Dermatology drugs Flashcards
What are Topical Vehicles
In order of moisturizing to drying:
Ointment
Pastes
Creams
Foams
Powders
Aerosols
Gels
Lotions
Wet Dressings
Tinctures
Which Vehicle is more appropriate
Use moisturizing if skin is dry; xerosis, lichenification, scaling.
Use drying if the skin is wet; weeping, oozing, vesicular, crusting.
Administration differences
Hairy areas my be best to use tinctures, aerosols, lotions, gels.
Pt preference for look and feel ; creams rub in and feel better than ointments.
General use for steroids
Anti-inflamatory, anti-pruritic;
Low-Medium dose Steroids
Eczema, irritant dermatitis, seborrhea, AD
Low Dose Corticosteroids
Alclometasone dipropionate .05%
Hydrocortisone base or acetate .25-2.5%
Triamcinolone .025%
Desonide .05%
*Know in general that triamcinolone is a common topical that varies in potency based on strength.
Intermediate Str Corticosteroids
Fluticasone propionate 0.005% - 0.05%
Hydrocortisone Valerate 0.2%
Mometasone 0.1%
High Dose Corticosteroid Usage
Psoriasis, Lichen planus, Allergic CD
High Does Corticosteroid Drugs
Amcinonide 0.1%
Halcinonide 0.1%
Very High Dose
Clobetasol
Halobetasol
What are the Topical Corticosteroid ADRs
Cutaneous atrophy; can have purpura and telangiectasia; resolves some months after cessation.
Striae, Acne, refractory rosacea, hypopigmentation, hypertrichosis, glaucoma, alopecia.
Adrenal suppression and iatrogenic Cushing’s
Safety Considerations of Top Steroids
CI w/ infection + hypersensitivity
Caution in pregnancy, Children <12
Tx Considerations
Use lower does one area of higher absorption
Occlusive dressings - Caution with low-mid; CI in high; AVOID DIAPER AREA
Ointments have the highest effects
What are some considerations for Very High Potency Drugs
Do not abruptly stop; swap to a lower potency
No more than 3 weeks
No more than 50 grams per week
What are the 3’s of Top steroids
Very High no longer than 3 weeks
Low to high no longer than 3 months
What are some additional prescribing considerations
Hydration improves absorption; consider dosing s/p showers.
Most are once or twice a day.
Fingertip = 0.5g = two hands = 2% BSA
What About Psoriasis
Typically going to be a very high does medication (betafish) in an ointment vehicle for penetration, and may be BID.
Can Use Vitamin D analogues (calcipotriene)
Retinoids (tazarotene)
These are first line used in mild disease, calcipotriene + corticosteroids most effective.
What about Vitamin D analogues (psoriasis)
Calcipotriene - ADR photo-sensitivity, increase to Ca levels, Very irritating (burning, stinging, peeling).
What About Retinoids (psoriasis)
Tazarotene - ADR Photo-sensitivity, Cat X, Very irritating (burning, stinging peeling).
This is the only retinoid for psoriasis.
What about Calcineurin (psoriasis)
Tacrolimus, pimecrolimus - ADRS Local stinging and buring, but less so than vit D analogues and retinoids.
Good for face and folds
Steroid free options (psoriasis)
Generally good for long term use, anywhere on the body.
Non Oral Biologics (psoriasis)
Methotrexate - CI in pregnancy, caution in hepatic dysfunction
Soriatane (retinoid) - CI in Pregnancy, Avoid pregnancy x3years after d/c; Causes significant Dryness.
Cyclosporine - CI in uncontrolled HTN and renal DF, Hx of malignancy, phototherapy; Has many drug interactions with 3A4 metabolism
Otezla - My cause weight loss, diarrhea, H/A
Important Pearls for oral Nonbiologics
Frequent labs for methotrexate, cyclosporine, Soriatane. -especially pregnancy tests.
Concern for drug interactions with Methotrexate/cyclosporine
Biological Injectables for (psoriasis)
Mab’s - Adalimumab, Ustekinumab, Ixekizumab, Risankizumab
Have BBW with concern of srs infections; Very expensive.
Phytotherapy (psoriasis)
Is an option
Urticaria
Antihistamines!
2nd gen - Cetirizine, levocetirizine, loratadine, fexofenadine
1st gen - Benedryl (diphenhydramine) doxylamine. Drowsiness!
Mild to Moderate AD
Top steroids - main stay, prevent and treat flares.
Calcineurin inhibitors - Tacrolimus, pimecrolimus; ADRs local burning and stinging good for face and folds.
Top phosphodiesterase-4 Inhibitors - Eucrisa
*All non steroids are good for long term use and any body part.
