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Pharmacology > Dermatology > Flashcards

Dermatology Flashcards

1
Q

Bacterial Infections: usual etiology

A
  • Staph Aureus/ MRSA or
  • Strep Pyogenes (Group A Strep)
  • less commonly: Pseudomonas, H. Influenza, Cornyebacter
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2
Q

Primary Infections: examples

A

impetigo, ecythema, folliculitis, furuncles, carbuncles, cellulitis, sweat glad infections

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3
Q

Impetigo: etiology

A
  • Caused by Group A Strep, Staph aureus

- More common in hot climates or with poor hygiene; Contagious (close living quarters can be an issue)

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4
Q

Impetigo: presentation

A
  • superficial
  • bullous = STAPH
  • nonbullous = STREP A
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5
Q

Ecthyma: etiology

A

-usually Group A Strep

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6
Q

Ecthyma: presentation

A
  • Thick, dry, hard crust (as large as 3 cm)
  • Superficial (but deeper than impetigo)
  • Commonly found : thighs or buttocks
  • Starts as vesicle and&raquo_space; vesicopustule
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7
Q

Folliculitis: etiology

A
  • VERY COMMON
    -Usually caused by coagulase positive staph
    -Other organisms include
    Pseudomonas
    Kiebsiella
    Escherichia
    Serratia marcescens
    Proteus
    MRSA
    Fungi
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8
Q

Folliculitis: presentation

A
  • usually bacterial infection of hair follicle
  • Red, elevated, tender pustule
  • Hair in center of pustule
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9
Q

Follicular Eczema: differential DX

A

-FE looks a lot like folliculitis but is allergic in nature; does not require antibiotics

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10
Q

Cellulitis/ Erysipelas: definition and presentation

A

=Superficial skin infection that spreads to deeper dermis and subcutaneous fat/cellulitis/dermal lymphatics

  • Caused by Group A streptococci, Staph aureus, Haemophilus influenza
  • Fever, low blood pressure, tachycardia, and regional lymphadenitis may occur
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11
Q

Furuncle: definition and etiology

A

= spread of acute Staph infection from hair follicle to adjacent dermis
-caused by Staph and MRSA

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12
Q

Furuncle: presentation

A

-painful nodule with pustular center

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13
Q

What is a secondary infection?

A

=complication of pre-existing skin disorder

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14
Q

Examples of secondary infections=

A 
Staph aureus
Methicillin-resistant Staph aureus
Streptococci
Enterococci
Enterobacteriaceae
Anaerobes
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15
Q

Nonpharmalogical TX for bacterial skin infections:

A
  • Clean the area
  • Bacteriocidal soap/chlorhexadine
  • Bleach baths
  • Warm compresses to furuncles
  • Incision and drainage
  • Culture
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16
Q

Topical TX of bacterial skin infections:

A
  • Bacitracin (not preferred)
  • Bactroban: BID x 5-10 d
  • Altabax 1%: BID x 5 d (only 9 mo +)
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17
Q

Topical TX options for folliculitis:

A
  • Clindamycin: topical BID
  • Erythromycin: topical BID
  • Bactroban: topical BID
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18
Q

Simple skin infections: 1st line oral antibiotics

A

-Amoxicillin/clavulinic acid: 25–50 mg/kg/day divided BID
-Cephalexin: 25–50 mg/kg/day divided TID, max 500 mg TID
Cannot be used for MRSA
-Dicloxacillin: 250–500 mg QID × 5–7 days

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19
Q

Pseudomonal Infections- TX:

A
  • If unsure whether infection is pseudomonas, can start with the previous agents, but may need to change to Cipro
  • If pseudomonas: start with Ciproflaxin: 500 mg BID × 7–14 days
  • Other options: beta lactam and a macrolide
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20
Q

Skin infections: second-line oral antibiotics

A
  • Note: If the patient has multiples allergies, look up second-line oral antibiotics on a case-by-case basis.
  • Azithromycin: 500 mg po on first day, then 250 mg po qd × 4 days
  • Erythromycin: 250–500 mg po (adult) × 5–7 days
  • Clindamycin: 15 mg/kg/day po TID × 10 days
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21
Q

MRSA: oral antibiotics

A
  • Clindamycin: 30–40 mg/kg/day max 450 mg po TID
  • Bactrim: 4–6 mg/kg/dose of TMP max 2 DS tabs BID
  • Doxycycline: 100 mg po BID
  • Minocycline: 200 mg po × 1, then 100 mg po BID
  • Linezolid: 600 mg po BID
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22
Q

Inpatient RX for MRSA:

A
  • Vancomycin IV
  • Daptomycin IV
  • Linezolid po/IV
  • Telavancin IV
  • Clindamycin po/IV
  • Tigecycline
  • Ceftaroline
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23
Q

What is decolonization? When is it used, how done?

A
  • Patients with persistent staph, strep, or MRSA infections (and even household contacts, on a case-by-case basis) may be considered for decolonization.
  • Mupirocin nasal: apply to nares BID × 5–10 days
  • Chlorhexadine: apply to body × 7–14 days
  • Bleach baths
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24
Q

Decolonization: Bleach baths- the “how to”

A

-Bleach baths have become a common recommendation and come in various forms:
-Spray on
-Tub
IDSA 2011 Treatment
For diluted bleach baths, use 1 teaspoon per gallon of water (or 1/4 cup per 1/4 tub, or 13 gallons of water), for 15 minutes twice a week for about 3 months.

