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
2
Q
What is the major barrier for percutaneous drug abdsorption?
A
The stratum corneum
3
Q
What in the stratum corneum can reversible or irreversibly bind to drugs?
A
Lipids and proteins
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
5
Q
What does penetrate mean with derm meds?
A
The movement of the drug into and through the barrier of the stratum corneum
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
7
Q
What is resorption
A
Uptake of the drug into the microvascluature and into systemic circulation
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
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
10
Q
What size molecular weight for derm drugs?
A
Low molecular weight (<500 daltons)
11
Q
Charged or uncharge have a easy time to cross into membrane?
A
Uncharged
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)
13
Q
Drugs that are two hydrophilic risk what?
A
Unable to partition from the vehicle into the stratum corneum
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
15
Q
What is the ideal amount of deliverable dose?
A
20 mg/day
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
17
Q
What are some side beneficial effects that a vehicle may have? (5)
A
Cooling
Protective
Emollient
Occlusive
Astringent
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
- promoting SC hydration by an occlusive effect
- Modulating the vehicle/SC partition
- Promoting increased drug solubility into the SC
19
Q
Does the vehicle carry the drug all the way through absorption?
A
No
20
Q
What group is the least potent?
A
Group 7
21
Q
Is ointments more potent than creams?
A
Yes, ointments are more potent than creams
22
Q
Are creams more potent than lotions?
A
Yes creams are more potent than lotions
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
24
Q
What two areas should avoid using ointments?
A
Intertrigious and hairy areas
25
What is the difference between ointments and creams with hydration
Ointments create more hydration
26
What would be better for an oozing skin lesson?
Creams, has drying affect
27
Can you use creams in intertrigious areas?
Yes
28
Which vehicle contains alcohol?
Lotions
29
Which vehicle is best for hairy areas?
Lotions
30
What vehicle is best for wet lesions like poison ivy?
Gels
Dry very quickly
31
Are gels more potent than ointments?
Yes. Best for derm to use
32
Topical meds have low absorption percentage. What matters more
The inherent potency
33
True or false…low absorption does not mean low efficacy
True
34
Efficacy depends on what
Ability to penetrate the skin
Penetration depends on concentration of the med
Concentration of the drug is very importaint
35
Does the amount of times you apply the drug a day have any effect on overal efficacy
No
36
What does occlusion do?
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
37
Anatomically, What is the hardest and the easier for the drug to penetrate
Thickest: nail (hardest to absorb) Then sole of foot ankle, palm
Easiest scrotum and eyelid and higher absorption
38
What kind of drugs are reduced with absorption as we age?
Less lipophilic drugs
39
The increase friablity of the older skin can increase what?
Percutaneous absorption
40
When is the acid mantle on the skin formed?
In the first 4 weeks of birth
41
Newborn skin is more what in regards to pH
Alkalinic
42
Because the skin of newborns are thinner, is the permeability higher or lower?
Higher
43
At birth is the skin dry or moist
Dry
44
Dry skin in children will increase the chance of what
Toxcity
45
Newborns have a BSA: BW ratio twice that of adults, what will this do?
Covers greater surface area and they are at greater risk for toxcity
46
When the integrity of the skin is compromised, like with atopic derm. Does penetration of the drug increase or lower?
Increase, with inflamed skin of atopic dermatitis
47
What does topical glucocorticoids do?
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
48
What happens to the vasucualtur when gluocoroids are applied to the skin? How does it do this
Vascoconstriction - inhibits natural vasodiatlaor (histamine, bradykinins, and prostaglandins)
49
What does glucocorticoids do the capillaries?
Decrease capillary permeability - Because of the reduced amount of histamines
50
What does glucosteroids do to the epidermal cell mitosis
Decrease - may help with psoriasis or other derm issues that are associated with increase epidermal cell turnover
51
What group containtains the most potent topical corticosteroids? What is the weakest. What groups should a NP know
Group 1
Group 7 is the lowest potent
Group 4-7
52
When do you discontinue topical steroids?
