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Pharm Seizures > Dermatological Disorders Pharm > Flashcards

Dermatological Disorders Pharm Flashcards

1
Q

What is the difference between topical and percutaneous absorption and transdermal?

A

Topical is treating the dermal disorder

Percutaneous or transdermal is using the skin as a mechanism to create a systemic effect

But transdermal is absorption through unbroken skin

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2
Q

What is the major barrier for percutaneous drug abdsorption?

A

The stratum corneum

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3
Q

What in the stratum corneum can reversible or irreversibly bind to drugs?

A

Lipids and proteins

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4
Q

What are the factors of the formulation and after application can determine the bioavailability of the ingredient from the drug product?

A

Evaporation

Mix with skin-surface lipids

Undergoing change in composition

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5
Q

What does penetrate mean with derm meds?

A

The movement of the drug into and through the barrier of the stratum corneum

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6
Q

What does permeation mean with derm meds?

A

Spreading or diffusion of the drug throughout an organ, tissue or body space

Spreading of drug through the viable epidermis and dermis

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7
Q

What is resorption

A

Uptake of the drug into the microvascluature and into systemic circulation

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8
Q

What is a reservoir

A

The amount of active ingredient that adheres to the skin surface and resides in the upper layers of the stratum corneum

Can’t be removed by rubbing and is a depot for drug absorption

Fentanyl patch - even after removed it makes a reservoir and still is absorbed

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9
Q

What are the three pathways that drugs penetrate the skin? The drug can use more than one

A

Transappendageal route: through sweat ducts, hair follicles, associated sebaceous glands (this is only a small amount 0.1 - 1%)

Transepidermal routes: across the continuous stratum corneum

INtercellular lipid route: between the corneocytes only continuous route and most important

Transcellular: through the corneocytes and lipids (shortest distance but most resistant, lipid twice and hydrophilic) This is the preferred route for hydrophilic drugs
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10
Q

What size molecular weight for derm drugs?

A

Low molecular weight (<500 daltons)

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11
Q

Charged or uncharge have a easy time to cross into membrane?

A

Uncharged

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12
Q

pH - will determine what is ionized compared with what is in-ionized

The normal stratum corneum is acidic or alkalinity?

A

Acidic (4-5)

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13
Q

Drugs that are two hydrophilic risk what?

A

Unable to partition from the vehicle into the stratum corneum

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14
Q

Too lipophilic drugs can do what to prevent skin permeation rate?

A

May be retained in intercellular stratum corneum lipids and will not partition to more aqueous viable epidermis, thus limiting their skin permeation rate

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15
Q

What is the ideal amount of deliverable dose?

A

20 mg/day

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16
Q

What is the vehicle or carrier

A

The inactive part of the topical preparation that brings a drug into contact with the skin

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17
Q

What are some side beneficial effects that a vehicle may have? (5)

A

Cooling

Protective

Emollient

Occlusive

Astringent

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18
Q

What determines the rate at which the activity ingredient is absorbed through the skin. What three ways does it do this?

A

The vehicle

  1. promoting SC hydration by an occlusive effect
  2. Modulating the vehicle/SC partition
  3. Promoting increased drug solubility into the SC
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19
Q

Does the vehicle carry the drug all the way through absorption?

A

No

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20
Q

What group is the least potent?

A

Group 7

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21
Q

Is ointments more potent than creams?

A

Yes, ointments are more potent than creams

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22
Q

Are creams more potent than lotions?

A

Yes creams are more potent than lotions

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23
Q

What is the benefits of ointments?

What kind of skin is it best for?

Where should you not use it?

A

Provide more lubrication and more occlusion (this prevents evaporative fluid loss)

Best for thick skin (atopic dermatitis, kertified skin) also palms and soles which is thicker

NOT BE used in intertrigious area

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24
Q

What two areas should avoid using ointments?

A

Intertrigious and hairy areas

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25
Q

What is the difference between ointments and creams with hydration

A

Ointments create more hydration

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26
Q

What would be better for an oozing skin lesson?

