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Y3 Patient sem 1 > Complex treatments in dermatology > Flashcards

Complex treatments in dermatology Flashcards

1
Q

What is Isotretinoin also known as?

A

Roaccutane

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2
Q

What is Isotretinoin used for?

A

Severe acne unresponsive to topical treatments and oral antibiotics

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3
Q

How can you get Isotretinoin?

A

Consultant dermatologist only: 16-week course usually sufficient

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4
Q

What is isotretinoins active ingredient?

A

13-cis-retinoic acid (at least 5 biologically active metabolites

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5
Q

How does isotretinoin work?

A
  • Reduces skin sebum excretion by 90% after 6 weeks (causes apoptosis in sebocytes) –> lowers P acnes concentrations on the skin
  • Decreases hyperkeratinisation (interferes with comedogenesis)
  • Anti-inflammatory properties
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6
Q

How long is the Isotretinoin treatment?

A
  • usually 16 weeks

- triple action

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7
Q

What are the risks of Isotretinoin?

A
  • TERATOGENIC (pregnancy prevention programme, PPP)
  • Depression, anxiety, suicidal ideation
  • Impaired night vision
  • Dry skin and mucous membranes, joint pains common - reduces bodily secretions
  • makes skin very fragile
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8
Q

What needs to be taken into account given the teratogenicity of Isotretinoin?

A
  • Effective contraception 1 month before treatment starts and 1 month after e.g. COC and condoms
  • Cannot donate blood before, during or after for a period of time
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9
Q

What needs to be taken into account given the risks of depression, anxiety and suicidal ideation of Isotretinoin?

A
  • psychiatric history needed; STOP and refer to psychiatrist if mental health deteriorates on treatment
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10
Q

What needs to be taken into account given the risks of impaired night vision for Isotretinoin?

A
  • inform DVLA if affected; do not drive at night

- contraindication in pilots

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11
Q

What needs to be taken into account given the risks fragile skin for Isotretinoin?

A
  • need UV protection in summer - SPF 50

- NO wax epilation, dermabrasion or laser treatments during or 6/12 after

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12
Q

What do the NICE guidelines for psoriasis say about when specialist treatment should be used?

A

Specialist treatment if symptoms severe, impact major, widespread (covering 10% BSA), and/or not controlled with topical therapy

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13
Q

What do the NICE guidelines for psoriasis say about when systemic therapy should be used?

A

Use systemic therapy only if severe impact, cannot be controlled with topical therapy, AND one or more of:

  • Extensive
  • Functional impairment/distress high
  • Phototherapy ineffective

In some circumstances, use phototherapy first. Otherwise methotrexate first line if appropriate, or ciclosporin if specific conditions

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14
Q

What are the 2 types of phototherapy in psoriasis?

A
  • Narrowband UVB (NB-UVB)

- Psoralen and UVA (PUVA)

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15
Q

What is Narrowband UVB (NB-UVB)?

A
  • first line treatment
  • generally better tolerated
  • treatment 2-3 times a week
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16
Q

What is Psoralen and UVA (PUVA)?

A
  • Oral 8-methoxypsoralen (MOP-8) 0.6mg/kg
  • 2 hours before UVA exposure
  • Disrupts DNA synthesis, inhibiting basal cell proliferation (slows basal cell growth to normal)
  • Treatment 3 times weekly
  • Clears in 5 to 6 weeks (20-30) exposures
17
Q

What are the adverse effects and precautions of Phototherapy?

A

Adverse effects:
- teratogenic (MOP), premature skin ageing, skin pigmentation, cataract formation

Precautions:

  • Effective contraception, UVA eye protection, regular skin examinations for pre- / malignant changes
  • History of cancer – avoid treatment as it can increase risk
18
Q

What is Acitretin?

A

A synthetic retinoid used in psoriasis

19
Q

What does Acitretin do?

A
  • decreases hyperkeratinisation (normalises skin cell proliferation, differentiation and cornification)
  • Side-effect profile similar to isotretinoin BUT longer half-life and prolonged therapy needed in psoriasis
20
Q

What are the risks of using Acitretin?

A
  • Contraception in women of child-bearing potential for 3 years after taking
    - (pregnancy prevention programme, PPP)
  • Hyperlipidaemia (contraindicated)
    - 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
21
Q

What is Methotrexate used in?

A

Psoriasis and eczema

22
Q

What is Methotrexate and what does it do?

A
  • folic acid antagonist (inhibits dihydrofolate reductase)
  • blocks DNA synthesis (folates co-factors for many enzymes)
    - slows basal cell proliferation in psoriasis
  • enzyme inhibition leads to increased adenosine which inhibits neutrophil chemotaxis and cytokine secretion (anti-inflammatory action in eczema)
23
Q

How long does it take for full effect of methotrexate to be seen at optimal dose?

A

1-3 months (dosing is WEEKLY)

24
Q

What are the risks of methotrexate?

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 – on a different day to methotrexate as they compete for cellular uptake (can reduce effectiveness)
  • Other considerations
    - Alopecia, family planning (teratogen), infection risk
25
Q

What is ciclosporin used in?

A

Psoriasis and eczema

26
Q

What is the dose for ciclosporin in psoriasis and eczema?

A

2.5/Kg DAILY (split into 2 doses)

27
Q

What does ciclosporin do?

A
  • Blocks calcineurin-dependent factor
    - Interleukin 2(IL2) blocked
    - Proliferation of T-lymphocytes and cytokines blocked
    - Proliferation of keratinocytes blocked
28
Q

What are the risks of ciclosporin?

A
  • Nephrotoxic
    - Monitor renal function
  • Hypertension
    - Monitor blood pressure
  • Teratogenic
    - Contraception
  • Immunosuppressant
    - Infection risk
29
Q

What do biologics in psoriasis target?

A

TNF

30
Q

What biologics are used?

A
  • Etanercept
    - Genetically engineered fusion protein
  • Infliximab, adalimumab, and many more
    - Anti-TNF monoclonal antibodies
31
Q

How long does it take to see a response from biologics treatment?

A

Highly effective: response seen in 6 weeks

32
Q

What are the risks of Biologics?

A
  • Increased risk of infections
    - Reactivation of latent TB particular concern
    - TB screening and intermittent monitoring for symptoms
    - Listeria and Salmonella risk
    - Do not consume raw or part cooked, meat, fish, eggs or dairy products
  • Cardiovascular risk
    - Do not use in severe heart failure and monitor patients with pre-existing CV disease closely
  • Worsening of neurological disease
    - Do not use in demyelinating disease e.g. MS
  • Cancer risk
33
Q

What is dupilumab?

A
  • used in eczema
  • Monoclonal antibody that inhibits activation of T helper cells. These T helper cells disrupt the skin barrier by inhibiting expression of filaggrin and antimicrobial peptides.
  • May predispose to worm infection, must ensure clear beforehand and suspend if present
  • Other side effects/ cautions as per MABs
  • NICE – use if no response/intolernace to MTX, AZA, CIC, myophenalate
  • Dose every 2 weeks, review treatment if no response at 16 weeks

Y3 Patient sem 1 (22 decks)

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