Acne / Dandruff / Seborrhea / Fungal Derm Flashcards
Characteristic etiology of acne?
-Inflammation
-Follicular stickiness increases
-Increased sebum production
-Pyogenes bacterial infection (occasionally)
T or F: Blackheads lead to inflammation.
False… Whiteheads only (which can be inflammatory).
Angie comes to your Pharmacy complaining of Acne. You conduct a full patient interview & determine that she’s also experienced uncontrolled weight gain over the past year, has irregular menstrual cycles, & has experienced very heavy menstrual bleeds. What condition might Angie have?
Polycystic Ovary Syndrome (PCOS)
Predisposing Factors of Acne?
-Hormones (Menstrual Cycle / Pregnancy / Puberty)
-Skin Hydration (Sweating on a hot day)
-Irritation / Occlusion (Masks)
-Cosmetic Products (Makeup)
-Diet (Sugary Diets… More Insulin… More Oils)
-Stress
-Heredity
-Occupational (Fast Food)
What sorts of foods cause Insulin spikes (& thus stimulate Sebaceous Glands to produce more oils)?
-Pasta
-White Rice
-White Bread
-Sugar
What percentage of adult acne cases are continuations from teenage years? Adult-onset cases?
80% continuations
20% Adult-Onset cases (more concerning)
Describe the potential lesion counts of a mild case of Acne.
< 20 comedones
< 15 inflammatory lesions
< 30 total lesions
Provide two less common Acne types (Hint: Both are drug-induced).
1) Topical Steroids… Used for years on end (way too long).
2) Birth Control… Most actually help, but some (in rare instances) can actually induce Acne.
How long does Milia (Baby Acne) take to clear up?
~2 weeks w/o treatment
Provide differential diagnosis factors that differentiate Rosacea from Acne.
i) Patient Age (usually > 30yrs)
ii) No Comedones
iii) Ocular Symptoms (Dry Eyes)
iv) Transient Flushing & Warmth
v) Appearance of Blood Vessels on Skin (Nose Tissues)
What treatment options do we have available for Perioral Dermatitis?
-Removal of suspected causes
-Oral / Topical Antibiotics (Tetracycline has some underlying AI properties to it)
Beneficial face-washing regime for Acne… How many times / day?
BID… Anything over = Overkill. Over-cleaning can actually increase sebum levels on the skin too!
-May need to add medicine to evening & morning cleanser.
What place do Astringents have in the treatment of Acne?
-Not much… They become overkill once a medicine (Benzoyl Peroxide or Oral / Topical Retinoids) is introduced.
Is there therapeutic benefit to using an exfoliating product such as the Buf-Puf for Acne treatment?
-Nope… Normal skin turnover occurs within 30 days, so scraping off top skin layers unnecessary.
What color of Cetaphil product do we recommend as a skin cleansing agent?
Blue… Green = More lice front (moisturizing lotion).
What is a realistic treatment duration for somebody who has long-standing (ie. Chronic) Acne?
2-4yrs
Weak, keratolytic agent used in 0.5 - 2% solutions for Acne treatment?
Salicylic Acid
What OTC products contain Salicylic Acid?
Clean & Clear Foaming Wash / Dual Action Moisturizer
Oxy Wipes / Pads
Clearasil Rapid Action Vanishing Treatment Cream
What two anti-bacterial agents are used in combination in Clearasil Acne Cream?
Sulfur & Resorcinol
i) What OTC product may begin to become a more prevalent player in Acne treatment once proper dosing & strengths are determined?
ii) What is its major action?
i) Topical / Oral Nicotinamide
ii) Anti-Inflammatory properties
Bath & Body Works product that may present some Anti-Bacterial properties (Hint: Minor Acne player)?
Tea Tree Oil
Two major actions of Benzoyl Peroxide?
i) Anti-Bacterial… O2 blast leading to decreases in Pyogenes-caused Acne.
ii) Exfoliant Action… Minor skin surface peeling.
Strengths of BP?
2.5% (OTC)
5% (OTC)
10% (Rx)
S/E’s of BP usage?
-Bleached Clothing
-Skin Burning & Redness
-Dryness
-Peeling
Are Retinoids or BP more photosensitive?