A

Creams, has drying affect

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27
Q

Can you use creams in intertrigious areas?

A

Yes

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28
Q

Which vehicle contains alcohol?

A

Lotions

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29
Q

Which vehicle is best for hairy areas?

A

Lotions

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30
Q

What vehicle is best for wet lesions like poison ivy?

A

Gels

Dry very quickly

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31
Q

Are gels more potent than ointments?

A

Yes. Best for derm to use

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32
Q

Topical meds have low absorption percentage. What matters more

A

The inherent potency

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33
Q

True or false…low absorption does not mean low efficacy

A

True

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34
Q

Efficacy depends on what

A

Ability to penetrate the skin

Penetration depends on concentration of the med

Concentration of the drug is very importaint

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35
Q

Does the amount of times you apply the drug a day have any effect on overal efficacy

A

No

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36
Q

What does occlusion do?

A

Increase the temp of the skin

Reduce evaporative water loss through the skin

This will increase the temp and increase the water - which increases the absorption of the drug

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37
Q

Anatomically, What is the hardest and the easier for the drug to penetrate

A

Thickest: nail (hardest to absorb) Then sole of foot ankle, palm

Easiest scrotum and eyelid and higher absorption

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38
Q

What kind of drugs are reduced with absorption as we age?

A

Less lipophilic drugs

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39
Q

The increase friablity of the older skin can increase what?

A

Percutaneous absorption

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40
Q

When is the acid mantle on the skin formed?

A

In the first 4 weeks of birth

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41
Q

Newborn skin is more what in regards to pH

A

Alkalinic

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42
Q

Because the skin of newborns are thinner, is the permeability higher or lower?

A

Higher

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43
Q

At birth is the skin dry or moist

A

Dry

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44
Q

Dry skin in children will increase the chance of what

A

Toxcity

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45
Q

Newborns have a BSA: BW ratio twice that of adults, what will this do?

A

Covers greater surface area and they are at greater risk for toxcity

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46
Q

When the integrity of the skin is compromised, like with atopic derm. Does penetration of the drug increase or lower?

A

Increase, with inflamed skin of atopic dermatitis

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47
Q

What does topical glucocorticoids do?

A

Inhibit the arachnids is acid cascade preventing inflammation

Stabilizing lysosomal membranes of phagocytizihg cells - producing anti-inflam

Also immunosupprsion - lymphocyte and monocyte apoptosis

Inhibit phagocytosis

Inhibit leukocyte migration to the site of inflammation

Limits macrophages from working

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48
Q

What happens to the vasucualtur when gluocoroids are applied to the skin? How does it do this

A

Vascoconstriction - inhibits natural vasodiatlaor (histamine, bradykinins, and prostaglandins)

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49
Q

What does glucocorticoids do the capillaries?

A

Decrease capillary permeability - Because of the reduced amount of histamines

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50
Q

What does glucosteroids do to the epidermal cell mitosis

A

Decrease - may help with psoriasis or other derm issues that are associated with increase epidermal cell turnover

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51
Q

What group containtains the most potent topical corticosteroids? What is the weakest. What groups should a NP know

A

Group 1

Group 7 is the lowest potent

Group 4-7

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52
Q

When do you discontinue topical steroids?

A

When the inflammation is controlled

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53
Q

Why is high potency fluoridated corticosteroids not indicated for children or elderly

A

Toxic effect

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54
Q

The more potent a steroid - how long should the treatment be?

A

Short

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55
Q

How long can a group 1 topical steroid be use? How long of rest?

A

2-3 weeks

then a week of rest

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56
Q

Group 2-7 how long should they be used? Then how much off between?

A

Twice a day, no longer than 6 weeks

Taper

One week off

Can be used chronic

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57
Q

What regiment do you use with moderate potency agents?

A
  1. Once or twice a day for 3-10 days (can do 3-5 day burst to gain control)
  2. After improvement, use it for once a day with a bland moisturized once or twice a day;
  3. After stabilization than consider proactive secondary prevention - use TCS on site for 2 consecutive days a week
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58
Q

How long can you use the plastic wrap when doing occlusion?

