Dermatology Flashcards
1
Q
Anatomy and Physiology of Skin (5)
A
- Skin is a barrier
- Function to protect and regulate
- Involved in immune response
* T-cells in the skin Patients with atopic dermatitis have an immune defect; they are at risk for infections - Biochemical synthesis of vitamin D
- Sensory detection
2
Q
Epidermis (5)
A
Top layer of skin
- .05 mm thickness on eye lids to 1.5 mm thickness on palms and soles
- Basal cells make up the innermost single layer
- The basal layer divides to form keratinocytes
- Other layers are formed from this and migrate to the stratum corneum
- Stratum corneum forms the outer layer and provide protection
3
Q
Dermis (5)
A
- 0.3 mm on eyelid to 3 mm on back
- Think about how this affects your choice of dermatologic creams
- Three kind of tissue make up dermis
- Collagen, elastic tissue and reticular fibers
- Has nerves, blood vessels, hair follicles, apocrine, eccrine gland
4
Q
Subcutaneous Tissue (3)
A
- Distribution is dependent on sex, age, heredity, and caloric intake
- Deepest layer
- Provides padding and insulation to underlying layer
5
Q
Factors Affecting Drug Absorption through the skin (3)
A
- Status of the skin; Increase absorption if there is a break in the skin and Increase in blood vessels, increase in absorption
- Characteristic of the drug
- Characteristic of the administration vehicle
6
Q
Percutaneous Route and Neonates and Young infants (3)
A
- Increased systemic exposure due to enhanced percutaneous absorption as a result of
- increased body surface area/mass ratio
- Higher rates of tissue perfusion
- Higher degree of skin hydration - Increased risk of toxicity to topically applied
agents even when systemic exposure is not the
goal
*Neonates have much greater absorption than older because they have thinner skin; they also have a greater need for water so toxicity can occur more likely; some drugs that have alcohol in them shouldn’t be used with babies
7
Q
Characteristics of Drugs that affect absorption
A
Vehicle can hydrate the skin which improves absorption of the skin and allows for greater depth of medication
8
Q
Status of skin and absorption (3)
A
- Absorption is higher where the skin is thinner
- Absorption is greater where its integrity has been broken
- Mucous membranes absorb more drug
9
Q
Percutaneous Route in Neonates and Young Infants (5)
A
Topical agents in neonates and young children is seen in many agents
- Antihistamines
- Steroid
- Sulfadiazine
- Talcum power
* Talcum powder should never be used or inhaled; can cause lung damage - Laundry detergent
10
Q
CREAMS (7)
A
- Mixture of different organic oils and water
- White, somewhat greasy
- Most frequently base prescribed used on nearly all body areas, especially useful in intertriginous areas
- Cosmetically more acceptable
- Can be drying after prolonged use
- Best if used as acute exfolliative dermatitis
- Creams are quick/easy ways to get medicine on to help a rash; but if you use a cream long enough as a vehicle it becomes drying (dont want to dry skin in diseases like atopical dermatitis) Creams are best in acute diseases like acute dermatitis from poison ivy
11
Q
OINTMENT (7)
A
- Mixture of limited number of organic compounds consists of petroleum jelly with little or no water
- Translucent, greasy feeling persists on skin
- Greater penetration useful for drier lesions, enhanced potency
- Too occlusive for acute exudative eczema inflammation too occlusive for intertriginous areas
- Ointments hydrate the skin and when they are rubbed in well it creates a tissue tap; should not see huge globs of ointment on skin (needs to be rubbed in)
