Drugs to skin disorders Flashcards
epidermis
is the protective layer—its outer most surface—the stratum corneum contains lipids & keratin
dermis
lies between the epidermis and SQ fat layer—it is composed of connective tissue and contains sweat glands, sebaceous glands, hair follicles and vessels
What does sunlight do?
One of the main effects is maintaining the body’s
supply of Vitamin D—this effect is positive
The photoreceptors on the skin [forearms/legs],
when uncovered [and not coated with sunscreen]
absorb Vitamin D2 from the sun rays
This form of Vitamin D is converted to Vitamin D3 in the
kidney and then to its active form in a second renal
conversion—1, 25 dihydroxyvitamin D3
What are the 2 types of UV?
UVB [bad] are the rays that burn us, cause wrinkling
and skin cancers
UVA can cause some wrinkling and with many decades
of “lead time” may manifest itself as BCC later in life
MED is?
minimal erythemal dose—minimum amount of UV radiation that produces clearly evident erythema
after one exposure
SPF is?
amount of UVB protection provided by a sunscreen [MED on protected skin ÷ MED on
unprotected skin]; gives direction for how long one will
be protected before burning
Broad spectrum is
effective against both UVA & UVB radiation; these protect against sunburn, skin cancer
and photoaging
Water resistant is
—sunscreen is effective for 40-80
minutes while a person is swimming [or is sweating]
How long should you apply insect repellant after you apply sunscreen
30 minutes
When does sunscreen expire
36 months after manufactured date
Effects of Sun exposure
Photoaging refers to damage done to the skin from
prolonged exposure to UV radiation—throughout one’s
lifetime
Normal skin changes of aging are exacerbated by sun
exposure
Photoaging includes—dark spots, wrinkles, droopy
skin, yellowish tint to the skin, blood vessels that are
fragile and break easily, leathery skin, skin cancers
skin phototype I
-Pale white skin; blue/hazel eyes; blonde
or red hair
-Always burns; does not
tan
skin phototype II
- Fair skin with blue eyes
- burns easily, tans rarely
skin phototype III
- darker white skin
- tans after initial burn
skin phototype IV
- light brown skin
- burns minimally, tans easily
skin phototype V
- brown skin
- rarely burns, tans darkly with ease
skin phototype VI
- dark brown or black
- never burns; tans darkly
Glucocorticoid Prescribing
Steroids work via intracellular receptors; they
initiate several transcriptions—inhibition of
arachidonic acid cascade, decrease production of
many cytokines and inflammatory cells
Potency is based on vasoconstriction—most potent
[VII] to least potent [I]
Tachyphylaxis
Decrease in response with repetitive use or recurrance
of s/s when drug stopped; giving drug holiday can
reduce chance of this phenomenon
Adverse effects of glucocorticoids
Skin atrophy, striae, purpura
Acneiform eruptions, dermatitis, local infections,
hypopigmentation
In children, applying potent steroids to large body
surface area [BSA] can cause systemic toxicity—
depression of HPA axis and growth retardation
Low potency glucocorticoids
-Alclometasone dipropionate .05% [C, O] -Clocortolone pivalate .1% [C -Flucinolone acetonide .01% [S] -Hydrocortisone base or acetate .25-2.5% [O, C] -Triamcinolone acetonide .025% [C, L, O]
Intermediate potency glucocorticoids
-Betamethasone dipropionate .05% [C] -Desonide .05% [C, L, O] H -Desoximetasone .05% [C] -Fluocinolone acetonide .025% [C, O] -Flurandrenolide .025% - .5% [C, O] -Fluticasone propionate .005%- .05% [O, C] -Hydrocortisone butyrate .1% [C, O, S] -Hydrocortisone valerate .2% [C, O] -Mometasone furoate .1% [C,O, L] -Triamcinolone acetonide .1- .2% [C, O]
High Potency glucocorticoids