When the inflammation is controlled
53
Why is high potency fluoridated corticosteroids not indicated for children or elderly
Toxic effect
54
The more potent a steroid - how long should the treatment be?
Short
55
How long can a group 1 topical steroid be use? How long of rest?
2-3 weeks
then a week of rest
56
Group 2-7 how long should they be used? Then how much off between?
Twice a day, no longer than 6 weeks
Taper
One week off
Can be used chronic
57
What regiment do you use with moderate potency agents?
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
58
How long can you use the plastic wrap when doing occlusion?
At least 2 hours
59
Which potency agent can cause tachyphylaxis? And what should you do if it happens
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
60
Side effect: If you find depressed, shiny, wrinkled skin…and they have been using steroids, what is happening
Atrophy of the skin
Can be perminate
61
What potency steroid can be use on the face?
Low petency
62
Another side effect of steroids is telangectasias, what is it?
Spider veins
63
Steroid use can cause striae, is it permanent?
Yes
64
What are some topical steroid side effects?
Striae,
Steroid acne
Steroid rosacea
Purpura
Atrophic skin
Delayed wound healing
Bacterial infection
Contact dermatitis
65
What kind of side effect happens when steroid is stopped and the build up of the vasodilators, (withdrawal)
Red skin syndrome
66
If you prescribe topical steroids and it only gets worse, what should you consider?
Infection
67
What are some systemic effects of topical steroids?
Cataracts
Hypertension
Cushing syndrome
Hyperglycemia
68
Recent study showed a HPA axis suppression in what age group, which caused cushing syndrome.
Children and infants
69
What does Contact dermatitis look like?
```
Symmetry?
Demarcation?
Color?
More?
Chronic?
```
Asymmetric lesions
Sharply demarcated
Erythema
Local edema
Vesicles
Ulceration
Chronic: dry thickened, fissured skin
70
Do antihistamines provide relief with contact dermatitis?
No, it is not IgE mediated
But if used, only used for sedation
71
With acute atopic derm, contact derm, what is the treatment?
Cold wet compresses - for acute care/ vasoconstriction happens to decrease inflammation/removed crust/hydration
Topical, oral, or IM steroids
Antibiotics
72
Sub acute and chronic inflammation with contact or atopic/ how do you treat?
Hydration/lubrication
Topical steroids (with or with occlusion)
Antibiotics
73
How much of the body surface area should happen with AD to be considered Moderate to severe?
Over 10% of the BSA
Also areas that are important for function
Affecting ADL’s
74
At what level of severity do you start using topical steroids with AD?
Mild to moderate - start with low-mid potency
NP do not prescribe high potency
75
What are the most common systemic steroid use with AD
Prednisone and prednisolone
76
What is a non-pharm way to lower the use of topical steroids?
The use of Moisturizers and emollients, twice a day
77
Many pts with AD will be colonized with more S. Aureus. What can this do?
Contribute to skin inflammation
Increase the risk for infection
78
Why do you do proactive therapy with AD
They think it might lower the colony of S. Aureus
79
What are the four types of treatment failures?
1. Inadequate clinical improvement
2. Failure to achieve stable long term disease control
3. Failure to relive impairment
4. Unacceptable adverse events
80
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
1
Super potent
Clobetasol
DONT use on face, axillae groin, or under breast. Limit to 14 days
81
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?
II and III
Diflorasone and Desoximetasone
Not for face, axillae, groin, or under breast.
Limit to 21 days
82
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?
IV and V medium
Triamcinolone
Hydrocortisone valerate
Limit using in children to 7-21 day
Limit use in intertirigious areas
83
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?
VI and VII
Desonide
Hydrocortisone
Reevaluate if disease does not respond in 28 days
Avoid long term continuous treatment in any area
84
What is the name of the two drugs that are topical calcineurin inhibitors?
Pimecrolimus
Tacrolimus
85
Can you use calcineurin inhibitors long term and not cause what side effects that steroid cause
Skin Atrophy
86
Can you use calcineurin in sensitive areas?
Yes
87
What is the equivalent of pimecrolimus to what group steroid?
