Pharm: Potpourri

Question 1

Lice - identify the drugs considered pediculicides

Answer 1

• pyrethroids
• malathion
• benzyl alcohol
• Spinosad
• ivermectin

Question 2

Lice - what is the choice for initial therapy in areas with low resistance?

Answer 2

Pyrethroids

Question 3

Lice - tx timeline with pediculocides

Answer 3

a second treatment is required in 7-9 days to treat nits from eggs for all pediculocides except ivermectin

Question 4

Lice - in which patients should pyrethroids be avoided?

Answer 4

in patients allergic to ragweed and chrysanthemums

Question 5

Lice - MOA of malathion

Answer 5

It is a pediculicide and ovicide

Question 6

Lice - age indication for pyrethrin and permethrin?

Answer 6

• Pyrethrin: okay for patients ≥ 2 years old

* Permethrin: okay for patients ≥ 2 months old

Question 7

Lice - age indication for malathion?

Answer 7

• contraindicated in kids < 2 y/o

- studies on safety in kids < 6 are limited

Question 8

Lice - age indication for benzyl alcohol, spinosad, and topical ivermectin?

Answer 8

• Benzyl Alcohol: used for patients ≥ 6 months old
• Spinosad: not recommended for kids < 6 months old
• Topical Ivermectin: no established safety in infants < 6 months old

Question 9

Lice - MOA of benzyl alcohol

Answer 9

• asphyxiation of lice
• benzyl alcohol paralyzes the louse respirator spiracles in an open state and mineral-oil-containing vehicle obstructs spiracles

Question 10

Lice - MOA of Spinosad

Answer 10

Compromises CNS of lice by interfering with nicotinic acetylcholine receptor, resulting in neuronal excitation and paralysis

Question 11

Lice - MOA of ivermectin

Answer 11

Induces paralysis and death of mice

Question 12

Lice - what is the drug of choice for drug of choice for refractory lice infestations?

Answer 12

Oral ivermectin

Question 13

Lice - dosing of ivermectin

Answer 13

• based on weight (not recommended if < 15kg)

- dose every 7 days for 2 doses, so take a pill on day 1 and then day 8

Question 14

Scabies - what is 1st line tx?

Answer 14

permethrin cream and oral ivermectin

Question 15

Scabies - what is the first line agent for large outbreaks?

Answer 15

1st line = oral ivermectin (200mcg/kg/dose—2 doses)

Question 16

Hidradenitis suppurativa - treatment goals

Answer 16

• Prevent formation of new lesions and thus reduce extent/progression of disease
• Treat new lesions quickly and effectively to prevent development of chronic sinuses
• Eliminate existing nodules/sinus tracts to limit/prevent scar formation

Question 17

Hidradenitis suppurativa - what abx are used to treat mild HS/AI

Answer 17

*1st line is topical clindamycin

Other treatment:

• Topical resorcinol: topical 15% resorcinol cream
• Intralesional corticosteroids (triamcinolone acetonide): useful adjunct therapy
• Systemic antibiotics: doxycycline, minocycline

Question 18

Hidradenitis suppurativa - MOA and clinical action of resorcinol

Answer 18

• Topical chemical peeling agent with keratolytic and anti-inflammatory actions
• Reduces pain and promotes healing of lesions

Question 19

Hidradenitis suppurativa - what is the purpose of intralesional steroids and systemic antibiotics for mild HS/AI?

Answer 19

• intralesional corticosteroid: useful adjunctive therapy for reducing symptoms
• -intent of treatment: accelerate resolution of early, painful inflammatory lesions
• systemic antibiotics: can quiet intermittent, acute flares in patients with mild disease

Question 20

Hidradenitis suppurativa - what are the first line antibiotics for moderate (stage II) HS/AI?

Answer 20

• Tetracyclines: tetracycline, doxycycline, minocycline

- Erythromycin/cephalosporin also used for long-term antibiotic treatment

Question 21

Hidradenitis suppurativa - what are the second line antibiotics for moderate (stage II) HS/AI?

Answer 21

If failure to respond to conventional antibiotic therapy: combination therapy with clindamycin and rifampin

Question 22

Hidradenitis suppurativa - what are the ADR for clindamycin and rifampin?