- Ointments aren’t good for things that are weeping because you need something that will dry the weeping (ex: a cream)
- Best for very dry skin
12
Q
LOTIONS (5)
A
- Alcohol, water, and some chemicals
- Clear or milky
- Most useful for covering a large area
- May be drying and irritating
- Lotions are good for covering large areas but they do not keep the moisture in; it allows skin to perspire rather than keeping water in (ointments and creams hold in moisture but lotions do not)
13
Q
GELS (7)
A
- Greaseless, mixtures of propylene glycol, water, and alcohol
- Unpleasant silky feeling
- May be irritating
- Feels cool but is more drying
- Useful in acute exudative inflammation
- Useful for scalp lesions
- Gels are NOT good for any underlying dry skin
* May feel good for bug bites or sunburn but will be drying Gel has clinical use in hair lesions
14
Q
Solutions (4)
A
- Alcohol, water, and some chemicals
- Most useful in penetrating scalp because it penetrates the hair shaft
- May be drying and irritating in the intertriginous areas
- Sinilar solution is great for atopic dermatitis in the scalp; very wattery and moisturizes scalp and treats atopic dermatitis well; it contains alcohol so do not put it on an open wound
15
Q
Aerosol (4)
A
- Drugs suspended in in a base and delivered via a propellant (i.e., isobutane propane)
- Useful for scalp
- Convenient for patients who lack mobility and has
difficulty reaching the lower legs - Ask patient about their sensitivity because some people do not like sprays
16
Q
Powders (2)
A
- Use a cotton ball
2. Mystatin powder is good for candiasiss in intertriginous areas***
17
Q
Differences in Child Absorption (5)
A
- Children absorb about three times as much as adults do
- Children younger than 12 years of age generally should not be treated with group I or Group II topical steroids
- You do need to consider if an adolescent might be pregnancy
- Children absorb more drugs than adult do b/c they have thinner skin
- If an adolescent is pregnant, a topical ointment could have systemic absorption so be careful with that
18
Q
Application and Amount of Rx (5)
A
- Face: If tid for ten days, need 45 gm
- Chest or back: If tid for ten days, 180 grams
- Arm: If tid for ten days, 90 gm for one arm
- Hand or foot: If tid for ten days, 45 gms
5: Upper thigh front: 9 gms
19
Q
Instructions for Creams, Ointment, Pastes (7)
A
- Finger tip method: Use the amount of steroid that can fit
from the distal interphalangeal joint to the top of the adult
finger for an area equaling two palms - Take a small amount of cream or ointment into the palm of the hand and rub the hands together until the medication has a thin sheen
- Apply a small amount of ointment or cream as a thin layer to the skin. Excess medication is lost when it rubs off onto the skin
- Apply in long downward strokes to the affected area
- No back and forth strokes since it irritates the hair follicle
- A tongue blade may be used in the application of topicals to make a paste
- make sure it is rubbed in in LONG DOWNWARD strokes; no back and forth
20
Q
Quantity of Ointment Application on Persons over 12 (6)
A
- Face and Neck: 2.f finger tips
- Arm: 3 finger tips
- Trunk/buttocks/front/back: 7 finger tips
- Both sides of hand: 1 finger tip
- Foot: 2 finger tips
- Leg: 6 finger tips
21
Q
Quantity of Ointment Application on Persons 6-10 years old (4)
A
- Face and Neck: 2 finger tip units
- Arm: 2.5 finger tips
- Trunk/buttocks/front/back: 3.5 on front, 5 on back
- Leg: 4.5
22
Q
Quantity of Ointment Application on Persons in 3-5 years old (4)
A
- Face and Neck: 1 finger tip unit
- Arm: 2 ftu
- Trunk/buttocks/front/back: 3 front, 3.5 back
- Leg: 3 finger tip units
23
Q