-Amcinonide .1% [C, L, O]
-Betamethasone dipropionate
augmented .05% [C, L]
-Desoximetasone .05% [O]
-Diflorasone diacetate .05% [O, C]
-Halcinonide .1% [C, O]
-Triamcinolone acetonide .5% [C, O]
-Fluocinonide .05% [C, G, O, S]
High potency glucocorticoids
- Betamethasone dipropionate .05% [O, G]
- Clobetasol prionate .05% [C, G, O]
- Diflorasone diacetate .05% [O]
- Fluocinonide .1% [C]
- Flurandrenolide .05% [L]
- Halobetasol .05% [C, O]
Patho of acne vulgaris
Excess sebum
Comedones
Propionibacterium acnes overgrowth
Inflammation
How is acne vulgaris classified
Disease classified as
-Comedones, pustular/papular and nodular
Disease further subdivided as→
- Mild—comedonal, pustular/papular
- Moderate—pustular/papular, small nodules [up to1 cm]
- Severe—nodular, cystic/pustular [also called acne conglobate]
Retinoids
Derivatives of Vitamin D
Influence cell proliferation, immune function, inflammation & sebum production [3rd generation agents, do not ↓ sebum production]; these agents are comedolytic and anti-inflammatory;
> > MOA: mediated through nucleic
retinoic acid receptors
Adverse effects—irritation, dryness, skin peeling, photosensitivity, dry MM, dry
eyes
Prototype Drug
» Tretinoin—1st generation agent
Other agents >>Isotretinoin—1st generation agent—category X agent—must be prescribed by licensed providers—I Pledge -Oral agent - Used in scarring acne and in severe disease
Adapalene / Tazorac—3rd generation agent—less irritating
1st line for comedonal and inflammatory acne
Benzoyl Peroxide
1 st line for mild to moderate acne with NO inflammation
MOA—antiseptic against P acnes and opens pores
Adverse effects—dry skin, peeling, irritation
Salicylic Acid
A Beta hydroxy acid, penetrates pilosebaceous unit
MOA—exfoliates to clear comedones; mild antiinflammatory activity and is keratolytic at high concentrations
For mild disease
Adverse effects—peeling, dryness, local irritation
Azelaic Acid
Antibacterial against P acnes and it has antiinflammatory actioins
Normalizes keratinization and it anticomedogenic
Used in mild to moderate inflammatory acne
Adverse effects include skin irritation
Antibiotics
P acnes is a gram + rod associated acne
For moderate to sever acne—with inflammatory lesions, topical or oral antibiotics can inhibit this bacteria’s growth—Erythromycin and Clindamycin [preferred] are
available and used
Topical antibiotics best when combined with BPO or retinoids
Topical Dapsone [a sulfonamide] is available
> > MOA is unknown—side effects have been reported— methylhemaglobinemia
Moderate to severe acne requires ORAL antibiotics— Doxycycline [preferred] or Minocycline
Treatment of Acne
Topical retinoids play a critical role in therapy— these agents:
>Reverse excess desquamation
>Improve penetration of other drugs
>Work best with antibiotics
>Reduce all acne lesions by 50% in 12 weeks of therapy
Selection of agents for mild acne vulgaris
If presentation is mainly comedones—treatment of
choice is topical retinoid
If presentation is papular/pustular—treatment of
choice is topical retinoid + benzoyl peroxide [BPO] OR
topical retinoid + BPO/antibiotic combination
Selection of agents for moderate disease
For Moderate Disease
For papular/pustular disease—topical retinoid
+ oral antibiotic & BPO [can add OCP in ⧬ ]
For nodular disease— topical retinoid + oral antibiotic & BPO [or BPO/antibiotic]
Alternative—Isotretinoin orally
Selection of agents for severe disease
For Severe Disease
For nodular—oral antibiotic and topical retinoid + BPO [can add OCP in ⧬]
Alternative—Isotretinoin oral
For cystic/pustular—oral Isotretinoin [Accutane]
Alternative is high dose oral antibiotic and topical retinoid + BPO [+ OCP in ⧬]
Considerations to Prescribe Isotretinoin