Answer 22

• MC: diarrhea
• C-dif specifically with clindamycin
• Orange discoloration of bodily secretion with rifampin

Question 23

Hidradenitis suppurativa - what is the oral retinoid of choice for HS/AI?

Answer 23

acitretin (soriatane)

Question 24

Hidradenitis suppurativa -what are the antiandrogens used for stage II HS/AI?

Answer 24

Cyproterone, spironolactone, finasteride

Question 25

Hidradenitis suppurativa - what are the contraindications for using antiandrogens during pregnancy?

Answer 25

Risk of adverse effects on the fetus

Question 26

Hidradenitis suppurative - what is the contraindication with finasteride?

Answer 26

contraindicated in women of childbearing capacity

Question 27

Diaper dermatitis - select appropriate barrier products to prevent and treat

Answer 27

- barrier preparations physically block chemical irritants/moisture from contacting skin and minimize friction - pastes/ointments generally better than creams/lotions - MC OTC barriers contain petrolatum, zinc oxide, or both. -Some contain lanolin, paraffin, dimethicone

Question 28

Diaper dermatitis - choose the appropriate use of topical corticosteroids for treatment

Answer 28

Low potency topical corticosteroid reduce inflammation

Question 29

Diaper dermatitis - which corticosteroids should you avoid??

Answer 29

Use of potent/fluorinated corticosteroids should be avoided because occlusion in area promotes systemic absorption and can cause adrenal suppression/iatrogenic Cushing disease

Question 30

Diaper dermatitis - select the appropriate use of topical antifungal agents

Answer 30

Topical antifungal agents good for diaper dermatitis caused secondarily from candida infection: - clotrimazole - miconazole - ketoconazole - sertaconazole

Question 31

Diaper dermatitis - list the harmful products or ingredients that should be avoided in the prevention or treatment

Answer 31

- powders like cornstarch/talcum powder: significant respiratory risk if aspirated - baking soda/boric acid powders: risk of systemic toxicity with percutaneous absorption - topical barriers/meds that contain fragrance, preservatives, etc. have allergic potential - containing boric acid, camphor, phenol, benzocaine, salicylates avoided because potential for systemic toxicity or methemoglobinemia

Question 32

Diaper dermatitis - what are the preventative behaviors?

Answer 32

Minimize direct skin contact with urine/feces with frequent diaper change/gentle cleansing of diaper area

Question 33

Diaper dermatitis - what is the appropriate antibiotic to treat a bacterial superinfection?

Answer 33

* Topical/oral antibiotics - Localized/mild: topical mupirocin (Bactroban) - Severe infection: oral antibiotics

Question 34

Seborrheic dermatitis - what are the treatments for dandruff?

Answer 34

- OTC antidandruff shampoo containing selenium sulfide 2.5% or zinc pyrithione 1-2%, coal tar, salicylic acid - rotation of different shampoo improves/maintains efficacy of these formulations

Question 35

Seborrheic dermatitis - what is the best treatment regimen for the scalp?

Answer 35

- Antifungal shampoo: selenium sulfide 2.5%, ketoconazole 2%, ciclopirox 1% - -Use medicated shampoo once weekly to prevent relapse - High-potency topical corticosteroid (Group 3 to 1): controls inflammation and itching - -Fluocinolone acetonide 0.01%

Question 36

Seborrheic dermatitis - what is the best treatment regimen for the face?

Answer 36

- Low-potency (group 6-7) topical corticosteroid cream, topical antifungal agent, combination of both - For long-term control: topical antifungal cream to involved area 1x/wk - Long-term continuous use of even mild topical steroids- permanent telangiectasia and atrophy - In men: consider ketoconazole 2% shampooing of facial hair daily until remission (then drop to once/week) - Low-potency (group 7) topical corticosteroid can be added initially

Question 37

Seborrheic dermatitis - what is the best treatment regimen for the trunk/intertriginous areas?

