topical retinoid + oral antibiotic & BPO [or BPO/antibiotic]
 Alternative—Isotretinoin orally

35
Q

Selection of agents for severe disease

A

 For Severe Disease
 For nodular—oral antibiotic and topical retinoid + BPO [can add OCP in ⧬]
 Alternative—Isotretinoin oral
 For cystic/pustular—oral Isotretinoin [Accutane]
 Alternative is high dose oral antibiotic and topical retinoid + BPO [+ OCP in ⧬]

36
Q

Considerations to Prescribe Isotretinoin

A

 Requires prescribers be trained and registered—
have a federal ID number [based on your NPI and
completion of training]

37
Q

Rosacea

A

 Description
> Chronic acne-like inflammation of central area of face, yet no comedones are present

 Etiology
> Cutaneous vascular disorder of capillaries
» Increased reaction to heat causes “flushing”
» Ocular symptoms may include blepharitis, conjunctivitis

 Incidence/Demographics

  • Common in fair skinned, middle aged to elderly people
  • Severe form with rhinophyma is seen almost exclusively in men >40 years

> > Irreversible hypertrophy of the nose, rhinophyma, is a result of chronic inflammation, and it is seen almost exclusively

38
Q

Prescriptions for Rosacea

A

 Sodium Sulfacetamide
[10%] with Sulfur 5%
- Usually prescribed as a daily wash

 Topical Metronidazole
[MetroGel]
- This agent is considered DOC
- Safe in pregancy

 Azelaic acid [Finacea]
- Effective for papules, pustules, erythema [does not
deter telangiectasias]
- Safe in pregnancy

 Oral Doxycycline

  • > > Writing the Rx…
  • BID Topicals
    • Metronidazole 0.75%
    • Erythromycin 2%
    • Clindamycin gel

 Oral Agents—Doxycycline 50- 100 mg @ HS for 4 weeks or Erythromycin 250 mg BID

 Response usually seen in 4 weeks, maximum response from one regimen may take up to 9 weeks

 Requires long term maintenance treatment

39
Q

Actinic Keratosis

A

 Discrete, dry, scaly lesions occurring on sunexposed skin of susceptible adults
 Precursor to squamous cell carcinoma [SCC]
 Etiology
-Recurrent or prolonged sun-exposure in skin photo types I, II and III
 Common in elders from photoaging of skin
 More common in males
 Appears in middle adulthood—earlier in Australia and southwestern US
 Lesions begin as single or multiple discrete adherent hyperkeratotic scaly lesions; near 1 cm in size— round/oval in shape; color ranges from light tan to brown with or without reddish tinge
 25% spontaneously regress, 1% progress to SCC [NIH,
2010]

40
Q

Topical therapies for actinic keratosis

A

 Topical Therapies
 Efudex [5-flourouracil]—twice daily for 3-4 weeks
 Side effects—redness, crusting, intense stinging
 Aldara [Imiquimod]—3 to 5 applications per week for 1-2 months
 Side effects—similar to Efudex

41
Q

5 Flourouracil

for actinic kerasosis

A

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

42
Q

Imiquimod

for actinic kerasosis

A

aka Aldara

 5% cream; apply 3 times per week @ hs for up to 16 weeks [MOA is unknown—immune modulator]

43
Q

Non-medication treatments for actinic keratosis

A

 Cryotherapy, curettage, photodynamic therapy,

facial resurfacing, medium depth chemical peels

44
Q

Allergic Dermatitis

A

 Global term that may be referring to atopic
dermatitis [eczema] or allergic contact dermatitis
 Inflammation of epidermis and dermis that causes
profound pruritus—often termed “the itch that
rashes”
 Chronic disorder; genetic linked—made worse by
emotional stress, hormonal variation
 These individuals often have marked allergies to food,
medications, pollens and the like
 Lesions often appear in first year of life

45
Q

Treatment for Atopic Dermatitis

A

> > Treated with a regimen of emollients, topical steroids [ointment preparations] +/- topical immune modulators [such as tacrolimus]
 Topical steroids—refer to earlier slides

 Calcineurin Inhibitors—refer to slide in psoriasis section [of this slide set]

 Tacrolimus ointment [.1%, .03%] [Protopic]

 Pimecrolimus cream [Elidel]