Quantity of Ointment Application on Persons in 1-2 years old (4)
A
- Face and Neck: 1.5 finger tip units
- Arm: 1.5 finger tip units
- Trunk/buttocks/front/back: 2 front, 3 back
- Leg: 2
24
Q
Quantity of Ointment Application on Persons on infants (4)
A
- Face and Neck: 1 ftu
- Arm: 1 ftu
- Trunk/buttocks/front/back: 1 front, 1.5 back
- Leg: 1.5 ftu
25
Moisturizer Dosing per age (Infant, Child, Adolescent/Adult)
Infant: 100g/week
Child: 150-200g/week
Adolescent: 500g/week
26
Infant Ointment Dosing (4)
1. Acute tx (2 times daily): 60-100g/week
2. 1-2 times weekly: 10g/month
3. 2-3 times weekly: 15g/month
4. 1-2 times daily: 75g/month
27
Child Ointment Dosing (4)
1. Acute tx (2 times daily): 125-250g/week
2. 1-2 times weekly: 20g/week
3. 2-3 times weekly: 30g/week
4. 1-2 times daily: 150g/week
28
Adolescent/Adult Ointment Dosing (4)
1. Acute tx (2 times daily): 260-300g/week
2. 1-2 times weekly: 40-60g/week
3. 2-3 times weekly: 60-90g/week
4. 1-2 times daily: 300-450g/week
29
Infant Cream Dosing (4)
1. Acute tx (2 times daily): 66-110g/week
2. 1-2 times weekly: 15g/month
3. 2-3 times weekly: 20g/month
4. 1-2 times daily: 100g/month
30
Child Cream Dosing (4)
1. Acute tx (2 times daily): 140-275g/week
2. 1-2 times weekly: 25g/month
3. 2-3 times weekly: 35g/month
4. 1-2 times daily: 175g/month
31
Adult/Adolescent Dosing (4)
1. Acute tx (2 times daily): 290-330g/week
2. 1-2 times weekly: 45-70g/month
3. 2-3 times weekly: 70-100g/month
4. 1-2 times daily: 350-500g/month
32
Instructions for Lotions (5)
1. Instruct the patients to shake the container to mix the suspension well
2. Carefully pour a small amount of lotion into the palm of the hand
3. Apply to the skin using firm, downward strokes.
4. Avoid using gauze unless the liquid is very thin
5. Wash hands after application
33
Instructions for Powders
Apply lightly to dry skin with gauze or power puff
as needed
*Should always be applied with powder puff or gauze; give gauze if pt. doesn’t have enough money
34
Instructions for Sprays and Aerosols (5)
1. Shake the container well
2. Apply toward the affected body part
3. Hold the container upright
4. Avoid spraying around eyes
5. Spray lightly, covering the surface once
* do not spray back and forth
35
Happy Hiney
Binds to bile salts and lowers cholesterol but also good for treating regular diaper rash that isn’t candiasis based
36
Lanolin
Made of wool products which is highly allergenic to atopic dermatitis so never use any lanalin with atopic dermatiis
*
Also don’t want balsomas peru in something
37
Diaper Rash Products (17)
1. A and D ointment*
2. Aloe Vesta Protective
3. Ointment*
4. Balmex Diaper rash ointment**
5. Cholysteramine in Aquaphor***, !
6. Aquaphor***
Aquaphor can be irritating to someone with atopic dermatitis
7. Happy Hiney!
8. Ilex paste
9. Neosporin Maximum strength
Neosporin should never be used* (never use triple antibiotic ointments)
10. Mystatin Ointment
11. Proshield
12. Super Dooper Diaper Do
13. Vaseline*
14. Zinc Oxide
15. Critic Acid
16. Dyprotex
17. Eucerin *
38
Mupirocin (5)
1. Blocks protein synthesis of bacteria by binding with the transfer ribonucleic acid (tRNA) synthetase
2. Treatment should be reevaluated if no improvement is seen in 3 to 5 days
3. Apply with caution to skin with impaired integrity because this allow increased systemic absorption of the drug
4. Impetigo can be treated with mupirocen (Bactroban); works as protein synthesis blocker by blocking RNA; 3x a day medicine that will be used for 7 days
5. Use cautiously when there is a lot of impaired integrity
For child with larger area of Impetigo, prescribe more
If it’s very extensive use oral but usually using topical
39
MRSA Guidelines (3)
