Drugs to skin disorders Flashcards

Question

Patho of acne vulgaris

Answer 1

 Excess sebum  Comedones  Propionibacterium acnes overgrowth  Inflammation

Answer 2

 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]

Answer 3

 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

Answer 4

 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

Answer 5

 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

Answer 6

 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

Answer 7

 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

Answer 8

 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

Answer 9

 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

Answer 10

 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

Answer 11

 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 ⧬]

Answer 12

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

Answer 13

 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

Answer 14

 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

Answer 15

 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]

Answer 16

 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

Answer 17

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

Answer 18

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

Answer 19

 Cryotherapy, curettage, photodynamic therapy, | facial resurfacing, medium depth chemical peels

Answer 20

 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

Answer 21

>>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

Answer 22

 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]

Answer 23

 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]

Answer 24

 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

Answer 25

 Freckles and Melasma (Hyperpigmentation disorders) |  Vitiligo (Hypopigmentation disorder)

Answer 26

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

Answer 27

 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

Answer 28

 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

Answer 29

 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

Answer 30

 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

Answer 31

 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

Answer 32

 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

Answer 33

Albicans; Glabrata; Tropicalis

Answer 34

 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”]

Answer 35

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

Answer 36

 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]

Answer 37

 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

Answer 38

```  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 ```

Answer 39

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

Answer 40

 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

Answer 41

 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

Answer 42

 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]

Answer 43

 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]

Answer 44

```  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] ```

Answer 45

 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

Answer 46

 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

Answer 47

 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

Answer 48

» 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

Answer 49

 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]

Answer 50

 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]

Answer 51

 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

Answer 52

 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

Answer 53

 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

Answer 54

1. Corticosteroids and immunenmodulators | 2. Calcineurin Inhibitors

Answer 55

```  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 ```

Answer 56

 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

Answer 57

 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

Drugs to skin disorders Flashcards

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