ENT + Skin Flashcards
Allergic Rhinitis:
-S/Sx
-Cold vs. Allergic Rhinitis
-Common Allergens
S/Sx: congestion, rhinorrhea (runny nose), sinus pressure, sneezing, itchy eyes
-Intermittent or chronic symptoms
Cold: from virus; symptoms of sneezing, runny nose, thick/dark mucus, sore throat, body aches; symptoms take about three days to appear and usually last for a week
Allergic Rhinitis: from allergen; symptoms can last days or months after contact w/ allergen; thin, clear mucus; can have postnasal drip
Common allergies: pollen, dust mite, animal dander, mold
Allergic Rhinitis:
-Non-pharmacological therapy
-Pharmacological TX
Non-pharmacological therapy:
-Avoidance of allergen exposure (IgE-mediated skin prick test can help identify allergens)
-Vacuuming
-Dust mites: removal of carpet and upholstered furniture, encasing pillows, mattresses, and box springs; washing bedding and soft toys in hot water weekly
-Viewing the air quality index (AQI) or pollen counts
-Wetting agents (ex. Ocean Little Remedies, Simply Saline): contain saline, propylene, or polyethylene glycol to provide moisture and reduce irritation to nasal passageways
-Nasal Irrigation (ex. NeilMed Sinus Rinse): isotonic or hypertonic saline solution to rinse out allergies and mucus, improve ciliar function, and reduce swelling –> mixtures can be premixed or need to be mixed w/ distilled water or previously boiled and cooled water (do NOT use tap: can cause infections)
Pharmacological TX:
-Chronic, moderate/severe symptoms: intranasal steroids (takes time to work)
-Milder, intermittent symptoms: oral antihsitamines (2nd gen preferred due to less sedation)
-Congestion present: decongestants
Intranasal Steroids:
-Drugs/Brands
-Which ones are OTC?
-TX
-Administration considerations
-AVEs
-Warnings
-Monitoring
Drugs: budesonide (Rhinocort Allergy), fluticasone (Flonase Allergy Relief, Flonase Semimist, Children’s Flonase, Xhance), fluticasone/azelastine (Dymista), triamcinolone (Nasocort Allergy 24HR, Nasocort Allergy 24HR Children), beclomethasone (Beconase AQ, Qnasl, Qnasl Children’s), cicleosnoide (Omnaris, Zetonna), flunisolide, mometasone (Nasonex 24HR Allergy), mometasone/olopatadine (Ryaltris)
OTC: budesonide, fluticasone, triamcinolone, mometasone
TX: first-line in moderate/severe chronic allergic rhinitis
-Budesonide, beclomethasone: preferred in pregnancy
Administration:
-Can take up to a full week for full relief
-Shake bottle well before each use
-Discard device after total number of labeled doses, even if the bottle does NOT feel completely empty
AVEs: epistaxis (nose bleeds), HA, dry nose, unpleasant taste, localized infection
Warnings:
-Avoid use if recent nasal septal ulcers, nasal surgery, or recent nasal trauma due to delayed wound healing
-High doses for prolonged periods can cause: adrenal suppression, decreased growth velocity in pediatrics, immunosuppression
-Caution in pts w/ cataracts and/or glaucoma: increased IOP, open-angle glaucoma, and cataracts have occurred with prolonged use
Monitoring: growth (pediatrics), vision changes, eye exams in long-term use, s/sx of oral thrush, and/or adrenal suppresion
-If using regularly for several months, recommend periodic nasal exams to evaluate for septal perforation or ulcers
First Generation Antihistamines in Allergic Rhinitis:
-Drugs/Brands
-Which ones are OTC?
-What at the effects in allergic rhinitis?
-Dosing for Benadryl
-Administration considerations
-AVEs
-Warnings
-CIs
Drugs: diphenhydramine (Benadryl), chlorpheniramine (Aller-Chlor), doxylamine (Unisom SleepTabs), clemastine, carbinoxamine
OTC: diphenhydramine, chlorpheniramine, doxylamine
Effects in allergic rhinitis: reduce symptoms of itching, sneezing, rhinorrhea –> LITTLE effects on congestion
Benadryl dosing
-Adults: 25mg PO Q4-6H or 50mg PO Q6-8H
-Age <6yo: do NOT use OTC unless directed by healthcare provider
Administration:
-Should D/C >/=72 hours prior to allergy skin testing
-Can cause photosensitivty: use sunscreen and wear protective clothing while taking
AVEs: somnolence, cognitive impairment, strong anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation) and seizures/arrhythmias at higher doses, paradoxysal reaction in children (hyped up, not sedated)
Warnings:
-Avoid in elderly due to strong anticholinergic effects (Beers criteria) and children <2yo
-CNS depression and sedation
-Caution in CV disease, prostate enlargement, glaucoma, asthma, pyloroduodenal obstruction, and thyroid disease
-do NOT use w/ MAOIs (especially clemastine or carbinoxamine)
-Age restriction for OTC use: Benadryl in <6yo and doxylamine <12 yo)
CI: neonates or premature infants, breastfeeding (2nd gen preferred)
Second generation Oral Antihistamines in Allergic Rhinitis
-Drugs/Brands
-Brands when combined with pseudophedrine
-Which ones are OTC?
-Administration considerations
-AVEs
-Warnings
-CIs
Drugs: cetirizine (Zyrtec Allergy, Zyrtec Childrens Allergy), levocetirizine (Xyzal Allergy 24HR, Xyzal Allergy 24HR Childrens), fexofenadine (Allegra Allergy, Allegra Allergy Childrens), loratadine (Claritin, Claritin Childrens, Alavert), desloratadine (Clarinex)
Brand w/ Pseudophedrine: add -D (ex. Zyrtec-D, Allegra-D, Claritin-D)
OTC: cetrizine, levoceterizine, fexofenadine, loratadine
Administration:
-D/C >/=72 hours prior to allergy skin test
-Fexofenadine: take with water (NOT fruit juice due to decreased absorption), avoid w/ Al or Mg-containing products
-In pregnancy, loratadine and cetirizine preferred
-Cetirizine, levocetirizine: fast onset and may work best for some pts
AVEs: HA, somnolence can still be seen (more w/ ceterizine and levocetrizine; least sedating: fexofenadine and loratadine)
Warnings: can cause CNS depression/sedation especially w/ other sedating drugs, caution in elderly or renal/hepatic impairment
CIs (levocetirizine): end-stage renal disease (CrCl <10mL/min), hemodialysis, infants and children 6 months to 11 yo of age w/ renal impairment
Intranasal antihistamines that can be used w/ allergic rhinitis and role in therapy
-What age are these indicated in?
