3. Dermatologic Pharm Flashcards
what are adverse effects of spironolactone
(contraindicated in preg)
menstrual irregularity, breast tenderness
minor GI symptoms
orthostatic hypotension
hyperK
dizzy, HA, Fatigue
Topical imidazoles block ergosterol synthesis, what are examples of these medications
Miconazole: cream/lotion; vaginal cream/suppository for vulvovaginal candidiasis
Clotrimazole: cream/lotion; vaginal cream/tablet for vulvovaginal candidiasis
Efinaconazole: onychomycosis treatment (give for 48 wks)
Ketoconazole: topical treatment for dermatophytosis & candidiasis; shampoo/foam for seborrheic dermatitis
what UV light therapy is used for moderate to severe psoriasis
UVB- (290-320 nm) radiation to point of erythema 3x/wk (+/-) topical tar; narrowband (311 nm) cause apoptosis of T cells at sub-erythema doses
PUVA- photochemotherapy - uses UVA - penetrate deep into skin w/o sunburn; ingest plant photosensitizer psorlen 2 hrs before treatment; 3x/wk - must protect from sun and have increased chance of melanoma
what do you need for adequate wound healing
oxygenation
nutrition
debridement
what is crisaborole
PDE4 inhibitor recently approved as topical therapy for dermatitis
what is the pathogenesis of follicular distention, rupture, inflammation in acne vulgaris
what type of skin would you use water based products labeled “noncomedogenic”
oily skin
to prevent acne
how does epidermal gorwth factor affect epithelialization
IT DOES NOT significantly improve epithelialization
what is the pharmacokinetics, MOA and effects of apremilast
take orally
MOA : (-) PDE4 –> increase cAMP in cell
effect = regulate inflam mediators, decrease NO synthase, TNF-alpha and IL23 & increase IL10
What are local anesthetics and what are they useful for
pramoxine 1-2.5% - OTC remedies alone w/ hydrocortisone ; use for pruritus on face & thats associated w/ CKD
lidocaine patch - for neuropathic pruritis
what is the ancient remedy for psoriasis?
tar
anti-prolif effects, largely displaced by less messy/odorous choices
can be useful adjunct for psoriasis
(topical tar used w/ UVB therapy)
what treatment is considered for melanoma
- surgical excision - w/ 1-2 cm margins, combined w/ sentinel node biopsy
- conventional chemo: Dacarbazine (+/- carmustine & tamoxifen) or (+/- cisplatin & vinblastin)
- MAP kinase pathway inhibitor- if BRAF V600D gene mutation present –> vemurafenib
what are the most/least resistant bacteria, viruses, protozoa & yeast?
What type of moisturizer do you choose for normal skin?
water-based moisturizer w/ light, nongreasy feel
-contain light weight oils, like cetyl alcohol, or silicone-derived ingredients like cyclomethicone
what can cause antibiotic resistance of bioflims
limited penetration
antibiotic neutralization
(enzymes, persistent cells non-replicative, biofilm phenotype, slow growth)
When it comes to wound dressing, what is the concensus on choice for :
debridement stage
granulation stage
epilthelialization stage
debridement stage- hydrogel
granulation stage- foam & low-adherence dressing
epilthelialization stage- hydrocolloid & low adherence dressing
what can be used to kill ectoparasites
malathion - organophosphate cholinesterase inhibitor
permethrin- bind to insect Na channels & block repol
ivermectin- binds to glutamate-gated Cl- –> hyperpolarize N & M. cells
lindane: disrupt GABAergic tranmission (use at last resort!)
what hormonal agents are used for acne treatment?
BC - (estrogen/progestin)
Spiranolactone - esp for women w/ menstrual cycle related breakouts on lower face
list the 1st choice of acne treatment from mild to severe
what is the treatment for alopecia areata
(chronic, relapsing immune mediated disorder–> non-scarring hairloss)
untreated - 50% grow back in < 1 yr but have recurrence
Tx: corticosteroids (intalesional or topical)
topical immunotherapy - diphenylcycloprpenone (DPCP) -cause contact dermatitis–> cause hair growth
what can be reasons for inadequate oxygenation
local vasoconstriction due to sympathetic overactivity
blood volume deficit, unrelieved pain, hypothermia
what are systemic therapies for pruritus?
