Eyes, Ears, Nose & Skin Conditions Flashcards
Intranasal Steroids
-moderate - severe, chronic symptoms
–> ex: Flonase, budesonide, triamcinolone
SEs: headache, dry nose, pharyngitis, epistaxis, unpleasant taste, localized infection, nasal septal perforation
Antihistamines: 1st generation
-mild-moderate symptoms
–> oral: blocks histamine-1, reduce symptoms of itching, sneezing, rhinorrhea but not congestion
1st gen: diphenhydramine, chlorpheniramine, doxylamine
-more sedation and cognitive impairment
-strong anticholinergic effects (dry mouth, blurred vision, urinary retention, constipation)
-seizures/arrhythmias at higher doses
Warnings: caution in elderly, pts with prostate enlargement, glaucoma, CV disease, thyroid disease
-avoid in children < 2 y/o due to risk of SEs
Diphenhydramine
1st gen antihistamine, used for many indications:
-tx of acute allergic reactions
-prevention of allergic reactions
-allergic rhinitis
-cough
-sleep
-dystonic reactions
-motion sickness
–> due to its wide range of effects, it can worsen some disease states (BPH, constipation, dementia, glaucoma)
Antihistamines: 2nd generation
-cetirizine (Zyrtec), levocetirizine (Xyzal), fexofenadine (allegra), loratadine (Claritan)
-less sedation, response is pt specific
-Fexofenadine (allegra): seperate from juice and antacids by 2 hrs (decs absorption)
-avoid use with erythromycin and ketoconazole
Oral: most indicated in children 2 y/o + (desloratadine and levocetirizine may be used in > 6 month)
Nasal: 5 yrs +
Decongestants
Oral: Phenylephrine (Sudafed PE),- 10 mg q 4h Pseudoephedrine (Sudafed) - behind counter- 30-60 mg q4-6 h
Topical: Oxymetazoline (Afrin) - do not use for more than 3 days
CI: do not use within 14 days of MAOIs
Warnings/SE:
-caution in pts with CV disease (tachycardia, palpitaions, inc BP), hyperthyroidism, DM, bowel obstruction, glaucoma, BPH, elderly
-CNS stimulation (anxiety, tremors), dizziness, HA, anorexia
Combat Methamphetamine Epidemic Act of 2005
-limit sales of pseudoephedrine to 3.6 grams/day (120 tablets of 30 mg) and 9 grams in 30 days period (exception: 60 mg single pack)
-behind the counter, requires ID and signature
Topical intranasal decongestants
-Oxymetazoline (afrin), phenylephrine
Warnings: do not use with MAOIs or if have closed-angle glaucoma
SE: burning, stinging, sneezing - do not use for > 3 days or rebound congestion can occur
fast acting: within 5-10 mins
Intranasal mast cell stabilizer: Cromolyn (Nasalcrom)
-start using at onset of allergy season
-dosed every 6-8 hrs regularly (NOT PRN)
-symptom improvement can be seen within 4-7 days but max effect in 2-4 weeks
-good safety profile: can be used in children and pregnancy
Intranasal ipatropium bromide (Atrovent nasal spray)
useful to decrease rhinorrhea but not effective for other nasal symptoms
Oral antileukotrienes
-Montelukast (Singulair)
-similiar efficacy to oral antihistamines or PSE
-dosed once daily
Sublingual Immunotherapy
-for allergic rhibitis caused by specific allergens
-first dose must be given in docs office; subsequent doses at home
–> monitor pt for 30 mins for everes allergic reactions (BBW)
-give rx for autoinjectable epinephrine
Sublingual immunotherapy meds
–> Oralair: 5 diff grass pollen extracts - 1 tab is placed under the tongue daily, starting 4 months before and during grass szn
–> Grastek: Timothy grass pollen extract - 1 tab daily, starting 3 months before and during grass szn
–>Ragwitek: ragweed grass pollen extract
–> Odactra: house dust mite allergen - 1 daily
Expectorant: Guaifenesin
-decreases viscosity of mucus
-used to treat a productive, wet cough
-may make it easier to cough phlem out of airway tract
Cough Suppressant: Dextromethorphan (DM)
-cough suppressant:
–> indicated for dry, unproductive coughs
–> blocks the cough reflex center in the brain
–> acts as a serotonin reuptake inhibitor –> risk of serotonergic syndrome
High doses: NMDA receptor blocker = euphoric and hallucinogenic properties (2012 CA banned sales to minors
–> MDD: 120 mg/day
Cough Suppressants: Codeine
-indicated for dry, unproductive coughs
-acts centrally on respiratory center in the medulla to increase the cough threshold
C-II!!
