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Pharmacology > Dermatology Pharmacology > Flashcards

Dermatology Pharmacology Flashcards

1
Q

What are some topical steroids?

A

Clobetasol propionate, triamcinolone acetonide, hydrocortisone

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2
Q

Topical steroid AEs?

A

Chronic use AEs: skin atrophy, striae, telangiectasias, purpura, acneiform eruption

Risk of w/ high potency steroids over large BSA: Cushing’s syndrome, immunosuppression, hyperglycemia, osteoporosis, glaucoma

Masking of dermatophyte infection (can mask fungal infection) – avoid combination products

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3
Q

Rank the potentcy of topical steroids

A

Clobetasol propionate: very high potentcy
Triamcinolone acetonide: medium to high potency
Hydrocortisone: low potency

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4
Q

Topical steroid pearls

A

Ointments have better absorption than creams but poorer adherence (can alternate w/ creams for convenience)
Application post-shower/bath increases absorption
Inflammation increases absorption
Avoid fluorinated formulations on the face (can cause rosacea/perioral dermatitis)
Avoid ointments in hairy areas or intertriginous areas
Taper higher potency steroids –> can get rebound effect

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5
Q

General principles of topical steroid agent selection?

A

Super high-potency preparations: palms and soles; severe dermatoses (psoriasis, severe atopic dermatitis, severe contact dermatitis)

Medium to high-potency preparations: mild to mod nonfacial/nonintertriginous dermatoses

Low-potency preparations: eyelid and genital dermatoses for limited time periods; large body areas

Super high potency preparations are for nonfacial/nonintertriginous areas only

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6
Q

Topical steroid general treatment duration recommendations?

A

Low-to-high potency topical steroids: 3 mo of continuous use

Ultra-high potency topical steroids: 3 weeks of continuous use

Avoid in perioral dermatitis

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7
Q

What are some therapeutic targets for acne?

A

Follicular hyperproloferation and abnormal desquamation:topical retinoids, oral isotretinoin, azelaic acid, salicylic acid

Increased sebum production: oral isotretinoin, oral contraceptives, spironolactone, clascoterone

Cutibacterium acnes proliferation: benzoyl peroxide, topical and oral abx, azelaic acid

Inflammation: oral isotretinoin, oral tetracyclines, topical retinoids, azelaic acid, topical dapsone

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8
Q

Benzoyl Peroxide (Clearasil) indication?

A

Acne

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9
Q

Benzoyl Peroxide MOA?

A

Antibiotic and comedolytic

Of note: comedones are pores or hair follicles that have gotten blocked with bacteria, oil, and dead skin

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10
Q

Benzoyl Peroxide AEs?

A

Dose-dependent irritation (erythema, scaling, xerosis, or stinging, tightening, or burning sensations)

Can bleach hair/clothing

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11
Q

Benzoyl Peroxide effectiveness?

A

Visible improvement 3 weeks, max results 8-12 weeks

> 2.5% may not increase effectiveness

Higher conc. not necessarily more effective but greater AEs

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12
Q

Benzoyl Peroxide pearls?

A

Combo w/ topical abx can decrease time to effect and prevent abx resistance

Avoid applying with tretinoin

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13
Q

Salicylic Acid (Stridex) indication?

A

Acne

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14
Q

Salicylic Acid MOA?

A

desquamating agent (“exfoliating”), mild anti-inflammatory

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15
Q

Salicylic Acid AEs?

A

Dryness, peeling

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16
Q

Azelaic Acid Topical (Azelex, Finacea) indication?

A

Acne, rosaeca

Particularily useful for rosacea as it’s good at reducing redness

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17
Q

Azelaic Acid MOA?

A

Largely unknown; may be antimicrobial, comedolytic, mild antiinflammatory; reduces redness

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18
Q

Azelaic Acid AEs?

A

Burning/tingling

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19
Q

Clascoterone Topical (Winlevi) indication?

A

Acne

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20
Q

What is clascoterone and its MOA?

A

Type: androgen receptor inhibitor

MOA: reduces sebum production, inflammation

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21
Q

Clascoterone AEs?

A

Redness, dryness, itching, burning/tingling

HPA axis suppression (avoid use over large areas/occlusive dressings)

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22
Q

Clascoterone pearls?

A

M and F ≥12 yo

$$$

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23
Q

Minocycline Topical (Amzeeq, Zilxi) indication?