(provide examples and use if needed)
antihistamine
antidepressants (mirtazapine - nocturnal pruritus & sertaline- cholestatic pruritis)
mu-opioid receptor antagonists ( naltrexone - cholestatic & CKD related)
k-opioid receptor agonist/mu-opioid receptor antagonist (butorphanol - nocturnl & intractable pruritus)
anticonvulsants (gabapentin & pregabalin - neuropathic pruritis)
substance P antagonist
what is anthralin
topical treatment for psoriasis
anti-inflam effects and slows the dz
what is the general principle for wound dressing
keep moist
not exposed to air
- occluded wounds heal 40% faster and have less scarring
- wounds are exposed to own fluid, mix of metalloproteases & cytokines
what is the general application instructions for topical imidazoles?
adverse effects?
1-2x/day application to the affected area - usually clear superficial dermatophyte infxn in 2-3 wks
adverse effects = local - stinging, pruritis, erythema, iritation
What is amphotericin B
binds to fungal sterols alters membrane permeability
topical Tx of cutaneous candida infxn
well tolerated, possible yellow staining of skin
What oral acne medication is absolutely contraindicated in pregnancy? and why?
oral isotretinoin
=teratogeniticty
(also can cause mucocutaneous effects, hypertriglyceridemia, increased suicide ideation, etc)
what eye drops can be used to remove redness
all = adrenergic agonist
naphazoline
tetrahydrozoline
phenylephrine
oxymetazoline
What is ciclopirox
synthetic topical antimycotic agent, disrupts macromolecular synthesis
active against dermatophytes, candida & malassezia
low incidence of adverse rxns & contact dermatitis
The use of dilute iodine, chlorhexidine or hydrogen peroxide not necessary
what are these examples of?
=antiseptic wash sol’n
have minimal action against bacteria
-potentially impede wound healing
what are home skin care recommendations for acne?
synthetic detergent cleanser (pH 5.5-7) w/ warm water 2x/day
water based lotions, cosmetics and hair products
what are oral antibiotics used for acne?
tetracycline
doxycycline
minocycline
erythromycin
azithromycin
trimethoprim-sulfamethoxazole
what is the MOA for chlorhexidine?
Why is it used often in homes/hospitals
target cytoplasmic membrane - affect membrane integrity at [low]
and congealing of cytoplasm at [high]
used as antimicrobial agent bc general efficacy on skin (& oral mucosa) & low irritablity
what is the initial choice for mild to moderate psoriasis
emollients
corticosteroids
what are chemical components that can be found in sunscreen
PABA - active in UVB range
Benzophenones : 250-360 nm (wide range but less effective than PABA)
dibenzylmethanes: UVA range; useful for drug induced photosensitivity & cutaneous lupus
what is the MOA for retinoids
What is Azaleic Acid
dicarboxylic acid (white powder in wheat, rye and barely - involved in plant defense response)
kills acne bacteria and decreases the production of keratin
Tx for mild-moderate acne and post-inflam hyperpigmentation
what are examples of moisturizer components that form an oily layer on top of skin and trap water in the skin
=emollients
petrolatum, lanolin, mineral oil and dimethicone
what are characteristics of ointments:
mix of 20% h2o in 80% oil
greasy and occlusive - stay on surface of skin (not well abs)
Use for dry skin -to trap moisture
-for more complete Abs
- less likely to cause allergic rxn (compared to creams)
what is the pharmacokinetics, MOA and effects of secukinumab
subQ
MOA: human monoclonal Ab - target proinflam cytokine IL17a
effect: blunt IL17a -> decrease ability to induce production of proinflam signal molecules (cytokines IL6, GC-CSF, IL1beta, TGF beta & alpha, chemokines IL8, GRO-alpha and NCP1 and prostoglandins)
Discuss the variables that affect cutaneous absorption & the steps of absorption
variables that affect abs:
regional: ex. axilla more permable than forearm
concentration gradient: increased concentration –> drug mass/unit time
dosing schedule: local half-life of skin reservoir affect dosing
occlusion/vehicle: can maximize penetration
What is acyclovir
synthetic guanine analog w/ inhibitory activity against HSV-1 & 2
used for recurrent orolabial HSV in immunocompetent adults
=ointment, cream & buccal
who is most likely to get salicylate toxicity with prolonged use
kids
people w/ reduced kidney or liver fxn
differentiate gels and pastes?