  • 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
46
Q

Plantar Warts

A

 Small, usually painless growths on the skin caused human papillomavirus [HPV]; generally harmless—they can itch or hurt if on plantar aspect of the feet
 Different types of warts—common warts are usually on hands, but can appear anywhere
 Flat warts—often found on face and forehead; common, in children, rare in adults
 Genital warts—also known as condyloma— seen on genitals, in pubic area, and in between the thighs, but can appear inside the vagina and anal canal
 Subungual and periungual warts—appear around the fingernails and toenails
 Plantar warts are found on soles of feet [NIH, 2009]

47
Q

Plantar wart treatments

A

 OTC wart removal products—patients should try and file the wart down after bathing before applying the agent

 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]

 Other prescription agents
—Podophyllin 0.5% solution; apply
BID for 3 days; off 4 days; can repeat until cleared [MOA is unknown; inhibits cell mitosis] or
– Imiquimod [Aldara] 5% cream;
apply 3 times per week @ hs for up to 16 weeks [MOA is unknown—immunomodulator]

 Other treatments—surgical removal, cryotherapy,electrocautery or laser [NIH, 2009]

48
Q

Alopecia

A

 Trichogenic agents are used to treat androgenic alopecia [male pattern baldness]

> > > Minoxidil—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

> > Finasteride—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

49
Q

Pigment Skin Disorders that are Treated

A

 Freckles and Melasma (Hyperpigmentation disorders)

 Vitiligo (Hypopigmentation disorder)

50
Q

Meds for pigment skin disorders

A
  1. Protoype Drug— Hydroquinone
     Topical skin whitening agent; it inhibits the tyrosinase enzyme required for melanin synthesis
     Used to reduce pigmentation—along with topical retinoids
     4% preparation is best agent [2-3% may be available in
    your area as OTC products]
     Adverse effects—local skin irritation
  2. Monobenzone—benzyl ether of Hydroquinone—this agent can be used to even out the skin discoloration of
    vitiligo
  3. Methoxsalen—photoactive substance [psoralen] that stimulates melanocytes; used as a repigmentation agent for vitiligo
     Must be activated by UVA radiation [PUVA]
     This agent inhibits cell proliferation & promotes cell differentiation of epithelial cells; topical may be used for small patches of vitiligo; oral used for widespread disease
     Adverse effects—aging of the skin and increased risk of skin cancer
51
Q

Common bacterial infections of the skin

A

 Staphylococcus aureus [MSSA and MRSA strains]
 Streptococcus pyogenes [Group A beta-hemolytic]
 Streptococcus agalactiae [Group B]
 Gram negative bacilli or anaerobes such—Escherichia coli, Pseudom

52
Q

Treatment for gram + infections

A

 Bacitracin—used most often for prevention of skin disease after burns and scrapes

 Mupirocin—protein synthesis inhibitor
- Useful for treating impetigo and other serious gram + skin infections—including MRSA Staph aureus

 Retapamulin—newer protein synthesis inhibitor approved for the treatment of impetigo

53
Q

Treatment for gram - infections

A

 Polymyxin B—cyclic hydrophobic peptide that disrupts the bacterial cell membrane of gram negative pathogens
– Commonly combined with Neomycin** & Bacitracin in triple antibiotic [TAO] products

 Gentamycin can be used to treat skin infections caused by gram negative bugs such as Pseudomonas, E. coli and Klebsiella species

 **Allergic dermatitis and other sensitivities common with Neomycin

54
Q

When systemic agents are needed for bacterial infections

A

 Augmentin 875 mg BID for 7 days [or high dose Amoxicillin]
 Cephalexin 250-500 mg QID for 7 days
 Doxycycline 100 mg BID for 7 days [Sanford, 2013]

 If MRSA suspected—Trimethoprim/Sulfa DS [2] BID or Doxycycline 100 mg BID
 Clindamycin 300 mg q6h or Rifampin if infection severe [Sanford, 2014]
 Fluoroquinolones might be an option—depending on your geographical area—Levofloxacin 500 mg QD or Moxifloxacin 400mg QD

55
Q

Ectoparasitic Infections

A

 Parasites that live on animal skin [where they obtain their nutrition] and can jump “species” and infect the human
 Pediculosis—lice
 Scabies—mite
 Agents we use in these infections—Lindane, Permethrin, Synergized pyrethrins with piperonyl butoxide