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25
Q

Acne: prevalence

A
  • 85% of population (12-25 yo)
  • more severe/ frequent in males
  • can occur in neonates related to maternal androgen exposure
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26
Q

Acne: definition

A
  • Acne is a disorder of the pilosebaceous unit of the skin
  • inflammatory or noninflammatory
  • Usually inflammatory by the time of primary care consultation
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27
Q

Acne: development

A
  1. Comedo (dried sebum and keratin) plugs a pore, creating a “whitehead”
    2 .Oxidation of melanin and sebum in the plugs creates open comedones
  2. Proliferation of Propionibacterium acnes creates inflammation, inciting formation of erythematous papules
  3. Inflammation progresses, forming pustules
  4. Pustules can become cystic due to abscess formation, and scarring may occur (at this point the patient should see a doctor)
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28
Q

Acne: nonpharmacologic TX

A

Patients should:

  1. Gently wash face twice a day using mild soap
  2. Avoid oil-based skin care, cosmetics, and hair care products
  3. If using oil-based ethnic hair care products, follow up by washing off skin along hairline
  4. Avoid friction or scrubbing
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29
Q

Acne: PCP review and Pt ed-

A

As a dermatologist, you should

  1. Review full current regimen for both skin and hair
  2. Review what you will do for the patient
  3. Explain that it usually takes up to three medications to find the right option
  4. Provide drug education (e.g., skin usually gets worse before it gets better)
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30
Q

Pharmacologic TX for Acne:

A
  1. Keratolytics
    Antibacterial action
    Reduce hyperkeratinization
  2. Retinoids
    Reverse abnormal keratinization
  3. Antibiotics
    Reduce microbial colonization and decrease inflammatory response
    Used best when in combination with keratolytic or retinoid
    If used alone, bacterial resistance can occur
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31
Q

Keratolytics: examples

A
  • Benzoyl Peroxide
  • Salicylic Acid
  • Azelaic Acid
  • Sulfur (has odor; rare)
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32
Q

Benzoyl Peroxide: options/ notable

A
  • OTC or Rx
  • Forms: wash, soap, lotion, gel, solution
  • Can cause irritation or scaling
  • May bleach clothing or hair (rare)
  • No bacterial resistance
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33
Q

Retinoids: 3 options/ notable

A

-Tretinoin (Retin-A)
Forms: cream, gel, solution
May cause local irritation, but this usually improves with time
Tumorigenic in animals with UV light, so must always use sunscreen!
-Adapalene (Differin) 0.1%
Works well, comparatively, with less irritation
-Tazarotene (Tazorac)
Forms: 0.1% gel and cream
Should not be used during pregnancy
Women who use it should be on contraception

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34
Q

Topical Antibiotics: options/ notable

A
  • Available in gel, solution, or lotion
  • Must be used in combination with benzoyl peroxide to decrease keratinization and bacterial drug resistance
  • As insurance companies do not usually cover the combination medications that include benzoyl peroxide, these antibiotics require drug education to ensure the patient knows to use both together
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35
Q

Topical Antibiotics: name 3

A

Types

  • Erythromycin
  • Clindamycin
  • Sulfacetamide
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36
Q

TX of severe acne in primary care-

A

In cases of severe acne, the patient should be sent to dermatology, but the following options are available in primary care:

  • Tetracycline: 250 mg QID
  • Doxycycline: 100 mg BID
  • Minocycline: 50–100 mg QD-BID
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37
Q

Accutane (Isoretinoin) : Indications and who can RX

A
  • Accutane must be prescribed by a dermatologist registered through the I-PLEDGE program
  • Only for severe cystic acne and may have some harsh side effects
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38
Q

Accutane: SE’s and pt monitoring

A
  • Dryness, itching of mucous membranes and skin, and premature closure of epiphyses
  • When using, patients must undergo:
    1. regular pregnancy tests and
    2. monitor their lipids, also
    3. monitor the patient for depression
    4. and osteoporosis
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39
Q

Stepwise care for acne

A
  1. Nonpharmalogical care
  2. Topical keratolytic
  3. Topical retinoid (alone) at PM
  4. Topical antibiotic
  5. Systemic antibiotic
  6. Systemic isotretinoin (Accutane)
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40
Q

Scabies: presentation

A
  • Look for dermatitis that is worse on trunk, hands, feet, and perineum
  • May have burrows
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41
Q

Scabies: TX (and SEs, pregnancy category)

A

-Elimite cream:
Sleep with cream on, then shower it off in the morning and wash clothing and bedding in HOT water
-Topical antiparasitic/pediculocide/scabicidal
-Pregnancy Factor B
-Lactation safety: unknown
-Side effects: pruritis, erythema, rash, and edema

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42
Q

Flea or mosquito bites: presentation and TX

A

-Characterized by punctate papules
-Many patients have hypersensitivity reactions
There is widespread id reaction or papular urticaria
-Treat with Benadryl, topical Benadryl, or calamine
-If those fail, steroid creams can be used.