Azelastine (Astepro Allergy) and olopatadine (Patanase) - helps with congestion, can be combined w/ intranasal steroid
Age: 5 yo and older
Decongestants: Phenylephrine and Pseudophedrine
-Brands
-MOA
-Comparison in efficacy in allergic rhinitis
-Under federal law, Pseudophedrine is kept behind pharmacy counter because __________. The maximum amount allowed for purchase is ____ grams per day and ____ grams in a 30-day period.
-AVEs
-Warnings
-CIs
Brand:Sudafed PE (phenlephrine), Sudafed Nexafed or Zephrex-D (pseudophedrine)
MOA: alpha-adrenergic agonists (sympathomimetics) causing vasoconstriction to decrease sinus vessel engorgement and mucosal edema to treat sinus and nasal congestion
Efficacy: pseudophedrine is effective decongestant; phenylephrine has poor oral absorption and comes as nasal spray, but lasts for shorter time w/ more AVEs that oxymetazoline
-Onset about 15-60 minutes
Federal law: pseudophedrine stored behind counter due to being precursor to methamphetamine; max: 3.6g/day, 9g/30 days
AVEs: CV stimulation (tachycardia, palpitations, increased BP), CNS stimulation (anxiety, tremors, insomnia, nervousness, restlessness, fear, hallucinations), decreased appetite, dizziness, HA
Warnings:
-Avoid in children <2 yo (FDA) and <4 yo (packaging)
-Avoid in first trimester of pregnancy
-Caution in CV disease and uncontrolled HTN, hyperthyroidism (can worsen), DM (can increase BG), bowel obstruction, glaucoma (can increase IOP), BPH (can cause urinary retention), renal impairment, seizure disorder, and elderly
CI: use within 14 days of MAOIs
Intranasal Oxymetazoline and Phenylephrine for Allergic Rhinitis
-Brand for oxymetazoline
-MOA
-Onset of action
-AVEs
-Warnings
-CIs
Brand: Afrin (Oxymetazoline)
MOA: alpha-adrenergic agonists (sympathomimetics) causing vasoconstriction to decrease sinus vessel engorgement and mucosal edema to treat sinus and nasal congestion
Onset of action: 5-10 minutes
AVEs: rhinitis medicamentoas (rebound congestion if used longer than 3 days); nasal stinging, burning, and dryness; sneezing; trauma from tip of device
Warnings:
-do NOT use with MAOIs
-Caution in CV disease, uncontrolled HTN, thyroid disease, DM, and BPH
CI (oxymetazoline): do NOT use more than 3 days
Discuss additional medications used for Allergic Rhinitis:
-Intranasal Cromolyn
-Montelukast
-Intranasal Ipratropium
-Immunotherapy
Cromolyn (NasalCrom): OTC mast cell stabilizer for TX and prophylaxis – takes about 3-7 days to start improving and up 2-4 weeks for full effect (do NOT use PRN), safe in children >/=2 yo and pregnancy
Montelukast (Singulair): oral leukotriene receptor antagonist for asthma and allergic rhiniitis, commonly used in children, for allergic rhinitis reserve more as last line
Intranasal ipratropium (Atrovent nasal spray): effective for decreasing rhinorrhea by causing nasal dryness, but NOT for other symptoms
Immunotherapy: preventative for allergies by slowly increasing exposure to allergen and densensitizing immune system (recommended to treat for minimum of three years)
-Can be SC or SL
-First dose given in medical office to be monitor fpr at least 30 minutes (BBW: allergic rxn)
-If tolerated, take at home and all pts should have epinephrine auto-injector while on SL TX
-Oralair: 5 different grass pollen extracts, Grastek: Timothy grass pollen extract, Ragwitek: ragwed pollen extract, and Odactra: house dust mite allergen extract
Cold: TX and Natural Products
Natural Products:
-Zinc: possibly effective when used correctly by using at first sign of symptoms within 48 hours (do NOT use more than 5-7 days - long term can cause copper deficiency), nasal swabs or sprays can cause loss of smell
-Vitamin C (ascorbic acid): little to no efficacy for cold prevention, some data to show decrease in duration of cold (possibly effective per NatMed)
-Echinacea: rated possibly effective
-Check correct dose for products as many have variety of ingredients (ex. Airborne, Emergen-C)
Treatment: based on symptoms
-Productive cough: expectorants to thin mucus and move secretions up and out of respiratory tract –> questionable benefit
-Dry, nonproductive cough: cough suppressants
-Congestion, rhinorrhea: decongestants (systemic or nasal)
-Sore throat, body malaise, fever: analgesics/antipyretics (ex. APAP, ibuprofen - caution to NOT exceed maximum daily if multiple medications used)
Guafiensin:
-Brands
-MOA
-Administration considerations
-AVEs
Brands: Mucinex, Robitussin Mucus + Chest Congestion, Robafen)
-With dextromethorphan (Robafen DM, Robitussin DM)
MOA: thin mucus (for productive coughs)
Administration:
-Some formulations contain phenylephrine (avoid w/ PKU)
-OTC: do NOT use ER tablets in children <12 yo
AVEs: N/V (dose-related), dizziness, HA, rash, diarrhea, stomach pain
Dextromethorphan:
-Brands
-MOA
-Administration considerations
-AVEs
-Warnings
-CIs
Brands: Delsym, Robafen Cough, Robitussin Cough
-With guaifenesin: Robafen DM, Robitussin DM
MOA: cough suppressant for dry, nonproductive coughs –> high affinity along with opioids fo several regions of brain, including medullary cough center, suppressing cough reflex
-Other targets: acts as an SSRI, high doses: NMDA receptor inhibition (euphoria and hallucinations)
Administration:
-If product name has DM at end of it, contains dextromethorphan
-OTC: do NOT use in children <4yo
AVEs: N/V, drowsiness, CNS depression (especially w/ other sedating drugs)
Warnings: serotonin syndrome (if co-administered w/ other serotonergic drugs), use w/ caution in poor metabolizers of CYP2D6 or with CYP2D6 inhibitors, debillitated (sedated, confined to supine position)
CIs: do NOT use within 14 days of MAOIs
Codeine in Colds and Coughs:
-Control schedule
-MOA
-Administration considerations
-CIs
-BBWs
Control schedule:
-CII if single entity for pain
-CV if combination production for cough and cold
MOA: high affinity to several areas of brain, including medullary cough center to decrease cough reflex (cough suppressant for dry, nonproductive coughs)
Administration: FDA recommends avoiding codeine-containing cough and cold products for pts <18 yo
CIs: use in children <12 yo (any indication) or children <18 yo after tonsillectomy and/or adenoidectomy
BBW: respiratory depression and death in children following tonsillectomy or adenoidectomy and had evidence of ultra-rapid metabolizers for CYP2D6; deaths have occurred in nursing infants with ultra-rapid metabolizing mothers
Benzonatate:
-Brand
-MOA
-AVEs
-Warnings
Brand: Tessalon Pearls
MOA: cough suppressant -suppresses topical action on respiratory stretch receptors
AVEs: somnolence, confusion, hallucinations
Warnings: use in children <10 yo; accidental ingestion and fatal overdose has been reported
What are Benadryl’s various uses?