A

Acne and rosacea

Amzeeq indication: acne

Zilxi indication: rosacea

For mod to severe acne vulgaris (not 1st line tx)

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24
Q

Minocycline type and MOA?

A

Type: tetracycline abx

MOA: binds to bacterial 30S ribosomal subunit and interferes w/ protein synthesis

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25
Q

Minocycline AEs?

A

Generally well-tolerated

Burning, stinging, redness

Can penetrate CNS so vestibular side effects (HA, dizziness, vertigo); serum sickness reaction (typically occurs days after initiation)

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26
Q

Tetracycline indication?

A

Acne

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27
Q

Types of tetracyclines for acne?

A

Doxycycline, Minocycline, Sarecycline (Seysara)

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28
Q

Tetracycline type and MOA?

A

Type: tetracycline abx

MOA: inhibit growth of C. acnes, anti-inflammatory action

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29
Q

Tetracycline AEs?

A

Pregnant people, children < 8 yo: tooth discoloration, slowing of skeletal development

Esophagitis, photosensitivity, skin discoloration, idiopathic intracranial HTN (rare but serious AE), microbiome effects,

Minocycline: can penetrate CNS so vestibular side effects (HA, dizziness, vertigo); serum sickness reaction (typically occurs days after initiation)

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30
Q

Tetracycline pearls?

A

Sarecycline: narrower spectrum, $$$

Duration: 3-4 mo (also use topical retinoid and benzoyl peroxide – use at different times of day (retnoid usually at HS))

Avoid administration w/ antacids, calcium, iron, magnesium

Take with a full glass of water, if pill gets stuck in throat can lead to esophagitis

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31
Q

Dapsone Topical (Aczone) indication?

A

Indication: acne

Best for papulopustular acne, not first-line

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32
Q

Type and MOA of Dapsone topical?

A

Type: sulfone abx

MOA: anti-inflammatory and antimicrobial (but not confirmed for derm purposes)

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33
Q

Dapsone topical AEs?

A

Adverse effects are rare

Methemoglobinemia, hemolytic anemia in pts w/ G6PD deficiency (MC w/ systemic)

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34
Q

Dapsone topical pearls?

A

Do not combine w/ benzoyl peroxide (yellow/orange skin and hair discoloration) –> can last for days to mo

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35
Q

Metronidazole gel (Metrogel) indication?

A

Rosacea

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36
Q

Metrogel type and MOA?

A

Type: nitroimidazole antimicrobials

MOA: details unknown but overall inhibits protein synthesis by interacting with DNA; causes loss of helical DNA structure and strand breakage

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37
Q

Metrogel AEs?

A

Skin reactions (contact dermatitis), burning, dryness

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38
Q

Metrogel pearls?

A

Do not confuse w/ vaginal formulation

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39
Q

What can retinoids be used for?

A

Acne, aging

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40
Q

How do retinoids work?

A

Retinoids exhibit biological activity similar to vitamin A)

Overall MOA: if bind to retinoid receptor –> form heterodimers; if bind to DNA sequences –> activates transcription of genes

Product produces the pharmacologic effect

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41
Q

What are some examples of retinoids?

A

Adapalene, Trifarotene, Tretinoin, Tazarotene

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42
Q

Retinoid AEs?

A

Dryness, irritation, flaking (most noticeable during first mo of use)

May cause increased photosensitivity (important to wear suscreen when using retinoids)

Micronized tretinoin contains fish proteins

43
Q

Retinoid pearls

A

Avoid Tazarotene in pregnancy

Retinoids for acne: indicated for both inflammatory and non-inflammatory acne; systemic retinoids also decrease sebum production; reduce C. acnes; has become more popular in lieu of using an antimicrobial

Retinoid administration: apply a thin layer to clean, dry skin at night (inactivated by UV light, benzoyl peroxide (adapalene, tretinoin micronized forms of tretinoin more stable)); apply to entire affected area (do not spot treat); avoid eyes

Least to most irritating: adapalene < trifarotene < tretinoin < tazarotene

44
Q

What is isotretinoin?

A

Systemic retionoid

45
Q

Isotretinoin indication?

A

Severe acne

Only acne medication that can permanently alter course of disorder

46
Q

Isotretinoin AEs?

