Complex treatments of dermatology

Question 1

features of complex therapies?

Answer 1

high toxicity risk
high costs
need monitoring
specialist prescribing not GP

Question 2

complex therapies ____ first line

Answer 2

aren’t

Question 3

use of isotretinoin? brief

Answer 3

retinoid in acne

severe acne unresponsive to topical treatments and oral antibiotics

Question 4

acitretin use?

Answer 4

retinoid in psoriasis- not commonly used

Question 5

what does photo therapy treat?

Answer 5

psoriasis and also seen in eczema

Question 6

isotretinioin is used in…

Answer 6

severe acne unresponsive to topical treatments and oral antibiotics

Question 7

isotretinioin time frame?

Answer 7

16 week course

Question 8

how many biologically active metabolites in isotretinioin

Answer 8

5 at least

Question 9

what are the 3 mechanisms of action of isotretinioin?

Answer 9

reduces skin sebum excretion by 90% after 6 weeks- lowers bacteria concentrations on the skin

decreases hyperheritinisation- reduces down to normal level if hyper. interferes with comedogenesis

anti-inflammatory

Question 10

how does isotretinoin educe skin sebum excretion?

Answer 10

causes apoptosis of sebocytes

Question 11

how does isotretinoin decrease hyperkeratinisation?

Answer 11

blocks the follicles

Question 12

can you do a repeat course of isotretinoin?

Answer 12

yes if relapse

Question 13

risks of isotretinoin?

Answer 13

teratogenic- need contraception for 1 month before and after, tested before during and after.

cant donate blood during or after as it remains in the system
CV risk increased by 30%
depression, suicidal ideation
impaired night vision- DVLA must be informed

dry skin
joint pains
fragile skin- UV protection

Question 14

what must happen to people with mental health problems when isotretinoin?

Answer 14

psychiatric monitoring

stop if mental health deteriorates

Question 15

why does isotretinoin cause dry skin and mucous membranes and cause joint pain?

Answer 15

reduces bodily secretions

dry

Question 16

if topical treatments dont work for psoriasis treatment, what should you do next?

Answer 16

phototherapy

then oral or injectables

Question 17

when is specialist treatment needed for psoriasis?

Answer 17

severe, widespread (10% BSA) and not controlled by topical therapy

Question 18

when is systemic therapy used?

Answer 18

severe
cant be controlled topically 
AND one off: 
extensive 
function impairment 
phototherapy ineffective

Question 19

TF: UVA is usually better tolerated in psoriasis phototherapy

Answer 19

no, narrowband (ND-UVB) UVB

Question 20

UVB is ____ ______

Answer 20

first line

Question 21

how often do you have NB-UVB treatment

Answer 21

2/3 times a week

Question 22

how are psoralen and UVA used together?

Answer 22

apply psoralen 2 hours before UVA exposure

is activated in UVA presence

Question 23

how does activated psoralen work?

Answer 23

disrupts DNA synthesis, inhibiting basal cell proliferation- prevents thickening which is key in psoriasis

Question 24

how often is treatment with UVA and psoralen given?

Answer 24

3 times weekly

Question 25

how long till UVA and psoralen is effective?

Answer 25

5-6 weeks

Question 26

adverse effects of phototherapy?

Answer 26

teratogenic premature skin ageing pigmentation cateract formation

Question 27

side effects of psoralen? solution?

Answer 27

nausea can use MOP-5 in this case (psoralen is MOP-8)

Question 28

precautions to be taken when on phototherapy?

Answer 28

contraceptions UVA eye protection regular skin examinations history of cancer

Question 29

what is acitretin, what does it treat

Answer 29

synthetic retinoid | psoriasis

Question 30

how does acitretin work??

Answer 30

decreases hyperkeratinisation- normalises skin proliferation, differentiation and cornification

Question 31

acitretin has a _____ half life than isotretinoin but...

Answer 31

longer | can convert back into parent molecule so prolonged therapy

Question 32

how long is acitretin therapy?