1. Minor skin infections such as impetigo:
- Mupirocin 2% topical ointment
2. Cutaneous abscess
- Incision and drainage is the primary treatment
- Role of antibiotics need further research studies
3. Use antibiotics for severe infections, rapid progression, systemic illness, etc.
40
Mucipirocin Bactroban (11)
1. Generic as ointment
2. S. aureus, beta-hemolytic streptococci, S. pyrogenes
3. Naturally occurring antibiotics produced by Pseudomonas fluoresens
4. Cannot use in eye
5. Use with caution in large deep wounds
6. Intranasal use can produce stinging and drying
7. Suspended in polyethylene glycol and therefore use with caution in renal patients
8. Class B drug in pregnancy
9. Not more than 20% of the body
10. Pharmcokinetics: no measurable absorption
11. If not better in 2-3 days, reassess
41
Bacitracin (7)
OTC Ointment
1. Inhibits streptococci, clostridium, and staphylococci.
2. Poorly absorbed
3. Allergy is rare but may develop
4. Not as strong
5. Inhibits cell wall synthesis
6. Bactericidal of narrow spectrum
7. Side effects: Pruritis and burning at the application site
42
Polymixin B (4)
1. Peptide antibiotic
2. Cyclic peptides composed of 10 amino acids which are diaminobutyric acid
3. Functions as detergents to disrupt the phospholipid bacterial cell membrane
4. Good against gram negative bacteria, Proteus mirabilis, Pseudomonas aeruginosa, and Serratia marcesscens
43
Neomycin Antibacterial (3)
1. Binds to the bacterial 30S ribosome subunit and inhibits protein synthesis
2. Very sensitizing with prevalence of contact dermatitis
as high as 24% in patients with stasis dermatitis
3. Aminoglycoside and in in triple antibiotic ointments
44
Gentamycin (3)
1. Is more effective than neomycin but both should be avoided with renal toxicity
2. Adverse reaction: dryness, stinging, burning, and contact allergy
3. Mainly used as eye ointment
45
Tinea (5)
1. Dermatophyte fungus common in skin and nail infections
2. Dermatophytes live and infect dead keratin of the stratum corneum, hair, and nails
3. Affects skin and mucosal surfaces
4. They can infect internal infection
5. Tinea (dermatophyte fungus) are extremely slow growing and therefore must be treated for a much longer period of time
46
Candida Species
Infections in the skin folders
47
Azole Antifungals (6)
1. Clotrimazole (Lotrimin)
2. Exonazole (Spectazole)
3. Ketoconazole(Nizoril)
4. Miconazole (Monistat- Derm)
5. Oxiconazole (Oxistat)
6. Suconazole (Exelderm)
48
Azole Info (5)
1. Azoles are used 2x/day for ___ weeks
2. The newer ones are used 2x/day for 2 weeks
3. Oxistat is 1x/day
4. Economically, Motrimom makes the most sense
5. Need to consider the cost when you’re prescribin
49
Allylamine/Benzylamine derivative Antifungals (3)
1. Butenafine (Mentax)
2. Naftifine (Naftin)
3. Terbinafine (Lamisil)
50
Hydroxypyridones Antifungal
Penlac/Loprox
51
First line agent for treating tinea
Clotrimazole
52
Tinea Pedis (2)
1. More and more antifungals are over the counter
| 2. Tx: Lotrimin, Tinactin, Lamisil (Terbinafine), and Miconazole
53
Antifungals (4)
1. Topical allylamines and azoles are effective for athlete’s foot
2. All azoles are equally effective for T. pedis
3. If ineffective, allylamine may be used
4. Terbinafine is a popular choice
54
How do Azoles work?