Retinoids (far more)
What BP formulation would be most appropriate for treating a minor case of Acne? For moderate-severe cases?
Minor: BP Soap / Wash
Mod-Severe: Lotions or Gels
BP Gel strengths: Rank the products…
Acetone
Aqueous
Alcohol
1) Acetone
2) Alcohol
3) Aqueous
Why would a BP soap / wash be an unsuitable agent for treating a moderate case of Acne?
Lack of contact time & delayed OOA…
Oily skin & moderate Acne… What BP formulation is best?
BP Gel… More drying effect.
Winter-time Acne accompanied by dryer skin… What BP formulation is best?
BP Lotion… More hydrating in nature.
Sensitive skin… Which BP formulation is best?
Lotion (best on sensitive skin)
If BP isn’t working effectively, what advice should be given (or what path of treatment should be taken instead)?
-DO NOT (!!!) PUT MORE ON! This is NOT standard place advice.
-Ask instead; do I need to switch strengths or formulation instead?
When applying BP products, what sorts of things would patients want to avoid doing whenever possible?
-Avoidance of spot treatment (treat entire face).
-Ramp up usage slowly (to combat potential Contact Dermatitis).
-Utilizing dry skin lotion when needed.
At what point in treatment can BP treatment of Acne be ramped up from OD to BID?
1-2 months (patience required in order to ensure product is working).
In the US, what % BP solutions are considered to be OTC?
Anything < 10% (5 and less in Canada… Rx grade = 10% here).
MOA of Topical Retinoids in Acne treatment?
i) Reduces Follicular Wall stickiness
ii) Increases penetrating abilities of other agents (ie. BP)
What initial Topical Retinoid strengths should be used for the first 2 months of Acne treatment?
0.01 - 0.025% creams
-Progress to 0.025 - 0.05% gels after assessing 2 months in…
One major s/e of Topical Retinoid (ie. Tretinoin) treatment?
Erythema
Two directional usage parameters for Topical Retinoids?
i) Dry skin before applying
ii) Pea-sized amounts (disappear on skin within 1 min)
Why do Topical Retinoids occasionally cause an initial worsening of Acne conditions?
-Increase in cell turnover & pore unclogging combined with the fact that stuff is being brought to the skin surface can result in temporary breakouts.
Least irritating TR?
Adapalene
Most photosensitizing TR?
Tretinoin
Most potent TR?
Tazarotene
Population of people that shouldn’t use TR’s (or, at the very least, utilize with caution)?
Pregnant Women… TR’s = Teratogenic to unborn children.
Is BP safe for treating pregnancy-related acne?
Absolutely
When would a combination BP + Retinoid treatment regime be appropriate?
For cases of mod-severe acne… Simple BP product for mild acne cases.
Jennivere is on a combination therapy of 5% Benzoyl Peroxide cream & 0.1% Tretinoin cream for her Acne. When should these agents be taken?
Day: BP
Night: Tretinoin (due to photosensitive nature of Retinoids & potential BP neutralizing effects)
T or F: Retinoid Gels cannot be administered simultaneously with Benzoyl Peroxide products.
False… They can! BP degrades creams, but NOT micronized Gels.
In which situations would solo BP treatment be appropriate? Solo Retinoid?
BP: Must see pimple formation & inflammation that indicates bacteria are present… Not suitable for treating just whiteheads & blackheads.
Retinoid: Prevention of whitehead / blackhead formation (because of its works at the follicular level).
Two common Antibiotics used for Acne treatment?
Clindamycin
Erythromycin
Mild-Mod Acne & I want to use an Antibiotic… Propose two different combination therapy ideas (just suggest two products).
BP & AB
Retinoid & AB
Severe Acne & I want to use an Antibiotic… Propose a combination therapy.
AM: Clindamycin & BP
PM: Tretinoin
Combo product containing Erythromycin & Tretinoin?
Stievamycin Gel (0.05% Tretinoin & 4% Erythromycin)
Combo product containing Clindamycin & Benzoyl Peroxide?
Clindoxyl OD Gel (1% Clindamycin & 5% BP)
Combo product containing Adapalene & BP?
TactuPump FORTE (0.3% Adapalene & 2.5% BP)
When should Topical Antibiotic usage in treatment of Acne be discontinued?
