Dermatology Flashcards
1
Q
Regional Differences of Penetration: most penetrable to least
A
Mucous membrane Scrotum Eyelids Face Chest and back Upper arms and legs Lower arms and legs Dorsa of hands and feet Palmar and plantar skin Nails
2
Q
Rule of 9’s
A
1 palm area = 1% BSA
2 palm areas at 2 times a day requires 30mg for 1 month
3
Q
Fingertip Units (FTUs)
A
for corticosteroids
2 FTUs = 1g topical steroid
4
Q
Corticosteroids: MOI
A
antimitotic effects on epidermis
5
Q
Corticosteroids: absorption (normal skin, inc)
A
minimally absorbed on normal skin
inc absorption w/ occlusion
penetration inc in inflamed skin and exfoliative dz
inc absorption –> inc risk of systemic sx
6
Q
Corticosteroids: Class I (potency, locations, duration, agents)
A
super high potency
scalp, palms, soles, extensor surfaces
<3wks
clobetasol proionate 0.05% cream, ointment
7
Q
Corticosteroids: Class II (potency, locations, duration, agents)
A
medium-high potency
non-facial, non-intertriginous areas, flexural surfaces for limited periods
<6-8wks
betamethasone dipropionate 0.05% cream, ointment
fluocinonide 0.05% cream, gel, ointment, solution
8
Q
Corticosteroids: Class III (potency, locations, duration, agents)
A
medium-high potency
non-facial, non-intertriginous areas, flexural surfaces for limited periods
<6-8wks
betamethasone dipropionate 0.05% cream, lotion
betamethasone valerate 0.1% ointment
triamcinolone acetonide 0.1% ointment
9
Q
Corticosteroids: Class IV (potency, locations, duration, agents)
A
medium-high potency
non-facial, non-intertriginous areas, flexural surfaces for limited periods
<6-8wks
fluocinonide acetonide 0.025% ointment
triamcinolone acetonide 0.1% cream, ointment
10
Q
Corticosteroids: Class V (potency, locations, duration, agents)
A
medium-high potency
non-facial, non-intertriginous areas, flexural surfaces for limited periods
<6-8wks
fluocinonide 0.025% cream
11
Q
Corticosteroids: Class VI (potency, locations, duration, agents)
A
low potency
face, eyelids, genitals, intertriginous areas (thin skin)
1-2wks (>: skin atrophy, telangiectasia, steroid induced acne)
triamcinolone 0.1% cream
12
Q
Corticosteroids: Class VII (potency, locations, duration, agents)
A
low potency
face, eyelids, genitals, intertriginous areas (thin skin)
1-2wks (>: skin atrophy, telangiectasia, steroid induced acne)
hydrocortisone 0.1% or 0.025% cream, lotion, ointment
13
Q
Topical Glucocorticoid Therapy: ADEs
A
SYSTEMIC: HPA axis suppression cushing's syndrome psuedotumor cerebri growth retardation Na retention, edema
OCULAR: glaucoma cataracts retarded healing of corneal abrasion extension of herpetic infx inc susceptibility of bacterial/fungal infx
CUTANEOUS: (irreversible) atrophy striae distensae telangiectasias, purpura, ecchymosis hypopigmentation retarded wound healing contact allergic dermatitis (its the base) topical glucocorticoid habituation
14
Q
Bacitracin: target organisms, base, ADEs
A
active against gram+’s (strep, staph, pneumococci)
ointment
poorly absorbed through skin
ADEs:
- allergic contact dermatitis (neomycin most likely)
- systemic toxicity (rare)
15
Q
Mupirocin: target organisms, base, ADEs
A
active against gram+’s (incl MRSA)
cream, ointment
ADEs: stinging burning pruritis HA
16
Q
Triple Antibiotic Ointment: agents, target organisms
A
POLYMYXIN B (gram-‘s: P aeruginosa, enterobacter, E coli)(all gram+’s are resistant)
NEOMYCIN (gram+’s and gram- bacilli: S aureus, E coli)(ADE:contact dermatoses)
BACITRACIN (gram+: staph, strep)
**GENTAMICIN has greater activity against P aeruginosa than neomycin
17
Q
What is the best topical antibiotic per Mary Lou Brubaker?