Inhibit fungal activity by preventing formation of ergosterol required for cell wall synthesis
55
Side effects of azoles (9)
1. Erythema
2. Burning
3. Stinging
4. Peeling
5. Blistering
6. Edema
7. Pruritis
8. Urticaria
9. Allergic contact dermatitis
56
Econazole (Spectazole) (Use and dosage 6)
1. T. pedis daily for one month
2. T. cruris daily for 2 weeks
3. T. corporis daily for 2 weeks
4. T versicolor daily for 2 weeks
5. Candida bid for 2 weeks
6. T. corporis bid for four weeks
*Spectazole is a great drug, and will cause clearance quickly but must keep taking the drug after to make sure it stays away
57
Ketoconazole (Nizoral) (Use and dosage 4)
1. T. pedis daily for 6 weeks
2. T. cruris daily for 2 weeks
3. T. corporis daily for 2 weeks
4. Candida daily for 2 weeks
58
Clotrimazole (Lotrimin)
Tinea Peda BID for 4 weeks
59
Micanozole (Monistat) (Use and dosage (4)
1. T. pedis bid for 4 weeks
2. T. cruris daily for 2 weeks
3. T corporis daily for 2 weeks
4. Candida daily for 2 weeks
Use Lotrimin for kids with Nystatin
60
Nystatin (Mycostatin cream)
Candida 2-3 times per day
Nystatin at least 3 times per day
Nystatin is good for young babies with Nystatin
61
Penlac (ciclopirox)
Onychomycosis at bedtime
8% topical solution
Penlac should be put on after a bath and onto the nail; clear off residue
*Oral penlac has liver toxicity
62
Naftifine (3)
1. Allylamine derivative
2. Does not work well on trichophyton tonsurans and Microsporum species
3. Limited use in pediatrics
63
Terbinafine (4)
1. Well tolerated with no reported toxicity
2. Inhibits the fungal enzyme squalene epoxidase
3. Effective in seborrhea dermatitis
4. Stinging, pruritis, edema
64
Pearls of Antifungal Treatment (9)
1. Apply by gently massaging into affected area and surrounding skin
2. Treatment must be long enough for a complete turnover of skin
3. Newer antifungals reach high concentrations in the epidermis and appendages persist over time
4. Ciclopirox first topical antifungal to be effective against onychomycosis
5. Use an older agent first as it is cheaper and available in generic
6. Terbinfine is a newer more potent agent available as OTC and has shorter duration of treatment
7. All Azoles are equally effective for T pedis; If resistant than try allylamine
8. Terbinafine by RX is popular choice; Improvement can take up to two weeks
9. Wash skin with soap and water before treatment
65
Pityarisis Versicolor (5)
1. Widespread, hypopigmented, minimally scaly plaque (Tinea pityriasis)
2. Superficial yeast infection resulting from Malassezia furfur
3. Superficial scaling hypopigmented or hyperpigmented macules or flat papules on the upper trunk, arms, neck and face
- Common in Spring and Summer due to heat and humidity factors
- May present as Folliculitis
4. Most commonly in high humidity and temperatures
5. Many adolescence call this a “non disease” and may not want to be treated
* Can hold off treatment until they are ready
66
Pityarisis Versicolor Treatment (2)
1. Selenium sulfide 2.5% or ketoconazole shampoo can be helpful
2. Oral ketoconazole for three days 200mg can be helpful but longer doses can cause idiosyncratic hypersensitivity
67
Selenium Sulfide for Pityarisis Versicolor
Selenium sulfide is smelly; sleep overnight with it
and use it for a whole week
Then apply it 1x/week and then 1x/month so it doesn’t come back
*Rare risk of liver toxicity
68
Pityarisis Versicolor Patient Treatment (5)
1. Will reoccur
2. Treatment must be thorough
3. Hypopigmentation will return with sun exposure
4. Treat recurrences early
5. Monthly treatment for prophylaxis
69
Seborrheic dermatitis (2)
Dandruff!