Requires prescribers be trained and registered—
have a federal ID number [based on your NPI and
completion of training]
Rosacea
Description
> Chronic acne-like inflammation of central area of face, yet no comedones are present
Etiology
> Cutaneous vascular disorder of capillaries
» Increased reaction to heat causes “flushing”
» Ocular symptoms may include blepharitis, conjunctivitis
Incidence/Demographics
- Common in fair skinned, middle aged to elderly people
- Severe form with rhinophyma is seen almost exclusively in men >40 years
> > Irreversible hypertrophy of the nose, rhinophyma, is a result of chronic inflammation, and it is seen almost exclusively
Prescriptions for Rosacea
Sodium Sulfacetamide
[10%] with Sulfur 5%
- Usually prescribed as a daily wash
Topical Metronidazole
[MetroGel]
- This agent is considered DOC
- Safe in pregancy
Azelaic acid [Finacea]
- Effective for papules, pustules, erythema [does not
deter telangiectasias]
- Safe in pregnancy
Oral Doxycycline
- > > Writing the Rx…
- BID Topicals
- Metronidazole 0.75%
- Erythromycin 2%
- Clindamycin gel
Oral Agents—Doxycycline 50- 100 mg @ HS for 4 weeks or Erythromycin 250 mg BID
Response usually seen in 4 weeks, maximum response from one regimen may take up to 9 weeks
Requires long term maintenance treatment
Actinic Keratosis
Discrete, dry, scaly lesions occurring on sunexposed skin of susceptible adults
Precursor to squamous cell carcinoma [SCC]
Etiology
-Recurrent or prolonged sun-exposure in skin photo types I, II and III
Common in elders from photoaging of skin
More common in males
Appears in middle adulthood—earlier in Australia and southwestern US
Lesions begin as single or multiple discrete adherent hyperkeratotic scaly lesions; near 1 cm in size— round/oval in shape; color ranges from light tan to brown with or without reddish tinge
25% spontaneously regress, 1% progress to SCC [NIH,
2010]
Topical therapies for actinic keratosis
Topical Therapies
Efudex [5-flourouracil]—twice daily for 3-4 weeks
Side effects—redness, crusting, intense stinging
Aldara [Imiquimod]—3 to 5 applications per week for 1-2 months
Side effects—similar to Efudex
5 Flourouracil
for actinic kerasosis
aka Efudex
5% cream or 2%/5% solution
Apply to affected area BID for 2-4 weeks
MOA—inhibits DNA & RNA synthesis
Imiquimod
for actinic kerasosis
aka Aldara
5% cream; apply 3 times per week @ hs for up to 16 weeks [MOA is unknown—immune modulator]
Non-medication treatments for actinic keratosis
Cryotherapy, curettage, photodynamic therapy,
facial resurfacing, medium depth chemical peels
Allergic Dermatitis
Global term that may be referring to atopic
dermatitis [eczema] or allergic contact dermatitis
Inflammation of epidermis and dermis that causes
profound pruritus—often termed “the itch that
rashes”
Chronic disorder; genetic linked—made worse by
emotional stress, hormonal variation
These individuals often have marked allergies to food,
medications, pollens and the like
Lesions often appear in first year of life
Treatment for Atopic Dermatitis
> > Treated with a regimen of emollients, topical steroids [ointment preparations] +/- topical immune modulators [such as tacrolimus]
Topical steroids—refer to earlier slides
Calcineurin Inhibitors—refer to slide in psoriasis section [of this slide set]
Tacrolimus ointment [.1%, .03%] [Protopic]
Pimecrolimus cream [Elidel]
- Used as steroid sparing agents in chronic eczema
- Both agents have BB for skin malignancies and lymphoma
- Neither to be used in children under the age of 3 years
Plantar Warts
Small, usually painless growths on the skin caused human papillomavirus [HPV]; generally harmless—they can itch or hurt if on plantar aspect of the feet