Warnings: respiratory depression and death in children who recieved codeine after tonsel/adenoidectomy
CI: paralutic ileus, children < 12 y/o
SE: CNS depression, constipation, hypotension
CYP2D6 metabolism
Cough suppressants: Benzonatate (Tessalon Perles)
-suppresses cough by topical action or respiratory stretch receptors
Warnings: avoid in children < 10 y/o: accidental ingestion and fatal overdose
SE: sedation, confusion, hallucinations
Cough and Cold combo products: whats in a Name?
Cough = contains a cough suppressant
Congestion = contains an expectorant
D: decongestant (Mucinex D)
PE: Phenylephrine (Sudafed PE)
DM: Dextromethorphan (Robafen DM)
AC: Codeine (Robafen AC)
Pediatric cough and cold treatment: caution needed
-Children < 12 y/o: avoid codeine-containing products
-Children < 6 y/o: avoid ALL OTC cough and cold products
-Children < 4 y/o: avoid many OTC cough and cold products
-Children < 2 y/o: avoid all OTC cough and cold product, avoid promethazine, avoid topical menthol and camphor
Dosing od Tylenol and Motrin in Peds
-Acetaminophen
–> 10-15 mg/kg Q4-6 hrs
-do not exceed 5 doses in 24 hrs
-infant drops/childrens liquid - 160 mg/5mL
Ibuprofen
–> 5-10 mg/kg Q6-8H
-do not exceed 40 mg/kg/day
-infant drops = 50 mg/1.25 mL
-childrens liquid: 100 mg/5 mL
Eye and ear formulations
- 1 drop - 5 mL
-suspension: shake well
-Ointments: apply to the conjunctive sac or over lid margins. ointments can make vision blurry, do not use with contact lenses
-Gels: with cap on, invert and shake once to get the medication into the tip before instilling into the eye
Ear & Eye rx interpretations
AD: right ear
AS: left ear
AU: each ear
OD: right ear
OS: left ear
OU: each eye
Drugs that can increase Intraoccular pressure
-anticholinergics (oxybutynin, tolterodine, benztropine, trihexyphenidyl, TCAs)
-cough, cold, and motion sickness medications (antihistamines, scopolamine)
-chronic steroids, especially eye drops such as prednosolone (PredForte)
-Topiramate (Topamax)
Glaucoma Treatment Goal: Decrease IOP
-reduce aqueous humor production (make less fluid)
–> BBs (timolol)
–> carbonic anhydrase inhibitors (dorzolamine)
-increase aqueous humor outflow (move fluid out)
–> prostaglandin analogs, like latanoprost
- or do both: often achieved with add-on treatment
–> alpha-2 agonists (brimonidine)
Prostaglandin Ananlogs
-increase aqueous outflow, decrease IOP ~30%
-dosed 1 drop QHS
–> Bimatoprost (Lumigan)
–> Latanoprost (Xalatan)
–> Travoprost (Travatan Z)
–> Latanoprostene bunod (Vyzulta)
–> tefluprost (Zioptan)
Warnings:
-darkening of the eye, skin, and eyelashes, thick eyelashes
-Benzalkonium chloride can be irritating or cause contact lens discoloration
Beta Blockers for Glaucoma
-reduce aqueous humor production, decrease IOP ~22% (non-selective)
-dosed 1 drop daily or BID
–> Timolol (Timoptic)
+ dorzolamide (Cosopt)
+ brimonidine (Combigan)
–> Betaxolol
–> Carteolol
Warnings: cardiac, pulmonary, BAK warnings
Other meds to treat glaucoma
–> cholinergics- increase aqueous outflow - carbachol (Isopto Carbachol, Miostat) and pilocarpine (Isopto Carpine)
–> Carbonic anhydrase inhibitors: reduce aqueous humor production - dorzolamide (Trusopt) and brinzolamide (Azopt)
–> adrenergic alpha-2 agonists: increase outflow AND reduce production - Brimonidine (Alphagen P), timolol/Brimonidine (Combigan), Brinzolamide/Brimonidine (Simbrinza) (SE: sedation/CNS depression)
–> Rho kinase inhibitor: increase outflow- Netarsudil (Rhopressa)
Conjunctivitis symptoms and treatment
“pink eye”
-causes: viral, bacterial, allergic, irritant
Symptoms: iching, burning, redness, swelling
-usually self limiting
Treatment:
–> viral: none
–> Bacterial: moxifloxacin (Vigamox), Neomycin/Polymyxin B/Dexamethasone (Maxitrol), Ofloxacin (Ocuflox), Trimethoprim/Polymyxin B (Polytrim)
–> Allergic: cromolyn, azelastine, Olopatadine (Pataday), Ketotifen (Alaway, Zaditor)
Blepharitis
-inflammation of the eyelid
Treatment: eyelid hygiene
–> place clean, wet washcloth, w/ warm water over the closed eyelid for 5 mins
-can add diluted solution of 50% baby shampoo or mild soap