1. Greasy scaly dermatitis characterized by diffuse red, crusted with yellow scaling in infancy
2. Pitysporum ovale versus Malassezia yeast
- Acts as the trigger
70
Antifungal Topical Shampoos (4)
1. Nizoril shampoo 2%
- No efficacy data in tinea
2. Keratolytic shampoo: Sebulex shampoo
- Good for dandruff
3. Keratolytic shampoo: Selsun shampoo 2%
4. Topical Tacrolimus has antifungal properties
71
Topical Antivirals (3)
1. Acyclovir (Zovirax) 5% ointment six times per day for 7 days
- Unlabeled use is cold sores
2. Penciclovir (Denavir) 1% cream every 2 hours while awake for 4 days for use on face and lips only
- Safety and efficacy in children have not been established
3. Adverse events—burning, stinging, mild pain, pruritus, edema
72
Herpes Labilis (5)
1. Combination produce of 5% Acyclovir/1%hydrocortisone cream
* The combo of Acyclovir and hydrocortisone can work (Xerese)
2. AHC cream
3. Approved as prescription medication (Strand, et. al, 2014)
4. Abreva cream is a waste of money
- Docosanol 10% Cream
- Marketed with lysine ointment
5. Oral lysene is also effective
73
Head Lice treatment: Pyrethrins and Permethrin (3)
1. Leads to death due to nerve depolarization and
hyperexcitation
2. Permethrin 1% is still the first-line treatment of
head lice
3. Increasing resistence but natural product
74
Malathion for Head Lice Tx
Organophosphate and inhibits acetylcholine leading to neuronal hyperexcitability and insect death
75
Benzyl alcohol 5% (Ulefsia) for Head Lice Tx (4)
1. kills lice by inhibiting their ability to close their respiratory spiracles, causing the lice to asphyxiate. It does not have ovicidal activity.
2. Restricted to patients 6 months of age and older.
3. Use in younger infants, particularly neonates or premature infants, could produce toxic serum concentrations as the result of impaired clearance stemming from reduced levels of alcohol dehydrogenase.
4. Toxicity resulting from administration of IV medications containing benzyl alcohol in infants, referred to as "gasping syndrome," was first noted in the 1980's.
* 100% effective but $130/bottle
76
Spinosad (Natroba) for Head Lice Tx
1. Interferes with nicotinic acetylcholine receptors in insects, causing neuronal excitation. Paralysis then results from neuromuscular fatigue.
2. Natural fermentation products of a soil actinomycete
bacterium, Saccharopolyspora spinosa.
3. While many spinosyns have been identified, the most common are spinosyn A and spinosyn D.
4. Spinosad, a 5:1 ratio of the two, interferes with nicotinic
acetylcholine receptors in insects, causing neuronal
excitation.
5. The lice develop paralysis from neuromuscular fatigue.
6. Pediculocidal and ovicidal activity, killing nits as well as
adult lice.
77
Sklice (topical ivermectin 0.5%) for Head Lice Tx (5)
1. Binds to glutamate and GABA gated chloride channels leading to insect’s death
2. Ivermectin selectively binds to glutamate-gated chloride channels in invertebrate nerve and cell muscles which leads to increased permeability to chloride and hyperpolarization, resulting in paralysis and death.
3. Can bind to gamma-aminobutyric acid (GABA)-gated chloride channels, augmenting this response.
4. Low affinity for mammalian ligand-gated chloride channels and limited penetration into the central nervous system, reducing its potential for toxicity.
5. Little to no ovicidal activity
78
Dosing and how to apply Spinosad for lice (7)
1. 0.9% topical suspension
2. Shake thoroughly
3. Apply to dry hair, including complete coverage of the
scalp.
4. Let dry for 10 minutes
5. Wash off with warm water.
6. Use of a nit-comb is not essential, but it is recommended in patients being treated with spinosad to remove dead lice and nits.
7. If lice are seen 7 or more days after the initial treatment, a second treatment should be applied
79
Application of Sklice (3)
1. Apply to dry hair for ten minutes in an amount sufficient to cover the hair and scalp.
2. Rinse with warm water
3. Use of a nit comb is not necessary, but may be
helpful to remove dead lice and nits.
80
Info for individual applying sklice lotion (2)
Wash hands after applying the lotion!!
81
Ivermectin (3)
1. Oral off label use for lice
2. May cross the blood/brain barrier and block essential neural transmission
3. Oral ivermectin is currently approved by the FDA as a pediculicide.
82
Occlusive agents for lice (3)
1. Cetaphil cleanser
2. Dimethicone lotion (4% long-chain linear silicone in a volatile silicone base)
- OTC product LiceMD contains dimethicone.