- Acute allergic rxns
- Prevention of allergic rxns
- Allergic rhinitis
- Cough - antitussive (cough suppressant) properties for dry, nonproductive cough
- Sleep
- Dystonic reactions - anticholinergic properties
- Motion sickness
Cough and Cold Combinations:
1. If the name contains D, PE, DM, and AC, what does this indicate?
- Brand for brompheniramine/pseudophedrine/dextromethorphan
- Brand for chlorpheniramine/hydrocodone
1.
-D: contains decongestant (ex. pehnylephrine, pseudophedrine –> Mucinex D = guaifenesin + pseudophedrine)
-PE: contains pehnylephrine (ex. Sudafed PE)
-DM: contains dextromethorphan (ex. Robafen DM)
-AC: contains codeine (ex. G Tussin AC = guaifenesin + codeine)
- Bromfed DM
- TussiCaps
Cough and Colds in Children:
-What to avoid in children and at what age
-General considerations
-Dosing in APAP and ibuprofen
Avoid:
-<2 yo: OTC cough and cold products (FDA), promethazine (FDA - fatal respiratory depression), topical menthol and camphor (package)
-<4 yo: OTC cough and cold products (package)
-<6 yo: OTC cough and cold products (AAP)
-<18 yo: codeine and hydrocodone-containing cough and cold products (FDA)
Considerations:
-Safe to recommend proper hydration, nasal bulbs for gentle suctioning, saline drops/sprays, vaporizers/humidifers, APAP, and ibuprofen
-Cough and cold products do NOT offer much symptom relief to young children w/ side effect risk (especially from multiple products)
-Topical products containing menthol (Vicks VapoRub) can be applied to chest and neck to open airway and suppress cough (never directly apply to nose)
APAP dose: 10-15mg/kg Q4-6H (do NOT exceed 5 doses in 24 hours)
-Infants drops/children’s liquid: 160mg/5mL
Ibuprofen dose: 5-10mg/kg Q6-8H (do NOT exceed 40mg/kg/day)
-Infant drops: 50mg/1.25mL
-Children’s liquid: 100mg/5m
General Ear and Eye Concepts:
1. What are the following sigs: AD, AS, AU, OD, OS, and OU?
- Can eye drops be used in the ear, and vice versa?
- In general, 1 drop = ______mL.
- How should ointments and gels be used for the eyes?
- D = right, S = left, A = ear, O = eye
- Eye drops can be placed in ear, BUT ear drops cannot be used in eye (needs sterile formulation)
- 0.05
- -Ointments: apply to conjunctival sac or over lid magins (for blepharitis) - can make vision blurry, do NOT use w/ contact lenses)
-Gels: with cap on, invert and shake once to get medication into tip before instilling into eye
Glaucoma:
-Open-angle versus closed-angle glaucoma
-TX goals
-TX
Open-angle glaucoma: most common, loss of visual field and damage to optic nerve w/o symptoms
Closed-angle glaucoma: sharp, sudden increase in IOP
TX goals: decrease IOP (normal range: 12-22mmHg)
TX:
-Increase aqueous humor outflow (move fluid out): prostaglandin analogs (most effective)
-Reduce aqueous humor production (make less fluid): beta-blockers (preferred if pt has one eye - since prostaglandins darken iris or thicken eyelash), carbonic anhydrous inhibitors
-Both: alpha-2 agonists
Drugs that can increase intraocular pressure (IOP)
-Anticholinergics (ex. antihistamines, oxybutynin, tolterodine, benztropine, scopolamine, trihexyphenidyl, TCAs)
-Decongestants (ex. pseudophedrine)
-Chronic steroids, especially eye drops (ex. prednisolone)
-Topiramate
Prostaglandin analogs in glaucoma
-Drugs/Brands
-MOA
-Dose frequency
-Adminstration considerations
-AVEs
-Warnings
Drugs: bimatoprost (Lumigan, Latisse), latanoprost (Xalatan, Xelpros), travoprost (Travatan Z), latanoprostene bound (Vyzulta), tafluprost (Zioptan), latanoprost/netarsudil (Rocklatan)
MOA: increase aqueous humor outflow
Dose: 1 drop QHS
Administration:
-Latisse: indicated only for eyelash growth
-Travatan Z, Xelpros: do NOT contain BAK (different preservative is used) and can be used in pts w/ previous rxn to BAK or dry eye
-Zioptan: comes as 10 single-use, preservative free-containers in foil pouch (discard after each use)
-Latanoprost, latanoprostene, and tafluprost: store in refrigerator before opening –> once opened, store at room temperature
AVEs: blurred vision, stinging, increased pigmentation of iris/eyelashes, eyelash growth/thickening, foreign body sensation
Warnings: darkening of iris, eyelid skin, and eyelashes; eyelash length and number can increase; contamination of multiple-dose solutions can cause bacterial keratitis
Beta-blockers in glaucoma
-Drugs/Brands
-MOA
-Dosing frequency
-Administration considerations
-AVEs
-CIs
Drugs: timolol 0.25% and 0.5% (Timoptic, Timoptic-XE, Istalol, Timolol GFS, Betimol, Timpotic Ocudose), betaxolol (Betoptic S), carteolol, levobunolol (Betagan)
MOA: reduce aqueous humor production
Dose:
-Tomolol: 1 drop QD or BID
-Timoptic-XE, Timolol GFS (Gels): QD
Administration:
-Gels: shake once before use and wait 10 minutes after administering other eye drops before inserting gel
-Cosopt PF: PF = Preservative Free –> packaged in single-use containers
-Some products contain sulfites which can cause allergic rxns
AVEs: burning, stinging, bradycardia, fatigue, bronchospasm (with non-selective: ALL except betaxolol), itching of eyes/eyelids, changes in vision, increased light sensitivity