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43
Q

Pediculosis: presentation

A
  • Found on the head, body, or pubis

- Erythema and scaling may be present

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44
Q

Pediculosis: notable

A
  • Very contagious and highly resistant to medication

- Patients should take great care to avoid recurrence

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45
Q

Pediculosis: TX

A
  1. Pyrethrins or permethrin (OTC)
  2. Malathion (RX): Ovide
    -For those ages 6 and older
    -Inhibits cholinesterase
    Apply to dry hair/scalp and leave on for 8–12 hours
    Do not use with infants or neonates
  3. Ivermectin topical and spinosad (RX): both are ovicidal
  4. Lindane (RX): not first line and cannot be used with children less than 2 years of age or those with seizures
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46
Q

Pediculosis TX: NONNEUROTOXIC TX

A

-Benzyl alcohol lotion 5% (Ulesfia)
-4% dimeticone lotion (not occlusive)
-Other occlusives: olive oil, vaseline, mayonnaise
[Benzoyl alcohol is FDA approved, dimeticone has one study
Others have no evidence base]

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47
Q

Atopic Dermatitis: presentation/ cardinal SX

A
  • Can be intrinsic or extrinsic
  • Characterized by acute erythema, scaling, fissuring, and may have vesicles or papules
  • Called “the itch that rashes” (if it does not itch, it is not atopic dermatitis)
  • Chronic signs and symptoms develop into lichenification of skin
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48
Q

Atopic Dermatitis: TX

A

-Medical treatment is primarily: topical corticosteroids
-Can try nonpharmacologic treatments at first
Avoidance of perfumes, irritants such as smoke, laundry detergent, soaps, and bubble bath
Decrease in frequency of bathing, temperature of bath water, and duration of shower/bath
Wearing loose/cotton clothing (avoid synthetic fibers and wool)

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49
Q

Atopic Dermatitis: notable-

A

Note: Evidence shows that a large number of people with AD also have a metal allergy. Make sure to exclude all metal, and cover with nail polish. Otherwise, the treatment may not work.

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50
Q

Atopic Dermatitis: first line TX

A

First Line: Emollients

  • Steroid sparing
  • Minimum or BID application and after bathing
  • Ideal moisturizer is thick, as well as fragrance and alcohol free
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51
Q

Atopic Dermatitis: second line TX

A

TOPICAL CORTICOSTEROIDS
=Mainstay of pharmacologic treatment
Anti-inflammatory

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52
Q

Topical Corticosteroids- Classes/ how rated

A

Rated by vasoconstrictor effect (most potent: Class 1; least potent: Class 7)

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53
Q

Topical Corticosteroids: duration of action potency/ absorption

A
  • Longer duration of use and higher potency steroid increases risk of side effects
  • Absorption is influenced by surface area used, thickness of the skin, vehicle type, drug concentration, and use of occlusive dressings (or not)
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54
Q

Topical Corticosteroids- RULES OF THUMB

A
  • No Class 1–5 topical steroids should touch eyelids, face, mucous membranes, genitalia, intertriginous areas
  • Potent topical steroids may be needed on the palms and soles
  • The younger the child, the lower the potency
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55
Q

Atopic Dermatitis: example-

3-month-old infant with papules and xerosis on face

A

3-month-old infant with papules and xerosis on face
-Start with 0.5% hydrocortisone cream
-Always use 0.5% or 1% HCT on young infants, unless severe
Example 2: 36-year-old with lichenification of popliteal and antecubital space

Use an ointment like Triamcinalone 0.025%, and move up higher if needed

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56
Q

Atopic Dermatitis: example-

36-year-old with lichenification of popliteal and antecubital space

A

36-year-old with lichenification of popliteal and antecubital space
-Use an ointment like Triamcinalone 0.025%, and move up higher if needed

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57
Q

Choices of “vehicles” for topical steroids

A
  • Use a low-potency topical steroid for maintenance and higher potency steroids for acute exacerbations (e.g., an oral steroid “burst”)
  • Ointments: more potent and penetrate stratum corneum better
  • Foams and loations: less messy for hairy areas
  • Creams
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58
Q

Topical Steroids: SEs

A
  • HPA access suppression
  • Systemic absorption
  • Skin atrophy, corticoid rosacea
  • Steroid-induced acne
  • Hypopigmentation
  • Hypertrichosis
  • Increased intraocular pressure
  • Cataracts
  • Contact dermatitis
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59
Q

Calcineurin Inhibitors: uses, benefits

A
  • May be used with steroids or as an alternative to topical steroids
  • No steroid side effects, so can be used in areas of thinner epidermis
  • Use only for the short term, second line, and not for those younger than 2 years of age
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60
Q

Calcineurin Inhibitors: SEs and Adv Effects

A
  • burning sensation possible
  • Adverse effects: viral infections, HSV, molluscum, varicella, warts
  • Side effects: flu-like symptoms, allergic reactions, asthma, coughing, fever, AOM, headache
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61
Q

Calcineurin Inhibitors: FDA warning

A

Warning from FDA in 2005: use increases risk of skin cancer and lymphoma

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62
Q

Calcineurin Inhibitors: 2 RX options

A
  1. Pimecrolimus (Elidel): use for ages 2 and older
  2. Tacrolimus (Protopic):
    Ages 2–15: .03% ung
    Ages 16 and older: 0.1% tacrolimus ung
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63
Q

