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MSK II Exam II > Dermatologic Pharm > Flashcards

Dermatologic Pharm Flashcards

1
Q

4 major variables affecting cutaneous absorption

A

Regional — e.g., axilla more permeable than forearm

Concentration gradient — increased concentration —> drug mass/unit time

Dosing schedule — long local t1/2 of skin reservoir may permit QD dosing

Vehicles/occlusion — both can maximize drug penetration

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2
Q

Difference in composition of creams vs. ointments

A

Creams = mixture of ~half water/half oil with emulsifier (e.g., cetyl alcohol), water evaporates. Spread easily (good for large areas), are well absorbed, and wash off with water

Ointments = mixture of ~20% water in ~80% oil (oil component is made from hydrocarbons such as mineral oil or petroleum jelly). Feel greasy and are “occlusive”, meaning they stay on the surface of skin and are NOT well absorbed

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3
Q

Cream or ointment?: packaged in tub or tube, beter for oozing/“wet” skin conditions

A

Cream

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4
Q

Cream or ointment?: best used on dry skin since they trap moisture, provide more complete absorption of active ingredient or medication

A

Ointment

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5
Q

Cream or ointment?: Less likely to cause an allergic reaction

A

Ointments, because creams contain preservatives

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6
Q

T/F: Hands should be washed for 15-30 seconds using plain soap, although this does not reliably prevent microbial transmission

A

True

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7
Q

Alcohol-based hand disinfection is easier and faster than soap and water, and is rapidly effective against gram-positive, gram-negative, and viral pathogens. However, it is not effective against _______ so you must use soap and water to protect against transmission of that

A

C.difficile

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8
Q

Component of moisturizer that forms an oily layer on top of skin that traps water in the skin

A

Emollient

[common emolllients: petrolatum, lanolin, mineral oil, dimethicone]

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9
Q

Component of moisturizer that draws water into the outer layer of the skin

A

Humectants

[common humectants: glycerin, lecithin, and propylene glycol]

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10
Q

Component of moisturizer that loosens the bond between the top layer of cells to help dead skin cells fall off, helps the skin retain water, and gives it a smoother softer feel

A

Horny substance (keratin) softeners

[common agents: urea, alpha hydroxy acids (e.g., lactic, citric, glycolic), allantoin]

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11
Q

3 compounds found in sunscreens and their utility

A

p-aminobenzoic acid (PABA) and its esters — active in UVB range

Benzophenones — wider 250-360 nm range but less effective than PABA

Dibenzoylmethanes — active in UVA range, particularly useful for conditions such as drug-induced photosensitivity and cutaneous lupus erythematosus

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12
Q

Sunshades are opaque materials that reflect light, the classic example is _____ ______

A

Titanium dioxide

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13
Q

Broad-spectrum antimicrobial agent widely used in homes and hospitals due to general efficacy on skin (including oral mucosa) and low irritability; low concentrations affect cytoplasmic (inner) cell membrane integrity while high concentrations cause congealing of cytoplasm

A

Chlorhexidine

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14
Q

Utility of chlorhexidine against bacterial spores

A

Not sporicidal but prevents development of spores; inhibits spore outgrowth but not germination

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15
Q

Chlorhexidine action against mycobacteria

A

Mycobacteriostatic (mechanism unknown) but not mycobacteriocidal

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16
Q

Action of chlorhexidine against nonsporulating bacteria

A

Membrane-active agent, causing protoplast and spheroplast lysis

High concentrations cause precipitation of proteins and nucleic acids

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17
Q

Action of chlorhexidine against yeasts

A

Membrane-active agent, causing protoplast lysis and intracellular leakage, high concentrations cause intracellular coagulation

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18
Q

Action of chlorhexidine against viruses

A

Low activity against many viruses; lipid enveloped viruses more sensitive than nonenveloped; effect possibly on viral envelope (e.g., lipid moieties)

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19
Q

Effects of chlorhexidine on protozoa

A

Has activity against trophozoites, less toward cysts

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20
Q

Protozoan that causes diarrhea in humans, especially in HIV+ pts; oocysts are especially resistant to antiseptics and disinfectants

A

Coccidia (Cryptosporidium)

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21
Q

Organism considered to be the most resistant to antiseptic and disinfectants, after a chimp developed CJD when neurosurgical tools had been treated with 70% alcohol and formaldehyde vapor and stored for 2 years

A

Prions (CJD, BSE)

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22
Q

Organism(s) highly resistant to antiseptics and disinfectants that have increased in incidence in hospitalized pts, with CDC recommending using bleach or other EPA-approved agent with sporocidal claims

A

Spores (Bacillus, C.diff)

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23
Q

The top 3 organisms resistant to antiseptics and disinfectants are prions, coccidia, and spores. What are some others that are considered resistant?