CIs: sinus bradycardia;; heart block >1st degree (except in pacemaker); cardiogenic shock; uncompensated cardiac failure; bronchospastic disease
Cholinergics for glaucoma:
-Drugs/Brands
-MOA
-AVEs
-Warnings
Drugs: carbachol (Miostat), pilocarpine (Isopto Carpine)
MOA: increase aqueous humor outflow
AVEs: poor vision at night due to pupil constriction, corneal clouding, burning (transient), hypotension, bronchospasm, abdominal crmaps/GI distress
Warnings: caution in hx of retinal detachment or corneal abrasian
Carbonic Anhydrase Inhibitors for glaucoma:
-Drugs/Brands
-MOA
-TX
-AVEs
-Warnings
Drugs: dorlozamide (Trusopt), brinzolamide (Azopt), acetazolamide, methazolamide
MOA: reduce aqueous humor production
TX (acetazolamide): NOT often for glaucoma, but more for altitude sickness (PO)
AVEs:
-Eye drops: burning, blurred vision, blpeharitis, dry eye
-PO (acetazolamide): CNS effects (ataxia, confusion), photosensitivity, skin rash, anorexia, nausea, risk of hematological toxicities
Warnings: sulfonamide allergy (ends in -amide)
Adrenergic Alpha-2 Agonists for glaucoma:
-Drugs/Brands
-MOA
-AVEs
-Warnings
Drugs: bimonidine (Alphagan P, Lumify - OTC for ocular redness), apracolonidine (Iodipine)
MOA: increases aqueous humor outflow AND reduces aqueous humor production
AVEs: sedation, dry mouth, dry nose
Warnings: CNS depression (caution w/ heavy machinery or driving)
Netarsudil:
-Brand
-MOA
-ROA
-Administration considerations
-TX
-AVEs
Brand: Rhopressa
MOA: rho kinase inhibitor that increases aqueous humor outflow
ROA: eye drops
Administration: store in refrigerator before opening; once opened, store at room temperature for </=6 weeks
TX: open-angle glaucoma
AVEs: burning/eye pain, corneal disease, conjunctival hemorrhage, conjunectival hyperemia (excess blood vessels)
Glaucoma: Brand Name Combinations
1. Rocklatan = ________ + __________
- Cosopt, Cosopt = _______ + ___________
- Combigan = _________ + __________
- Simbrinza = _________ + ___________
- Latanoprost + Netarsudil
- Timolol + Dorzolamide
- Timolol + Brimonidine
- Binzolamide + Brimonidine
Conjunctivitis:
-Define
-Non-pharmacological TX
-Types
-TX based on types
Conjunctivitis: “pink eye” - swelling, itching, burning, and redness of conjunctiva, the protective membrane of the eyelids and covers the white parts of the eye
-Highly contagious and mostly in children
Non-pharmacological: avoid touching eyes, hand hygiene, change towels and washcloths daily, discard eye cosmetics (especially mascara)
Types:
-Chemical: flush out eye, no specific TX
-Viral: adenovirus (most common), sometimes zoster or HIV (severe)
-Bacterial: S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis (most seveve: N. gonorrhea or Chlamyida)
-Allergic: common allergens (pollen, dust mites, animal dander, molds)
TX: NOT necessarily needed if non-severe and typically self-limiting
-Viral: no topical TX, self-limiting
-Bacterial: ABX eye drops or ointments (ex. moxifloxacin, neomycin/polymyxin B/dexamethasone, ofloxacin, trimethoprim/polymyxin B, azithromycin - store in fridge, stable for 14 days at room temp)
-Allergic: mast cell stabilizers (cromolyn, lodoxamide, nedocromil), antihistamines (azelastine, olopatadine, cetrizine, epinastine), antihistamine/mast cell stabilizer (ketotifen - OTC, alacftadine); severe: prednisolone/steroid eye drops (NOT long term due to increasing IOP)
Brand names for Conjunctivitis:
1. moxifloxacin
- neomycin/polymyxin B/dexamethasone
- ofloxacin
- Vigamax
- Maxitrol
- Ocuflox
Brand Names for Conjunctivitis:
1. trimethoprim/polymyxin B
- olopatadine
- ketotifen
- Polytrim
- Pataday
- Alaway, Zaditor
Various eye conditions: TX
-Bepharitis
-Inflammation
Blepharitis: eyelid inflammation - inflammation, irritation, and itchy
-Warm compress over eye then warm, moist washcloth to remove debris
-Some cases: artifical tears, steroid eye drops, or ABX ointments
Inflammation: cold compress, steroid eye drops (prednisolone - Pred Forte, Pred Mild; others: dexamethasone, fluromethalone, loteprednol), or NSAIDs (ketorolac - Acular; others: nepafenac, bromfenac, diclofenac, flurbiprofen)
-Steroid eye drops should be used short-term due to increased IOP risk
Various eye conditions: TX
-Dryness
-Chronic dry eye disease
-Redness
Dryness: Refresh (OTC), Systane (OTC), Liquifilm Tears (OTC), others –> referred to as “Artificial Tears”
-Administered multiple times PRN
-Common lubricants: mineral oil, glycerin, propylene glycol, dextran, hypromellose
Chronic Dry Eye: cyclosporine emulsion eye drops (Restasis), others: liftegrast, loteprednol, varnicline nasal spray
-Restasis: indicated for keratoconjunctivitis sicca
Redness: naphazoline (Clear Eyes Redness Relief: OTC), naphazoline/pheniramine (Naphacon A, Visine A: OTC), tetrahydrozoloine (Visine: OTC), brimonidine (Lumify: OTC)
-Can be used in allergic conjunctivitis
Opthalamic Issues:
1. Why do most eye drops burn?
- Contact lenses should be removed before using eye drops and waiting at least _____ minutes after administration. Why?
- Wait ___ minutes in between drops of same medication. Wait ____ minutes in between drops of two different medications.
