18 - Dermatology Common Drugs Flashcards

1
Q
A
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2
Q

What are some of the different formulations of emollients and what are they prescribed for?

A

Formulations

  • Aqueous cream,
  • Ointment
  • Liquid paraffin
  • White soft paraffin in equal parts (50:50)

Indications

  • Rehydrate skin and re-establish the surface lipid layer
  • Useful for dry, scaling conditions and as soap substitutes
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3
Q

What are some of the adverse effects of emollients?

A
  • Irritant or allergic reactions due to perfumes or preservatives
  • Flammable if contain paraffin
  • –Pump dispensers minimise the risk of bacterial contamination; if using a pot, use a clean spoon / spatula every time to reduce risk
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4
Q

What is the potency ladder with topical steroids?

A
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5
Q

What are some side effects of topical steroids for the treatment of eczema?

A
  • Skin atrophy
  • Telangiectasia
  • Striae
  • Acne
  • Perioral dermatitis
  • Allergic contact dermatitis
  • May mask / cause / exacerbate skin infections
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6
Q

What are some of the side effects of long term oral steroids use for eczema?

A
  • Cushing’s syndrome
  • Immunosuppression
  • Hypertension
  • Diabetes
  • Osteoporosis (give bone-protection alongside)
  • Cataracts
  • Steroid-induced psychosis
  • Fluid retention
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7
Q

Why should you avoid oral corticosteroids in psoriasis?

A
  • Risk of unstable disease
  • Can develop into pustular psoriasis
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8
Q

What are some of the side effects of anti-histamines used in eczema?

A

Sedating Antihistamines e.g Chlorphenamine

  • Sedation
  • Anticholinergic effects (e.g. dry mouth, blurred vision, urinary retention, constipation, acute angle closure glaucoma)
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9
Q

How is dermatitis herpatiformis diagnosed?

A

Skin biopsy

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10
Q

What is the summary of treatment for eczema? (ladder)

A

Treated as maintenance and flare ups

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11
Q

Why are topical calcineurin inhibitors used in the treatment of atopic eczema, how do they work and what are some examples of these?

A

- Steroid sparing agents when steroids are not controlling symptoms but the risk of side effects outweighs the benefits

  • Suppress overactivity of T-cells

- Tacrolimus Ointment (Protopic) if severe or Pimecrolimus cream (Elidel) if moderate

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12
Q

What are some side effects and contraindications of topical calcineurin inhibitors?

A

Side Effects

  • Skin irritation (e.g stinging/burning)
  • Photosensitivity
  • Increased risk of skin cancer and lymphoma

Contraindications

  • Do not use near eyes or mucous membranes
  • Do not use in infected areas or people susceptible to infections, e.g HSV, as increased risk of developing infection in area used
  • Immunodeficiency
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13
Q

What are some of the side effects of oral aciclovir?

A
  • GI upset
  • Raised liver enzymes
  • Reversible neurological reactions
  • Haematological disorders
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14
Q

What is the aim of prescribing anti-virals in shingles?

A

Reduce the incidence of post-herpetic neuralgia

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15
Q

What antibiotic class has a risk of TEN?

A

Penicillins

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16
Q

How do you explain to a patient how to apply topical calcineurin inhibitors?

A

Applied thinly twice a day when active eczema starts and then when cleared continued as a maintenance only twice a week.

Do not apply steroid cream to the same areas

Tacrolimus: Apply 2 hours after emollient

Pimecrolimus: Apply to dry skin then add emollient

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17
Q

Methotrexate is an immunosuppressant that can be used for eczema and psoriasis. How does it work and how is it taken?

A

Dihydrofolate reductase inhibitor, leading to nitric oxide synthase uncoupling and increased sensitivity of T cells to apoptosis, thereby diminishing immune responses

Only take ONCE A WEEK with folic acid co-prescribed

Can take 8-12 weeks to take effect

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18
Q

What is some pre-treatment screening and monitoring after starting that needs to be done with Methotrexate?

A

Pre-treatment: –Pregnancy test, FBC, U&Es, LFTs, Start contraception, ?CXR, ?Viral Serology

Monitoring (every 1-2 weeks initially then every 2-3 months): FBC, U+Es, LFTs

Report any signs of infection e.g sore throat

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19
Q

What are some side effects and contraindications for the use of Methotrexate in Psoriasis and Eczema?

A

Side Effects:

  • Bone marrow suppression (need to report any infection symptoms)
  • GI upset
  • Mouth ulcers
  • Liver and Lung fibrosis (rare but can develop if also got RA)

Contraindications

  • Immunodeficiency syndromes
  • Active infections
  • Taking trimethoprim can increase risk of bone-marrow suppression
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20
Q

What are some pieces of advice to give patients when starting methotrexate?

