Dermatological Disorders Pharm Flashcards
What is the difference between topical and percutaneous absorption and transdermal?
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
What is the major barrier for percutaneous drug abdsorption?
The stratum corneum
What in the stratum corneum can reversible or irreversibly bind to drugs?
Lipids and proteins
What are the factors of the formulation and after application can determine the bioavailability of the ingredient from the drug product?
Evaporation
Mix with skin-surface lipids
Undergoing change in composition
What does penetrate mean with derm meds?
The movement of the drug into and through the barrier of the stratum corneum
What does permeation mean with derm meds?
Spreading or diffusion of the drug throughout an organ, tissue or body space
Spreading of drug through the viable epidermis and dermis
What is resorption
Uptake of the drug into the microvascluature and into systemic circulation
What is a reservoir
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
What are the three pathways that drugs penetrate the skin? The drug can use more than one
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
What size molecular weight for derm drugs?
Low molecular weight (<500 daltons)
Charged or uncharge have a easy time to cross into membrane?
Uncharged
pH - will determine what is ionized compared with what is in-ionized
The normal stratum corneum is acidic or alkalinity?
Acidic (4-5)
Drugs that are two hydrophilic risk what?
Unable to partition from the vehicle into the stratum corneum
Too lipophilic drugs can do what to prevent skin permeation rate?
May be retained in intercellular stratum corneum lipids and will not partition to more aqueous viable epidermis, thus limiting their skin permeation rate
What is the ideal amount of deliverable dose?
20 mg/day
What is the vehicle or carrier
The inactive part of the topical preparation that brings a drug into contact with the skin
What are some side beneficial effects that a vehicle may have? (5)
Cooling
Protective
Emollient
Occlusive
Astringent
What determines the rate at which the activity ingredient is absorbed through the skin. What three ways does it do this?
The vehicle
- promoting SC hydration by an occlusive effect
- Modulating the vehicle/SC partition
- Promoting increased drug solubility into the SC
Does the vehicle carry the drug all the way through absorption?
No
What group is the least potent?
Group 7
Is ointments more potent than creams?
Yes, ointments are more potent than creams
Are creams more potent than lotions?
Yes creams are more potent than lotions
What is the benefits of ointments?
What kind of skin is it best for?
Where should you not use it?
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
What two areas should avoid using ointments?
Intertrigious and hairy areas
What is the difference between ointments and creams with hydration
Ointments create more hydration
What would be better for an oozing skin lesson?
Creams, has drying affect
Can you use creams in intertrigious areas?
Yes
Which vehicle contains alcohol?
Lotions
Which vehicle is best for hairy areas?
Lotions
What vehicle is best for wet lesions like poison ivy?
Gels
Dry very quickly
Are gels more potent than ointments?
Yes. Best for derm to use
Topical meds have low absorption percentage. What matters more
The inherent potency
True or false…low absorption does not mean low efficacy
True
Efficacy depends on what
Ability to penetrate the skin
Penetration depends on concentration of the med
Concentration of the drug is very importaint
Does the amount of times you apply the drug a day have any effect on overal efficacy
No
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
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
What kind of drugs are reduced with absorption as we age?
Less lipophilic drugs
The increase friablity of the older skin can increase what?
Percutaneous absorption
When is the acid mantle on the skin formed?
In the first 4 weeks of birth
Newborn skin is more what in regards to pH
Alkalinic
Because the skin of newborns are thinner, is the permeability higher or lower?
Higher
At birth is the skin dry or moist
Dry
Dry skin in children will increase the chance of what
Toxcity
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
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
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
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)
What does glucocorticoids do the capillaries?
Decrease capillary permeability - Because of the reduced amount of histamines
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
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
When do you discontinue topical steroids?
When the inflammation is controlled
Why is high potency fluoridated corticosteroids not indicated for children or elderly
Toxic effect
The more potent a steroid - how long should the treatment be?
Short
How long can a group 1 topical steroid be use? How long of rest?
2-3 weeks
then a week of rest
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
What regiment do you use with moderate potency agents?
- Once or twice a day for 3-10 days (can do 3-5 day burst to gain control)
- After improvement, use it for once a day with a bland moisturized once or twice a day;
- After stabilization than consider proactive secondary prevention - use TCS on site for 2 consecutive days a week
How long can you use the plastic wrap when doing occlusion?
At least 2 hours
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
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
What potency steroid can be use on the face?
Low petency
Another side effect of steroids is telangectasias, what is it?
Spider veins
Steroid use can cause striae, is it permanent?
Yes
What are some topical steroid side effects?
Striae,
Steroid acne
Steroid rosacea
Purpura
Atrophic skin
Delayed wound healing
Bacterial infection
Contact dermatitis
What kind of side effect happens when steroid is stopped and the build up of the vasodilators, (withdrawal)
Red skin syndrome
If you prescribe topical steroids and it only gets worse, what should you consider?
Infection
What are some systemic effects of topical steroids?
Cataracts
Hypertension
Cushing syndrome
Hyperglycemia
Recent study showed a HPA axis suppression in what age group, which caused cushing syndrome.
Children and infants
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
Do antihistamines provide relief with contact dermatitis?
No, it is not IgE mediated
But if used, only used for sedation
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
Sub acute and chronic inflammation with contact or atopic/ how do you treat?
Hydration/lubrication
Topical steroids (with or with occlusion)
Antibiotics
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
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
What are the most common systemic steroid use with AD
Prednisone and prednisolone
What is a non-pharm way to lower the use of topical steroids?
The use of Moisturizers and emollients, twice a day
Many pts with AD will be colonized with more S. Aureus. What can this do?
Contribute to skin inflammation
Increase the risk for infection
Why do you do proactive therapy with AD
They think it might lower the colony of S. Aureus
What are the four types of treatment failures?