Answer 32

>16 weeks

Question 33

risks of acitretin?

Answer 33

``` teratogenic blood donation hyperlipidaemia CV risk assessment needed monitor lipid profile hepatotoxic- monitor liver function keep alcohol intake at t he bare minimum ```

Question 34

how long must women take contraception after taking acitretin?

Answer 34

3 years

Question 35

how often is methotrexate given for the treatment of psoriasis and eczema?

Answer 35

once weekly

Question 36

methotrexate mechanism of action?

Answer 36

folic acid antagonist- inhibits DHFR Blocks DNA synthesis- as folate co factors many enzymes enzyme inhibition leads to increased adenosine which inhibits neutrophil chemotaxis and cytokine secretion- anti-inflammatory action

Question 37

what is the effect of enzyme inhibition of methotrexate

Answer 37

increased adenosine which inhibits neutrophil chemotaxis and cytokine secretion anti-inflammatory

Question 38

at optimal methotrexate dose, how long till effects are seen?

Answer 38

1-3 months

Question 39

TF: methotrexate is used for psoriasis and eczema at the same concentrations as in cancer

Answer 39

False

Question 40

methotrexate risks

Answer 40

liver cirrhosis- LFTs every month then every 3 months if stable blood disorders GI symptoms alopecia, infection risk

Question 41

what blood disorders can methotrexate cause? why

Answer 41

thrombocytopenia, anaemia and leucopenia | as all the productions are suppressed

Question 42

what are the gastric side effects of methotrexate?

Answer 42

inflammed | nausea

Question 43

how can these gastric side effects be counteracted?

Answer 43

5mg folic acid weekly

Question 44

if you give folic acid 5mg with methotrexate what must you do?

Answer 44

give on alternate days as they compete for cellular uptake

Question 45

advice on vaccines to patients taking methotrexate

Answer 45

increased infection risk cant have live vaccines while on methotrexate make sure up to date with vaccines before starting to take

Question 46

interaction between NSAIDs and methotrexate?

Answer 46

NSAIDs increase levels of methotrexate

Question 47

how often is ciclosporin given in patients with psoriasis and eczema?

Answer 47

twice daily - split 2.5mg/kg

Question 48

mechanism of action cyclosporin

Answer 48

blocks calcineurin development factor IL2 blocked proliferation of T-lymps and cytokines blocked proliferation of keratinocytes blocked

Question 49

cyclosporin duration of treatment?

Answer 49

2-4 months

Question 50

TF: cyclosporin is more effective than methotrexate

Answer 50

false, they're just as effective as each other

Question 51

risks of ciclosporin

Answer 51

``` nephrotoxic hypertension teratogenic immunosuppresant bruising ```

Question 52

can you use ciclosporin in pregnancy?

Answer 52

only if necessary but try to avoid

Question 53

biologics in psoriasis all target ____

Answer 53

TNF

Question 54

2 types of biologics?

Answer 54

Etanercept- genetically engineered fusion protein infliximab etc- monoclonal ABs

Question 55

response to biologics seen within ....

Answer 55

6 weeks

Question 56

risks of using biologics?

Answer 56

infections- avoid live vaccines CV risk- severe HF worsening of neurological disease e.g. MS cancer risk- varieties not just skin

Question 57

what infections are risks in the use of biologics?

Answer 57

reactivation of latent TB so must screen for TB listeria and salmonella risk- careful with meats and dairy

Question 58

how does dupilumab work? what does it treat?

Answer 58

eczema monoclonal antibody inhibits Th cell activation

Question 59

how does dupilumabs ability to inhibit Th cell activation help in eczema?

Answer 59

T helper cells disrupt the skin barrier by inhibiting expression of filaggrin- which helps regulate outer skin cells and antimicrobial peptides

Question 60

what can dupilumabs predispose you too?

Answer 60

worm infection- must clear before hand

Question 61

dose of dupilumab?

Answer 61

injection every 2 weeks

Question 62

when must dupilumab be reviewed?

Answer 62

review if no response at 16 weeks