Risk v Benefit of Calcineurnin Inhibitors
Tacrolimus, pimecrolimus
Okay for any body part and long term use; only local ARDs burning and stinging.
There is a BBW for skin CA and lymphoma but not set in stone.
Injectables for AD
Very expensive;
Dupixent (dupilumab)
First line medications for Acne
Mild - BPO/Top retinoid
Moderate - Top retinoid + Oral ABX with or w/o BPO
Severe - Oral Isotretinoin
Acne Keratolytics
BPO, Salicyclic Acid
BPO - oxidizes bacterial, an effective topical antimicrobial w/ no resistance. OTC
Considerations for Keratolytics
Formulation - gels penetrates better than creams; want oil free; Alcohol increases ADRs
Strength - Equally effective at all doses
ADR -skin irritations, CD, Dryness, erythema, peeling, stinging, photo-sensitivity. BPO bleaches
Acne Topical Retinoids
Adapalene (3rd generation) - Least irritating, availible in combo with BPO, 1% gel OTC
Tararotene - Accumulates under upper dermis, good for psoriasis too; ADR: photosensitivity, Cat X. Burning, Stinging, peeling
Trifarotene - against gamma subtype; $$$, selectively targets one type of retinoic receptor - less severe ADR
Tretinoin (1st gen) - OG
Do not contribute to bacterial resistance; Daily or BID
More on Topical Retinoids
Gels, creams, solutions, lotions; solutions are the most irritating.
Consider Pt skin type, preference, and previous usage.
ADEs: skin peeling, dryness, burning, pruritus, photosensitivity
CAT X
Counseling: use a daily moisturizer with sunscreen
apply to the entire affected area
Sx may worsen with initiations, takes about 8 weeks to see benefits.
Shortened contact time and applying to dry skin will lessen irritation.
Antimicrobials for Acne
Minocycline top/oral
Doxycycline PO
Sarecycline PO
Do not use PO more than 3 months
Should not be a monotherapy, use multiple MOA Not two ABX
Isotretinoin
Vit A derivative that reduces sebum production, comedone formation, c acnes colonization, inflammation.
ADRs - Excessive drying, burning, and inflammation of the skin; H/A, inflammation of the lips, dyslipidemia, arthralgias,myalgias, my increase suicidality, ophthalmic ADRs
Need to monitor LFTs, and CBC
CI with pregnancy; IPLEDGE
OTC Pediculocides
Permethrin, and pyrethrins (nix and rid).
Apply to damp hair for 10 min; Reapply 7-10 days
If there is resistance to one the other will not work.
If after 8 - 12 hours there are no dead lice, there is resistance.
Ivermectin is an OTC ovicidal. Applied similarly; good for >6y/o Pt where resistance is suspected
Pediculocides
Linedane - ovacidal - BBW for neurologic toxicity (seizures), use only when 1st line fail.
Benzyl Alcohol 5% - apply to dry hair for 10 min; suffocates lice. Reapply x1 week
Malathion - ovacidal - apply to dry hair 10 min
Spinosad - ovacidal - apply to dry hair for 10 min; high ovacidal activity; no need to reapply unless you see living lice still.
Xeglyze - ovacidal - apply to dry hair for 10 min.
Scabicide
Permethrin 5% cream
Applied from next to soles.
wash off 8-14 hours later, repeat in 48 hours.
Adult dose is usually 30 grams; no more than 2 ounce tube per person, can be used >2y/o
Fungal infections
Tx is Top/PO depending on location
Topical is sufficient for tinea corporis, tinea pedis, tinea cruris, and tinea versicolor.
Tinea capitis and unguium need oral.
Antifungals Imidazoles, triazoles
clotrimazole OTC
Ketoconazole OTC (shampoos) RX (cream)
Fluconazole Rx
Antifungals Allylamines
Butenafine OTC
Terbinafine Rx/OTC
Ciclopirox Rx
Topical Antibacterial Agents
gm+ : bacitracin
gm - : polymycin b, neomycin
IMPETIGO: Mupirocin (Bactroban)
When considering Cellulitis
Empiric Tx will be based on purulent v nonpurulent
The organism
Other health conditions: DM, opioid use disorder, renal functions, drug allergies.
Mild to moderate non-purulent Cellulitis
PO for streptococci - pen VK, cephalexin, dicloxacillin, clindamycin
PO for MRSA - Bactrim, Doxycycline, linazolid.
Increased resistance risk from infections from nasal colonization, recent hosp stays, long term care facilities, ABX use, IV drug use, Immunosuppression, sharing of sports equipment.