Chronic ocular conditions and treatment
–> inflammation:
-Steroids: prednisolone, dexamethasone)
-NSAIDs (ketorolac, bromfenac)
–> Dryness: refresh, systane
–> Redness: naphazoline (clear eyes), naphazoline/pheniramine (Naphcon), tetrahydrozoline (Visine)
Common drugs that are known to cause vision changes or damage
–> Retinal changes/retinopathy:
-chloroquine
-hydroxychloroquine
–> Optic Neuropathy:
-amiodarone (plus corneal deposits)
-Ethambutol
-Linezolid
–> Floppy iris syndrome:
-alpha blockers (tamsulosin)
–> Color discrimination:
-Digoxin (yellow/green halo)
-PDE-5i (greenish tint around objects)
-Voriconazole: color visions changes
Drugs that can cause vision loss/abnormal vision
-Digoxin (with toxicity) - blurred vision, halos
-PDE-5i: vision loss (one or both eyes; can be premanent)
-Isotretinoin: dec night vision, dryness, irritation
-Topiramate: visual field defects
-Vigabatrin: permanent vision loss (high risk)
-Voriconazole: abnormal vision, photophobia
Common ear conditions: otitis externa
-outer ear infection
TX:
-otic antibiotic drops
–> Ciprofloxacin and dexamethasone (Ciprodex)
–> Ciprofloxacin and hydrocortisone (Cipro HC)
-symptomatic tx w/ APAP, ibuprofen
Common ear conditions: ear wax (cerumen) blockage
tx:
-removal in medical office
–> Carbamide peroxide (Debrox)
Drugs that can discolor skin and secretions: brown
-entacapone
-levodopa
-methyldopa
Drugs that can discolor skin and secretions: Brown/black/green
-iron (black stool)
-methocarbamol
Drugs that can discolor skin and secretions: Brown/yellow
-nitrofurantoin
-metronidazole
-tinidazole
-riboflavin (B2)
Drugs that can discolor skin and secretions: purple/red/orange
chlorzoxazone
Drugs that can discolor skin and secretions: orange/yellow
-propofol
-flutamide
Drugs that can discolor skin and secretions: red-orange
-phenazopyridine
-rifampin (can dye contact lenses)
-rifapentine
Drugs that can discolor skin and secretions: red
-anthracyclines
-deferasirox (urine)
Drugs that can discolor skin and secretions: blue (smurf drugs)
-methylene blue
-mitoxantrone
Drugs that can discolor skin and secretions: blue-gray (smurf drugs)
-amiodarone
-chloroquine
Acne treatment: Mild
-First line:
–> benzyl peroxide
–> topical retinoid
-Alt tx:
–> add topical retinoid or benzyl
–> switch to another retinoid
–> topical dapsone
Acne treatment: Moderate
-First Line:
–> topical combination therapy
–> oral abx + benzyl P + retinoid (+/- topical antibiotic)
-Alt tx:
–> other combination therapy
–> change oral abx
–> add combined oral contraceptives or spironolactone
–> oral isotretinoin
Acne Treatment: severe
-First line:
–> topical combination therapy + oral antibiotic
–> oral isotretinoin
Alt tx:
–> change oral abx
–> add combined oral contraceptive or spironolactone
–> oral isotretinoin
Topical Retinoids for acne tx
–> Tretinon (Atralin)
–> Adapalene (Differin)
-limit sun exposure, apply daily
-pea sized amount
-takes 4-12 weeks to work, may worsen acne initially
other products:
–> benzyl peroxide (BPO)
–> Salicylic acid (clearasil)
–> Azelaic acid
Oral Retinoids for acne tx
–> Isotretinoin (Absorbica)
-for severe acne only
-females must sign a consent form about birth defects
-must have 2 neg pregnancy tests before starting
- do NOT with w/ vitamin A, tetracyclines, steroids, progestin only pills or st. johns wort
*REMS, 1 month at a time
*2 forms of BC
Alopecia: causes and treatment
Causes:
-hereditary
-chemo agents, heparin, valproic acid, spirnolactone
-medication conditions: hypothyroidism, scalp infections, lupus
-zinc and vit D deficiency
TX:
–> OTC- minoxidil
–> RX: Finasteride (Propecia)- hazardous drug (pregos dont handle it)
-Bimatoprost (Latisse): for eyelash growth
Cold Sores: causes and tx
Causes:
-herpes simplex - HSV-1
-spread with active lesions, kissing and sharing drinks
-triggers for sore eruption include stress, fatigue, dental work
Treatment:
OTC: lysine (prevention), Docosanol (Abreva)
RX: acyclovir, penciclovir
Dandruff tx
-itchy and/or scaly scalp that sloughs white oily flakes (dead skin)
Treatment:
–> OTC: selenium sulfide (selsun), pyrithione zinc (head & shoulders), coal tar, ketoconazole shampoo 1%
–> RX: ketoconazole shampoo 2% Nizoral
Diaper Rash: causes and tx
Causes: exposure of sensitive skin to urine and stools and irritation from the diaper
Prevention: frequent diaper changes, thorough cleaning, allowing the skin to air dry
–> OTC: plain petrolatum (Vitamin A&D ointment), Petrolatum + zinc oxide (Desitin)
–> RX: topicals containing clotrimazole, miconazole (+ zinc oxide + petrolatum; Vusion)
Eczema (Atopic dermatitis) causes and tx
-skin inflammation with skin rash: crusty and scaly, itchy, red, dry and sore - commonly affects the elbows, behind the knees/ears. butt and hands
-Causes: irritants, allergens, pollution, stress or weather changes
Treatment:
–> OTC: petrolatum, antihistamines
–> RX: steroids, topical tacrolimus, crisaborole, dupilumab, abrocitinib
Infections of the skin: athletes foot & ring worm
OTC:
-terbinafine (Lamisil)
-butenafine (Lotrimin)
-clotrimazole (Lortrimin)
RX:
-Betamethasone/clotrimazole (Lotrisone)
-Ketoconazol
onychomycosis: infections of the toenail & fingernail
-topical agents are not potent enough to cure most infection
Diagnosis via potassium hydroxide (KOH) smear
RX: PO meds
–> Itraconazole (Sporanox)- DIs, AT prolong, hepatotoxicity- do NOT use in HF pts
–> Terbinafine (Lamisol) - hepatotoxicity
-treat for 6 weeks
Fungal infections: vaginal
-Causes: menstruation, high-dose estrogen or hormone replacement therapy, recent abx use, douching or use of lubricants
-Symptoms: itching, pain/burning during urination or sex, cottage-cheese like discharge
TX:
–> OTC: Miconazole (Monistat), clotrimazole (Gyne-Lotrimin)
–> RX: Flluconazole (Diflucan) 150 mg PO x 1
Genital Warts
-Cause: HPV, sexually transmitted
-TX:
–> Gardasil vaccine prevents infection with HPV for most strains causing genital warts
–> tx is reuired only if pt is symptomatic
RX: Imiquimod cream (Aldara, Zyclara)
Hemorrhoids
-Cause: constipation and straining to have a bowel movement
-Symptoms: rectal burning, itching and bleeding (bright red blood)
TX:
–> OTC:
-Phenylephrine (preparation H)
-Hydrocortisone
-Witch hazel (Tucks pads)
Lice
-affects primarily children
-attach to the hair shafts
-insects
Tx: OTC
–> Premethrin (Nix)
–> Pyrethin/Piperonyl butoxide (Rid)
-needs repeat treatment
RX:
–> Ivermectin (Sklice) - topical
Scabies
-affects primarily adults
-burrow under the skin
-mites
Tx; RX
–> permethrin (Eliminate) cream
–> Oral Ivermectin (Stromectol)
Pinworms (Vermicularis)
-Causes: easily spread by children, contaminated fingers can transfer eggs to surfaces and are then ingested
-Symptoms: anal itching
-Diagnosis: tape test (tape to anus in the am before going to br, will see eggs when pulled off)
-Treatment:
–> OTC: Pyrantel pamoate (Reese’s Pinworm Medicine)
–> RX: Albendazole, Mebendazole
Poison Ivy, Oak and Sumac
-Causes: allergic reaction from touching the sap of the plants contianing the toxin, Urochiol
-Treatment: wash any items that came into contact with the plant, including under the fingernails
–> OTC:
-Aluminum acetate solution (Burrow’s Boro-Packs, Domeboro)
-Colloidal oatmea;
-Calamine lotion + pramoxine
–> RX: topical or oral steroids for severe rash
Inflammation and rash: Hives (Urticaria)
OTC:
–> antihistamines (2nd gen)
–> H2RAs
RX:
–> Hydroxyzine (Vistaril)
-topical steroids are first line
- ointment > creams > lotions> solutions> gels> sprays
-use only lose potency steroids on areas where absorption is higher
-long term use can have local effects to the skin
Lowest potency topical steroids
-hydrocortisone cream: 0.5, 1%
-only ones OTC
Medium potency topical steroids
-mometasone furoate 0.1 % lotion
-triamcinolone acetonide 0.1% cream
high-medium potency topical steroids
-fluocinonide 0.05% cream
-dexamethasone 0.05% cream
High potency topical steroids
-betamethasone diproplonate 0.05% cream (Diprolene)
-Fluocinonide 0.1% ointment
-Mometasone furoate 0.1% ointment
Very High potency steroids
-clobetasol proplonate 0.05% lotion/spray (Clobex)
-fluocinonide 0.1% cream (Vanos)