A

At least 2 hours

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59
Q

Which potency agent can cause tachyphylaxis? And what should you do if it happens

A

High potency - after just a few doses

Educate: response in 2-3 days and have a response, then inflammation worsens,

Stop drug and rest for 2-7 days

Restart with less potent

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60
Q

Side effect: If you find depressed, shiny, wrinkled skin…and they have been using steroids, what is happening

A

Atrophy of the skin

Can be perminate

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61
Q

What potency steroid can be use on the face?

A

Low petency

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62
Q

Another side effect of steroids is telangectasias, what is it?

A

Spider veins

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63
Q

Steroid use can cause striae, is it permanent?

A

Yes

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64
Q

What are some topical steroid side effects?

A

Striae,

Steroid acne

Steroid rosacea

Purpura

Atrophic skin

Delayed wound healing

Bacterial infection

Contact dermatitis

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65
Q

What kind of side effect happens when steroid is stopped and the build up of the vasodilators, (withdrawal)

A

Red skin syndrome

66
Q

If you prescribe topical steroids and it only gets worse, what should you consider?

A

Infection

67
Q

What are some systemic effects of topical steroids?

A

Cataracts

Hypertension

Cushing syndrome

Hyperglycemia

68
Q

Recent study showed a HPA axis suppression in what age group, which caused cushing syndrome.

A

Children and infants

69
Q

What does Contact dermatitis look like?

Symmetry?
Demarcation?
Color?
More?
Chronic?
A

Asymmetric lesions

Sharply demarcated

Erythema

Local edema

Vesicles

Ulceration

Chronic: dry thickened, fissured skin

70
Q

Do antihistamines provide relief with contact dermatitis?

A

No, it is not IgE mediated

But if used, only used for sedation

71
Q

With acute atopic derm, contact derm, what is the treatment?

A

Cold wet compresses - for acute care/ vasoconstriction happens to decrease inflammation/removed crust/hydration

Topical, oral, or IM steroids

Antibiotics

72
Q

Sub acute and chronic inflammation with contact or atopic/ how do you treat?

A

Hydration/lubrication

Topical steroids (with or with occlusion)

Antibiotics

73
Q

How much of the body surface area should happen with AD to be considered Moderate to severe?

A

Over 10% of the BSA

Also areas that are important for function

Affecting ADL’s

74
Q

At what level of severity do you start using topical steroids with AD?

A

Mild to moderate - start with low-mid potency

NP do not prescribe high potency

75
Q

What are the most common systemic steroid use with AD

A

Prednisone and prednisolone

76
Q

What is a non-pharm way to lower the use of topical steroids?

A

The use of Moisturizers and emollients, twice a day

77
Q

Many pts with AD will be colonized with more S. Aureus. What can this do?

A

Contribute to skin inflammation

Increase the risk for infection

78
Q

Why do you do proactive therapy with AD

A

They think it might lower the colony of S. Aureus

79
Q

What are the four types of treatment failures?

A
  1. Inadequate clinical improvement
  2. Failure to achieve stable long term disease control
  3. Failure to relive impairment
  4. Unacceptable adverse events
80
Q

What potency and the drug name, do you prescribe for Psoriasis of the hand/ Eczema? And the warning as in what area not to use it in and how many day limit

A

1

Super potent

Clobetasol

DONT use on face, axillae groin, or under breast. Limit to 14 days

81
Q

What potency do you prescribe atopic dermatitis in adults?

What is the name of the meds?

What area should you not use it in?

What is the limit of days?

A

II and III

Diflorasone and Desoximetasone

Not for face, axillae, groin, or under breast.

Limit to 21 days

82
Q

What potency would you use for atopic dermatitis in children?
What is the name of some of the meds?
How many days do you limit it?
Do not use in what area?