Once inflammatory symptoms resolve themselves.
Prescribed Topical Antibiotic that, when used simultaneously with BP, causes a yellow-ish tinge to commence on the skin?
Aczone (Dapsone 7.5% Gel)
Although it’s not a first-line agent like the Topical Retinoids, when might administration of Dapsone Gel be appropriate for Acne treatment?
In patients who are allergic or cannot tolerate other treatments.
Dapsone Gel s/e’s?
-Yellowing of skin (with simul. BP treatment)
-Erythema
-Dryness
Other prescribed Topical Antibiotic we discussed in class that may serve to normalize Keratin stickiness & is used for mild-mod acne (BID treatments)?
Azelex 20% (Azelaic Acid Cream)
Why must all Oral & Topical Antibiotics be used with a Topical Retinoid or BP?
i) Increases Efficacy
ii) Reduces Bacterial Resistance
What products must we avoid giving oral antibiotics with?
Antacids
i) What antibiotic should we NOT give with food or other dairy products?
ii) Which one has less problems with food interactions?
iii) Which one do we WANT to give with food?
i) Tetracycline
ii) Minocycline
iii) Doxycycline
i) Which antibiotic is GREATLY photosensitive?
ii) Which antibiotic is MODERATELY photosensitive?
iii) Which antibiotic is LESS photosensitive (relative to the others)?
i) Doxycycline
ii) Tetracycline
iii) Minocycline
Dr. Chang faxes a prescription to your Pharmacy; it’s for a severe acne patient. He prescribes Azelex 20% cream and oral Doxycycline tablets (125mg). What benefits might co-administration of Topical & Oral antibiotics have for this patient’s severe acne?
ZERO (!!!). Using topical & oral antibiotics at the same time has proven to not be of clinical value.
i) How do Isotretinoin & Tretinoin differ?
ii) What is the trade name for Isotretinoin?
i) Iso = Oral ; Tret = Topical
ii) Accutane
What product should be supplemented to those who take Accutane?
Lip Balm & potentially eye drops (major s/e is drying of the mucous membranes).
What is the standard dosing regimen for Isotretinoin?
0.5 - 1mg / kg x 12-16wks
What parameters should suggestively be undertaken by a woman in her childbearing years on Accutane?
-Utilization of contraception (potentially even two forms at once).
-Two negative pregnancy tests prior to starting therapy.
-Acknowledgement & understanding of teratogenic effects of Accutane prior to undertaking therapy.
What benefit does the Epuris Isotretinoin product have over other similar products?
-Doesn’t require fats from a meal to be absorbed.
When would an oral contraceptive be the superior acne product?
-When it can be used as a combination product (as a birth control agent & for acne).
Diane 35-R is a contraceptive agent used to treat women with severe acne who are unresponsive to oral AB’s & other treatments… When (& why) should its use be stopped?
-Stop once acne clears.
-CV problems associated with this drug!!! Discussed Shoppers Drug Mart being sued by the parent of an 18yr old girl who suffered from 4 cardiac arrests, a pulmonary embolism & a brain hemorrhage.
Name of the prescribed product that is “officially” indicated for chest / shoulder / back acne.
Aklief (Trifarotene 0.005% Cream)
Note: Other retinoids can be used too, but this is the one product that went after the indication (simply to profit more).
Taylor & Dermatologists say to treat Acne in what manner?
-Treat more aggressive!
-Treat early (ESPECIALLY if they have a familial history of Acne)!
Taylor & Dermatologists say to treat Acne in what manner?
-Treat more aggressive!
-Treat early (ESPECIALLY if they have a familial history of Acne)!
Michael comes in complaining of oily scales in his hair & scalp inflammation. They are slightly discolored, & you gather that his hair has been thinning for some time. What condition might Michael have?
Seborrhea
Dry, powdery scales with minimal inflammation… What condition is this?
Dandruff
What sorts of patients might have exacerbated Dandruff?
-Males
-Teenagers going through puberty (androgenic acceleration)
-HIV Patients
-Psoriasis Patients
-Those with heavy stress
What major distinguishing factor differentiates Tinea of the scalp from Dandruff?
-Location… Tinea in one spot, Dandruff is diffuse.
1st line treatment for Dandruff?