gels= polyionic colloids expanded w/ water
pastes = mixture of oil, water and powder
when do you use dermal antibiotic therapy
for wounds that appear clinically infected
*no evidence to support use for prophylaxis or healing non-infected wounds*
what is the clinical application and toxicites of apremilast
applications - moderate to severe plaque psoriasis,
active psoriatic arthritis
(55% pt have >= 75% reduction in psoariasis area and severity index (PASI)
Toxicities: severe diarrhea, nausea, vomit, HA (most common CNS complaint)
what is the function of topical vitamin D analogs (calcipotriene and calcitriol)
reduce keratinocytes
used in psoriasis
Define SPF
ratio of minimal erythema dose w/ sunscreen to the minimal erythema does w/o sunscreen
why is soap and water better than alcohol based hand disinfection?
alc-based hand disinfection NOT EFFECTIVE against C.difficile
Polymixin B
MOA
used for
side effect
=peptide antibiotic, bind phophor-lipids to alter permeability & damage bacterial cytoplasmic membrane
(against gram (-): Paeruginosa, E.coli, Enterobacter & Klebsiella)
side effect: rarely cause allergic rxn
what type of moisturizer do you use for dry skin
heavier, oil based w/ antioxidants, grape seed oil or dimethicone (helps to keep skin hydrated)
very dry skin - petrolatum to prevent water evaporation
Pt presents with chronic pain/pruritus and you tell them to eat chili peppers, jk take this medication that derived from chili peppers… why does this work
=capsaisin - activate transient release potential vanilloid-1, TRPV-1, on ion channel in cutaneous N fibers –>
stimulate neurons to release and eventually deplete certain neuropeptides (including substance P)
induce lasting desensitization
(cold is sensed & menthol cool by activating TRPM8)
what are the phases for wound healing
& compare first intention vs second
what is the clinical application and toxicities of secukinumab
applications - ankylosing spondylitis
plaque psoriasis
prosiatic arthritis
toxicities: increase risk for infxn, exacerbate IBD, hypersensitivity rxn
What happens when a pt takes 5-FU for actinic keratosis
decreased DNA synthesis bc inhibit thymidylate synthetase
cause inflam and destruction of the lesion
4-6 wk progress from erythema through blistering, necrosis w/ erosin and then re-epithelialization
What are nonphamacologic interventions for pruritus?
skin moisturization- gentle cleanser & apply emollient daily
cool environment- light wt clothing, air conditioned environment, cooling lotion, lukewarm shower/bath
avoidance of skin irritants
stres reduction- meditation, acupunture and yoga
physical interventions- occlusive dressing to stop itch-scratch cycle
what is the fxn and examples of humectants
draw water into outer layer of skin
ex: glycerin, lecithin and propylene glycol
What treatments are considered from advanced BCC
vismodegib or sonidegib
(both hedgehog signaling pathway)
What is terbinafine
allylamine, selectively inhibits squalene epoxidase (key enxyme for synthesis of ergosterol)
HIGHLY active against dermatophytes, less so for yeasts
cream can cause local irritation, avoid contact w/ mucous membranes
what are the clinical applications and toxicities for ustekinumab
application: plaque psoriasis
psoriatic arthritis
Crohn dz
toxicity - increase rise for infxn, SCC & hypersensitivity rxns
what are characteristics of creams:
mixture - half h2o/half oil w/ emulsifier, h2o evaporate
spread easily (good for large SA!), well absorbed, wash off w/ h2o
use of oozing/wet skin
BUT- too think to pump
what type of moisturizer do you use for sensitive skin
soothing ingredients (chamomile or aloe)
w/o allergens or acids
Urea, alpha hydroxy acids (lactic, citric, glycolic) and allantoin are examples of ….
how do they fxn?