Different types of warts—common warts are usually on hands, but can appear anywhere
Flat warts—often found on face and forehead; common, in children, rare in adults
Genital warts—also known as condyloma— seen on genitals, in pubic area, and in between the thighs, but can appear inside the vagina and anal canal
Subungual and periungual warts—appear around the fingernails and toenails
Plantar warts are found on soles of feet [NIH, 2009]
Plantar wart treatments
OTC wart removal products—patients should try and file the wart down after bathing before applying the agent
Salicylic acid topically—many OTC formulations [Compound
W; DuoFilm, others]; Virasal [27.5% Rx required—topical ];
50% can be compounded as a paste [Rx required]
Other prescription agents
—Podophyllin 0.5% solution; apply
BID for 3 days; off 4 days; can repeat until cleared [MOA is unknown; inhibits cell mitosis] or
– Imiquimod [Aldara] 5% cream;
apply 3 times per week @ hs for up to 16 weeks [MOA is unknown—immunomodulator]
Other treatments—surgical removal, cryotherapy,electrocautery or laser [NIH, 2009]
Alopecia
Trichogenic agents are used to treat androgenic alopecia [male pattern baldness]
> > > Minoxidil—originally used as an antihypertensive—used to halt hair loss in both men &
women
MOA unknown; thought to act by shortening the rest
phase of the hair cycle; must be used continuously
> > Finasteride—5 alpha reductase inhibitor that blocks conversion of testosterone to 5 alpha dihydrotestosterone [DHT]
High levels of DHT cause the hair follicle to atrophy; this
agent lowers scalp and serum DHT levels [in large doses this agent is used to treat BPH]
Adverse effects—decreased libido, decreased ejaculation, ED
Approved for men, should no be used or handled in
pregnancy as it can cause hypospadius in the male fetus
Pigment Skin Disorders that are Treated
Freckles and Melasma (Hyperpigmentation disorders)
Vitiligo (Hypopigmentation disorder)
Meds for pigment skin disorders
- Protoype Drug— Hydroquinone
Topical skin whitening agent; it inhibits the tyrosinase enzyme required for melanin synthesis
Used to reduce pigmentation—along with topical retinoids
4% preparation is best agent [2-3% may be available in
your area as OTC products]
Adverse effects—local skin irritation - Monobenzone—benzyl ether of Hydroquinone—this agent can be used to even out the skin discoloration of
vitiligo - Methoxsalen—photoactive substance [psoralen] that stimulates melanocytes; used as a repigmentation agent for vitiligo
Must be activated by UVA radiation [PUVA]
This agent inhibits cell proliferation & promotes cell differentiation of epithelial cells; topical may be used for small patches of vitiligo; oral used for widespread disease
Adverse effects—aging of the skin and increased risk of skin cancer
Common bacterial infections of the skin
Staphylococcus aureus [MSSA and MRSA strains]
Streptococcus pyogenes [Group A beta-hemolytic]
Streptococcus agalactiae [Group B]
Gram negative bacilli or anaerobes such—Escherichia coli, Pseudom
Treatment for gram + infections
Bacitracin—used most often for prevention of skin disease after burns and scrapes
Mupirocin—protein synthesis inhibitor
- Useful for treating impetigo and other serious gram + skin infections—including MRSA Staph aureus
Retapamulin—newer protein synthesis inhibitor approved for the treatment of impetigo
Treatment for gram - infections
Polymyxin B—cyclic hydrophobic peptide that disrupts the bacterial cell membrane of gram negative pathogens
– Commonly combined with Neomycin** & Bacitracin in triple antibiotic [TAO] products
Gentamycin can be used to treat skin infections caused by gram negative bugs such as Pseudomonas, E. coli and Klebsiella species