A

- Avoid live vaccines

- Highly teratogenic so both men and women should use contraception whilst using and for 6 months after stopping

- At increased risk of infections. If develop dry cough, diarrhoea, fever or any symptoms need to report as could be toxicity and bone-marrow suppression

  • Take care when using with trimethoprim as bone marrow suppression risk

- Avoid alcohol due to liver damage risk

  • Need folic acid co-prescribed
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21
Q

What patients taking methotrexate are at an increased risk of developing hepatotoxicity (liver fibrosis)?

A
  • Obesity
  • Diabetes
  • Alcohol
  • Higher dose of MTX
22
Q

Azathioprine is an steroid-sparing immunosuppressant that can be used off-licence for atopic eczema. What is some pre-treatment screening that needs to be done and monitoring that needs to be done after starting this drug?

A

Pre-treatment: TPMT levels as if low then risk of bone marrow suppression

Monitoring (at least every 3 months): FBCs, LFTs, U+Es

Takes 4-6 weeks to show effect so not useful for acute flares like ciclosporin is

23
Q

What are some side effects and contraindications for the use of Azathioprine?

A

Side effects:

  • Nausea, Diarrhoea, Loss of appetitie
  • Pancreatitis
  • Bone marrow suppression
  • Increased risk of skin cancers and lymphomas
  • ‘Flu-Like Symptoms’ due to allergy

Contraindications:

  • Low levels of TPMT
  • Do not have live vaccines
24
Q

Ciclosporin is a steroid-sparing immunosuppressant used in eczema and psoriasis. How does this drug work and why is this immunosuppressant sometimes preferred?

A

Inhibition of the production of cytokines involved in the regulation of T-cell activation. Calcineurin Inhibitor

  • Faster acting
  • Not as teratogenic so not so bad if fall pregnant
  • Can still drink alcohol
25
Q

What monitoring needs to be done whilst on ciclosporin?

A

Pretreatment: Need U+Es and blood pressure taken twice before starting

Monitoring:

  • BP, U+Es and Serum Creatinine every 3/12
  • LFTs
  • Investigate any persistent lymphadenopathy
  • Blood lipids before and after 1/12
26
Q

What are some of the side effects of ciclosporin?

A

SIDE EFFECTS INCREASE OVER TIME SO SHOULD ONLY USE FOR 12 MONTHS!!!!!!

  • Reduced renal function (long term)
  • Hypertension (long term)

–- Gingival hyperplasia

  • Hyperlipidaemia
  • Skin cancer
  • Hyperglycaemia
  • GI upset,
  • Fatigue and tremor
  • Hypertrichosis
27
Q

What are some contraindications for the use of ciclosporin?

A
  • Avoid live vaccines
  • Malignancy
  • Uncontrolled hypertension
  • Uncontrolled infections
28
Q

What are the different types of phototherapy used in psoriasis and eczema?

A

1. Broadband UVB (full UVB spectrum used): Psoriasis, Eczema but rarely used

2. Narrowband UVB (more effective): Severe Psoriasis & Eczema

3. PUVA (Psoralen+UVA): Psoriasis (if UVB not effective), Vitiligo, Cutaneous T-cell lymphoma

29
Q

What are some of the side effects of phototherapy?

A

–Short-term:

  • Sun burn
  • Dry itchy skin
  • Polymorphic light eruption (sunlight-induced rash)
  • Cold sores and Eczema Herpeticum
  • Initial worsening of skin disease

- Psoralen: Nausea so take with food

–

Long-term: Premature skin ageing, skin cancer

30
Q

What is the summary of treatment for psoriasis?

A
31
Q

What are some examples of Vit D analogues used in the treatment of psoriasis and how does this topical treatment work?

A

- –Calcipotriol, Tacalcitol, and Calcitriol

  • Can be combined with steroid in gel/ointment for short term use
  • –Help regulate the immune system and slow the overgrowth of skin in psoriasis
32
Q

What are some of the side effects of topical Vit D analogues in the treatment of psoriasis?

A

Usually consider very safe and effective!!

  • Can irritate sensitive skin areas e.g face and skin folds

- Cannot be used in pregnancy and breast feeding

  • Can cause hypercalcaemia so do not exceed weekly limit and do not use in pustular or erythrodermic psoriasis
33
Q

Apart from Steroids and Vit D analogues, what are some other topical treatments for Psoriasis?

A

Coal tar: good for scalp psoriasis, can stain, photosensitivity

Dithranol: may stain the skin purple/brown, put on for ten minutes then wash off, only apply to scales not normal skin

Calcineurin Inhibitors: Protopic

34
Q

What are the systemic treatments for psoriasis after topical and phototherapy treatments have failed?

A
  • Methotrexate (gold standard)
  • Ciclosporin
  • Acitretin (retinoid)
  • Apremilast
  • Dimethyl Fumarate
35
Q

Who is offered Acitretin in psoriasis patients and how does this work?