=horny substance (keratin) softners
loosening the bonds btn the top layer of cells helps dead skin fall off, helps the skin retain water and gives it a smoother, softer feeling
What is nystatin?
binds fungal sterols, alters membrane permeablity
topical Tx of cutaneous & mucosal candida infxns (only) (hold in mouth before swallowing), narrow spectrum & negligible abs from GI tract
non-irritating topically, mild nausea/diarrhea if swallowed
what are 5 circumstances to wash hands to save lives!?
before touching pt
before cleaning/aseptic procedures
after body fluid exposure/risk
after touching pt
after touching pt surrounding
where are human scabies mites often found?
btn fingers and on wrists
What is the peptide antibiotic that inhibits bacterial cell wall synthesis?
used for?
effects?
bacitracin (target gram (+), most anaerobic cocci, neisseriae, tetanus bacilli, diphtheria bacilli)
side effect: allergic contact dermatits & rarely allergic contact urticaria
(poorly abs thru skin- systemic effects rare)
what is the purpose of wound debridement?
what are the types of debridement?
-remove dead tissue and debris - promote wound healing by limiting protease production & conserving the resources for healing
- low pressure irrigation w/ normal saline: ROUTINE! -flush out bacteria and remove loose material
- surgical: appropriate for removing large areas of necrotic/infected tissue
- enzymatic: collagenase may promote endothelial and keratinocyte migration for angiogenesis & epithelialization (mixed results)
- biologic: maggot therapy has neg perception - results in liquefaction of necrotic tissue while leaving healthy intact - BUT pressure ulcer healing time is not consistent
Salicyclic acid is a COX inhibitor, used for anti-inflam and found in many skin care products..why?
- epidermal cells to shed more readily (keratolytic) –> dissolve the intercellular cement; applied in more concentrated sol’ns to calluse for hour and wash away
- antibacterial properties
- open clogged pores
*treated areas will be photosensitive: protect from sun*
what are the exceptions of antibiotic therapy when it comes to prophylaxis or treating non-infected wounds
cadexomer iodine- reduce bacterial load while providing moist wound environment
silver- toxic to bacteria & widely used by clinicals to decrease bacterial surface contamination; but rate of healing NOT improved
what medications can be used for Rosacea
brimonidine - alpha2-agonist; topical gel; –> (+) postsyn vascular alpha2 –> vasoconstrict
oxymetazoline- alpha1a & alpha2 agonist; topical cream; vasoconstrict
what is the pharmacokinetics, MOA and effects of ustekinumab
subQ at 8-12 wk intervals
MOA: human monoclonal Ab - target proinflam cytokines IL12 & IL23
effect= blunts IL12/IL23 –> decrease NK cell activation, CD4 Tcell differentiation and activtion and MCP-1, TNF-alpha, CXCL-10 and IL-8 expressoin
Neomycin:
MOA?
Used for?