A

Mycobacteria

Cysts (giardia)

Small non-enveloped viruses (polio)

Trophozoites (acanthamoeba)

Gram-negative non-sporulating bacteria (pseudomonas, providencia)

Fungi (candida, aspergillus)

Large non-enveloped viruses (enterovirus, adenovirus)

Gram positive bacteria (s.aureus, enterococcus)

Lipid enveloped viruses (HIV, HBV)

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24
Q

2 ways in which biofilms affect the utility of disinfectants and/or hand hygiene practices

A

Limited penetration of disinfectants

Antibiotic neutralization

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25
Q

Role of antiseptics and antibiotics in wound management

A

Antiseptic wash solutions such as iodine, chlorhexidine, or hydrogen peroxide are generally NOT necessary and potentially impede wound healing

Antibiotic therapy should be reserved for wounds that appear clinically infected

[exceptions: cadexomer iodine, silver]

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26
Q

T/F: tighter glycemic control is strongly linked to improved primary closure of surgical wounds as well as other types of wound healing

A

True

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27
Q

T/F: During wound healing it is important to ensure adequate oxygenation and nutrition

A

True

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28
Q

What type of wound debridement should be routine since it flushes bacteria and removes loose material?

A

Low-pressure irrigation with normal saline

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29
Q

What type of debridement is appropriate for removing large areas of necrotic/infected tissue?

A

Surgical debridement

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30
Q

Enzymatic debridement utilizes a variety of products with mixed results. _______ may promote endothelial cell and keratinocyte migration for angiogenesis and epithelialization

A

Collagenase

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31
Q

What is biologic debridement?

A

Maggot therapy — has negative perception but does result in liquefaction of necrotic tissue while leaving healthy tissue intact

Pressure ulcer healing time is not consistently reduced

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32
Q

Platelet derived growth factor that promotes cell proliferation and angiogenesis; only agent approved for tx of chronic diabetic foot ulcers

A

Becaplermin

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33
Q

Black box warning associated with becaplermin

A

Malignancy — use of >3 tubes increases risk for malignant complications x4

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34
Q

T/F: use of epidermal growth factor during wound healing has significant benefit in improving epithelialization

A

False — does NOT significantly improve epithelialization

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35
Q

General principles regarding wound dressings

A

Wounds should be kept moist, and should not be exposed to air. Occluded wounds heal 40% faster and have less scarring. Wounds are exposed to their own fluid, a mix of metalloproteases and cytokines

[consensus is to use hydrogels for debridement stage, foam and low-adherence dressings for granulation stage, and hydrocolloid + low adherence dressings for epithelialization stage]

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36
Q

MOA of bacitracin and clinical indications

A

Topical peptide antibiotic, inhibits bacterial cell wall synthesis

Active against gram-positive organisms, most anaerobic cocci, neisseriae, tetanus bacilli, diphtheria bacilli

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37
Q

MOA and clinical indication of neomycin

A

Topical aminoglycoside antibiotic, binds to 30S ribosomal subunit to inhibit protein synthesis

Active against gram-negative organisms

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38
Q

MOA and clinical indication for polymixin B

A

Topical peptide antibiotic, binds to phosphor-lipids to alter permeability and damage bacterial cytoplasmic membrane

Effective against gram-negative organisms including P.aeruginosa, E.coli, Enterobacter, and Klebsiella

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39
Q

MOA of topical imidazoles

A

Block ergosterol synthesis, have a wide range of activity against dermatophytes and yeast

[applied 1-2x/day, typically clears superficial dermatophyte infection in 2-3 wks. Local rxns may include stinging, pruritis, erythema, and local irritation]

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40
Q

List 4 topical imidazoles used to treat dermatophytes and yeast

A

Miconazole
Clotrimazole
Efinaconazole
Ketoconazole

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41
Q

Prescription synthetic broad-spectrum topical antimycotic agent, disrupts macromolecular synthesis; active against dermatophytes, candida, and malassezia