Calcineurin Inhibitors: MOA

A

Inhibits phosphatase activity of calcineurin: results in inhibition of T-cell activation

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64
Q

Atopic Dermatits: systemic TX options

A
  1. Oral antihistamines
  2. Oral steroids: rebound
  3. Immunomodulators
  4. Phototherapy
  5. Antimicrobials
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65
Q

Seborrheic Dermatitis: presentation / occurrence

A
  • Characterized by diffuse papular rash that can develop into greasy, crusty, scaly lesions
  • -Ranges from nonpruitic (in infants) to very pruritic
  • When on the scalp, often accompanied by hair loss (alopecia)
  • Most frequently occurs in the first year of life, but can occur again in adolescence and adulthood
  • More common in men
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66
Q

Seborrheic Dermatitis: etiology

A

-Malassezia furfur has been implicated as a causative agent in older onset seborrhea (unclear whether this is consistent for infantile seborrhea)

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67
Q

Seborrheic Dermatitis: TX

A
  • There is no FDA-approved treatment for those under 2 years old.
  • Pharmacologic therapy works best if wet compresses are applied before application of medication.
  • OTC solutions: daily use of antiseborrheic shampoo containing selenium sulfide, sulfur, salicylic acid, zinc pyrithione, tar
  • Topical corticosteroids (ketoconazole to treat Malassezia furfur)
  • Topical immunomodulators if older than 2 years old
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68
Q

Psoriasis: presentation / SX

A

=Skin disorder caused by uncontrolled accelerated replication of the basal epidermal cells

  • Causes redness, flaking, and thickened patches (plaques)
  • Frequently has exacerbations and remissions
69
Q

Psoriasis: precipitated by-

A

Precipitated by

  • Infection
  • Skin trauma
  • Medications (lithium, antimalarials, beta-blockers, etc.)
  • Sunlight: improves or worsens
  • Stress and/or emotional upset
  • Alcohol and smoking
  • Hormonal changes
70
Q

Psoriasis: categorizations

A
  • Plaque psoriasis
  • Guttate psoriasis
  • Palmo-plantar psoriasis
  • Generalized pustular psoriasis
  • Flexural psoriasis
  • Erythrodermic psoriasis
  • Scalp psoriasis
  • Nail psoriasis
71
Q

Psoriasis: TX (pharm and nonpharm)

A

NONPHARM:
-Emollients (for bath or shower): soap, moisturizers
-Tar or keratolytic shampoos (selenium, ketoconazole, anthralin, salicylic acid)
-Tar and UV light
-Keratolytic agents (to plaques): sulfur, salicylic acid
-Vitamin D: calcitrol for those 12 years and older
PHARM RX:
-Topical steroids
-Anthralin ung (to plaques)
-Tazarotene: retinoid

72
Q

Psoriasis: systemic TX monitoring

A

-All systemic agents for psoriasis require monthly liver function tests (LFTs) and specialty management

73
Q

Psoriasis: systemic TX options

A
  • Methotrexate
  • Cyclosporine
  • Acitretin
  • Azathioprine
  • Fumaric acid esters
  • Hydroxyurea
  • Leflunomide
  • Mycophenolate mofetil
  • Sulfasalazine
  • Tacrolimus
  • 6 thioguanine
74
Q

Polyene Antifungals: MOA and 2 options

A
  • Bind to sterols in the cell membrane of the fungus, causing increased membrane permeability and loss of intracellular contents
  • Examples:
    1. Amphotericin B
    2. Nystatin
75
Q

Amphotericin B (polyene antifungal): MOA, preparation, absorption, protein binding

A

-One of the earliest effective antifungals available systemically (Also comes in topical formulation)
-Selective fungicidal: binds to ergosterol in fungi cell wall
»Causes leakage of intracellular ions and macromolecules, leading to cell death
**High toxicity [Can also bind to human membrane sterols (possible cause for toxicity)]
= An amphoteric polyene macrolide
= Insoluble in water, so needs to be a colloidal suspension
-Poorly absorbed from the GI tract: only effective PO for infections of GI tract
-90% protein bound

76
Q

Amphotericin B (polyene antifungal): T 1/2

A

-Has a very long half-life: slow excretion (15 days)

77
Q

Amphotericin B (polyene antifungal): spectrum of action against these fungi

A 
Broad spectrum of action
Effective against
Candida
Cryptococcus
Histoplasma capsulatum
Blastomyces dermatidis
Coccidiodes
Aspergillus
78
Q

Amphotericin B (polyene antifungal): Uses

A

Being highly effective, may be used initially for serious fungal infection (then switched to an azole)
Topical uses: corneal ulcers, keratitis, joints, bladder irrigation
Also for paronychia, intertrigo (yeast)

79
Q

Amphotericin B (polyene antifungal): SEs (systemic and topical)

A
  • Side effects (topical): yellow staining, mild irritation
  • Side effects (systemic): fever, chills, muscle spasm, vomiting, headache, hypotension
  • Over time, leads to renal damage
80
Q

Nystatin: Polyene antifungal- Preparations, Uses

A

= Polyene macrolide

  • Too toxic for parenteral use but widely used topically
  • Available in cream, ointment, suppositories, oral suspension
  • Not absorbed to any significant degree through GI tract, skin, or MM
  • Active against Candida: oropharyngeal, vaginal, intertriginous, paronynchia
81
Q