Non-medicated shampoos
T or F: Infrequent shampooing / hair washing will allow the scalp to absorb more oils, thus combating Dandruff induced by a dry scalp.
False… Frequent washing is actually the recommended Dandruff treatment. Dandruff is NOT caused by dry scalp & not washing actually aggravates the condition (prevents cell shedding).
Salicylic Acid MOA in Dandruff treatment… What is it?
Keratolytic agent (dissolves skin flakes & superficial scalp levels)
Coal Tar MOA in Dandruff treatment…?
Cytostatic
Primary & Secondary MOA’s of the following Dandruff agents (Hint: They’re all the same):
Selenium Sulfide
Zinc Pyrithione
Ketoconazole
Ciclopirox
Primary: Antifungal
Secondary: Cytostatic
-Note that Selenium Sulfide & Zinc Pyrithione MAY have Keratolytic capabilities as well.
Strongest Anti-Fungal agent used in Dandruff treatment?
Ketoconazole
Provide an OTC Dandruff shampoo that contains Tar (either Tar cpd. or sol’n).
Neutrogena T/Gel (Tar cpd. 0.5%)
Denorex (10% Tar sol’n & 1.5% Menthol)
Name of OTC Dandruff shampoo that contains 1% Selenium?
Selsun Blue
Name of OTC Dandruff shampoo that contains Zinc Pyrithione?
Head & Shoulders
Name of OTC Dandruff shampoo containing Ketoconazole?
Nizoral
Two primary Dandruff treatment goals?
-Use medicated OTC shampoos 2x / week (generally).
-Treat the SCALP (not the hair)!!!
When might utilizing a Topical Steroid such as Betamethasone Dipropionate / Valerate for the Scalp be indicated?
Seborrhea-related inflammation & redness (overkill for Dandruff).
Where might Seborrhea present itself on the body?
-Eyelids
-Ear Canal
-Scalp (referred to as Cradle Cap with infants)
-Nasal Folds
-Chest
-Armpits
-Pubic Region
In terms of scale color, what do silvery scales indicate? Yellow scales?
Silver: Psoriasis
Yellow: Seborrhea
Options in the treatment of Seborrheic Dermatitis?
-OTC Tar Shampoos
-Topical Steroids
-Ketoconazole 2% Cream (Anti-Fungal)
-Ciclopirox Shampoo (Anti-Fungal)
-Pimecrolimus Cream (Anti-Inflammatory properties & 2nd line)
How do Ketoconazole treatment regimens for Seborrheic Dermatitis differ from that of Dandruff?
Dandruff: 2x / week (until clearing up of Dandruff)
SD: OD-BID x 4 weeks
Brand name of prescription grade shampoo that contains Ciclopirox & is used in Seborrheic Dermatitis treatments?
StieProx
When treating Seborrheic Dermatitis of the body, why might a 2% Ketoconazole Cream be a beneficial product to use?
-More contact time.
When might Cradle Cap present itself in infants? When does it disappear?
-Week 3 or 4… Disappears after ~8 months.
How do we treat Cradle Cap?
Baby Oil or Vasoline (prn)
Term for Scalp Ringworm?
Tinea Capitis
-Think… Cap goes on the head.
Term for standard Ringworm?
Tinea Corporis
Term for Jock Itch?
Tinea Cruris
-Cruris means “of the leg”… Jock goes on the inside of the leg.
Term for Athlete’s Foot?
Tinea Pedis
-Pedi = Foot…
Fungal infection of the nails is referred to as…?
Onychomycosis
What is Tinea Versicolor?
-Fungal infection that causes skin discoloration… Overgrowth of yeast on the skin that is triggered by hot / humid climate.
What age demographic typically sees cases of Tinea Capitis?
5-10yrs… Rare in adults.
What do medicated shampoos also have to be combined with when treating Tinea Capitis (as a topical shampoo alone won’t cut it)?
Oral Antifungal (Griseofulvin or Terbinafine HCl)
How is Tinea Corporis spread?
-Direct skin to skin contact… Most commonly humans or house pets (Dogs & Cats).
Common signs & symptoms of Tinea Corporis infection?
-Small, round red spots on the face / neck / trunk / limbs
-Usually located on smooth, hairless areas of the body
-Clear central area
-Itchiness & burning sensation common (can be asymptomatic)
What do “azole” agents such as Clotrimazole, Miconazole & Ketoconazole inhibit?