A

Ciclopirox

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42
Q

Allylamine, selectively inhibits squalene epoxidase, a key enzyme for the synthesis of ergosterol; highly active against dermatophytes but less active against yeasts

A

Terbinafine

[can cause local irritation, avoid contact with mucous membranes]

43
Q

Synthetic antifungal compound, MOA uncertain but distorts hyphae/stunts mycelial growth

Effective topically against various dermatophyte and malassezia infections, but not candida

A

Tolnaftate

44
Q

MOA of nystatin as a topical antifungal

A

Binds to fungal sterols, alters membrane permeability

[limited to topical tx of cutaneous and mucosal candida infections because of its narrow spectrum and negligible absorption from the GI tract following oral administration]

45
Q

MOA of amphotericin B as a topical antifungal

A

Binds to fungal sterols, alters membrane permeability

Limited to topical tx of cutaneous candida infection

[may cause temporary yellow staining of skin]

46
Q

2 oral antifungal agents used for cutaneous infections; broad spectrum and can treat tinea versicolor

A

Fluconazole

Itraconazole

47
Q

Oral antifungal given to treat onychomycosis

A

Terbinafine

48
Q

_______ is given orally to treat dermatophyte infections of scalp and non-hairy skin caused by epidermophyton, microsporum, and trichophyton; MOA is unclear and is ineffective against candida and malassezia

A

Griseofulvin

49
Q

Topical antiviral agent used for tx of recurrent orolabial herpes simplex virus infection in immunocompetent adults

A

Acyclovir

[available as ointment, cream, and buccal tablet]

50
Q

MOA of acyclovir as topical antiviral agent

A

Synthetic guanine analog with inhibitory activity against HSV 1 and 2

51
Q

Common causes of localized pruritis

A

Ringworm, nail infection, seborrheic dermatitis of the scalp, head lice, grover disease (transient acantholytic dermatosis), pompholyx, hand dermatitis, vulvovaginal candida, pubic lice, lichen sclerosis, jock itch, gravitational eczema, athlete’s foot

Trigeminal trophic syndrome, brachioradial pruritis, pruritis vulvae, pruriis ani, herpes zoster during recovery phase

52
Q

Systemic causes of pruritis

A

Chronic renal failure, cholestatic pruritis, diabetes, hyperthyroidism, hypoparathyroidism, myxedema, hypercalcemia, iron deficiency anemia, polycythemia, lymphatic leukemia, hodgkin lymphoma, generalized neuropathic pruritis, pregnancy, post-menopasual pruritis

53
Q

Nonpharmacologic interventions for pruritis

A

Skin moisturization

Cool environment — may consider cooling lotions (calamine, those with menthol)

Avoid skin irritants

Stress reduction

Physical interventions — may consider occlusive dressings, trim fingernails, etc

54
Q

Topical therapies for pruritis may include barrier repair creams, moisturizers, and emollients — and ____ pH products may be particularly useful

A

Low

55
Q

Medication class used as topical therapy for pruritis that is not directly anti-pruritic, but may be useful in pruritis cases due to inflammatory skin dermatoses

A

Topical corticosteroids

56
Q

Tacrolimus ointment and Pimecrolimus cream are particularly useful in anogenital pruritis, but may cause transient burning and stinging. What is the MOA of these products?

A

Topical calcineurin inhibitors

57
Q

Possible H1 antagonist used as topical therapy for pruritis, but should be avoided in children and there is a 20-25% risk of sedation

A

Doxepin cream

58
Q

MOA of capsaicin

A

Activates transient release potential vanilloid-1 (TRPV1), an ion channel in cutaneous nerve fibers

Stimulates neurons to release and eventually deplete certain neuropeptides, including substance P

Can also induce lasting desensitization of neurons to a variety of stimuli

59
Q

MOA of salicylic acid as a topical therapy for pruritis

A

COX inhibitor and keratolytic

Keratolytic effects caused by ability to dissolve intercellular cement

[useful in lichen simplex chronicus; avoid in acute inflammatory dermatoses and children; treated areas are photosensitive]

60
Q

Topical local anesthetic found in a variety of OTC remedies along with hydrocortixone; e.g., useful for pruritis on face and that associated with CKD