56
Q

Antiparasitic agents

A

 Lindane—cyclohexane derivative [Kwell; brand no longer available]
 Available as cream or shampoo; kills lice & scabies
 Permethrin—synthetic pyrethroid that is neurotoxic to lice [1% OTC] [Nix] and scabies [5% prescription] [Elimite]
 Preferred over Lindane, as Lindane can cause neurotoxicity
 Ivermectin—given orally, is an alternative therapy for lice and scabies [Stromectol; comes in topical—Soolantra]
 Synergized pyrethrins with piperonyl butoxide—OTC product used to treat head and pubic lice [Rid]
 Pyrethrins are pesticides; piperonyl butoxide prevents lice from
metabolizing the pyrethrins, making them more potent
 Low risk of toxicity; DOC for pediculosis

57
Q

Treating Fungal Infections: yeast- candida species

A

Albicans; Glabrata; Tropicalis

58
Q

Treating Fungal Infections: non yeast fungal infections–dermatophytes {tinea}

A

 Most common—Trichophyton, Microsporum, Epidermophyton, Malassezia [previously called
Pityrosporum]

 Tinea is classified by area of body it affects—tinea pedis [tinea on feet]

 Tinea appears as rings or round red patches with clear centers [often called “ringworm”]

59
Q

Dermatophytosis

A

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

60
Q

Candidiasis

A

 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 [NIH, 2010]

61
Q

Squalene Epoxidase Inhibitors: Terbinafine [Lamisil]

A

 Prototype drug—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
 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

62
Q

Squalene Epoxidase Inhibitors: Naftifine [Naftin]

A 
 Naftifine [Naftin]
-- 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
63
Q

Squalene Epoxidase Inhibitors: Butenafine [Lotrimin Ultra]

A

 Butenafine [Lotrimin Ultra]
 Active against Trichophyton, Epidermophyton, Malassezia
 Same indications as Naftin; 1% cream BID for 2 week

64
Q

What do Squalene Epoxidase Inhibitors do?

A

 These agents block the biosynthesis of ergosterol— which is needed in the fungal cell membrane
 Accumulation of toxic amounts of squalene causes increased cell membrane permeability & death

65
Q

Griseofulvin

A

 This agent disrupts the mitotic spindle and inhibits fungal mitosis
 Older agent—has been replaced for the most part by Terbinafine, but still used for dermatophytes of scalp and hair
 Agent is fungostatic—so duration of treatment is long—
500 mg po daily 6 to 12 months for nails
 Absorbed from GI tract, enhanced by high fat meal
 It increases the metabolism of anticoagulants
 Contraindicated in pregnancy and patients with porphyria

66
Q

Nystatin

A

 This agent is a polyene antifungal—MOA is much like that of Amphotericin B
 Used for treatment of cutaneous and oral Candida infections
 Negligibly from GI tract; not used systemically because it causes toxicity
 For oral-pharyngeal infection—it is given as a swish & swallow regimen [QID for 7-10 days]; used topical for cutaneous infections [BID for 7-14 days]; intravaginally
for vulvovaginal infections [at HS for 3-7 days]

67
Q

Imidazoles

A

 Azole derivatives that have a wide range of activity against the 4 most common dermatophytes and
Candida species
 These agents are given for tinean corporis, cruris and pedis; oral/pharyngeal & vaginal Candida
 Prolonged topical use can cause contact dermatitis, vulvovaginal irritation/edema
 Clotrimazole and Miconazole both come in a troche/buccal forms
 The only AZOLE that covers Candida glabrata is terconazole [Terazol]

68
Q

Examples of Imidazoles

A 
 Butoconazole—Gynazole-1
 Clotrimazole—Mycelex; Lotrimin AF
 Econazole—Spectazole
 Ketoconazole—Nizoral
 Miconazole—Desenex; Micatin;
Monistat Derm; Zeasorb AF [powder]
 Oxiconazole—Oxistat
 Sertaconazole—Ertaczo
 Sulconazole—Exelderm
 Terconazole—Terazol [vaginal]
 Tioconazole—Monistat [vaginal]
 Fluconazole—Diflucan [oral]
 Itraconazole—Sporanox [oral]
69
Q

Ciclopirox

A

 Agent inhibits transport of essential elements that allow DNA, RNA and protein synthesis
 Active against Trichophyton, Epidermophyton,
Microsporum, Candida and Malassezia
 Only topical antifungal active against ALL
dermatophytes and all strains of Candida
 Used for tinea pedis, corporis & cruris, cutaneous candidiasis and tinea versicolor
 Available in shampoo [1%] for seborrhea dermatitis; .77% cream, gel or suspension [Loprox]; topical for nails [Penlac]
 Not used for vaginal candidiasis