-Inhibit fungal synthesis of Ergosterol (fungal cell membrane sterol).
What sorts of drugs are classified as Allylamines? What do they inhibit?
Naftifine
Terbinafine
Ciclopirox
-Also inhibit fungal Ergosterol synthesis (like azoles).
Treatment strategy for Tinea Corporis… What can we give, & what is the treatment regimen?
Tinactin (Tolnaftate 1% cream)
Micatin (Miconazole 2% cream)
Canesten (Clotrimazole 1% cream)
-BID for at least 3-4 weeks & use 1 week post-fungal resolution (to prevent recurrent infections from occurring).
Product that’s marketed as the “ideal agent” for treating Tinea Pedis?
Canesten
If a patient comes in wanting an Anti-Fungal product & complains of long-term adherence problems, what product might you recommend?
-Lamisil (Terbinafine 1% crm)… Can be used OD for 7 days instead of BID 3-4wk treatment!
Guidelines for low-med potency Topical Corticosteroid use in combination with Antifungals for Tinea?
-Use only for the first few days of treatment (to treat inflammation)… Prolonged use can cause recurrent infection / longer treatment duration / skin atrophy / striae / telangiectasia.
What leaves one susceptive to catching Tinea Pedis?
-Direct contact with infected people or animals
-Increased moisture
-Impaired immunity (Diabetes / HIV / Chemo)
-Barefoot in public spaces (Change Rooms)
What is the most common form of Athlete’s Foot?
Interdigital (between the toes)
Name of the condition that is indistinguishable from classic Athlete’s Foot?
Candidiasis (yeast infection between the toes that presents similarly with moist, white peeling skin)
When might we want to refer a case of Athlete’s Foot to a Doc?
-Extensive lesions (top & bottom of feet)
-No improvements > 1wk after treatment
-Diabetic / Immunocompromised patient
-Presence of Onychomycosis (fungal nail infection)
What preventative measures can be taken to prevent Athlete’s Foot?
-Keep skin dry
-Cotton Socks
-Avoid going barefoot
-Non-medicated powders to absorb moisture
Treatment regime for Athlete’s Foot?
-Similar to other Tinea forms… BID x 3-4wks + 1wk.
-Same AF products!
What other fungal conditions are often co-demonstrated with Tinea Cruris?
Tinea Pedis (Athlete’s Foot) & Tinea Unguium (Onychomycosis… Nail Infection)
What condition is Tinea Cruris often confused with?
Candida Intertrigo (Yeast infection affecting skin folds)
Main cause of Jock Itch?
-Transfer of microorganism from patient’s feet.
Can we as Pharmacists prescribe Ciclopirox for Tinea infections?
-NO!!! Terbinafine 1% crm or spray & Ketoconazole 2% crm are the three options we have.
What is the most common treatment for male yeast infections?
Oral Diflucan
How fast does your toenail fully grow back? Why is this relevant with regards to the scope of Onychomycosis treatment?
-About 1 to 1.5yrs… Relevant as this provides a rough timeline of how long it takes to see improvements in the nail.
Why is oral treatment for Tinea Unguium often better than topical treatment?
-Oral agents (generally) penetrate toenail surfaces better than topical agents.
-Treatment duration is 2-3 months (vs. up to 12 months for topical).
Prescription grade product used to treat DLSO? What’s the regimen?
i) Jublia (Efinaconazole 10% sol’n)
ii) 1 drop OD x 48wks
-Follow ups are recommended at 12wks to see if improvements are being seen with treatment.
OTC solution used to treat DLSO?
Emtrix (contains Propylene Glycol, Urea, Lactic Acid)
What’s a shitty Onychomycosis product (due to its limited efficacy, requirement of weekly nail trimming & lacquer removal, & monthly debridement)?
Topical Ciclopirox
When should topical agents be reserved for onychomycosis treatment (ie. What scenario is best-case for its involvement)?
-Cases with minimal nail involvement (< 50% of the nail)… As seen priorly, topical products such as Ciclopirox don’t penetrate nails effectively.
What does DLSO stand for?
Distal & Lateral Subungual Onychomycosis
