Complex treatment in dermatology Flashcards
1
Q
What are complex therapies?
A
- High risk of toxicity
- High cost
- Intensive monitoring required
- Specialist prescribing (generally hospital consultant; not GP)
- NOT first line treatments; for moderate to severe treatment-resistant skin conditions
2
Q
What is isotretinoin?
A
- For severe acne unresponsive to topical treatments and oral antibiotics
- Consultant dermatologist prescription only
3
Q
How long (usually) is the course for isotretinoin?
A
16-week course usually sufficient
4
Q
How does isotretinoin work?
A
- Reduces skin sebum excretion by ~90% after 6 weeks (causes apoptosis in sebocytes)
- Lowers P acnes concentrations on skin
- Decreases hyperkeratinisation
- interferes with comedogenesis
- Anti-inflammatory properties
5
Q
Isotretinoin - risks?
A
- TERATOGENIC (pregnancy prevention programme, PPP)
o Effective contraception 1 month before treatment starts and 1 month after e.g. COC and condoms
o Cannot donate blood before, during or after. - Depression, anxiety, suicidal ideation
o Psychiatric history needed; STOP and refer to psychiatrist if mental health deteriorates on treatment - Impaired night vision
o Inform DVLA if affected; do not drive at night
o Contraindicated in pilots. - Dry skin and mucous membranes, joint pains common
- Makes skin very fragile
o Need UV protection in summer – SPF 50
o NO wax epilation, dermabrasion or laser treatments during
6
Q
What do you need to consider with complex therapies in psoriasis?
A
Age, treatment history, disease type, disease severity, impact arthritis, contraception plans, co morbidities, patients personal views
7
Q
NICE guidelines for complex treatment of psoriasis?
A
- Specialist treatment if symptoms severe, impact major, widespread (covering 10% BSA), and/or not controlled with topical therapy
- Use systemic therapy only if severe impact, cannot be controlled with topical therapy, AND one or more of:
o Extensive
o Functional impairment/distress high
o Phototherapy ineffective - In some circumstances, use phototherapy first. Otherwise methotrexate first line if appropriate, or ciclosporin if specific conditions
8
Q
Describe the two types of phototherapy in psoriasis:
A
Narrowband UVB (NB-UVB) - First line treatment
Psoralen and UVA (PUVA)
Oral 8-methoxypsoralen (MOP-8) (most common) 0.6mg/kg
9
Q
What is PUVA?
A
Oral 8-methoxypsoralen (MOP-8) (most common) 0.6mg/kg
- Two hours before UVA exposure
- Disrupts DNA synthesis, inhibiting basal cell proliferation
- Slows basal cell growth to normal
- Treatment 3 x weekly
- Clears in 5 to 6 weeks (20-30) exposures
10
Q
Risks of phototherapy:
A
- Adverse effects
o Teratogenic (MOP), premature skin ageing, skin pigmentation, cataract formation - Precautions
o Effective contraception, UVA eye protection, regular skin examinations for pre- / malignant changes
o History of cancer
11
Q
What is acitretin (for psoriasis) and what are its risks?
A
- Synthetic Retinoid
- Decreases hyperkeratinisation
o Normalises skin cell proliferation, differentiation and cornification - Side-effect profile similar to isotretinoin BUT longer half-life and prolonged therapy needed in psoriasis
Risks;
- Contraception in women of child-bearing potential for 3 years after taking
- (pregnancy prevention programme, PPP)
- Hyperlipidaemia
- cardiovascular risk assessment needed
- monitoring of lipid profile
- Hepatotoxic
- Monitor liver function every 3/12 during treatment (more frequently at start)
- Do not drink alcohol or keep to absolute minimum
12
Q
How is methotrexate used in psoriasis (mode of actions)?
A
- Folic acid antagonist
o inhibits dihydrofolate reductase - Blocks DNA synthesis (folates co-factors for many enzymes)
o slows basal cell proliferation in psoriasis - Enzyme inhibition leads to increased adenosine which inhibits neutrophil chemotaxis and cytokine secretion
o anti-inflammatory action in eczema - Takes 1-3 months for full effect to be seen at optimal dose
o Expectation setting important
13
Q
Methotrexate – risks?
A
- Can cause liver cirrhosis
- Liver function tests every month initially
- Can cause blood disorders
- Thrombocytopaenia, leucopaenia, anaemia
- Full blood count every week then monthly
- GI symptoms; stomatitis, nausea
- 5mg folic acid weekly (both drugs compete for cellular uptake so need to be taken separately)
- Other considerations
- Alopecia, family planning (teratogen), infection risk (avoid vaccinations or ensure they have them before)
- Interactions – trImethorpin, NSAIDs
14
Q
How is cyclosporin used in psoriasis?
A
- Ciclosporin 2.5/kg DAILY (spilt into two doses)
- Blocks calcineurin-dependent factor
o Interleukin 2(IL2) blocked
o Proliferation of T-lymphocytes and cytokines blocked
o Proliferation of keratinocytes blocked
15
Q
Ciclosporin – risks
A
Nephrotoxic
o Monitor renal function
Hypertension
o Monitor blood pressure
Teratogenic o Contraception (although ciclosporin can be reserved for use in pregnancy) not as teratogenic as others
Immunosuppressant
o Infection risk
Avoid grapefruit juice