70
Q

Tolnaftate

A

 This agent distorts the hyphae and stuns mycelial growth
 Active against Epidermophyton, Microsporum, Malassezia; NOT effective for Trichophyton or Candida
 Used to treat tinea pedis, cruris & corporis
 1% solution, cream, powder BID for 2-4 weeks
 Tinactin; Lamisil AF Defense

71
Q

Newest Agents

A

 Onychomycosis best treated with oral Lamisil
 Within last year, 2 topicals with reasonable efficacy have come to market
 Boric acid key component of both!!
 Efinaconazole—an azole that is pegelated in a boric acid solution—Jublia 1-2 gtts to each affected nail for 48 weeks
 Tavaborole—new compound based on boric acid that penetrates nail/plate and polish—Kerydin—paint on nail and under tip at HS for 48 weeks

72
Q

Candida—Writing the Rx….

A

» Vaginal infections
 Oral fluconazole [Diflucan 150 mg] x1
» Options for cutaneous Candidiasis [use these agents 2x daily]
 Imidazole topical cream, solution, powder
 Clotrimazole 1 % cream; Miconazole 2% cream
 Ketoconazole 2% cream; Econazole [Spectazole] 1% cream;
Terconazole [Terazol] 0.4-0.8% cream
 Terbinafine [Lamisil] 1% cream, solution
 Tolnaftate [Tinactin] 1% cream, solution, powder
» Oral antifungals may be needed in extensive infection
 Oral
- Treat for 10-14 days
- Nystatin oral suspension 500,000 units S/S QID
- Clotrimazole 10 mg troches 3-5x/day
- Systemic ketoconazole 200 mg QD to BID
- Fluconazole 100-200 mg QD to BID
- Amphotericin B 3 mg/kg/day given IV for resistant cases in compromised hosts

73
Q

Psoriasis

A

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

 Chronic, scaling papules and plaques

 Usual distribution is knees, elbows,nscalp

 Silvery-white scaling with pinpointnbleeding when scale removed

 Assess quality of life—ask aboutnpain

 Important nondrug therapies—avoidnrubbing/scratching; advise patient to eat a healthful diet, exercise and
lose weight, stop smoking [if applicable]

74
Q

Drugs Used to Treat Psoriasis

A

 Patients with mild to moderate disease [<5% of BSA and not involving palms or soles] can be managed with topicals—retinoids, Vitamin D analogues, keratolytics, topical steroids
 For more severe disease—systemic therapies— Methotrexate, Cyclosporine, immune modulators
 If patient not a candidate for the aforementioned— phototherapy [Methoxsalen + UVA [PUVA] OR UVB
alone]

75
Q

Retinoids used in psoriasis

A

 Tazarotene [Tazorac]—topical retinoid for plaque psoriasis

 Acitretin [Soriatane]—2 nd generation retinoid; given PO for pustular 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—cheiliitis, pruritus, peeling skin, hyperlipidemia

76
Q

Vitamin D analogues fo psoriasis

A

 These agents inhibit growth of keratinocytes
» Calcipotriene [Dovonex; Taclonex if combined with Betamethasone] and Calcitriol [generic 3 mcg/g ointment]
- 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

77
Q

Keratolytic Agents for psoriasis

A

 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

78
Q

Other Topical Agents for psoriasis

A
  1. Corticosteroids and immunenmodulators

2. Calcineurin Inhibitors

79
Q

Other topical agents for psoriasis : Corticosteroids and immune
modulators

A 
 Corticosteroids and immune
modulators—suppress the
dysregulated immune response
 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
80
Q

Other topical agents for Psoriasis : Calcineurin Inhibitors

A

 Calcineurin Inhibitors
 Tacrolimus [Protopic]
 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 [keyncytokines in a ramped up Tcell response]
 Steroid sparing agents; usedm in flexural and facial
psoriasis

81
Q

Systemic Therapies for Psoriasis

A

 If unresponsive to topicals
or BSA >5%

  1. Apremilast [Otezla]
    - Phosphodiesterase 4 inhibitor
  2. Methotrexate
    - With Folic acid 1-5 mg/d
  3. Cyclosporine
  4. TNF Alpha Blockers
    - Adalimumab [Humira]
    - Etanercept [Enbrel]
    - Infliximab [Remicade]
  5. Interleukin IL-12 & IL 23
    Blocker
    - Ustekinumab [Stelara]
  6. Interleukin IL-17A Blocker
    - Secukinumab [Cosentyx]
  7. Phototherapy
    - Can be uses with topicals
    - PUVA [Psoralen with UVA light]
    - Narrow band UVB therapy

Advanced Pharmacology (18 decks)

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