A
Vaseline
18
Q
What are the 4 factors involved in acne vulgaris pathogenesis?
A
- inc sebum production influenced by androgens
- keratin and sebum plug hair follicle –> hyperkeratosis w/ comedone formation
- Propionibacterium acnes bacteria (gram+) proliferates in sebaceous follicle (releases enzymes, pro inflammatory cytokines)
- inflammatory response
19
Q
Which agents act on P acnes proliferation in acne vulgaris?
A
benzoyl peroxide
topical/oral abx
isotretinoin
20
Q
Which agents act on abnormal keratinization of the follicle in acne vulgaris?
A
salicyclic acid
benzoyl peroxide
topical retinoids
isotretinoin
21
Q
Which agents act on abnormal sebum in acne vulgaris?
A
antiandrogens isotretinoin topical/oral abx corticosteroids estrogens
22
Q
Which agents act on inflammatory response in acne vulgaris?
A
oral/intralesional corticosteroids
topial/oral abx
23
Q
Which agents are used to treat comedones?
A
topical tretinoin
24
Q
Which agents are used to treat mild inflammatory acne?
A
topical retinoid OR benzoyl peroxide
+/- topical abx
25
Which agents are used to treat moderate acne?
topical retinoid AND benzoyl peroxide
+/- topical abx
-consider oral abx, derm referral, hormone therapy for F
26
Which agents are used to treat severe acne?
topical retinoid AND benzoyl peroxide
+/- topical abx
AND oral bx
-consider oral isotretinoin, derm referral, hormone therapy for F
27
Which agents are used to treat cystic acne?
intralesional triamcinolone
28
What is the preferred antibiotic for the treatment of acne vulgaris? (ADEs)
tetracyclines (doxycycline, minocycline > tetracycline)
**topial/oral abx NOT used as monotherapy bc resistance
ADEs:
- slate gray hyperpigmentation of skin
- drug induced lupus
- NOT used w/ pregnancy
* *minocycline: dizziness --> N/V
29
What topical antibiotics are used in the treatment of acne and what are their ADEs?
Erythromycin
ADEs:
-burning, drying, irritation (water based gel is less drying)
-gi upset
Clindamycin
ADE: C difficile
**both are combined w/ benzoyl peroxide to prevent resistance (benzaclin, duac, benzamycin)
30
Sarecycline: indications, drug family, ADEs
indication: inflammatory lesions of NONNODULAR mod-sev acne vulgaris
ages 9+
narrow spectrum tetracycline
ADEs: low rate similar to other TCNs
31
Retinoic Acid: def, action, ADE, directions for use
acid form of vitamin A
- action: dec cohesion bt epidermal cells and inc epidermal cell turnover
- expulsion of open comedones
- transformation of closed comedones to open
ADE: initially: slight erythema, mild peeling
NOT SPOT TX - apply to entire face
32
Tretinoin, Adapalene, Tazarotene: directions for use
applied every day at bedtime to dry skin only
avoid contact w/ corners of nose eyes mouth, mucous membranes
avoid sun exposure, use sunscreen
33
When do you see improvement with benzoyl peroxide in the treatment of acne?
about 5 days
34
Tretinoin, Adapalene, Tazarotene: expectations for the course of treatment
4-6wks: might appear worse initially
8-12wks: lesions clear
35
Tretinoin, Adapalene, Tazarotene: ADEs, patients who benefit
ADE: prolonged use --> inc collagen synthesis/thickening of epidermis
benefit for pts w/:
- photo-damaged skin
- thickened skin (psoriasis)
- atrophic areas
36
Tretinoin, Adapalene, Tazarotene: Retinoid Acid Receptor Selectivity
Tretinoin: beta, gamma
Adapalene: alpha, beta, gamma
Tazarotene: beta, gamma
37
Tretinoin, Adapalene, Tazarotene: Pregnancy Category
Tretinoin: C
Adapalene: C
TAZAROTENE: X
38
Benzoyl Peroxide: action
converted to benzoyl acid in epidermis/dermis
bacteriostatic against P acnes
peeling and comedolytic effects
will bleach clothing, bedding, towels
39
When are topical retinoids+antibiotics used as initial therapy?