A
  • If not responded to phototherapy and topical treatments.
  • Also for papulopustular psoriasis on hands and feet
  • Can take alongside phototherapy treatment
  • Taken orally once a day with food

They do not suppress the immune system, they are a Retinoid (vitamin A analogue) that slow skin cell reproduction

36
Q

What are some contraindications for Acitretin?

A
  • Women of childbearing age NOT ON CONTRACEPTION. Stays in body for 2 years after stopping so not good if want children
  • Taking other Vit A based medications, Methotrexate, Salicyclic Acid, POP
  • Severe kidney or liver problems
37
Q

What are some side effects of Acitretin?

A
  • Birth defects (need contraception 1 month before and for 2 years after stopping)
  • Dry mucous membranes
  • Burning sensation or itching on the skin
  • Hair loss
  • Blurred vision
  • Muscle pain
38
Q

Apremilast is a systemic drug used in Psoriasis when other systemic treatments and phototherapy has failed. What is the mechanism of action of this drug?

A

Oral medication that is a PDE4 inhibitor to control the inflammatory process in the skin

Good for psoriatic arthritis

Can be used alongside methotrexate

39
Q

What are some of the side effects of Apremilast?

A
  • D+V
  • URTIs
  • Depression and suicidal thoughts
40
Q

When are biologics used in Psoriasis and what are some examples of the biologics used?

A

–Used when

  1. Phototherapy, Methotrexate, Ciclosporin and Acetretin have failed/contraindicated
  2. Psoriasis has a large impact on physical, psychological or social functioning
  3. Psoriasis is extensive or severely localised with functional impairment
41
Q

What are some side effects of biologics (both in use for eczema and psoriasis)?

A

Local: redness, swelling, bruising at the site of injection

Systemic: allergic reactions, flu-like symptoms, infections, hepatitis, demyelinating disease, heart failure, cancer, TB reactivation

42
Q

What is some essential pre-screening needed before initiating biologics?

A
  • Screen for TB, Hep B & C, HIV, VZV
  • CXR
  • Urine dip
43
Q

What are some tools used to define the severity of a patients Psoriasis?

A

Psoriasis Area Severity Index (PASI): used to measure the severity and extent of psoriasis

Dermatology Life Quality Index (DLQI): used to measure the impact a skin disease is having on a patients’ quality of life

44
Q

What is the summary of management for Acne Vulgaris?

A

Comedonal: Topical retinoid (Adapalene e.g) +/- benzoyl peroxide. If doesn’t work try Azelaic acid

Mild Pustular: Benzoyl peroxide (to reduce bacterial resistance) with either a topical retinoid OR topical antibiotic

Not responding to above or Severe: Combined topical PLUS systemic antibiotic e.g Tetracyclin or Macrolide if pregnant or <12. Try for 3/12. Could also try COCP (not POP, may make worse)

Still not responding: Oral Isotretinoin, High dose oral abx, Dianette

45
Q

What do you need to advise people who are being treated for acne?

A

Can take 6-8 weeks to start seeing effects

46
Q

What are some examples of topical antiseptics and topical antibiotics and what are their side effects?

A

Antiseptics: chlorhexidine, cetrimide, povidone-iodine

Antibiotics: fusidic acid, mupirocin (Bactroban), neomycin

Side effects: Local skin irritation/allergy

47
Q

What are some examples of oral antibiotics used for acne and what are their side effects?

A

Tetracyclines (Doxycycline, Lymecycline): teeth staining in <12 years, photosensitivity, Nausea

Macrolides (Erythromycin, Clarithromycin): GI upset

48
Q

Isotretinoin is used in severe acne that has not responded to other acne treatments. What is some pre-screening needed before starting this drug and monitoring needed once it is initiated?

A

Retinoid!!!! (Vit A derivative that decreases sebum production)

Pre-screen: Fasting lipids, LFTs, U+Es, Pregnancy test, Contraception at least 1 month before and 1 month after stopping

Monitoring: LFTs and Serum Lipids every 3/12, pregnancy test before every prescription

49
Q

Who is isotretinoin contraindicated in?

A
  • Hypervitaminosis A
  • Hyperlipidaemia
  • Pregnant
  • Take care when history of depression
  • Take care in diabetics
50
Q

What are some of the side effects of isotretinoin and some drugs that can interact with this drug?

A
  • Dry skin, lips, eyes
  • Photosensitivity (SPF 50 and cover up)
  • Depression and suicidal thoughts
  • Hepatotoxicity
  • Hyperlipidaemia
  • Myalgia
  • Teratogenicity
51
Q

What drugs have an increased risk of TEN?

A
52
Q

What are some side effects of antifungal medication?

A
  • Itching or burning
  • Nausea
  • Abdominal pain
  • Diarrhoea
  • Rash or allergic reaction