A

Mucotaneous: dose-dependent; cheilitis, dry skin and mucous membranes, epistaxis, photosensitivity, and pruritus; eye issues (dryness, irritation, conjunctivitis)

Hyperlipidemia (45% of patients see high triglycerides, 35% see high LDLs)

Psychiatric: potential depression/suicide risk

Inflammatory bowel disease (conflicting evidence)

Less frequent: acne fulminans, myalgias, hepatotoxicity, idiopathic intracranial HTN

47
Q

Isotretinoin cautions/contraindications?

A

CI in pregnancy (causes severe, life-threatening, congenital malformations and spontaneous abortions) and soy allergy (capsules contian soy beans)

Avoid giving alongside tetracycline d/t similar AE of idiopathic intracranial HTN

Avoid blood donation as isotretinoin can linger in blood (donated blood could possibly be given to a pregnant person (which is CI))

Avoid excessive EtOH use (metabolized in liver)

Avoid vitamin A supplementation

Avoid skin procedures for 6 mo (full-face manual dermabrasion)

Avoid breastfeeding

48
Q

Considerations before prescribing isotretinoin?

A

iPLEDGE program (provider requirements)

Initial assessment: prior contraceptive failure, assessing personal or family hx of AEs, heavy EtOH use, extreme physical activity

49
Q

Isotretinoin monitoring?

A

Monitoring: development or worsening of AEs; vision changes and HA important to check to minitor for intracranial HTN

Baseline labs: ALT and triglyceride levels w/in 1 mo prior to the start of therapy; urine or serum pregnancy test in pts of childbearing potential (2 tests are required prior to the start of therapy for the iPLEDGE)

50
Q

Isotretinoin pearls?

A

Sometimes in 1st month when taking systemic retinoid pts can experience a flare –> can take glucocorticoid to mitigate

51
Q

What are some hormonal treatment options for acne?

A

OCPs, spironolactone

52
Q

OCP AEs

A

Blood clots with taking estrogen

53
Q

OCP screening before prescribing?

A

Smoking, HTN

54
Q

OCP for acne pearls

A

For postmenarchal F only

Should contain estrogen and progestin (progestin only pills won’t help with acne, may make it worse)

Can take several months before seeing effects

55
Q

Spironolactone type and MOA?

A

Type: mineralocorticoid receptor antagonist

MOA: antiandrogen (blocks receptors, inhibits production; decreases sebum production)

56
Q

Spironolactone AEs?

A

Menstrual irregularities, breast tenderness, minor GI symptoms (anorexia, nausea, vomiting, and diarrhea), hyperkalemia, orthostatic HoTN, CNS symptoms (HA, dizziness, and fatigue)

CNS effects are not dose dependent but other AEs are

57
Q

Spironolactone contraindications?

A

Avoid in pregnancy

58
Q

Spironolactone pearls?

A

Start at a lower dose and titrate up to avoid HoTN

59
Q

How to approach treating mild acne?

A

Assess for need for more aggressive tx; manage as mod-to-severe if necessary
* Comedonal lesions only: topical retinoid
* Papulopustular +/- comedonal lesions: topical retinoid + benzoyl peroxide

Assess after 3 mo – if satisfactory, continue topical retinoid maintenance
If unsatisfactory response:
* Manage as mod-to-severe (consider alt. therapies or manage as mod-to-severe)
* Add: topical clindamycin OR topical daspone

60
Q

How to approach treating moderate to severe acne?

A

Assess for need for more aggressive tx; offer isotretinoin if appropriate
* Comedonal lesions only: topical therapy + oral contraceptive (F only) OR oral spironolactone (F only) OR oral isotretinoin
* Papulopustular +/- comedonal lesions: topical therapy + oral tetracycline OR oral contraceptive (F only) OR oral spironolactone (F only) OR oral isotretinoin

Assess after 3 mo – if satisfactory, continue OC or spironolactone + topical as maintenance; d/c antimicrobial; isotretinoin given until cumulative dose achieved
If unsatisfactory response:
* Try combo or escalate to isotretinoin

61
Q

Mupirocin (Bactroban) indication?

A

Impetigo, MRSA dermatologic infection

62
Q

Mupirocin AEs?

A

Resistance w/ prolonged use

63
Q

Butenafine (Lotrimin) indication?

A

Tinea (do not use terbinafine for tinea unguium)

64
Q

Butenafine AEs?

A

Generally well-tolerated

Itching, burning, erythema, contact dermatitis

65
Q

Terbinafine (Lamisil) indication?

A

Tinea

Oral used to tx things like toenail fungus (toenail not a well perfused area, etc)

66
Q

Terbinafine (Lamisil) AEs?