3. Isopropyl myristate 50% (Resultz)
- Hair rinse that dissolves the waxy exoskeleton of the louse, which leads to dehydration and death of the louse
83
Permethrin (elimite cream) (7)
1. An antiparisitic for scabies
2. Made from chrysanthemum cinerariaefolium
3. Acts on parasite cell membrane ATPases to disrupt sodium transport and lead to paralysis of the mite
4. Treatment of choice for scabies
5. Apply from the neck down for 8 to 14 hours
6. Side effect of irritation, tingling sensation, and application site burning
7. Make sure to put it underneath the fingernails or it will come back!!!!!
* B/c if they scratched the bug may be under there
84
Second line treatment for scabies (5)
1. Malathion 0.5% lotion
2. Organophosphate pesticide—cholinesterase inhibitor
3. Fastest killing
4. Disadvantage odor and alcohol vehicle
5. applied for 12 hours and then washed off
85
Third line treatment for scabies (3)
LIDOCAINE LOTION
1. Used as agricultural pesticide
2. Not recommended for use
3. Risk of neurotoxicity
86
Scabies Monitoring (5)
1. Follow back in 10 days
2. Use of oral antihistamines as supplement for pruritic
3. Medium strength steroid can be used " Shake well
4. Treat of all members of the family " Avoid eyes
5. Non washable clothing should be sealed in plastic for 48 to 72 hours
87
Crotamiton (Eurax) (4)
1. Colorless oil used in treatment of scabies
2. Safe in babies
3. 10% cream or lotion
4. Lots of resistance
88
Alternative Lice treatments (5)
1. Vaseline
2. Mayonnaise
3. Cetaphil lotion
4. Dimethicone
5. Oral Ivermection
89
Crotamiton ADEs (2)
```
skin irritation (common)
allergic sensitivity (severe)
```
90
Malathinon ADEs (2)
1. Skin irritation (common)
| 2. Remote possibility of systemic toxicity, abdominal cramps, respiratory distress, muscle paralysis, seizure
91
Permethrin ADEs (2 common, 3 severe)
common:
1. Pruritis
2. Mild transient burning/Stining
severe:
1. Tingling
2. numbness
3. Rash
92
Lindane ADEs (1 common, 1 severe)
1.skin irritation
severe:
2. 0.001% will have CNS effects
93
Acne (5)
1. Common disorder
2. Significant psychosocial impact
3. Potential permanent effect including scarring and abnormal pigmentation
4 Often trivialized and under treated
5. Lack of drugs approved for children under 12
94
Causative factors of acne (
1. Androgens are causative factor
2. Other hormones include Estrogen, Growth hormone, IGF-1, insulin, Corticotropin releasing hormone, melanocortins, and glucocorticoids
3. Excess sebum production due to a difference in
response of the pilosebaceous unit.