Nystatin: Polyene antifungal- SEs

A 
Side effects (oral): bad taste, mild nausea, diarrhea, vomiting
-No or limited topical irritation or hypersensitivity reactions
82
Q

TRIAZOLE antifungals: MOA

A
  • Reduce ergosterol synthesis by inhibition of fungal cytochrome P450
  • Less active against human cyt P450 than fungal cyt P450
83
Q

TRIAZOLE antifungals: examples

A

Examples:

  • Fluconazole
  • Itraconazole
  • Posoconazole
  • Voriconazole
84
Q

IMIDAZOLE antifungals: MOA

A

Same mechanism of action, but less selective to fungal vs. human cells so more problematic if given orally

85
Q

IMIDAZOLE antifungals: examples

A

Examples

  • Butoconazole
  • Clotrimazole
  • Ketoconazole
  • Econazole
  • Miconazole
  • Oxiconazole
  • Sulconazole
  • Terconazole
  • Tioconazole
86
Q

AZOLE antifungals: spectrum of action

A 
All display broad activity including
Candida
C. neoformans
Blastomycosis
Coccidioidomycosis
Histoplasmosis
Dermatophytes
87
Q

AZOLE antifungals: SEs and interactions

A

Side effects: minor GI upset (common)
Can cause drug-induced hepatitis, elevated liver enzymes
Major cyt P450 interactions

88
Q

AZOLE antifungals: most commonly used in clinical practice

A

Most commonly used in clinical practice

  • Topical ketoconazole
  • PO itraconazole
  • PO fluconazole
  • Topical clotrimazole, miconazole, econazole
89
Q

Ketoconazole (Nizoral): type of antifungal

A

=Imidazole antifungal
Earliest drug in its class
Greater propensity to inhibit CYP450 enzymes than newer azoles when given systemically

90
Q

Ketoconazole (Nizoral): typcial uses

A

-Systemic use has fallen out of favor due to side effect profile (hepatotoxicity, nausea/vomiting)
-Topical use common: available as shampoo, cream
=Used primarily for tinea versicolor, but also for seborrhea
-The shampoo can be used to decrease shedding of tinea capitis

91
Q

Ketoconazole (Nizoral): effective against-

A

Effective against:

  • Epidermophyton
  • Microsporum
  • Tricophyton
92
Q

Ketoconazole (Nizoral): systemic TX

A

Systemic treatment:

  • Glabrous skin responds in 2 to 3 weeks
  • Palmar-plantar skin slowest to respond
  • Hair and nails longer, low cure rate with tinea capitis
93
Q

Ketoconazole (Nizoral): topical SEs

A

Side effects (topical): increased hair loss, skin irritation, change in hair texture, pruritis and dry skin
Contraindication: hypersensitivity
Precautions: liver disease, achlorhydria or hypochlorydria, alcohol abuse

94
Q

Ketoconazole (Nizoral): systemic SEs

A 
Side effects (systemic): nausea, pruritis, gynecomastia
May increase AST, ALT, alkaline phosphate, bilirubin, drug-induced hepatitis risk
95
Q

Ketoconazole (Nizoral): notables- odor, cost

A
  • Less concern regarding odor than selenium shampoo (also used for tinea)
  • Increased cost
96
Q

Allylamine antifungals: MOA

A

=Inhibit the synthesis of ergosterol by inhibiting squalene epoxidase

97
Q

Allylamine antifungals: examples

A

Examples
Butenafine (Mentex)
Naftifine (Naftin)
Terbinafine (Lamisil)

98
Q

Terbinafine (Lamisil): MOA and effective against…

A

-Inhibits epoxidation of squalene in fungi, so is toxic to fungi
-Also reduces ergosterol and prevents synthesis of fungal cell membrane
Highly effective against dermatophytes but less effective against yeast

99
Q

Terbinafine (Lamisil): SEs (topical and systemic)

A
  • Side effects (topical): local irritation, burning, erythema
  • Side effects (systemic): monitor closely for hepatic dysfunction
100
Q

Glucan Synthesis Inhibitors- examples

A

Not used in primary care!

  • Caspofungin
  • Mycafungin
  • Anidulafungin
101
Q

Griseofulvin (misc. antifungal): preferred agent for; preparations available

A

=Preferred agent for tinea capitis, and for tinea corporis if oral treatment needed
-Microsize vs. ultramicrosize (be careful!)
Microsize 10–20 mg/kg/day
Ultramicrosize 5–10 mg/kg/day
-Easiest for patients to find in liquid form

102
Q

Griseofulvin (misc. antifungal): MOA, absorption (how best absorbed); interactions

A
  • Inhibits fungal cell mitosis at metaphase by interfering with cells mitotic spindle structure
  • Cytochrome P450 isoenzyme CYP1A2 inducer
  • Has increased absorption with simultaneous ingestion of fatty foods
103
Q

Griseofulvin (misc. antifungal): Pt teaching and monitoring

A
  • Teach your patients to take with dinner and with butter, gravy, whole milk, or ice cream
  • Can cause hepatotoxicity, so mandates close follow-up
  • Some will draw LFTs at baseline
  • Most recommend LFTs after 1 to 2 months of therapy
104
Q