6 and 7
88
Tacrolimus is equivalent to what group of steroids? And can use in what level of AD
5
Moderate to severe
89
What drugs have steroid sparing effects when used at first appearance of erythema and pruritus
Pimecrolimus and Tacrolimus
90
What is the BB warning to Topical Tacrolimus and pimecrolimus?
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
What is the FDA recommendation of the use of Calcineurin inhibitors?
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
What is the MOA of Crisaborole (Euscisa)?
Topical phosphodiesterase inhibitor
increased PDE4 increases inflammatory mediators
This inhibits this
93
Can you use Crisaborole in pregnancy and lactation?
Yes but there is limited data
Don’t apply to area that can get in the infants mouth
94
What can you use Crisaborole for?
Mild to moderate AD in adults, peds and pt 3 month of age and older
95
What class is Dupilumab
Human monoclonal IgG4 antibody
96
What is Dupilumab MOA
Binds to the IL-4 subunit of the receptor complex, inhibit good the release of pro inflammatory cytokines
97
What is Dupilumab indicated for? How is it given
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
Can you use Dupilumab in pregnancy or lactation?
Not enough data
99
When do we refer for AD?
```
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
What are the two pathogens that cause many of the derm infections?
S. Aureus
Group A beta streptococcus
101
Typically is impetigo systemic?
No
Sometimes you can get a fever, but it doesn’t happen often
102
What dose Impetigo start as and move into?
Small vesicles to blisters to crusting
103
What are the two different forms of Impetigo?
Bullous and non-bollous
104
Which one of the types of impetigo can cause dehydration?
Bullous
105
When is topical antibiotics indicated with impetigo? (2)
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
When do you use systemic antibiotics in impintago?
1. Multi sites of infection
2. Lack of adequate response to topical therapy
3. Systemic signs of infection
107
When do we use Bacitracin and Gramicidin? And what gram organism?
Prophylaxis, against gram positive organisms
108
MOA of Bacitracin?
Inhibits cell wall synthesis
109
What is the MOA of Gramicidin
Disrupts cell wall function
110
What med is active against MRSA?
Mupirocin
111
What is the MOA of Mupirocin?
Inhibits protein synthesis
112
What is Mupirocin use to treat? (2)
Impetigo in pts greater than 2 years of age
Also to eliminate nasal colonization of S. aureus
113
Retapamulin is active against what pathogen?
MSSR and Group A strep
114
What two meds can be use for impetigo and what is the age minimum?
Retapamulin Greater than 9 months (MSSA) (blocks protein synthesis)
Mupirocin greater than 2 months (MRSA) (blocks protein synthesis)
115
What are the two aminoglycosides and what gram level are they good for? What are they indicated for? And side effects of each?
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
What do dermatophytes cause?
Organisms that cause tinea
117
What part of the body does Dermatophytes affect and why?
The Stratum corneum
Because they survive on the keratin that is in the cells in the stratum corneum
118
What is Tinea versicolor caused by?
Pityrosporum obisculare or P. Ovale
119
Where is Tinea corporis located?
arms, legs, torso
120
Where is the Tinea cruris located?
The genitocrural folds
121
What is the last 6 letters of topical antifungals? What is the MOA? What are more effective with and less effective against
- Azoles
Prevents the fungus from generating a cell wall
Yeast - most effective
Dermatophytes - less effetive
122
Name Allylamines/Benzylamines. What are they most effective in killing, and least effective? MOA
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
Using a antifungal twice a day will clear up in what amount of time? And how long after clinical cure
2-3 weeks
2 weeks
124
If you use a steroid/antifungal combo, what should you know?
That it can lower the immune response and it should only be used for a short period of time
125
What is a big indication do use oral antifungal and why
Tinea capitis
It gets into the hair bulb and hair shaft
The meds will not penetrate
126
What are other reasons to use an antifungal orally?
```
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
Griseofulvin is a oral or topical antifungal?
Oral
128
What teaching point can you tell your pt if they take griseofulvin
Take with fatty food
129
How long should you take griseoflulvin?