4. Pathophysiology suggests combination therapy unless on oral isotretinoin
95
Acne Pathophysiology (5)
1. Sebaceous hyperplasia with seborrhea
2. Ductal hypercornification
3. Propiobacterium acnes colonization of the duct
4. Inflammation and immune response
5. Target multiple factors
96
Acne Papules (6)
1. 1-5 mm erythematous ‘bumps’
2. Can be felt as well as seen
3. May or may not be tender
4. Part of the continuum from pustule to nodules
5. Resoles with post inflammatory red/ brown pigmentation
6. Potential for scarring
97
Acne Pustules (4)
1. Up to 5 mm erythematous ‘bumps’ with soft, white center
2. When the pustules ruptures, the papules remain
3. Usually fewer and more transient than papules
4. High Potential for scarring
98
Abnormal Signs when looking for Acne in Children (4)
1. Growth abnormalities—height spurt before expected
2. Blood Pressure
3. Early signs of puberty—3 to 8 year " Acne that is very resistant to treatment
4. Polycystic ovarian syndrome
These require referral to endocrinologist is indicated
99
endocrine disorders associated with acne (7)
1. Polycystic ovarian syndrome
2. Cushing Syndrome
3. Congenital adrenal hyperplasia
4. Androgen secreting tumors
5. Serum level of DHEA-s > 8000 indicative of adrenal tumor
6. Total testosterone > 200 ng/dL is associated with ovarian or testicular tumor
7. Acromegaly
100
Preteen vs. Teen stages of acne
1. Preteen: Centro facial with comedomal acne
| 2. Teen: Face and trunk with mixed appearance
101
Acne Grading/Classification (3)
1. Associated description of the lesions with the extent of involvement to classify the type and severity of acne
2. Scarring and pigmentation
3. Impact on the individual
102
Benzyol Peroxide tx for acne (9)
1. Effective for mild to moderate acne
2. Oxidizing agent
3. Bacteriocidal
4. OTC and prescription
5. 2.5% less irritation
6. Use water based preparation rather than alcohol
7. Not absorbed systemically
8. Antibacterial against P. acne
9. Removes excess sebum
103
ADEs of bezyol peroxide
1. Stains clothing
2. Irritation, erythema, and edema
- If develops, cool compresses
3. Category C pregnancy
4. Avoid sunlight
104
3 dot method for applying benzyol peroxide
apply three dots on each side of face (size of pencil eraser) and then have them rub that in
105
Retinoids (6)
1. Natural compounds and synthetic derivative with Vitamin A activity
2. Altered gene transcription affects the epidermal layer and keratinocyte growth and differentiation
- Promotes and increases cell turnover of the normal follicle and comedones
- Comedone formation is prevented
3. Treats post inflammatory hyperpigmentation
4. Retinoids in combination with other topical or oral antibiotics are best for inflammatory acne
5. Not a spot treatment; Used on entire surface
6. Takes 2-3 months to get markedly better and it may look worse before it gets better
106
Dosing and application of retinoids (5 know all)
1. Never start retinoids BID on day 1; always start every other day to get patient used to it (do this for 5 days, then once a day for 7 days, then 2x/day and continue with 2x/day)
2. Apply using 3 dot method
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3. All-trans-retinoic acid (tretinoin) is available in
the following concentrations
- 0.025%, 0.05%, 0.1% cream
-0.01%, 0.025%, 0.04%, 0.1% gel
- .05% solution
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4. Tazarotene is available as cream or gel in 0.05% or 0.1%
5. Never start with .1%; start with lowest possible retin-A and then increase it if patient isn’t responding; tell them you like to start with lowest dose possible b/c any redness they will get will be minimized
107
Retinoid ADEs (10)
1. Erythema
2. scaling
3. pruritus
4. burning
5. stinging
6. dryness
7. increased photosensitivity and irritation
8. Tretinoin and adapalene are pregnancy category C
9. Very susceptible to irritation from sunburn and sun damage
10. Cosmetics, astringents, alcohol, and acne soaps may increased interaction with tretinoids
108
Salicylic Acid (3)
1. Content of Proactive
2. Well tolerated keratolytic agent
3. Less irritation than benzoyl peroxide
109
Topical Antibiotics (4)
1. Clindamycin and Erythromycin most common
2. Limit use to be able to avoid bacterial resistance
3. No more than 12 weeks
4. Sulfacet is an old product enjoying new use
110
Topical Acne Therapy (6)
1. Benzoyl Peroxide and Erythromycin
2. Benzoyl Peroxide and Clindamycin
3. Benzoyl Peroxide & Adapalene
4. Clindamycin + Tretinoin
5. Combination with benzoyl peroxide may prevent antibiotic resistance
6. Benzoyl peroxide with Retinoid (epiduo) is a new product
111
Epiduo
Benzyol Peroxide + Retinoid
1. Epiduo is approved from 9 y/o and over only
2. When Benzyoyl peroxide and retinoid are used together they will cancel each other out, so separate their use by one hour
4. HOWEVER, epiduo works and is approved for 9 and up whereas other retinoids are not; great product but very expensive and not covered under insurance