A

IV and V medium

Triamcinolone
Hydrocortisone valerate

Limit using in children to 7-21 day
Limit use in intertirigious areas

83
Q

What potency would you use for eyelid dermatitis and diaper dermatitis?
What is the name of the diaper, eyelid meds
What warning limits?
When do you reevaluate? How many days?

A

VI and VII

Desonide

Hydrocortisone

Reevaluate if disease does not respond in 28 days

Avoid long term continuous treatment in any area

84
Q

What is the name of the two drugs that are topical calcineurin inhibitors?

A

Pimecrolimus

Tacrolimus

85
Q

Can you use calcineurin inhibitors long term and not cause what side effects that steroid cause

A

Skin Atrophy

86
Q

Can you use calcineurin in sensitive areas?

A

Yes

87
Q

What is the equivalent of pimecrolimus to what group steroid?

A

6 and 7

88
Q

Tacrolimus is equivalent to what group of steroids? And can use in what level of AD

A

5

Moderate to severe

89
Q

What drugs have steroid sparing effects when used at first appearance of erythema and pruritus

A

Pimecrolimus and Tacrolimus

90
Q

What is the BB warning to Topical Tacrolimus and pimecrolimus?

A

Although a causal reactionship, rare cases of malignancy (skin and lymphoma) has been reported (organ transplant pts)

Warning to not use long term

Not to be used for children less than 2 years of age (because of the developing immune system)

91
Q

What is the FDA recommendation of the use of Calcineurin inhibitors?

A
  1. Avoid use in children less than 2 years of age
  2. Use TCI’s as a second line agent
  3. Use only as short term or intermittent
  4. Caution against people with weak immune system
  5. USe minimal amount
92
Q

What is the MOA of Crisaborole (Euscisa)?

A

Topical phosphodiesterase inhibitor
increased PDE4 increases inflammatory mediators
This inhibits this

93
Q

Can you use Crisaborole in pregnancy and lactation?

A

Yes but there is limited data

Don’t apply to area that can get in the infants mouth

94
Q

What can you use Crisaborole for?

A

Mild to moderate AD in adults, peds and pt 3 month of age and older

95
Q

What class is Dupilumab

A

Human monoclonal IgG4 antibody

96
Q

What is Dupilumab MOA

A

Binds to the IL-4 subunit of the receptor complex, inhibit good the release of pro inflammatory cytokines

97
Q

What is Dupilumab indicated for? How is it given

A

6 years and older with moderate to severe AD, if topical doesn’t work or they can’t use topical

It is an injection (SQ)

98
Q

Can you use Dupilumab in pregnancy or lactation?

A

Not enough data

99
Q

When do we refer for AD?

A 
Diagnosis uncertainty 
Poor compliance
Parental concern
Treatment failure with appropriate TD
Involvement of sites such as the face
Frequent infections
Poor sleep
Excessive scratching
Psychological disturbance
100
Q

What are the two pathogens that cause many of the derm infections?

A

S. Aureus

Group A beta streptococcus

101
Q

Typically is impetigo systemic?

A

No

Sometimes you can get a fever, but it doesn’t happen often

102
Q

What dose Impetigo start as and move into?

A

Small vesicles to blisters to crusting

103
Q

What are the two different forms of Impetigo?

A

Bullous and non-bollous

104
Q

Which one of the types of impetigo can cause dehydration?

A

Bullous

105
Q

When is topical antibiotics indicated with impetigo? (2)

A
  1. Uncomplicated superficial skin infection (no systemic infection)
  2. Limited localized lesions (<10 lesion over <100 cm2 or <2% BSA as a rule of thumb
106
Q

When do you use systemic antibiotics in impintago?

A
  1. Multi sites of infection
  2. Lack of adequate response to topical therapy
  3. Systemic signs of infection
107
Q

When do we use Bacitracin and Gramicidin? And what gram organism?

A

Prophylaxis, against gram positive organisms

108
Q

MOA of Bacitracin?

A

Inhibits cell wall synthesis

109
Q

What is the MOA of Gramicidin

A

Disrupts cell wall function

110
Q

What med is active against MRSA?