- Preservatives are toxic to bacteria and irritating to sensitive tissues in eyes, some drugs as well burn
- 15 minutes; preservatives can get trapped in lenses and damage eyes
- 5 minutes; 5-10 minutes
Drugs that cause retinal changes/retinopathy, optic neuropathy, introperative floppy iris syndrome (IFIS), color discrimination, and vision loss/abnormal vision
Retinal changes/retinopathy: chloroquine, hydroxychloroquine
-Optic neuropathy: amiodarone (plus corneal deposits), ethambutol, linezolid
-IFIS: alpha-blockers (ex. tamsulosin)
-Color discoloration: digoxin (w/ toxicity - yellow/green vision), PDE5is (sildenafil - greenish tinge around objects), voriconazole (color vision changes)
-Vision loss/abnormal vision: digoxin (w/ toxicity - blurriness, halos), PDE5is (vision loss, can be permanent, one or both eyes), isotretinoin (decrease night vision which can be permanent, dyness, irritation), topiramate (visual field defects), vigabatrin (permanent vision loss - high risk), voriconazole (abnormal vision, photophobia)
Common Ear Issues: TX for tinnitus, cerumen (ear wax), and optic externa
Tinnitus: NO drug TX (caused by drug toxicities such as salicylates, noise exposure, or idiopathic)
Cerumen: removal in medical office or cerumenolytics to soften ear wax (ex. water, saline solution, mineral oil, hydrogen peroxide, carbamide peroxide - Debrox) –> limit to 3-5 days with follow-up
Optic externa: “swimmer’s ear”
-Mild cases: acetic acid and a glucocorticoid (VoSol HC)
-Moderate/severe: toptical otic ABXs (ciprofloxacin and dexamethasone - Ciprodex, ciprofloxacin and hydrocortisone (Cipro HC), neomycin/colistin/hydrocortisone/thonzonium - Cortisporin TC)
-Pain treatment: oral APAP, ibuprofen
Drugs that can discolor skin and body secretions:
-Brown
-Brown/yellow
-Black/green
-Orange/yellow
-Yellow/green
Brown: entacapone, levodopa, methyldopa
Brown/yellow: nitrofurantoin (urine)
Black/green: iron (black stool)
Orange/yellow: sulfasalazine
Yellow/green: propofol
Drugs that can discolor skin and body secretions:
-Red/orange
-Red
-Blue
-Blue/gray
Red/orange: phenazopyridine, rifampin
Red: anthracyclines
Blue: methylene blue, mitoxantrone
Blue/gray: amiodarone
Natural Products used in skin
- Aloe - sunburn, psoriasis –> soothing effect
- Tree oil - acne, onchomycosis (potentially, but will NOT eradicate infection)
- PO or topical lysine - cold sores prevention and TX
- Biotin - hair loss, brittle nails
- Topical vitamin D - diaper rash, psoriasis
Acne Vulgaris
-Causes
-Different classifications
-TX based on severity
Causes: androgen activity (primary determinant), prescene of bacteria (Cutibacterium acnes), sebum in oil
Classifications: whiteheads (closed comedones), blackheads (open comedones), papules, pustules, nodules (“cysts”)
TX:
-Weaker efficacy: salicycllic acid
-Mild (few occasional pimples): benzoyl perioxide (BPO) or retinoid or topical combination (first-line); alternatives: add topical retinoid or BPO, switch to another retinoid, or topical dapsone
-Moderate (inflammatory papules): topical combinaion or PO ABX + BPO + topical retinoid (+/- topical ABX); alternatives: other combinatoin, switch PO ABX, add oral contraceptive pill (OCP) or spirinolactone (females) or PO isotretinoin
-Severe (nodules): topical combination + PO ABX or PO isotretinoinl; alternatives: switch PO ABX, add OCP or spirinolactone (females), or PO isotretinoin if NOT previously tried
Topical Retinoids
-Drugs/Brands
-Which ones are OTC?
-MOA
-Warnings/CIs
-Which formulations have less or more irritation?
Drugs: tretinoin (Atralin, Renova, Retin-A, Retin-A Micro, Altreno, Avita), adapalene (Differin), tazarotene (Tazorac, Fabior, Tazora, Arazlo), trifarotene (Aklief)
OTC: Differin gel
MOA: vitamin A derivatives that reduce coheisoin of follicular epithelial cells, increasing cell turnover and unblocking pores
Warnings: topical retinoids should be avoided in pregnancy
-CI in pregnancy: tazarotene
Irritation:
-Less: Altreno (lotion form of tretinoin), Retin-A Micro (microsphere gel) and Avita (polymerized cream or gel) which have slower release
-More: Fabior (tazarotene foam)
Topical Retinoids: Counseling
-Apply daily usually at bedtime about 20 minutes after washing face (wash only w/ mild soap BID)
-If irritation occurs, use lower strength or decrease frequency to every other night –> may need to reduce contact initially (wash off if skin irritated)
-A pea-sized amount is sufficient for facial application –> smooth over enter surface NOT just on acne
-Avoid salicyclic acid scrubs or astringents –> worsen irritation
-Takes 4-12 weeks to see response –> may worsen acne initially
-Limit sun exposure
Benzoyl peroxide (BPO):
-Brand
-Is it OTC?
-Administration considerations/counseling
Brand: Benzac, Clearasil, PanOxyl
Yes, OTC
Administratoin:
-Start w/ 2.5-5%, generally adequate and less irritating
-Can bleach clothing and hair
-Limit sun exposure
Topical ABX and Combinations for Acne Vulgaris:
1. Counseling in clindamycin topicals
- Which gel should be avoided in G6PD deficiency?
- Which drug can cause HPA axis suppression and its MOA?
- Minocycline: Brands, age approved in, AVEs
- -Clean face, shake if lotion, and apply thin layer QD or BID
-Avoid contact w/ eyes –> if occurs, rinse with cold water
-Takes 2-6 weeks for effect and up to 12 weeks for full benefit - Dapsone gel
- Clascoterone - topical androgen receptor inhibitor indicated in those 12 yo and older
4.
-Brands: Minocin, Solodyn
-Approved in those 12 yo and older
-AVEs: photosensitivity, rash, dizziness, diarrhea, somnolence, fetal harm, discoloration in teeth
Isotretinoin:
-Brand
-MOA
-ROA
-TX
-REMS conditions/counseling
-Warnings
-BBW
Brand: Absorica, Amnesteem, Claravis, Myorisan, Zenatane
MOA: vitamin A derivatives that reduce coheisoin of follicular epithelial cells, increasing cell turnover and unblocking pores
ROA: PO (capsules)
TX: only FDA approved for severe, refractory nodular acne
REMS program:
-Pts who can get pregnant must sign patient informatin/informed consent form about birth defects
-Must have 2 negative pregnancy test prior to starting TX
-Do NOT get pregnant for 1 month before, during, and for 1 month after D/C (use two forms of birth control and pregnancy testing on monthly basis)
-Do NOT breastfeed or donate blood until at least 1 month after D/C
-do NOT use vitamin A supplements, tetracyclines, progestin-only contraceptives, St. John’s Wort, or steroids
-Must swallow capsules whole or puncture and sprinkle on applesauce or ice cream (this may irritate esophagus)