**Allergic dermatitis and other sensitivities common with Neomycin
When systemic agents are needed for bacterial infections
Augmentin 875 mg BID for 7 days [or high dose Amoxicillin]
Cephalexin 250-500 mg QID for 7 days
Doxycycline 100 mg BID for 7 days [Sanford, 2013]
If MRSA suspected—Trimethoprim/Sulfa DS [2] BID or Doxycycline 100 mg BID
Clindamycin 300 mg q6h or Rifampin if infection severe [Sanford, 2014]
Fluoroquinolones might be an option—depending on your geographical area—Levofloxacin 500 mg QD or Moxifloxacin 400mg QD
Ectoparasitic Infections
Parasites that live on animal skin [where they obtain their nutrition] and can jump “species” and infect the human
Pediculosis—lice
Scabies—mite
Agents we use in these infections—Lindane, Permethrin, Synergized pyrethrins with piperonyl butoxide
Antiparasitic agents
Lindane—cyclohexane derivative [Kwell; brand no longer available]
Available as cream or shampoo; kills lice & scabies
Permethrin—synthetic pyrethroid that is neurotoxic to lice [1% OTC] [Nix] and scabies [5% prescription] [Elimite]
Preferred over Lindane, as Lindane can cause neurotoxicity
Ivermectin—given orally, is an alternative therapy for lice and scabies [Stromectol; comes in topical—Soolantra]
Synergized pyrethrins with piperonyl butoxide—OTC product used to treat head and pubic lice [Rid]
Pyrethrins are pesticides; piperonyl butoxide prevents lice from
metabolizing the pyrethrins, making them more potent
Low risk of toxicity; DOC for pediculosis
Treating Fungal Infections: yeast- candida species
Albicans; Glabrata; Tropicalis
Treating Fungal Infections: non yeast fungal infections–dermatophytes {tinea}
Most common—Trichophyton, Microsporum, Epidermophyton, Malassezia [previously called
Pityrosporum]
Tinea is classified by area of body it affects—tinea pedis [tinea on feet]
Tinea appears as rings or round red patches with clear centers [often called “ringworm”]
Dermatophytosis
Classically presents with red annular scaly
plaques central clearing and a serpiginous
border
Do not invade dermis because of keratin dependency
Candidiasis
Characterized by pruritic, bright red, macerated plaques with surrounding ‘satellite’ vesiculopustules
Predilection for skin folds—axillary, inframammary, genitocrural
More common in patients with comorbidities—obesity, diabetes,
recent antibiotics
Also affects the mucous membranes and can cause systemic
disease in the immunosuppressed [NIH, 2010]
Squalene Epoxidase Inhibitors: Terbinafine [Lamisil]
Prototype drug—Terbinafine [Lamisil]
»Active against most all strains of dermatophytes [including Scopulariopsis—a fungus responsible for deep fungal and fungus ball infections in the
immunosuppressed] & near 50% of candida infections
» Comes in oral, cream, gel and solution
Oral form is DOC for onychomycosis
[250 mg daily for 3 months] and tinea capitis [250 mg daily for 1-2 weeks]
Topical [cream usually] treats tinea pedis, corporis, cruris BID for 1-6 weeks [depending on severity]
Highly protein bound; concentrates in breast milk [don’t prescribe to breast feeding mums]
½ life in tissues is 200-400 hours
Metabolized in liver and excreted in liver
Avoid in patients with liver dysfunction
Adverse Effects—diarrhea, dyspepsia,
nausea, headache, elevated LFTs
Squalene Epoxidase Inhibitors: Naftifine [Naftin]
Naftifine [Naftin] -- Active against Trichophyton, Microsporum, Epidermophyton --Available in 1% cream and gel --Used to treat tinea corporis, cruris, and pedis—must dose BID for at least 2 weeks
Squalene Epoxidase Inhibitors: Butenafine [Lotrimin Ultra]
Butenafine [Lotrimin Ultra]
Active against Trichophyton, Epidermophyton, Malassezia
Same indications as Naftin; 1% cream BID for 2 week
What do Squalene Epoxidase Inhibitors do?