A

Pramoxine

61
Q

2 Topical local anesthetics useful in neuropathic pruritis

A

Lidaine patch

Eutectic mixture of lidocaine and prilocaine

62
Q

Guidelines for usage of topical glucocorticoids based on potency

A

Use low-potency (e.g., hydrocortisone, methylpredinsolone, etc.) on face, genitals, and skin folds

Elsewhere, start with high potency (e.g., budesonide, betamethasone dipropionate, etc.) to gain control and titrate downward for maintenance

63
Q

Antidepressants useful in systemic tx of pruritis

A

NaSSA (Alpha-2 antagonist) — Mirtazapine

SSRIs — paroxetine, fluvoxamine, sertraline

64
Q

u-opioid receptor antagonist useful in systemic tx of pruritis

A

Naltrexone

65
Q

k-opioid receptor agonist/u-opioid receptor antagonist useful in systemic tx of pruritis

A

Butorphanol

66
Q

Anticonvulsants useful in systemic tx of pruritis

A

Gabapentin

Pregabalin

67
Q

Substance P antagonist useful in systemic tx of pruritis

A

Aprepitant

68
Q

4 agents used to tx ectoparasitic infections

A

Malathion
Permethrin
Ivermectin
Lindane

69
Q

Topical agent used to tx ectoparasitic infections; MOA: organophosphate cholinesterase inhibitor

A

Malathion

70
Q

Topical agent used to tx ectoparasitic infections; MOA: binds insect Na+ channels, blocks membrane repolarization

A

Permethrin

71
Q

Oral agent used to tx ectoparasitic infections; MOA: binds glutamate-gated Cl- channels in invertebrates, hyperpolarizes nerve and muscle cells

A

Ivermectin

72
Q

Topical agent used to tx ectoparasitic infections; MOA: disrupts GABAergic transmission in insects; toxic and only used when other methods have failed

A

Lindane

73
Q

Topical retinoids are often used in the tx of acne vulgaris, what is the MOA?

A

Metabolized to 4-oxo-RA, 4-OH-RA, 5,8-epoxy-RA

Contributes to normalization of follicular keratinization, decreased cohesiveness of keratinocytes, and reduces follicular occlusion and microcomedone formation

74
Q

3 topical retinoids used in tx of acne vulgaris

A

Tretinoin

Adapalene

Tazarotene

75
Q

AEs of tretinoin

A

Local irritation, dryness, flaking, sun sensitivity

Some formulations contain fish proteins, use with caution in patients with sensitivity or allergy

76
Q

AEs of adapalene

A

Local skin irritation, dryness and flaking, sun sensitivity

77
Q

Topical antimicrobials used in tx of acne vulgaris

A

Benzoyl peroxide (local skin irritation, may beach hair or clothing)

Clindamycin (rare risk of pseudomembranous colitis)

Erythomycin

Dapsone

Sulfacetamide

78
Q

Dicarboxylic acid that kills acne bacteria and decreases production of keratin; used to treat mild to moderate acne as well as post-inflammatory hyperpigmentation; AEs include local skin irritation

A

Azelaic acid

79
Q

Oral abx used in tx of acne vulgaris

A 
Tetracycline
Doxycycline
Minocycline
Erythromycin
Azithromycin
TMP-SMX
80
Q

AEs of tetracycline and doxycyline in tx of acne vulgaris

A

Photosensitivity, GI distress, contraindicated in pregnancy and young children

81
Q

AEs of minocycline

A

Dizziness
Drug-induced lupus
Skin discoloration

Contraindicated in pregnancy and young children

82
Q

AEs of erythromycin and azithromycin when used in tx of acne vulgaris

A

GI distress

83
Q

Severe AE associated with TMP-SMX used in acne vulgaris

A

Stevens-johnson syndrome

TEN

84
Q

Hormonal agents used in tx of acne vulgaris and their AEs

A

Combination OCPs — cause nausea, breast tenderness, weight gain, thromboembolic events

Spironolactone — contraindicated in pregnancy; cause menstrual irregularity, breast tenderness, minor GI symptoms, orthostatic hypotension, hyperkalemia, dizziness, headaches, fatigue

85
Q

AEs of oral isotretinoin used in tx of acne

A

Teratogenicity (absolute contraindication in pregnancy)

Mucocutaneous effects

Hypertriglyceridemia

86
Q

List topical and systemic therapies used for psoriasis

A

Topical: emollients, corticosteroids, topical vit D analogs (calcipotriene, calcitriol), tar, tazarotene, calcineurin inhibitors, anthralin, salt water baths, UV light therapy

Systemic therapies: methotrexate, apremilast, retinoids, systemic calcineurin inhibitors, biologics

87
Q

MOA of apremilast

A

Inhibits PDE4 —> increased cAMP levels

Decreases nitric oxide synthase, TNF-a, and IL-23

Increases IL-10

88
Q

Clinical applications of apremilast include moderate to severe plaque psoriasis and active psoriatic arthritis. What are associated AEs?