Warnings: dry skin, chapped lips, dry eyes/eye irritation (may cause difficulty wearing contact lenses), decrease night vision (may be permanent), arthralgas, skeletal hyperostosis (calcificatin of ligaments that attach to spine), osteoporosis, psychiatric issues (depression, psychosis, risk of suicide), increased cholesterol (TGs) and BG
BBW: birth defects (only dispense through REMS iPLEDGE - RX only 1 month at a time, fill within 7 days wtih yellow sticker attached)
Cold Sores: topicals and their counseling points
Topicals: docosanol (Abreva) - OTC, acyclovir (Zovirax), penciclovir cream (Denavir)
-Oral antivirals more effective
-Natural product: lysine for prevention and TX
Counseling:
-Start treatment during prodromal period
-Abreva: apply 5x daily at first sign of outbreak, continue until healed
-Zovirax: apply 5x daily for 4 days (can be used on genital sores)
-Denavir: apply Q2H during hours for 4 days
Dandruff in Scalp: TX and counseling
TX:
-OTC:* ketoconazole 1% shampoo (Nizoral A-D), selenium sulfide (Selsun*, Dandrex), pyrithione zinc (Head & Shoulders), coal tar shampoo (T/Gel, Suave, or store brand “dandruff” shampoos)
-Rx: ketoconazole 2% shampoo (Nizoral)
Counseling:
-Rub shampoo in well, leave in for 5 minutes then rinse out
-Shampoo daily. If shampoo stops working, switch products
-Nizoral A-D: apply twice weekly for up to 8 weeks, do NOT use on open sores, can cause skin irritation
Alopecia:
-Causes
-TX
-Considerations
Causes: hereditary male-pattern baldness (most common), hormonal changes in women (childbirth, pregnancy, or menopause), hypothyroidism, scalp infections, some autoimmune conditions (ex. lupus, alopecia, areata), chemotherapy, other drugs (valpraote, lamotrigine, tacrolimus, heparin, interferons, some OCs), vitamin/mineral deficiencies (biotin, zinc, selenium, vitamin D)
TX: medications work modestly for hair loss
-Finaseteride (Propecia): 1mg tablet PO QD, can take >/=3 months to see effects (do NOT use Proscar for BPH); Warning: hazardous for females of childbearing potential; CI: pregnancy
-Barictinib (Olumiant): janus kinase inhibitor for severe alopecia areata; BBW: serious infections, malignancy, thrombosis
-Minoxidil (Rogaine): 5% strength more effect and must be used indefinitely or condition reoccurs; flammable: do NOT use near heat source
-Bimatoprost (Latisse): for thinning eyelashes (hypotrichosis); do NOT use w/ prostaglandin analog for glaucoma; apply QHS with applicator brush to the skin at the base of the upper eyebrows only (do NOT apply to lower lid), blot any excess and repeat on other eye; AVEs: itchy eyes, eye redness, eyelid skin darkening, hair growth in other areas that solution touches
Eczema (Atopic Dermatitis):
-Non-pharmacological TX
-TX options and considerations
Non-pharmacological TX:
-Avoidance of triggers (ex. environmental, allergens, stress, weather changes)
-Hydration and moisturizers (ex. Aquaphor, Eucerin, Keri - contain petrolatum, lanolin)
TX:
-Oral antihistamines for itching
-Standard options: topical steroids (occassional PO courses), topical calcineurin inhibitors (tacrolimus, peimcrolimus)
-Mild/moderate: topical PDE4is (crisaborole - Eucrisa), topical Janus kinase inhibitors (ruxolitinib - Opzelura)
-Severe, refractory: SC interluekin receptor antagonists (dupilumab - Dupixent, tralokinumab - Adbry), oral Janus kinase inhibitors (abrocitinib - Cibinqo, upadacitnib - Rinvoq), other oral immunosuppressants may be used off-label
Considerations:
-ALL topical products: wash hands after application, apply thin layer to affected skin BID, use smallest amount needed to control symptoms
-Topical calcineurin inhibitors: do NOT use in <2 yo, associated w/ lymphoma and skin cancer (avoid exposure to natural or artifical sunlight, AVEs: HA, skin burning, itching, cough, flu-like symptoms)
-MABs: avoid live vaccines, injection site rxns and URTIs
-Janus kinase inhibitors: BBW for serious infections (ex. herpes zoster) and higher rates of malignancy, thrombosis, major CV events and mortality
Hyperhidrosis:
-Define
-TX and counseling
Hyperhidrosis: excessive sweating
TX: glycopyrronium topical (Qbrexza - RX), antiperspirants (Secret Clinical Strength, Certain Dri, others - OTC)
Counseling (glycopyyronium): topical anticholinergic
-do NOT use in medical conditions exacerbated by anticholinergics (ex. glaucoma, ulcerative colitis, masthenia gravis)
-Use on clean, dry skin
-Use one premoistened pad for both underarms
-Wash hands with soap and water afterwards
Types of Fungal Infections on the Skin:
-Tinea pedis
-Tinea cruris
-Tinea corporis
-Tinea capitis
-Candidia cutaneous infections
What are TX options and general counseling points?
Tinea pedis: “Athlete’s Foot” - itching, peeling, redness, mild burning, and sometime sores on foot
Tinea cruris: “Jock Itch” - red, itchy rash that can be ring-shaped on gentials, inner thighs, or buttocks
Tinea corporis: “Ringworm” - circular,red, flat sore where middle is normal, but outer part is raised (occassionally rash does NOT present and skin is just red and itchy)
Tinea capitis - ringworm on scalp
Cutaneous Candidia infections - red, itchy rashes commonly in groins, armpits, or anywhere with skin folds
TX options:
-OTC: terbinafine (Lamisil AT), butenafine (Lotrimin AF, Pro-Ex Antifungal, Shopko Athletes Foot), miconazole (Lotrimin AF, Cruex, Desenex, Jock Itch), miconazole/petrolatum (Baza), tolnaftate (Tinactin), undecylenic acid (Toelieva)
-RX: betamethasone/clotrimazole (Lotrisone), ketoconazole (Extina), luliconazole (Luzu)
Counseling:
-If infection on foot, do NOT walk barefoot to avoid spreading
-Apply medication 1-2 inches beyond rash
-Use for 2-4 weeks even if appears healed
-Reduce moisture to infected area
-Creams typically work best (solutions can be easier to apply, powders typically do NOT work well but for prevention)
Onychomycosis:
-Define
-TX
-TX considerations
Onychomycosis: fungal infection of nail from tinea unquium
TX:
-Mild: topical antifungals (terbinafine - Lamisil AT, ciclopirox, tavaborale, efinaconazole)
-Itraconazole and terbinafine often used (off-label: fluconazole, posaconazole, rarely: griseofulvin)
-Pulse therapy (intermittent) to reduce costs, but possibly toxic and not as effective (20% potassium hydroxide - KOH smear for diagnosis)
-Takes long time for nail bed appearance to improve - sometimes up to a year
Considerations:
-Systemic antifungals are hepatotoxic, can cause QT prolongation, and are CYP3A4 substrates and inhibitors
-N/D common
-Itraconazole: BBW in heart failure; requires gastric acid for absorption (do NOT use with strong acid-suppressing drugs)
-Recurrence common - pratice proper foot care and keep nails dry, keep BG controlled, do NOT smoke
Vaginal Fungal Infections:
-Who is it more common in?