Tolnaftate (Tinactin): uses, SEs, preparations available

A
  • Available OTC
  • Works well on dermatophytes
  • May cause some local skin irritation
  • Dosed BID as cream
  • May be used for prevention of reinfection (OTC powders and spray)
105
Q

Ciclopirox (Pen-Lac, Loprox) : MOA

A
  • Acts by chelating polyvalent cations (Fe+3) or (Al+3)

- Inhibits enzymes responsible for the breakdown of peroxidises within fungal cells

106
Q

Ciclopirox (Pen-Lac, Loprox): uses

A

=Alternative to systemic treatment for onychomycosis

-Also can be used for other dermatomycosese, candidiasis, tinea versicolor (lotion)

107
Q

Ciclopirox (Pen-Lac, Loprox): How to use in Onychomyosis

A

-Onychomysosis
Apply 8% solution over entire nail plate once daily
Make daily applications over previous coats
Remove with alcohol every 7 days
Nails may need to be filed down so drug can work

108
Q

Ciclopirox (Pen-Lac, Loprox): Do not use with…

A

Should not be used together with systemic antifungals

This is controversial in the literature

109
Q

Selenium Sulfide Shampoo (Selsun): MOA, uses; strengths

A

-Mechanism of action unknown but may block enzymes involved in growth of epithelial tissue
-Controls but does not cure fungal infections of the scalp and skin
-Also used for seborrhea and psoriasis
2.5% prescription strength
1% available widely OTC

110
Q

Selenium Sulfide Shampoo (Selsun): SEs, age limit

A
  • Has an odor: an issue for some patients
  • May also cause discoloration or alopecia
  • Questionable to use for
111
Q

Fungal infections- how to DX

A

=Diagnosis by clinical characteristics and, if needed, KOH and/or culture

112
Q

Mycoses: definition and examples

A
  • Mycoses: fungal infections where the fungus has bypassed the body’s first line of defense
  • Examples: vaginal candidiasis, tinea pedis, onychomycosis, many more
113
Q

Dermatophytes: examples of DX’s and organisms

A

-Tinea pedis, or “athlete’s foot” (see image)
-Tinea manus: tinea of hands
-Onychomycosis: fungus of nails
-Tinea cruris, or “jock itch”
-Tinea corporis: ringworm of skin
Organisms include:
-Epidermophyton
-Microsporum
-Trichophyton

114
Q

Tinea Pedis: TX

A 
Tinea pedis (all good choices):
Tinactin, Lotrimin, econazole
115
Q

Tinea Manum: TX

A

Tinea manum:

Imadazoles, allymaines, tolnaftate

116
Q

Tinea corporis: TX

A 
Tinea corporis (see image):
Imidazoles, allylamines, tolnaftate
117
Q

The “Tineas” - systemic TX

A

If systemic therapy needed: griseofulvin, itraconazole, terbinafine, Diflucan

118
Q

Tinea Versicolor: etiology, presentation

A

=Caused by Malassezia furfur (new name)

  • Scaly oval macules that can coalesce
  • Can be white, red, or brown, hyperpigmented, or hypopigmented
  • Most commonly found on the trunk, upper arms, neck
  • Normal part of skin flora but can proliferate if in warm/humid environment or immunosuppressed
  • Also due to genetic factors
119
Q

Tinea Versicolor: TX

A

-Can use any azole, but ketoconazole particularly effective

120
Q

Onychomosis: common presentation; organisms

A
  • More common on toenails
  • Caused by Trichophyton rubrum and Trichophyton mentagrophytes
  • Can be caused by candida (more common in fingernails)
121
Q

Onychomosis: TX and RISK

A
  • Oral treatment most effective: Lamisil (terbinafine), itraconazole
  • Possible alternatives, not FDA approved: fluconazole, pozaconazole
  • Difficult to get insurance to cover
  • *Significant risk of liver toxicity
122
Q

Tinea Capitis: presentation

A
  • Noninflammatory and inflammatory
  • Can be gray or white and scaly, broken hairs, or alopecia
  • Round pustular scaly patches
  • Can be in knots
  • Local lymphadenopathy common
123
Q

Tinea Capitis: TX and monitoring

A
  • Must be treated orally
  • Requires minimum of one month of treatment due to drug resistance
  • Requires monitoring of liver enzymes, especially in adults
  • If severe hair loss/inflammation, may use oral steroids as well
124
Q

What is Tinea Capitis + inflammation called?

A

Kerion

125
Q

Tinea Capitis: TX options-

A
  • Griseofulvin
  • Ketoconazole
  • Fluconazole
  • Itraconazole
126
Q

Yeast Infections: organisms

A

-Candida albicans: causative agent of oral, vaginal, skin, nails, lungs, and GI infections
-Part of normal flora
-Other Candida tropicalis and glabrata
Pityrosporum (Malassezia) indicated as well
-Can develop yeast folliculitis as well

127
Q

Candida: TX of oral, diaper/ skin, and vaginal

A
  • Oral: Nystatin suspension or Mycelex troches
  • Diaper rash, other candidal skin rashes: best with Nystatin ointment or cream
  • Vaginal yeast infections: imidazole antifungals all effective
  • Miconazole is least expensive and OTC
  • If severe, may use oral fluconazole
128
Q