A

Mupirocin

111
Q

What is the MOA of Mupirocin?

A

Inhibits protein synthesis

112
Q

What is Mupirocin use to treat? (2)

A

Impetigo in pts greater than 2 years of age

Also to eliminate nasal colonization of S. aureus

113
Q

Retapamulin is active against what pathogen?

A

MSSR and Group A strep

114
Q

What two meds can be use for impetigo and what is the age minimum?

A

Retapamulin Greater than 9 months (MSSA) (blocks protein synthesis)

Mupirocin greater than 2 months (MRSA) (blocks protein synthesis)

115
Q

What are the two aminoglycosides and what gram level are they good for? What are they indicated for? And side effects of each?

A

Active against gram negative organisms
Neomycin: minor skin infections: topical only: to toxic for systemic use: commonly causes contact derm
Gentamicin: minor skin infections: can cause serum levels when applied in water base to denuded skin: can lead to toxicity: neph and oto toxicity

116
Q

What do dermatophytes cause?

A

Organisms that cause tinea

117
Q

What part of the body does Dermatophytes affect and why?

A

The Stratum corneum

Because they survive on the keratin that is in the cells in the stratum corneum

118
Q

What is Tinea versicolor caused by?

A

Pityrosporum obisculare or P. Ovale

119
Q

Where is Tinea corporis located?

A

arms, legs, torso

120
Q

Where is the Tinea cruris located?

A

The genitocrural folds

121
Q

What is the last 6 letters of topical antifungals? What is the MOA? What are more effective with and less effective against

A
  • Azoles

Prevents the fungus from generating a cell wall

Yeast - most effective

Dermatophytes - less effetive

122
Q

Name Allylamines/Benzylamines. What are they most effective in killing, and least effective? MOA

A

Butenafine
Naftifine
Terbinafine

Most against Dermatophytes
Least against Yeast - don’t use it for yeast

MOA: Inhibit an enzyme to prevent the building a cell wall

123
Q

Using a antifungal twice a day will clear up in what amount of time? And how long after clinical cure

A

2-3 weeks

2 weeks

124
Q

If you use a steroid/antifungal combo, what should you know?

A

That it can lower the immune response and it should only be used for a short period of time

125
Q

What is a big indication do use oral antifungal and why

A

Tinea capitis

It gets into the hair bulb and hair shaft

The meds will not penetrate

126
Q

What are other reasons to use an antifungal orally?

A 
Hyperkeratonitic areas involved (like the palms or soles)
Disabling or extensive disease
Intolerant of topical therapy
Failed topical therapy
Chronic or recalcitrant infection
Immunosuppressive
127
Q

Griseofulvin is a oral or topical antifungal?

A

Oral

128
Q

What teaching point can you tell your pt if they take griseofulvin

A

Take with fatty food

129
Q

How long should you take griseoflulvin?

A

4-6 weeks and two weeks after the resolution of the S/S

130
Q

What are some more teaching points about Griseofulvin side effects?

A

Use sun protection

Nausea is common

131
Q

What are the contraindications of griseofluvin

A

Pregnancy

Hepatic failure

132
Q

How long should males wait to conceive a child after taking Griseofulvin

A

6 months

133
Q

What is the only systemic- azoles Agent used for tinea infections. And what is the BB warning?

A

Ketoconazole (for 2 and up)

Do not use routinely in children due to hepatotoxicity with long term use

134
Q

When to follow up with all the Tinea’ s?

Pedis?
Corporis?
Cruris?
Capitis?

A

Pedis - 1-6 weeks
Corporis - 2-4 weeks
Cruris - 10 days
Capitis - 4-10 weeks

135
Q

What is the target organ of acne? And what hormone is it tied to?

A

Pilosebaeous unit

Androgen

136
Q

How is ache classified?

A

Comedonal- non-inflammatory

Inflammatory

Mixed

137
Q

What are keratolytics? And name them?

A

They are agents that break down hardened or scaly skin

Salicylic acid - less effective than benzoyl
Benzoyl peroxide

138
Q

Topical agents for acne are for……..