when inflammatory lesions are present
40
When do you discontinue antibiotic use in combination therapy for acne?
when inflammatory lesions resolve
if not possible:
use benzoyl peroxide or benzoyl peroxide abx combo
41
What agents are used to maintain remission when antibiotic therapy is discontinued in combination therapy for acne?
topical retinoid
benzoyl peroxide/benzoyl peroxide washes PRN
42
Isotretinoin: indications, contraindication
indications: sev cystic acne, hidradenitis suppurativa
contraindication: TERATOGENIC
43
Isotretinoin: ADEs
dry mucous membranes, xerosis, cheilitis, conjunctivitis, epistaxis, pruritus
joint pain
thinning hair
HA
nausea
mood swings, suicidal ideation, sleep disturbances
hypertriglyceridemia, elevated liver transaminases, dec white count
44
Isotretinoin: labs (baseline, throughout course)
baseline:
CBC, LFT, lipid profile, serum pregnancy test
1st month only:
repeat CBC, LFT
every month:
fasting lipid profile, serum pregnancy test
45
What agents are used to treat rosacea?
first line: metronidazole
sodium sulfacetamide
- clindamycin, erythromycin
- topical imidazoles, ketoconazole cream
- azelaic acid cream
- tetracyclines (abx and anti-inflammatory effects)
- isotretinoin (stage III w/ rhinophyma, rosacea fulminans -- NOT recommended for ophthalmic rosacea)
46
Metronidazole: contraindication, ADEs
contraindication: pregnancy, nursing mothers, children
ADEs:
dryness
burning
stinging
47
Sodium Sulfacetamide: indications, contraindications
+/- sulfur
indication: rosacea, seborrheic dermatitis
contraindication:
sulfonamide sensitivity
48
What are the antifungal agents?
Triazoles (fluconazole, itraconazole)
Imidazoles (clotrimazole, ketoconazole, miconazole)
Nystatin
49
When/where do we use topical imidazoles? When do we not use them?
stratum corneum
mucosa
cornea by dermatophytes
candida sp infx
NOT for SQ, nail, hair infx
paronychial and intertriginous candidiasis
**also can treat seborrheic dermatitis (ketoconazole)
50
What are the risk evaluation and mitigation strategies associated w/ isotretinoin in females?
F must use 2 effective forms of contraception (1mo before, during, 1 menstrual cycle after discontinuation)
serum pregnancy test must be obtained w/in 2 wks before therapy
51
When/where do we use topical vs oral nystatin?
TOPICAL: cutaneous and mucosal candida
ORAL: oral candidiasis
vulvo-vaginal candidiasis
NOT effective against dermatophytes
52
What are the box warnings associated w/ immunomodulators?
malignancy (skin, lymphoma) (rare)
limit continuous long term use
limit use to areas of involvement
not indicated for <2yo
53
What are the immunomodulator agents? What is their MOI?
tacrolimus
pimecrolimus
calcineurin inhibitors (inhibit T lymphocyte activation, prevent degranulation of mast cells)
54
Tacrolimus, Pimecrolimus: indications
atopic dermatitis
off label: autoimmune dermatologic disorders (vitiligo, alopecia areata)
55
What agents are used in the general treatment of pruritis?
emollient (3x/d, 3min after bathing)(refrigerate to inc effectiveness)
topical steroids (w/ inflammatory conditions)
topical capsaicin (ADE: burning)
topical doxepin (ADE: anticholinergic effects, significant drowsiness)
56
What are some non-pharmacologic interventions for the treatment of pruritus?
cool skin - light clothes
air conditioning, humidifier
avoid topical products w/ fragrances, alcohol, wool, alkaline soap, potential allergens
tepid showers (limit bathing, use non soap low pH cleanser)
cool compress
57
What are the contraindications for doxepin 5% cream in the treatment of pruritus?