Side effects?
aminoglycoside antibiotic that binds 30S to inhibit protein synthesis (against gram (-))
side effect = allergic contact dermatitis, cross-sensitization to other aminoglycosides
(poorly abs so systemic detection rare)
what is becaplermin?
platelet derived growth factor –> promote cell proligeration & angiogenesis
ONLY agent approved for treatment of chronic diabetic foot ulcers
black box warning for malignancy
what are the treatment options for actinic keratosis
- liquid nitrogen cryotherapy
- surgical
- pharm - topical 5-FU, imiquimod, ingenol mebutate, topical diclofenac and retinoids
- photodynamic (red light) therapy
- dermabrasion
- chemical peel
what are systemic therapies used for psoriasis
methotrexate
apremilast- PDE4 inhibitor; side-effect -short-term diarrhea
retinoids
systemic calcineurin inhibitors
biological agents- ustekinumab (IL12 & IL23 mAB) & secukinumab/izekuzumab (IL17a AB)
What is tolnaftate
synthetic antifungal compounds - distort hyphae/stunt mycelial growth
effectively topically against various dermatophytes & malessezia infxn (not candida)
rarely cause irritation of allergic contact dermatitis
what are the treatments for male pattern baldness & their respective mechanisms
- minoxidil- vasodilate b/c K-channels open; increase growth phase (anagen), shorten rest phase (telogen) and enlarge miniaturized follicles
- finasteride; oral –> (-) DHT production (cause sexual dysfxn
- surgery- trasplant hair follicle units
how does glycemic control affect wound heeling
primary closure of surgical wounds in high-risk pts, poor glycemic control ==> worse outcome
-even single elevated glucose postop is adversly associated w/ morbidity and mortality
what is the difference btn UVB and UVA radiation & what do each cause
UVB = 280-320 nm –> erythema/sunburn, skin aging & photocarginogenesis
UVA = 320-400 nm –> skin aging and CA
What is used for female pattern hair loss?
- minoxidil (1st line)
-
anti-androgen (2nd line)
- spironolactone (androgen partial agonist)
- finasteride (block DHT synthesis)
- flutamide (androgen antagonist)
what is an example of an opaque material that reflects light
titanium dioxide
=sunshades!
What are the components for Tretinoin and what are the side effect?
creams, polyolprepolymer-2 cream, gels, microsphere gels, polyolprepolymer-2 gel & micronized gell
side effect = local skin irritation, dryness and flaking; sun sensitivity
*contain fish protien - ask about fish allergy!
(used in acne treatments)
when should you suspect malnutrition
*chronic illnesses
*inadequate societal support
*multisystem trauma
*GI/neuro problems
*must address protein-cal malnutrition and vitamin/mineral def
how does chlorhexidine act on:
bacterial spores
mycobacteria
nonsporulating bacteria
yeast
viruses
protozoa
- bacterial spores- not sporicidal but (-) spore formation/outgrowth
- mycobacteria- mycobacteriostatic
- nonsporulating bacteria- membrane active; cause protoplast & sheroplast lysis; [high] cause protein and nucleic acid precipitation
- yeast- membrane active; protoplast lysis and intracel leakage, [high] cause intracel coagulation
- viruses- low activity; lipid enveloped viruses more sensitive that nonenveloped
- protozoa- against trophozoites
which topical therapies are used for anogenital pruritus (transient burning/stinging)
topical calcineurin inhibitors
tacrolimus 0.03 & 0.1% ointment
pimecrolimus 1 cream
what type of moisturizer do you use for mature skin
oil-based w/ petrolatum as base to keep hydrated
plus antioxidants/alpha hydroxy acids (for wrinkles)
What is the cause of neuropathic localized pruritus w/o primary rash?
due to compresson/degeneration of Ns in the skin
en route to the spine or in the spine itself
how does the use of topical steroid vary throughout the body based on potency
low potency - face, genital and skin folds
high - everywhere else to gain control and titrate down for maintanance
which oral acne medication is contraindicated in pregnancy and young children ?
tetracycline -(bc it can cause yellowing of teeth)
doxycycline
minocycline
What topical antimicrobials are used for acne & what are their side effects?
benzoyl peroxide - local skin irritation; may bleach hair/clothes
clindamycin- rare risk of pseudomembrnous colitis
erythromycin
what anti-rejection medication can also be used for psoriasis
calcineurin inhibitors
(tacrolimus, pimecrolimus)