A

Disease prevention

139
Q

How can you manage a mild or moderate inflammatory acne?

A

1-2 times a day, antibacterial agent and comedolytic agent

140
Q

What should educate your pt on in regards to what to expect for anti-acne agents?

A

You will get an acute exacerbation

It will not be improved until 8 weeks of therapy

141
Q

When should you use systemic therapy for acne?

A

Potential for scarring

Nodular lesions

Unresponsive to topical therapy alone

142
Q

What is the MOA of retinoids for acne? And used for what stage of acne

A

Bind to retinoid receptors to normalize follicular keratinization

Used for all stages of acne - they are for prevention and also for treatment

143
Q

What is the life stage of retinoid treatment

A

Redness and new acne at first

Cleared 8-12 weeks

144
Q

What are some names of retinoids? And what class in pregnancy? Which one is OTC and less irritating

What drug should you not apply it with?

A

Tretinoin - C in preg

Adapalene - C in preg - less irritation and OTC

Taxarotene - X in pregnancy

Benzoyl peroxide - will inactivate the retinoids

145
Q

Retinoid: what side effects cause the stopping of use and what can you do to prevent it

A

Dryness, irritation, pigmentation changes, photosensitivity, erythema

Reduce the frequency of application and dose

146
Q

What is the name of the systemic retinoid? And how long is the treatment? And what is the biggest side effect with consent and testing

A

isotretinoin

20 weeks

Birth defectives - lots of pregnancy test

147
Q

How long should a female use 2 forms of contraception when using Isotretinion?

A

One month before and 1 months after

148
Q

What is the primary MOA with benzoyl peroxide

A

Antibacterial

149
Q

What topical agent is best for sensitive skin and is a category B in pregnancy?

A

Azelaic acid

150
Q

When do you use antibiotic therapy for acne

A

Inflammatory acne

151
Q

What agent should you use when using antibiotic therapy to increase efficacy and decrease the development of bacterial resistance?

A

Benzoyl peroxide

152
Q

What is the preferred topical antibiotic treatment and what are two others

A

Clindamycin 1%

Erythromycin 2% - reduced efficacy than clinda and increased resistance

Dapsone - don’t use as the same time as BP - orange discoloration

153
Q

Can you do mono therapy with topical antibiotics? What drugs do you use with it?

A

NO, increases resistance (BP or retinoids)

If you do, use it for a very short time

154
Q

What systemic antibiotics can be use for moderate to severe ache?

A

Tetracyclines
Doxycycline
Minocycline - more side effects

155
Q

When is tetracyclines contraindicated? And what age limit?

A

Pregnancy

Less than 8 years old

Allergy

156
Q

Why are tetracyclines preferred for acne?

A

They are lipophilic and can penetrate into the lipid rich environment of the pilosebaceous unit

Also have anti-inflammatory properties

157
Q

What are strategies to optimize oral antibiotics

A
  1. Use in moderate to severe cases with combo that includes BP
  2. Avoid mono therapy with using oral or topical
  3. Discontinue- taper within 2 months once inflammatory lesions have stoped emerging
  4. Start at higher doses of oral antibiotics
158
Q

When do you refer?

A 
Moderate to severe
Pitting, scaring
Nodules
Exacerbating factors
Reddened cheeks nose, with enlarged blood vessels or sold red papilla or pustules (acne rosacea)
159
Q

Steps with treatment of mild acne?

A
  1. Comedonal acne: BP or retinoid
  2. Inflammatory: combo therapy: Retinoid +BP or Antibiotic + BP or BP+Retinoid + antibiotic
    If inadequate response - add one that has not been used
160
Q

Treatment of moderate acne?

A
  1. Start with combo treatment with added recommendation of oral antibiotics
  2. Inadequate: change antibiotic, oral contraceptives, isotretinin
161
Q

Treatment of severe acne?

A
  1. Initial: Isotretinoin or a 3 drug regiment

2. Derm consult

Pharm Seizures (8 decks)

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