urinary retention
narrow angle glaucoma
**potent H1 and H2 receptor antagonist
58
Permethrin: indications
Pediculus humanus, Pthirus pubis, and Sarcoptes scabiei
59
Permethrin: directions for use
pediculosis: 1% cream rinse
scabies: 5% cream
single application
apply to body from neck down
leave on for 8-12hrs
wash off
**drug persists up to 10d following application
60
Ectoparasiticides
```
Permethrin (otc)
Lindane (rx)
Crotamiton (2 applications)
Sulfur
Spinosad (rx)
Malathion (rx)
Ivermectin (rx)
```
61
Why is Lindane NOT a first choice ectoparasiticide?
tx for lice, scabies
concentrates in fatty tissues INCLUDING THE BRAIN
potentially neurotoxic
can lead to seizures
62
What is a possible alternative treatment for lice/scabies in pregnant women and infants?
sulfur -- 2 applications
63
Which agents reduce hyperpigmentation? How long do their effects last?
HYDROQUINONE, MEQUINOL, MBEH
- temporary lightening
* *can be sped up if use w/ tretinoin or glycolic acid
MONOBENZONE - irreversible depigmentation
**may cause hypopigmentation at sites distant from area of application
64
Which agents increase pigmentation?
When are they indicated?
What risks do they pose?
psoralens: trioxsalen, methoxypsoralen
photoactivated by UVA light
indication: vitiligo (repigments depigmented macules)
risks: cataracts, skin cancer
65
What are the 3 classes of compounds in sunscreen?
p aminobenzoic acid (most effective available absorbers in B region)
benzophenones (oxybenzone, dioxybenzone, sulisobenzone)
dibenzoylmethanes (avobenzone)
66
What are the 3 classes of compounds in sunscreen?
P AMINOBENZOIC ACID (most effective available absorbers in B region)
BENZOPHENONES (oxybenzone, dioxybenzone, sulisobenzone)
DIBENZOYLMETHANES (avobenzone)
67
What chemical in sunscreen has complete UVA coverage?
parsol 1789 (aka avobenzone)
**mexoryl - recently FDA approved - better coverage than parsol 1789
68
When should you apply sunscreen?
20 min before going out
| replace every 2 hrs
69
What are the protective agents in sunblock?
What is a disadvantage of sunblock (compared to sunscreen)?
Directions for use
agents: zinc oxide paste, titanium dioxides
disadvantage: not as good UVA coverage
directions: reapply every 2 hours
70
What is the primary dermatologic condition in which SALICYLIC ACID is indicated?
(At what concentration is it pathologic? Caution use in which patients?)
acne
psoriasis
warts
* *>6%: destructive to tissues
* *be careful using in pts w/ diabetes, peripheral vascular dz
71
What is the primary dermatologic condition in which UREA is indicated?
hyperkeratosis of the palms and soles
30-50% used to soften the nail prior to avulsion
**urea can also be a humectant (inc water content of stratum corneum)
72
What is the primary dermatologic condition in which PODOPHYLLUM is indicated? (directions for use, contraindication)
condyloma acuminatum
cytotoxic - affinity for mitotic spindle
wash off 2-3 hrs after application
contraindication: pregnancy
73
What is the primary dermatologic condition in which FLUOROURACIL is indicated? (ADEs)
actinic keratoses
```
ADEs:
erythema
vesiculation
erosion
SF ulceration
necrosis
reepithelialization
```
inc exposure to sunlight --> inc intensity of reaction
74
What are the keratolytic agents? What do they do?
```
salicylic acid
urea
podophyllum resin and podophyllotoxin
fluorouracil
aminolevulinic acid
```
break down/dissolve keratin --> softening of the stratum corneum --> peeling
75
What are the agents use to treat warts?
```
salicyclic acid
topical retinoids
podophyllum resin
imiquimod
trichloroacetic acid
```
76
Imiquimod: indications
warts
actinic keratosis
BCC, SCC
lentigo maligna melanoma
77
Trichloroacetic Acid: indication, warning
condylomata
improper application --> skin damage, burns, swelling, pain
78
What are agents are utilized to increase/stimulate hair growth?
minoxidil
finesteride
bimatoprost
79
Topical Minoxidil:
MOI
Which form of balding is more responsive?
How long does the effect last?