- Inadequate clinical improvement
- Failure to achieve stable long term disease control
- Failure to relive impairment
- Unacceptable adverse events
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
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
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
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
What is the name of the two drugs that are topical calcineurin inhibitors?
Pimecrolimus
Tacrolimus
Can you use calcineurin inhibitors long term and not cause what side effects that steroid cause
Skin Atrophy
Can you use calcineurin in sensitive areas?
Yes
What is the equivalent of pimecrolimus to what group steroid?
6 and 7
Tacrolimus is equivalent to what group of steroids? And can use in what level of AD
5
Moderate to severe
What drugs have steroid sparing effects when used at first appearance of erythema and pruritus
Pimecrolimus and Tacrolimus
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)
What is the FDA recommendation of the use of Calcineurin inhibitors?
- Avoid use in children less than 2 years of age
- Use TCI’s as a second line agent
- Use only as short term or intermittent
- Caution against people with weak immune system
- USe minimal amount
What is the MOA of Crisaborole (Euscisa)?
Topical phosphodiesterase inhibitor
increased PDE4 increases inflammatory mediators
This inhibits this
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
What can you use Crisaborole for?
Mild to moderate AD in adults, peds and pt 3 month of age and older
What class is Dupilumab
Human monoclonal IgG4 antibody
What is Dupilumab MOA
Binds to the IL-4 subunit of the receptor complex, inhibit good the release of pro inflammatory cytokines
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)
Can you use Dupilumab in pregnancy or lactation?
Not enough data
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
What are the two pathogens that cause many of the derm infections?
S. Aureus
Group A beta streptococcus
Typically is impetigo systemic?
No
Sometimes you can get a fever, but it doesn’t happen often
What dose Impetigo start as and move into?
Small vesicles to blisters to crusting
What are the two different forms of Impetigo?
Bullous and non-bollous
Which one of the types of impetigo can cause dehydration?
Bullous
When is topical antibiotics indicated with impetigo? (2)
- Uncomplicated superficial skin infection (no systemic infection)
- Limited localized lesions (<10 lesion over <100 cm2 or <2% BSA as a rule of thumb
When do you use systemic antibiotics in impintago?
- Multi sites of infection
- Lack of adequate response to topical therapy
- Systemic signs of infection
When do we use Bacitracin and Gramicidin? And what gram organism?
Prophylaxis, against gram positive organisms
MOA of Bacitracin?
Inhibits cell wall synthesis
What is the MOA of Gramicidin
Disrupts cell wall function
What med is active against MRSA?
Mupirocin
What is the MOA of Mupirocin?
Inhibits protein synthesis
What is Mupirocin use to treat? (2)
Impetigo in pts greater than 2 years of age
Also to eliminate nasal colonization of S. aureus
Retapamulin is active against what pathogen?
MSSR and Group A strep
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)
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
What do dermatophytes cause?
Organisms that cause tinea
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
What is Tinea versicolor caused by?
Pityrosporum obisculare or P. Ovale
Where is Tinea corporis located?
arms, legs, torso
Where is the Tinea cruris located?
The genitocrural folds
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
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
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
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
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
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
Griseofulvin is a oral or topical antifungal?
Oral
What teaching point can you tell your pt if they take griseofulvin
Take with fatty food
How long should you take griseoflulvin?
4-6 weeks and two weeks after the resolution of the S/S
What are some more teaching points about Griseofulvin side effects?
Use sun protection
Nausea is common
What are the contraindications of griseofluvin
Pregnancy
Hepatic failure
How long should males wait to conceive a child after taking Griseofulvin
6 months
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
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
What is the target organ of acne? And what hormone is it tied to?
Pilosebaeous unit
Androgen
How is ache classified?
Comedonal- non-inflammatory
Inflammatory
Mixed
What are keratolytics? And name them?
They are agents that break down hardened or scaly skin
Salicylic acid - less effective than benzoyl
Benzoyl peroxide
Topical agents for acne are for……..
Disease prevention
How can you manage a mild or moderate inflammatory acne?
1-2 times a day, antibacterial agent and comedolytic agent
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
When should you use systemic therapy for acne?
Potential for scarring
Nodular lesions
Unresponsive to topical therapy alone
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
What is the life stage of retinoid treatment
Redness and new acne at first
Cleared 8-12 weeks
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
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
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
How long should a female use 2 forms of contraception when using Isotretinion?
One month before and 1 months after
What is the primary MOA with benzoyl peroxide
Antibacterial
What topical agent is best for sensitive skin and is a category B in pregnancy?
Azelaic acid
When do you use antibiotic therapy for acne
Inflammatory acne
What agent should you use when using antibiotic therapy to increase efficacy and decrease the development of bacterial resistance?
Benzoyl peroxide
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
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
What systemic antibiotics can be use for moderate to severe ache?
Tetracyclines
Doxycycline
Minocycline - more side effects
When is tetracyclines contraindicated? And what age limit?
Pregnancy
Less than 8 years old
Allergy
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
What are strategies to optimize oral antibiotics
- Use in moderate to severe cases with combo that includes BP
- Avoid mono therapy with using oral or topical
- Discontinue- taper within 2 months once inflammatory lesions have stoped emerging
- Start at higher doses of oral antibiotics
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)
Steps with treatment of mild acne?
- Comedonal acne: BP or retinoid
- Inflammatory: combo therapy: Retinoid +BP or Antibiotic + BP or BP+Retinoid + antibiotic
If inadequate response - add one that has not been used
Treatment of moderate acne?
- Start with combo treatment with added recommendation of oral antibiotics
- Inadequate: change antibiotic, oral contraceptives, isotretinin
Treatment of severe acne?
- Initial: Isotretinoin or a 3 drug regiment
2. Derm consult