These agents block the biosynthesis of ergosterol— which is needed in the fungal cell membrane
Accumulation of toxic amounts of squalene causes increased cell membrane permeability & death
Griseofulvin
This agent disrupts the mitotic spindle and inhibits fungal mitosis
Older agent—has been replaced for the most part by Terbinafine, but still used for dermatophytes of scalp and hair
Agent is fungostatic—so duration of treatment is long—
500 mg po daily 6 to 12 months for nails
Absorbed from GI tract, enhanced by high fat meal
It increases the metabolism of anticoagulants
Contraindicated in pregnancy and patients with porphyria
Nystatin
This agent is a polyene antifungal—MOA is much like that of Amphotericin B
Used for treatment of cutaneous and oral Candida infections
Negligibly from GI tract; not used systemically because it causes toxicity
For oral-pharyngeal infection—it is given as a swish & swallow regimen [QID for 7-10 days]; used topical for cutaneous infections [BID for 7-14 days]; intravaginally
for vulvovaginal infections [at HS for 3-7 days]
Imidazoles
Azole derivatives that have a wide range of activity against the 4 most common dermatophytes and
Candida species
These agents are given for tinean corporis, cruris and pedis; oral/pharyngeal & vaginal Candida
Prolonged topical use can cause contact dermatitis, vulvovaginal irritation/edema
Clotrimazole and Miconazole both come in a troche/buccal forms
The only AZOLE that covers Candida glabrata is terconazole [Terazol]
Examples of Imidazoles
Butoconazole—Gynazole-1 Clotrimazole—Mycelex; Lotrimin AF Econazole—Spectazole Ketoconazole—Nizoral Miconazole—Desenex; Micatin; Monistat Derm; Zeasorb AF [powder] Oxiconazole—Oxistat Sertaconazole—Ertaczo Sulconazole—Exelderm Terconazole—Terazol [vaginal] Tioconazole—Monistat [vaginal] Fluconazole—Diflucan [oral] Itraconazole—Sporanox [oral]
Ciclopirox
Agent inhibits transport of essential elements that allow DNA, RNA and protein synthesis
Active against Trichophyton, Epidermophyton,
Microsporum, Candida and Malassezia
Only topical antifungal active against ALL
dermatophytes and all strains of Candida
Used for tinea pedis, corporis & cruris, cutaneous candidiasis and tinea versicolor
Available in shampoo [1%] for seborrhea dermatitis; .77% cream, gel or suspension [Loprox]; topical for nails [Penlac]
Not used for vaginal candidiasis
Tolnaftate
This agent distorts the hyphae and stuns mycelial growth
Active against Epidermophyton, Microsporum, Malassezia; NOT effective for Trichophyton or Candida
Used to treat tinea pedis, cruris & corporis
1% solution, cream, powder BID for 2-4 weeks
Tinactin; Lamisil AF Defense
Newest Agents
Onychomycosis best treated with oral Lamisil
Within last year, 2 topicals with reasonable efficacy have come to market
Boric acid key component of both!!
Efinaconazole—an azole that is pegelated in a boric acid solution—Jublia 1-2 gtts to each affected nail for 48 weeks
Tavaborole—new compound based on boric acid that penetrates nail/plate and polish—Kerydin—paint on nail and under tip at HS for 48 weeks
Candida—Writing the Rx….