Antivirals: Nucleoside Analogues- examples and MOA

A
  • Acyclovir
  • Valacyclovir
  • Famciclovir
  • Penciclovir
  • Ganciclovir: used to treat CMV
  • Ribavirin: active against many viruses but less frequently used
  • These inhibit viral DNA synthesis.
129
Q

ACYCLOVIR Family anitvirals: MOA, efficacy, SE

A

-Similar in efficacy and s/e panels
-Inhibits DNA synthesis and viral replication
-Competes with deoxyguanosine triphosphate binding DNA templates into irreversible complexes
-Causes chain termination following incorporation of viral DNA
=Side effects: many, but hydration to prevent nephrotoxicity most important

130
Q

ACYCLOVIR Family anitvirals: major issues and pt monitoring

A
  • Major issues in choice: cost and frequency of dosing

- Also monitor cbc if long course

131
Q

Acyclovir effective against:

A
  • Active against HSV-1, HSV-2, and varicella
  • Much more against HSV than VZV
  • [Weak in vitro activity against Epstein-Barr, cytomegalovirus, and human herpes virus-6 (HHV-6)]
132
Q

Acyclovir: activation, absorption (with food?) and topical prep

A
  • Requires three phosphorylation steps for activation
  • Low bioavailability after oral absorption
  • Unaffected by food
  • As topical formulation, has high concentrations at lesion sites
133
Q

Acyclovir: clearance/ T 1/2

A

Cleared primarily by glomerular filtration and tubular secretion
Very long half-life if these processes are compromised

134
Q

Acyclovir: diffuses into CSF? Resistance?

A

Diffuses well: 20–50% into CSF
Can result in HSV and VZV becoming resistant, especially in immunocompromised hosts
Cross resistance to valacyclovir, famiciclovir, ganciclovir

135
Q

Acyclovir: SEs, risks of toxicity; how to prevent toxicity

A

Side effects (most common): nausea, diarrhea, headache
IV particularly associated with renal toxicity and neurologic effects (some drugs increase this)
Preventable for the most part with hydration and slow administration

136
Q

Valacyclovir: how related to Acyclovir/ how activated/ effective for-

A

L-valyl ester of acyclovir
Converted by body to acyclovir after oral administration via first pass
Levels are 3–5× that of oral acyclovir
Oral bioavailability of 54–70% (CSF is 50% of serum)
Effective for HSV infections, varicella, varicella zoster
Can be used in high dose for CMV prophylaxis

137
Q

Valacyclovir: SEs and risks

A

Side effects: nausea, headache, vomiting, rash
Side effects (at high doses): confusion, hallucinations, seizures
Also increased risk of thrombocytopenic purpura, hemolytic uremic syndrome

138
Q

Famciclovir: effective against

A
  • Active against HSV, VZV, EBV, and HBV

- Less affinity than acyclovir for viral DNA but higher intracellular concentration

139
Q

Famciclovir: SEs

A
  • Side effects: headache, nausea, diarrhea

- Acyclovir and famciclovir can cause testicular toxicity in animals, but in not humans

140
Q

Ganciclovir: effective against-

A
  • Effective against CMV: used most often post organ transplant or in HIV-infected patients
  • Activated in CMV infected cells
  • In vitro activity also against HSV, VZV, EBV, HHV-6, and HHV-8
141
Q

Ganciclovir: preps, resistance?

A

Can be given IV, orally, or intraocularly

Results in resistance, especially with longer courses of treatment

142
Q

Ganciclovir: SEs and toxicity?

A

-Side effects: myelosuppression
Nausea, diarrhea, fever, rash, headache, insomnia, peripheral neuropathy
-CNS toxicity and hepatotoxicity (less common)
-Mutagenic and carcinogenic, embryotoxic in animals

143
Q

Miscellaneous Meds for Viral Infections:

A
  • Salicylic acid: nongenital warts
  • Imiquimod: warts or molluscum
  • Cantharidin (blister beetle)
  • Cryotherapy
  • Cimetidine oral: for warts
  • Retinoic acid: flat warts
  • Podophyllin 25%: genital warts
  • TCA
144
Q

Salicylic Acid: use and MOA

A
  • Extensively used as a keratolytic
  • Solubilizes cell surface proteins in stratum corneum
  • Possible desquamation
145
Q

Salicylic Acid: % used; absorption; concerns in certain populations/ allergy

A

-3–6% keratolytic, >6% more destructive
Requires that you be wary of absorption
Salicylic acid levels of 30–50% are toxic
A concern in children
Allergy to salicylates: urticaria, anaphylaxis, erythema multiforme

146
Q

Salicylic Acid: SEs and caution in pts with _____ and _____

A
  • Side effects: local irritation, acute inflammation, ulceration
  • Caution with diabetics and peripheral vascular disease
147
Q

Imiquimod: MOA

A
  • Immune response modifier
  • Mechanism of action unknown
  • Possibly stimulates mononuclear cells to release interferon alpha and to stimluate macrophages to produce interleukins 1, 6, 8, and TNF alpha
148
Q

Imiquimod: how administered

A

-Widely used for genital warts, verucca vulgaris, actinic keratosis, molluscum
-Administered topically 2–5 times/week depending on pathology
5% cream for warts, actinic keratosis, basal cell carcinoma
3.75% for face and scalp actinic keratosis