A

Topical:
* Generally well-tolerated
* Itching, burning, erythema, and contact dermatitis

Oral:
* Hepatotoxicity, delayed hypersensitivity reactions (TENS/SJS)

67
Q

Ketoconazole (Nizoral) indication?

A

Tinea, seborrheic dermatitis, dandruff

68
Q

Ketoconazole AEs?

A

Generally well-tolerated

Itching, burning, erythema, contact dermatitis, angioedema

69
Q

How to approach mild to moderate psoriasis treatment?

A

Topicals +/- phototherapy

70
Q

How to approach moderate to severe psoriasis treatment?

A

Topicals +/- phototherapy, biologic +/- systemic agents added

71
Q

What are Tacrolimus (Protopic), Pimecrolimus (Elidel)?

A

Calcineurin inhibitors

72
Q

Tacrolimus and Pimecrolimus indications?

A

Indication: atopic dermatitis

Other uses: intertriginous psoriasis, vitiligo, mucosal lichen planus, graft-versus-host disease, allergic contact dermatitis, and rosacea

73
Q

MOA of calcineurin inhibitors?

A

Suppresses cellular immunity (inhibits T-lymphocyte activation)

74
Q

AEs of calcineurin inhibitors (tacrolimus, pimecrolimus)?

A

Common: transient erythema, burning, and pruritus

Rare: systemic immune-related effects (tacrolimus > pimecrolimus), skin papilloma, lymphadenopathy

75
Q

Do calcineurin inhibitors have a BBW?

A

YES: although a causal relationship has not been established, rare cases of malignancy (ie, skin cancer and lymphoma) have been reported

Avoid continuous long-term use

Limit application to areas of involvement w/ atopic dermatitis

76
Q

Calcineurin inhibitor pearls

A

Can be used on face, intertriginous areas

Tacrolimus: more effective compare to mediumpotency steroids

Pimecrolimus: fewer AEs

Avoid in Nethertom Syndrome (rare genetic disorder, causes some skin to be thinner so these types of drugs are absorbed more systemically)

77
Q

What are Calcipotriene and Calcitriol?

A

Vitamin D analogs

78
Q

Vitamin D analog indications?

A

Plaque psoriasis

79
Q

Vitamin D analog AEs?

A

Hypercalcemia and hypercalciuria may develop when the cumulative weekly dose exceeds the recommended limit

Irritation, mild photosensitivity

80
Q

Vitamin D analog pearls?

A

Concomitant admin of topical corticosteroids will reduce irritation and provides synergistic effect

Avoid w/ vitamins/calcium supplements, occlusive dressings, sunlight/UV exposure

81
Q

What is methotrexate?

A

Type: folate antagonist/antimetabolite

MOA: inhibits dihydrofolate reductase (targets cells during DNA synthesis, reduces hyperproliferation in psoriasis)

82
Q

What is MTX indication?

A

Psoriasis, sarcoidosis, rheumatoid arthritis

(high-dose used in oncology)

83
Q

MTX AEs?

A

AEs w/ low dose regimens:

Within days-weeks
* GI: nausea, stomach upset, anorexia, loose stools
* Stomatitis or soreness of the mouth
* HA, fatigue, malaise, or impaired ability to concentrate
* Macular punctate cutaneous eruption, which usually occurs on the extremities, often affecting the elbows and knees, but sparing the trunk (can cause severe SJS-like or TEN-like conditions)
* Alopecia (not dose-related)
* Fever (drug-related)
* Pancytopenia (can occur after 1 dose but up to 6 weeks later)

Weeks-months
* Abnormal liver chemistries, (typically mild elevations in hepatic transaminases)
* Hematologic abnormalities (particularly macrocytosis, in addition to infrequent but severe myelosuppression)
* Pulmonary toxicity/pneumonitis (MC in RA)
* Lymphoma

Hepatotoxicity

84
Q

Does MTX have a BBW?

A

YES: toxicity, teratogenicity

85
Q

MTX cautions/contraindications?

A

CI: pregnancy/breastfeeding (wait 3 mo after d/c to become pregnant); EtOH dependence, EtOH liver disease or other chronic liver disease; immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia)

Caution: abnormalities in renal/liver function, active infection

Dose adjust for reduced renal function

86
Q

MTX drug-drug interactions?