MOI: vasodilation --> inc BF --> stimulation of resting hair follicles
vertex balding is more responsive than frontal balding
NOT permanent (cessation --> hair loss in 4-6mo)
80
Finsteride: MOI, contraindication, ADEs
blocks dihydrotestosterone
- promotes hair growth
- prevents further hair loss (androgenic alopecia)
NOT for F of child bearing age
ADEs:
dec libido
ejaculation disorders
erectile dysfunction
81
Bimatoprost: brand name, ADEs
aka latisse
prostaglandin analogue
ADEs:
- red/itchy eyes
- skin pigmentation
- permanent brown pigmentation of iris
82
What is Eflornithine and what is it indicated for?
irreversible ornithine decarboxylase inhibitor
anti-trichogenic agent
reduction of facial hair growth in women
83
What is the initial treatment for psoriasis?
high potency topical steroid
| phototherapy
84
What agents are used to treat psoriasis?
```
dovonex
tars
tazarotene
acitretin
apremilast
methotrexate
biologic agents
```
85
What are the biologic agents used to treat psoriasis?
What are their contraindications?
What are the risks to use?
ADEs
TNF blockers (enbrel, humira, remicade, simponi)
Interleukin 12/23 (stelara)
contraindications:
IM
active infection
screen for TB
risks:
inc risk for infx
unknown for dev fetus/infant
```
ADEs:
respiratory infx
flu like sx
injection site rxns
MS, seizures, optic neuritis
hemolytic anemia
lymphoma
```
86
Dovonex: what is it, indication, ADE
vitamin D3 analog
indication: psoriasis
ADE: hypercalcemia
may be used in combo w/ topical steroid or in rotation
87
Tars: indication
dandruff, psoriasis
88
Tazarotene: what is it, indication, ADEs
topical retinoid
generally rx'd w/ topical corticosteroid
psoriasis
ADEs:
skin irritation
photosensitivity
89
Acitretin: what is it, indication
retinoid metabolite
psoriasis
90
What are the contraindications/warnings for acitretin?
MUST NOT be pregnant/become pregnant during and 3yrs after tx
MUST strictly avoid ethanol during and 2mo after tx
MUST NOT donate blood during and 3yrs after tx
91
Apremilast: what is it, indication, ADEs
PDE4 inhibitor (dec cAMP, inflammatory mediators)
psoriasis
ADEs:
diarrhea
nausea
URI
92
Methotrexate: what is it, indication, contraindications
folate antagonist
psoriasis
pregnancy category X:
- avoid in pregnancy, breastfeeding
- men advised not to father children during and 3mo after tx
contraindications:
low blood counts (anemia, leukopenia, thrombocytopenia)
sev liver dz
caution use:
mild liver dz, kidney dz, infections, obesity, diabetes
93
What are the principals of topical therapy?
efficacy: depends on potency and penetration
topical formulation: meant to enhance beneficial effects
vehicle or active ingredient may cause local toxicity
topical meds may induce systemic toxicity
94
What are some factors that affect penetration?
```
concentration
thickness/integrity of stratum corneum
frequency of application
occlusiveness of vehicle
compliance
```
95
What are the principle aims of dermatologic therapy?
```
Specific agent to counteract disease
Reduce inflammation
Relieve symptoms
Promote epithelial healing
Restore integrity of cutaneous barrier
Prevent complications
```
96
Cleansing Agents
soaps
detergents
solvents
97
Anti-Inflammatory Agents
corticosteroids
| noncorticosteroids
98
Astringents
drying agents that precipitate protein and shrink/contract the skin
99
Drying Agents
dry macerated skin and reduce friction by absorbing moisture
100
Moisturizing Agents
emollients
skin hydrators
softeners
restore water, oils to skin
help maintain skin hydration
101
Keratolytics
soften, loosen, facilitate exfoliation of squamous cells of epidermis
102
Antipruritics
protect against stimulation of scratching, friction, changes in temp
103
What are the principal pharmacologic effects of topical therapy?
Anti-inflammatory
Immunosuppressive
Inhibition of Mitosis
Anti-exudative
Cleansing
Symptomatic relief of pruritis and pain
Protection from mechanical, thermal, actinic and chemical irritation
Relief of dryness and chapping by increasing water content of keratin
Modification of microbial environment and population of the skin
Dissolution of the keratin layer
Destruction of pathologic tissue