149
Q

Imiquimod: SEs

A

Side effects: local inflammatory reactions, pruritis, erythema, erosion, flu-like symptoms

150
Q

Podophyllum Resin: uses, MOA, absorption

A

-Same as mandrake root or Mayapple
-Used in the treatment of condyloma acculumlata or veruccae in general
-Office-applied solution: a mix of podophyllotoxin and many similar compounds in alcohol or benzoin
Can be absorbed and once absorbed distributes widely
Mechanism of action
Cytotoxic with an affinity for the microtubule of the mitotic spindle
Interrupts in metaphase
As 25% solution, to be applied to wart tissue only!
Should have limited application area to avoid systemic absorption
Side effects with normal use: local irritation, severe conjunctivitis if contact with eye
Cytotoxic to embryo in pregnancy (Do not use!)
Signs of toxicity: nausea, vomiting, alterations in sensorium, muscle weakness, neuropathy, coma, death

151
Q

Podophyllum Resin: % solution, how to avoid absorption

A
  • As 25% solution, to be applied to wart tissue only!

- Should have limited application area to avoid systemic absorption

152
Q

Podophyllum Resin: SEs, USE IN PREG?, signs of toxicity

A
  • Side effects with normal use: local irritation, severe conjunctivitis if contact with eye
  • Cytotoxic to embryo in pregnancy (Do not use!)
  • Signs of toxicity: nausea, vomiting, alterations in sensorium, muscle weakness, neuropathy, coma, death
153
Q

Podofilox: preparations and indications; administration

A
  • Solution or gel (0.5%) can by applied by patient
  • Indicated for genital condylomas
  • Low concentration: reduces the potential of toxicity
  • Self-administered at BID dosing (2×/day) for 3 days, then 4 days break
154
Q

Podofilox: SEs

A

Side effects: inflammation, erosions, burning, itching

155
Q

Anti-Influenza Medications:

A

1) Neuraminidase inhibitors
- Oseltamir
- Zanamivir
2) M2 protein inhibitors
- Amantadine
- Rimantadine

156
Q

Anti-Influenza Meds: general guidelines

A
  • Guidelines change every year: check CDC each year
  • With appropriate use, can shorten the course of illness, decrease viral shedding, and prevent complications
  • Recommended to start within 48 hours of beginning of illness
157
Q

Anti-INfluenza Meds: age limitations, contraindications; resistance, elder dosing

A

-Oseltamivir preferred for peds

158
Q

Who should be treated for Influenza?

A

-Peds

159
Q

Viral Skin Infections:

A 
-Herpes simplex virus
Gingivostomatitis
Herpes labialis
Herpetic whitlow
Skin infections
Neonatal herpes
Genital herpes
-Viral skin warts
-Herpes zoster and varicella
-Molluscum contagiosum
160
Q

Gingivostomatitis: TX

A

-Generally treatment just for comfort
Tylenol
-Avoidance of acidic or spicy foods
-Swish and spit Benadryl: Kaopectate (????) 1:1 solution (dose by weight if swallowed)
-Lidocaine generally not used outpatient, but may be inpatient
-If severe (i.e., not taking POs, high fever), may treat with oral acyclovir

161
Q

Herpes Labialis: prevention, OTC TX and RX TX

A

-prevention with sunscreen, chapstick, avoiding cracks in lips
-May use OTC treatment: fair effectiveness
Abreva
Carmex
-Acyclovir ointment (though more and more insurances not covering)
-Oral acyclovir if severe

162
Q

Skin Infections with HSV: primary and secondary TX

A

-Primary infection: treatment optional if well appearing
-Secondary infection (e.g., eczema herpeticum)
May need to be admitted for IV acyclovir, some outpatient management
Be very careful: need systemic treatment and consult

163
Q

Neonatal Herpes: incubation, TX

A
  • Incubation period is 2–4 weeks of age but systemic diseases can develop much later
  • Must have high index of suspicion in all neonates
  • Must be admitted for IV acyclovir (to prevent devastating systemic diseases)
164
Q

Genital Herpes: TX

A 
-Can be treated with
Oral acyclovir: 3–5 times/day
Famciclovir TID
Valacyclovir BID
-To decide what regimen consider
Cost
Frequency of dosing
Is this the initial infection? Recurrent infection? Prophylaxis?
165
Q

Viral Warts: types/ etiology

A
  • Caused by HPV virus: 150+ subtypes
  • Verrucae vulgaris
  • Flat warts
  • Plantar warts
  • Genital warts
166
Q

Viral Warts: TX

A
  • All miscellaneous agents
  • Cryotherapy
  • Tape: duct tape or scotch tape
  • Imiquimod
  • TCA
  • Podophyllin
  • Oral cimetidine
167
Q

Molluscum Contagiosum: presentation, how spread

A
  • Very common in kids, spread by self-inoculation
  • May also be seen as STI, or as superinfection of eczema
  • Dome-shaped lesions that may become umbilicated
168
Q

Molluscum Contagiosum: TX

A 
*Treatment may be worse than no treatment
Treatment:
-Cantharidin (dermatology)
-Imiquod (best but expensive)
-Oral cimetidine (children)
-Tretinoin
-Curettage
-Cryotherapy
-Podophyllotoxin, TCA, salicylic acid can be used in office

Pharmacology (17 decks)

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