» Vaginal infections
Oral fluconazole [Diflucan 150 mg] x1
» Options for cutaneous Candidiasis [use these agents 2x daily]
Imidazole topical cream, solution, powder
Clotrimazole 1 % cream; Miconazole 2% cream
Ketoconazole 2% cream; Econazole [Spectazole] 1% cream;
Terconazole [Terazol] 0.4-0.8% cream
Terbinafine [Lamisil] 1% cream, solution
Tolnaftate [Tinactin] 1% cream, solution, powder
» Oral antifungals may be needed in extensive infection
Oral
- Treat for 10-14 days
- Nystatin oral suspension 500,000 units S/S QID
- Clotrimazole 10 mg troches 3-5x/day
- Systemic ketoconazole 200 mg QD to BID
- Fluconazole 100-200 mg QD to BID
- Amphotericin B 3 mg/kg/day given IV for resistant cases in compromised hosts
Psoriasis
Description
- Chronic, scaling papules and plaques
Characteristic distribution is knees, elbows, scalp
Skin lesions occur insidiously [on occasion may be acute] +/-pruritus; may be associated with acute systemic illness with fever and malaise
Etiology
- Alteration in cell kinetics of keratinocytes with shortening of cell turnover rate, resulting in increased production of epidermal cells
Chronic, scaling papules and plaques
Usual distribution is knees, elbows,nscalp
Silvery-white scaling with pinpointnbleeding when scale removed
Assess quality of life—ask aboutnpain
Important nondrug therapies—avoidnrubbing/scratching; advise patient to eat a healthful diet, exercise and
lose weight, stop smoking [if applicable]
Drugs Used to Treat Psoriasis
Patients with mild to moderate disease [<5% of BSA and not involving palms or soles] can be managed with topicals—retinoids, Vitamin D analogues, keratolytics, topical steroids
For more severe disease—systemic therapies— Methotrexate, Cyclosporine, immune modulators
If patient not a candidate for the aforementioned— phototherapy [Methoxsalen + UVA [PUVA] OR UVB
alone]
Retinoids used in psoriasis
Tazarotene [Tazorac]—topical retinoid for plaque psoriasis
Acitretin [Soriatane]—2 nd generation retinoid; given PO for pustular psoriasis
- ½ life of 120 days; ETOH contraindicated as it increases potency and prolongs ½ life
- Teratogenic and women must avoid pregnancy for at least 3 years after using Acitretin
> > Adverse effects—cheiliitis, pruritus, peeling skin, hyperlipidemia
Vitamin D analogues fo psoriasis
These agents inhibit growth of keratinocytes
» Calcipotriene [Dovonex; Taclonex if combined with Betamethasone] and Calcitriol [generic 3 mcg/g ointment]
- Synthetic Vitamin D3 derivatives used topically to treat plaque psoriasis
- These agents inhibit keratinocyte production
- These agents can cause hypercalcemia
Adverse effects—itching, dryness, burning irritation and erythema
Keratolytic Agents for psoriasis
Coal tar—inhibits excessive skin cell proliferation
Salicylic acid
Both used on scalp to remove scale and improve steroid penetration
These agents have largely been replaced in psoriatic care by the newer topical agents
Other Topical Agents for psoriasis
- Corticosteroids and immunenmodulators
2. Calcineurin Inhibitors
Other topical agents for psoriasis : Corticosteroids and immune
modulators
Corticosteroids and immune modulators—suppress the dysregulated immune response High potency topical steroids BID for 2-3 weeks; then, use in pulse fashion BID for 2 d/week Intralesional steroids Avoid oral steroids which can cause rebound flares May control mild disease but may be irritating or messy Long term use of topical corticosteroids is limited by cutaneous atrophy
Other topical agents for Psoriasis : Calcineurin Inhibitors
Calcineurin Inhibitors
Tacrolimus [Protopic]
Pimecrolimus [Elidel]
These agents suppress T-cell activation/proliferation; they block calcineurin phosphatase & prevent dephosphorylation of activated T cells, causing inhibition of these activated cells & production of proinflammatory cytokines—TNF-α, IFN-γ and IL-2 [keyncytokines in a ramped up Tcell response]
Steroid sparing agents; usedm in flexural and facial
psoriasis
Systemic Therapies for Psoriasis
If unresponsive to topicals
or BSA >5%
- Apremilast [Otezla]
- Phosphodiesterase 4 inhibitor - Methotrexate
- With Folic acid 1-5 mg/d - Cyclosporine
- TNF Alpha Blockers
- Adalimumab [Humira]
- Etanercept [Enbrel]
- Infliximab [Remicade] - Interleukin IL-12 & IL 23
Blocker
- Ustekinumab [Stelara] - Interleukin IL-17A Blocker
- Secukinumab [Cosentyx] - Phototherapy
- Can be uses with topicals
- PUVA [Psoralen with UVA light]
- Narrow band UVB therapy