4-6 weeks and two weeks after the resolution of the S/S
130
What are some more teaching points about Griseofulvin side effects?
Use sun protection
Nausea is common
131
What are the contraindications of griseofluvin
Pregnancy
Hepatic failure
132
How long should males wait to conceive a child after taking Griseofulvin
6 months
133
What is the only systemic- azoles Agent used for tinea infections. And what is the BB warning?
Ketoconazole (for 2 and up)
Do not use routinely in children due to hepatotoxicity with long term use
134
When to follow up with all the Tinea’ s?
Pedis?
Corporis?
Cruris?
Capitis?
Pedis - 1-6 weeks
Corporis - 2-4 weeks
Cruris - 10 days
Capitis - 4-10 weeks
135
What is the target organ of acne? And what hormone is it tied to?
Pilosebaeous unit
Androgen
136
How is ache classified?
Comedonal- non-inflammatory
Inflammatory
Mixed
137
What are keratolytics? And name them?
They are agents that break down hardened or scaly skin
Salicylic acid - less effective than benzoyl
Benzoyl peroxide
138
Topical agents for acne are for……..
Disease prevention
139
How can you manage a mild or moderate inflammatory acne?
1-2 times a day, antibacterial agent and comedolytic agent
140
What should educate your pt on in regards to what to expect for anti-acne agents?
You will get an acute exacerbation
It will not be improved until 8 weeks of therapy
141
When should you use systemic therapy for acne?
Potential for scarring
Nodular lesions
Unresponsive to topical therapy alone
142
What is the MOA of retinoids for acne? And used for what stage of acne
Bind to retinoid receptors to normalize follicular keratinization
Used for all stages of acne - they are for prevention and also for treatment
143
What is the life stage of retinoid treatment
Redness and new acne at first
Cleared 8-12 weeks
144
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?
Tretinoin - C in preg
Adapalene - C in preg - less irritation and OTC
Taxarotene - X in pregnancy
Benzoyl peroxide - will inactivate the retinoids
145
Retinoid: what side effects cause the stopping of use and what can you do to prevent it
Dryness, irritation, pigmentation changes, photosensitivity, erythema
Reduce the frequency of application and dose
146
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
isotretinoin
20 weeks
Birth defectives - lots of pregnancy test
147
How long should a female use 2 forms of contraception when using Isotretinion?
One month before and 1 months after
148
What is the primary MOA with benzoyl peroxide
Antibacterial
149
What topical agent is best for sensitive skin and is a category B in pregnancy?
Azelaic acid
150
When do you use antibiotic therapy for acne
Inflammatory acne
151
What agent should you use when using antibiotic therapy to increase efficacy and decrease the development of bacterial resistance?
Benzoyl peroxide
152
What is the preferred topical antibiotic treatment and what are two others
Clindamycin 1%
Erythromycin 2% - reduced efficacy than clinda and increased resistance
Dapsone - don’t use as the same time as BP - orange discoloration
153
Can you do mono therapy with topical antibiotics? What drugs do you use with it?
NO, increases resistance (BP or retinoids)
If you do, use it for a very short time
154
What systemic antibiotics can be use for moderate to severe ache?
Tetracyclines
Doxycycline
Minocycline - more side effects
155
When is tetracyclines contraindicated? And what age limit?
Pregnancy
Less than 8 years old
Allergy
156
Why are tetracyclines preferred for acne?
They are lipophilic and can penetrate into the lipid rich environment of the pilosebaceous unit
Also have anti-inflammatory properties
157
What are strategies to optimize oral antibiotics
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
When do you refer?
```
Moderate to severe
Pitting, scaring
Nodules
Exacerbating factors
Reddened cheeks nose, with enlarged blood vessels or sold red papilla or pustules (acne rosacea)
```
159
Steps with treatment of mild acne?
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
Treatment of moderate acne?
1. Start with combo treatment with added recommendation of oral antibiotics
2. Inadequate: change antibiotic, oral contraceptives, isotretinin
161
Treatment of severe acne?
1. Initial: Isotretinoin or a 3 drug regiment
| 2. Derm consult