-S/Sx
-Diagnosis
-Nonpharmacological TX
More common in: pregnancy
-Also elevated risk: high-dose estrogen, hormone replacement therapy, steroids, immunosuppressants, ABXs, use of lubricants, vaingal douching
S/Sx: itching, soreness, pain, cotage-cheese like discharge (white, thick, clumpy)
Diagnosis: vaginal culture
-pH >4.5 consistent in bacterial vaginosis or trichomoniasis
-Testing NOT necessary if women has already been seen for initial infection (if infection occurs more than 4/year or symptoms recur within 2 months —> refer to physician)
Nonpharmacological:
-Lactobacillus or yogurt w/ cultures (rated possibly ineffective per NatMed)
-Keep vaginal area clean
-Wipe front to back after using restroom
-Change pads/tampons often
-Use cotton underweat, avoid tight-fitting clothing
-Remove wet swimsuits or clothing promptly
-Avoid using vaginal douches, sprays, or other products that alter vaginal pH
Vaginal Fungal Infections:
-TX
-Counseling on OTC antifungals
TX:
-Mild/moderate, infrequent: 1, 3, or 7 day TX with vaginal cream, ointment, or vaginal suppository/tab –> if fails, fluconazole 150mg PO x1
-Complicated infections, preganancy: 7-10 day treatment or refer to healthcare provider
Counseling for OTC antifungals:
-Prior to using, wash the external genital area with mild soap and water and pat dry w/ towel
-Insert applicator/suppository/vaginal tab at night before bed lying down immediately after helps reatin medicine, protective pad can be used
-Creams and suppositories: oil-based that can weaken latex condoms and diaphgrams –> avoid sexual intercourse
-Complete entire course, continue even if menstrual cycle occurs (do NOT use tampons)
-Medical care warranted if symptoms persist/return within 2 months or if >4/year
Diaper Rash:
-Prevention
-TX
Prevention:
-Change diapers often, do NOT cover diapers w/ plastic
-Clean area well w/ unscented wipes or plain water
-Leave diaper off when possible to let skin air-dry
-Skin protectants: petrolatum ointment (Vitamin A&D Ointment), petrolatum w/ zinc oxide (Desitin - dessicant to dry out skin)
TX:
-Clotrimazole, miconazole, nystatin for stubborn rashses if yeast involved
-Hydrocortisone 0.5-1% cream applied BID, but NOT for more than several days at a time
-Infants should be referred to physician especially in under 6 months, refer toddlers if condition worsens
-Rash can have more than one contributing organism (topical ABXs can be used if needed)
Hemorrhoids:
-Define
-TX
-TX counseling
Hemorrhoids: swollen blood vessels in lower rectum often from constipation and straining - can cause bright red blood, itching, burning
TX:
-Increase fiber intake to reduce straining (ex. psyllium)
-Barrier skin protectants: reduce irritation from stool/urine
-Combo products: mineral oil (skin protectant), zinc oxide (desiccant), or pramoxine (anesthetic)
-Phenylephrine (Preparation H): vasoconstrictor to shrink hemorrhoid and reduce burning/itching – for external symptoms
-Hydrocortisone (Anusol-H, Preparation H): reduce itching and inflammation
-Witch hazel (Tucks Medicated Cooling Pads): mild astringent that relives mild itching
Phenylephrine Counseling:
-Clean skin first with mild soap and warm water. Pat dry. Apply ointment externally up to five times/day.
-For suppostiroy: hold wrapped suppository container w/ rounded end up, seperate the foil tabs and slowly peel apart, remove from the wrapper, insert into the rectum up to QID, especially at night and after bowel movements
Pinworm (Vermicularis):
-How to identify
-TX
-Counseling
How to identify: often in children as anal itching; use tape test: stick a piece of tape around the anus in the morning prior to voiding defecating then bring to healthcare provider to look under microscope (can take up to three tests to identify)
TX: anthelminitics - mebendazole (Emverm), pyrantel pamoate (Reese’s Pinworm Medicine - OTC), albendazole
-Often resistant to TX
-Wash hands frequently and treat entire household
-TX for systemic worm infections are toxic - in some cases, steroids and antiseizure medications willl be used for CNS infections
Counseling:
-Pyrantel: HAs, dizziness - given as single dose and repeated in 2 weeks
-Mebendazole, albendazole: HA, nausea, hepatotoxic
-Albendazole: give w/ high-fat meal to increase absorption
Lice and Scabies:
-Who does lice mostly effect
-Lice versus scabies
-Procedure of removing nits from hair, bedding, etc.
Lice (Pediculus humanus capitis): mostly effects elementary school-age children
Lice: attach to hair shaft, insects
Scabies: primarily adults, burrow under skin, mites
Removal of nits:
-Wash clothes and bedding in hot water followed by hot dryer –> if cannot be washed, seal in air-proof bag for 2 weeks or dry clean
-Vaccum carpet, soak combs and brushes in hot water for 10 minutes
-After TX, nit comb to remove nits and lice Q2-3 days and continue to check for 2-3 weeks to make sure all gone
Lice and Scabies:
-TX
-TX counseling
TX options for lice:
-First line (lice): typically topical OTC (ex. permethrin 1% lotion - Nix, pyrethrin/piperonyl butoxide - RID, LiceMD, ivermectin lotion -Sklice) –> avoid products w/ chrysanthemum or ragweed allergy
-Malathion lotion (Ovide): RX; organophosphate only for those 6 yo and older - causes skin irritation and is flammable
-Spinosad (Natroba): RX; works well, but expensive
-Lindane shampoo - no longer available (neurotoxicity)
Scabies: RX permethrin cream (Elimite), PO ivermectin
Counseling:
-Permethrin: for 2 months and older, pyrethrin/piperonyl butoxide: for 2 yo and older
-do NOT use conditioner before using lice medicine –> do NOT re-wash hair in 1-2 days after TX
-Many products (except Sklice) require re-treatment (OTC topicals - repeat on day 9)
-Most products must be left on hair for 10 minutes before rinsing (malathion: left on for 8-12 hours)
-Nits are “cemented” to hair shaft and do NOT fall after TX –> need nit removal
Define and discuss general TX for:
-Bites
-Burns
Bites:
-Animal and human bites: high risk of infection –> seek medical evaluation
-Spider bites: spiders tend to stay hidden and are NOT aggressive –> avoid bites with inspection of clothing or equipment, wearing protective clothing; if bitten: wash w/ soap and water, apply cold compress w/ ice, evaluate extremity, and seek medical evaluation
-Minor, harmless insect bites: topical steroid or oral antihistamine
Burns:
-Characterized as first degree (red/painful, minor swelling), second degree (thicker, produces blisters, very painful), or third degree (damage to all layers of skin - appears white or charred)
-Burns from chemical exposure or in immunosuppressed pts: seek emergency medical care