A

May increase MTX concentrations (NSAIDs, sulfamethoxazole-trimethoprim, loop diuretics, thiazide diuretics, sulfonylureas, PCN, minocycline, ciprofloxacin, phenytoin, barbiturates, PPIs)

Avoid live vaccines (can increase risk of infection)

Avoid with topical immunosuppressants

Minimize alcohol intake

87
Q

MTX monitoring?

A

Baseline/pretx: pregnancy; CBC, LFTs, serum albumin; noninvasive liver fibrosis assessment; hepatitis B and C screening; test for latent TB

Ongoing: liver/renal functioning (CBC, LFTs, serum albumin, serum creatinine, FIB-4, Fibrosure, Fibrometer, Hepascore annually)

88
Q

MTX pearls?

A

Can be used w/ phototherapy

Supplement w/ daily folic acid to reduce adverse effects

89
Q

Other medications for systemic treatment of psoriasis? What is their indication?

A

Acitretin, Apremilast, Cyclosporine

Moderate to severe plaque psoriasis

90
Q

Acitretin pearls?

A

Not immunosuppressive

Place in therapy: HIV pts on antiretrovirals

91
Q

What are biologics used for?

A
92
Q

Types of classes of biologics?

A

TNF-⍺ inhibitors, IL-23 inhibitors. IL-17 inhibitors, IL-4 antagonists

93
Q

Pretreatment screening for all biologics?

A

Yes: CBC w/ diff, CMP, TB test, hepatitis, HIV test, referral to ID on special case-by-case basis

94
Q

What are some examples of TNF-⍺ inhibitors?

A

Etanercept (Enbrel), Infliximab (Remicade), Adalimumab (Humira), Certolizumab Pegol (Cimzia)

95
Q

TNF-⍺ inhibitors AEs?

A

MS (rare); hepatotoxicity (especially w/ infliximab); drug-induced reversible lupus erythematosus w/o renal or CNS complications; exacerbation or new onset of CHF; cytopenia

Injection site reactions: mild (pruritic reaction), moderate-to-severe (macular erythema to erythematous annular plaques)

Infusion reactions w/ infliximab

96
Q

TNF-⍺ inhibitors cautions/contraindications?

A

Untx hepatitis B infection

Hx of lymphoreticular malignancy

Active infection (including TB) or sepsis

Initiation of therapy should be done in consultation w/ an infectious disease specialist

Significant New York class III or IV CHF or pre-existing multiple sclerosis

97
Q

Monitoring while taking TNF-⍺ inhibitors?

A

Ongoing monitoring: assessment for infections (ex: TB, histoplasmosis), esp. in those using TNF-a inhibitors + MTX; annual TB test in high-risk pts; LFTs for infliximab at 3 mo, then q 6-12 mo

98
Q

Describe an acute infusion reaction with infliximab

A

Acute: Occur during or w/in 24 hr of infusion; mitigated and/or prevented by pretx w/ APAP and diphenhydramine

Mild and mod infusion reactions:
* Usually consist of nausea, fever, erythema, and itching
* Resolve spontaneously after reduction of the infusion rate or temporary pause of the infusion

Severe infusion reactions:
* Occur immediately after the infusion has been started
* Are characterized by hypotension, chest tightness, respiratory distress, dyspnea, bronchospasm, laryngeal edema, urticaria, or rash
* Require immediate d/c of the infusion

99
Q

Describe a delayed infusion reaction with infliximab

A

Begin 1-14 days after infusion
Usually consist of myalgia, arthralgia, HA, fever, rash, and fatigue
Missing an infusion increases the chances of an infusion reaction
The next infusion should be done more slowly and w/ appropriate pretx (ie: w/ antihistamines)

100
Q

Types of IL-23 inhibitors

A

Guselkumab (Tremfya), Risankizumab-Rzaa (Skyrizi), Tildrakizumab-Asmn (Ilumya), Ustekinumab (Stelara)

101
Q

Types of IL-17 inhibitors

A

Seckinumab (Cosentyx), Ixekizumab (Taltz), Brodalumab (Siliq)

102
Q

Types of IL-4 antagonists

A

Dupilumab (Dupixent)

103
Q

Dupilumab indications/pearls?

A

Indications: atopic dermatitis, asthma, rhinosinusitis w/ nasal polyps

Drug interactions: can use w/ or w/out topical corticosteroids; topical calcineurin inhibitors should be reserved for problem areas only (eg, face, neck intertriginous and genital areas); may be able to reduce maintenance asthma medications; avoid live vaccines

Pharmacology (4 decks)

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