Answer 37

- Mild-potency (group 4-5) topical corticosteroid cream, topical antifungal, combination of both - Apply to affected area 1-2x/day until symptoms subside - Long-term control: topical antifungal cream to area 1x/week

Question 38

Tinea capitis - what is first line therapy?

Answer 38

- Griseofulvin: 1st line based on drug efficacy | - Terbinafine: alternative 1st line because of evidence that need shorter treatment

Question 39

Tinea capitis - what is second line therapy?

Answer 39

Fluconazole and itraconazole - effective, less frequently used

Question 40

Tinea capitis - which antifungal should not be used??

Answer 40

Ketoconazole

Question 41

Tinea capitis - what is the adjunctive therapy?

Answer 41

shampoo with antifungal properties (selenium sulfide, ciclopirox, ketoconazole) at least 2x/week to decrease shedding of fungal spores

Question 42

Tinea capitis - what are the duration of therapy and administration instructions for griseofulvin?

Answer 42

- it is available in microsize formulation as tablets or suspension and in ultramicrosize formulations in tablets - treatment regimen based on weight: 10mg/kg (5-15mg/kg for ultramicrosize) - treatment duration: up to 12 weeks

Question 43

Tinea capitis - what are the duration of therapy and administration instructions for terbinafine?

Answer 43

-oral is commercially available as granules or tablets -Granule: swallowed with food, can be sprinkled onto non-acidic food -Tablet: can be taken without regard to meals -Timeframe: 6 weeks < 25 kg: 125 mg 1x/day 25-35kg: 187.5 mg 1x/day > 35kg: 250 mg 1x/day

Question 44

Tinea capitis - how do you manage household contacts?

Answer 44

- Household members should be physically examined for signs and should be treated simultaneously if tinea capitis is detected - Asymptomatic carriers of dermatophytes serve as reservoirs for recurrent infections - Household members begin antifungal shampoo when infected individual begins - Avoid sharing hair care tools, pillowcases, head-to-head contact sports, bedding/towels - Pets/animals are reservoirs for infection. Evaluate by vet if show and signs of infection

Question 45

Atopic dermatitis - what are the nonpharm treatments that can help control pruritus?

Answer 45

- tepid baths, wed dressings/wraps, emollients applied to skin - meds: sedating/non-sedating antihistamines, topical calcineurin inhibitors - skin hydration: lotions with low/zero water content better protect (patient may complain it’s greasy); emollients applied 2+x/day after bathing/hand-washing

Question 46

Atopic dermatitis - what is the therapy for mild to moderate atopic derm?

Answer 46

- Initial: topical corticosteroids and emollients (liberally used before/after steroids) - Corticosteroid potency choice based on age, body area involved, degree of inflammation - Mild: group 5-6 - Others: topical calcineurin inhibitors as alternative (esp. for face)

Question 47

Chronic hand eczema - what methods decrease irritation?

Answer 47

- Harsh soaps should be avoided, wash with lukewarm water and mild unscented, fragrance-free soap, dry with pat dry - Hand washing/drying followed by application of heavy hand cream/ointment

Question 48

Chronic hand eczema - what methods protect skin?

Answer 48

- personal protective equipment (gloves used to cook, garden, clean) - vinyl/non-latex gloves suitable for routine exposures - moisturizers/skin barrier repair creams

Question 49

Chronic hand eczema - what is the best treatment regimen for mild-moderate disease?

Answer 49

- high-potency or super high-potency (group 1-3) topical corticosteroids as 1st line; apply 1-2x/day for 2-4 weeks - emollients applied liberally many times/day - maintenance: high/super high topical corticosteroids 2-3x/week to prevent relapse - long-term use may cause skin atrophy

Question 50

Chronic hand eczema - what is alternative treatment regimen?

Answer 50

topical calcineurin inhibitor (tacrolimus 01% oint) if don’t respond to topical corticosteroids of have contact allergy to topical corticosteroids

Question 51

Chronic hand eczema - how do you treat severe-recalcitrant disease?

Answer 51

if don’t respond to super-potent topical corticosteroids - systemic therapies (ex: oral corticosteroids, immunosuppressants, retinoids, phototherapy with narrow-band UVB or psoralen plus ultraviolet A-PUVA)