-First or second degree: OTC if area less than two inches in diameter and NOT located on face, over major joint, or on feet or genitals (DM: mild foot burn could lead to amputation)
-Minor burns: run under cool water for 5-20 minutes (do NOT apply ice as this can damage skin), ointments (ex. Aquaphor) can protect skin/retain moisture/reduce scarring, and silver sulfadiazine (Silvadene; SSD) can reduce infection risk and promote healing –> do NOT apply if skin is broken
-Burned skin itches as it heals –> skin can be sensitive to sun for up to a year
Cut, Lacerations, and Abrasians:
-Define each term
-Basic TX
-TX Counseling
Cut: uniform and regular
Lacerations: irregular wounds w/ ragged edges w/ potential for deeper skin damage and bruising
Abrasians: minor injuries to top layer of skin
TX:
-Clean (if bleeding does NOT stop or wound extends far below surface layers of skin - seek medical attention)
-ABX ointment can be applied
-Bandage (Tissue adhesives ex. Band-Aid, Liquid Bandage - create polymer layer to bind to skin, Wound Seal - topical powder to quickly form scap over bleeding wound and reduce risk of infection)
-If wound is NOT in area that will get dirty or be rubbed by clothing, does NOT need to be covered and uncovering can help dry and heal
ABX ointments:
-OTC: polymyxin/bacitracin/neomycin (Neosporin Original) –> for neomycin allergy, use bacitracin/polmyxin (Polysporin), or bacitracin alone (either sufficient)
-RX: mupirocin (Bactroban) - good staph and strep coverage including MRSA; bacitracin/neomycin/polymyxin B/hydrocortisone (Cortisporin), collagenase (Santyl) - topical debriding drug for chronic wounds
-Application: apply small amount of medication (equal to surface ot tip of finger) to affected area 1-3 times/day, change dressings daily
Poison Ivy, Oak, and Sumac:
-Define
-TX
-TX Counseling
Allergic rxns that result from touching sap of plants, containing toxin urushiol - could be in ashes of burned plants, on animla, or other objects as well
-“Leaf of three, let it be”
OTC options
-aluminum acetate solution (Boro-Packs, Domeboro Soothing Soak): astringent (drying agent)
-colloidal oatmeal (Aveeno)
-colamine lotion/pramoxine (asnesthetic - Caladryl, IvaRest)
-Zanfel: binds to urushiol, but LOW evidence for efficacy
-Topical steroid to help rash
Counseling:
-Small amounts of urushiol can remain under fingernails for days unless removed w/ good cleaning
-Wash urushiol off w/ soap and water and make sure to clean clothing
-Cold compresses
-Severe rash: PO steroids
Steroids:
1. List the types of vehicles (ex. cream, lotion, ointment) in order of highest to lowest efficacy for steroids
- What type of vehicle should be used in: thick/dry skin and hairy skin?
- What steroid is OTC, and what are the two strengths?
- What areas of body can absorb steroids the most and only LOW POTENCY steroids should be used?
- Ointment > Cream > Lotion > Solutoin > Gel > Spray
- Thick or dry: ointments; hair skin: lotions, gels, or foams
- Hydrocortisone - 0.05% and 0.1%
- Thin skin - on face, eyelids, genitals, skin folds (armpts, groin, under breast)
Steroids:
1. What are long-term AVEs with topical steroids?
- What other agents along with steroids may be used for skin reactions (ex. hives, rash)?
- What is general application counseling? How often should high-potency vs. low-potency steroids be applied?
- Skin thinning, pigment changes (lighter or darker), telangiectasia (spider veins or small blood vessels seen through skin), rosacea, perioral dermatitis and acne, risk of skin infections, delayed wound healing, irritation/burning/peeling, contact dermatits possibly
2.
-Hives: second-gen antihistamines > first gen antihistamines
-Histamine-2 receptor antagonists (ex. famotidine) can help in urticaria/hives –> hydroxyzine often for general hives
-Camphor, menthol, local anesthetics to relieve itching
3.
-“Fingertip” unit: from fingertip to 1st joint is enough to cover one adult ahnd (about 1/2 gram)
-do NOT use more than directed
-do NOT apply longer than 2 weeks
-High potency steroids: once daily
-Low potency steroids: QD or BID
-Can be common to see high potency product followed by low potency to treat acute inflammation
Steroids: list steroids under their potency category
-Very high potency
-High potency
-High-medium potency
-Medium potency
-Lowest potency
Very high:
-Clobetasol propionate 0.05% lotion/shampoo/spray (Clovex), cream/ointment (Temovate), foam (Olux), gel
-Fluocinonide 0.1% cream (Vanos)
-Betamethasone dipropionate 0,05% ointment (Diprolene), gel/lotion
-Halobetasol propionate 0.05% lotion (Ultravate), cream/ointment
-Diflorasone diacetate 0.05% ointment
High:
-Betamethasone dipropionate 0.05% cream (Diprolene AF)
-Fluocinonide 0.05% ointment
-Mometasone furoate 0.1% ointment
-Desoximetasone 0.05% gel (Topicort), 0.25% cream (Topicort)
-Diflorasone diacetate 0.05% cream
-Halcinonide 0.1% cream (Halog)
High/medium:
-Fluocinonide 0.05% cream
-Betamethasone valerate 0.12% foam (Luxig)
-Desoximetasone 0.05% cream (Topicort)
-Fluticasone propionate 0.005% ointment
Medium:
-Mometasone furoate 0.1% lotion
-Triamcinolone acetonide 0.1% cream (Triderm), 0.147 mg/g spray (Kenalog)
-Fluocinolone acetonide 0.025% cream/ointment (Synalar)
-Flurandrenolide 0.05% ointment (Cordran)
Lowest: hydrocortisone cream 0.5%, 1% (Cortisone-10), 2.5% (MiCort-HC), lotion 1%/2%; ointment: 0.5%/1%/2.5%
Sun protection:
1. The sun is strongest during what time of the day?
- A broad-spectrum sunscreen provides protection against _________.
- SPF stands for _____________.
- Sunscreen recommendations
- True or False: sunscreens can be waterproof or sweatproof
- Discuss types of sunscreens: chemical vs. physical, oral
- Calculate TTB (Time to Burn)
- 10am - 4pm (UV light penetrates clouds even in overcast days)
-
UVA and UVB
-A for “aging” and B for “burning” - Sun protection factor - measure of how well sunscreen deflects UVB rays
4.
-AAP (pediatrics): minimum SPF 15; AAD (dermatology): minimum SPF 30
-Apply at least Q2 hours and reapplied after swiming or sweating
-AAP recommends babies less than 6 months old out of sun
- False - no longer permitted to be labeled as this; sunscreens can claim to be “water-resistant” but ONLY for about 40-80 minutes
6.
-Chemical: AAD recommends containing either oxybenzone (can be irritating), avobenzone, octisalate, octocrylene, homosalate, or octinoxate
-Physical: alternative to chemical (zinc oxide and titanium dioxide recommended by AAD)
-Oral: NOT effective and NOT recommended
- TTB (w/ sunscreen in minutes) = SPF x TTB (w/o sunscreen)