A

Severe diarrhea, N/V, weight loss

Headache is most common CNS complaint, but depression, suicidal ideation, and mood changes have been observed

89
Q

Ustekinumab is used for plaque psoriasis, psoriatic arthritis, and Crohn disease. What is the MOA?

A

Human monoclonal Ab — targets proinflammatory cytokines IL-12 and IL-23

Blunts IL-12/IL-23 to decrease NK cell activation, CD4 T cell differentiation/activation, and MCP-1, TNF-a, CXCL-10, IL-8 expression

90
Q

AEs of ustekinumab

A

Generally well tolerated but increases risk for infections

May increase risk for SCC

HSR reactions

91
Q

Humanized monoclonal Ab against iL-17a utilized in tx of ankylosing spondylitis, plaque psoriasis, and psoriatic arthritis

A

Ixekuzumab

92
Q

MOA of secukinumab (used for ankylosing spondylitis, psoriatic arthritis, psoriasis)

A

Human mAb

Targets proinflammatory cytokine IL-17a

93
Q

AEs of secukinumab

A

Generally well tolerated but increases risk for infections; may cause exacerbations of IBD

HSR reactions

94
Q

General Treatment options for actinic keratosis

A

Liquid nitrogen cryotherapy

Surgical therapy

Pharmacotherapy

Photodynamic red light therapy

Dermabrasion

Chemical peels

95
Q

Topical immune response modifier that stimulates local cytokine induction; effective therapy for AK

A

Imiquimod

96
Q

Substance derived from sap of Euphorbia peplus plant used to tx AK; works by disrupting cell PM and mitochondria leading to necrosis, then neutrophil-mediated antibody-dependent cellular cytotoxicity eliminates remaining tumor cells

A

Ingenol mebutate

97
Q

T/F: topical diclofenac and retinoids are useful in tx of AK

A

True

98
Q

MOA of 5-fluorourical in tx of AK

A

Inhibits thymidylate synthetase, a critical enzyme in synthesis of DNA

Prevents cell proliferation and leads to cell death

After 4-6 weeks, skin will have progressed from erythema through blistering, necrosis with erosion, then re-epithelialization

99
Q

3 tx options for BCC or SCC

A

Surgical removal/ablation

Topical meds — imiquimod, 5-FU

Advanced BCC may be treated with vismodegib or sonidegib — both oral “hedgehog” inhibitors

100
Q

Treatment options for melanoma

A

Surgical excision

Conventional chemotherapy — dacarbazine (may be combined with carmustine+tamoxifen, or cisplatin+vinblastine)

MAP kinase pathway inhibitors (if BRAF V600D mutation) — vemurafenib

101
Q

List common causes of alopecia

A

Male pattern baldness

Female pattern hair loss (androgenic alopecia)

Alopecia areata

102
Q

Treatment of male pattern baldness may involve:

________ = vasodilates d/t K+ channel opening; promotes hair growth by increasing duration of anagen phase, shortening telogen phase, and enlarging miniturized follicles

_________ = oral inhibitor of DHT production, can cause sexual dysfunction; increases hair count

Surgery = transplant of hair follicle units

A

Minoxidil

Finasteride

103
Q

First and second line Treatment for androgenetic alopecia in women

A

First-line = minoxidil

Second-line = anti-androgens: spironolactone (androgen partial agonist), finasteride (blocks DHT synth), flutamide (androgen antagonist

104
Q

Alopecia areata is a chronic, relapsing immune-mediated inflammatory d/o affecting hair follicles, resulting in non-scarring hair loss

What are treatment options?

A

Intralesional or topical corticosteroids

Topical immunotherapy — contact allergen such as diphenylcyclopropenone (DPCP) is used to cause contact dermatitis, which causes hair growth for unknown reason

MSK II Exam II (10 decks)

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