FINAL - Dermatology Flashcards
Largest organ in the human body
Skin
-Average adult: 2,800sq in
16% of total body weight
-Largest sensory organ
Role of the pharmacist in managing patients w/dermatologic disorders
Pharmacists are often the first-line consult patient seeks
-Patients rely on pharmacists to know when to treat and when to refer
-Risks associated w/self-care
-Cost-savings
-Convenience
Must know how to guide patient with self-care
-Product selection
-Dressings
-Follow up
KEY PHARMACIST PROPERITES
Knowledge of vehicles and bases
Knowledge of commonly used terminology
Knowledge of drug-induced skin conditions
-Be able to identify common dermatologic lesions and rashes
-Know when to suggest self care or refer pts to PCP or dermatologist
-Know advantages and disadvantages of dermatologic products
-Advise pts on the proper use of dermatologic
What questions to ask
-Onset, duration, getting better or worse
-Which parts of the body are involved
-Isolated or symmetrical
-Symptoms (local vs systemic)
-Exposure to new drugs or irritants
General guidelines when to refer
Multiple extensive burns
-Human or animal bites
-Multiple or extensive cuts, bruises or abrasions
-Rash that is extensive, weeping, or infected
-Tumors or growths
-Yellow skin
-Deep infection (cellulitis)
-Large blisters of unknown origins
-Exposed deep tissue, muscle, or bone
Cost of Rx dern products
2009-2019
-Many brand products have increased 100%-500%
-Many generic products have increased 100-200%
Application of topicals
Finger tip units
Choice of bases
Combination of factors
-One factor may outweigh the others
Importance of working WITH patients
- Condition of the skin
-Desired effect from the base
-Dry the skin vs moisturize
-Water-resistance vs washes right off - Area of application
- Patient acceptability
- The nature of incorporated medication
-Bioavailability
-Stability
-Compatibility
Basic vehicles for dermatologic products
Ointments
Adv:
-Best for hydration
-Best for drug delivery
-Removes scales
Disadv:
-Greasy
-Low patient acceptance
(messy)
-Not ideal for hairy areas
Cream
Adv:
-Good for hydration
-Good for drug delivery
-Can apply to most areas: hairy, groin, face
-High patient acceptance
Lotion
Adv:
-Watered down creams
-Easy to apply
-Good patient acceptance
Disadv:
-Requires freq applications
-Not ideal for very dry skin
Gel
Adv:
-Excellent for EtOH soluble drugs
-Can apply to most areas: hairy, groin, face
-High patient acceptance - non greasy
Disadv:
-Can be drying
Solution; foam; spray:
Adv:
-Can apply to most areas
-Easy to apply in hairy and groin areas
-Not ideal for drug delivery
Disadv:
-Can be drying
-Not ideal for hydration
-Requires freq application
Vehicles for topical prep
Hair bearing skin
-solution/spray
-foam
-gel
-cream
Dry skin (Xerosis)
Common features
-Fall and winter
-Feet, lower legs
-Hands, elbows, face
-Rough, dry, scales, cracks
-Itching is common sx
Who is at risk?
-Elderly
Decreased activity of sweat and sebaceous glands
Very warm, dry environments
Frequent bathing
Dry Skin (Xerosis) tx
Emollients
-First line for itching
-Restores barrier and skin function
Agents for itching
Alter bathing habits
Emollients ex
Vaseline
Aquaphor
Cetaphil
Nivea
Keri
Lubriderm
AmLactin
Eucerin
CeraVe
Ointments vs Creams, vs lotions
Agents to reduce itching
Menthol and camphor
-1/2-1%
-Create a sensation of cooling
Pramoxine
-1%
-Local anesthetic
Aluminum acetate
-0.2%
-Alter C-fiber nerve transmission
Hydrocortisone
-0.5% and 1%
-Anti-inflammatory
Dermatitis
Inflammatory process of the upper two layers of skin
Dermatitis classifications
Acute
-Red patches or plagues
-Pebbly surface or blisters
Itching is intense
Ex:
Contact dermatitis
-Irritant cs Allergic
-Poison Ivy
Sub-acute
-Dry
-Less red
-Crusting; oozing
-Mild thickening
Itching is common, but less intense
Ex:
Atopic Dermatitis
-Eczema
Chronic
-Epidermal thickening
-Exaggerated skin markings
-Excoriations; fissures; scaling
Lichenification
-Less itching
Ex:
-Stasis dermatitis
-Any long standing acute or sub-acute dermatitis
-Irritation and trauma worsen itching
Acute contact Dermatitis
Look at pattern
Look at part of body involved
-Main sx - itching
Two types:
-Allergic
-Irritant
General tx principles of dermatitis
Stop the itch-scratch cycle
-Must understand patient’s personality, social and domestic conditions
Ability to carry out tx
No one best therapy for ever pt
Acute contact dermatitis
Irritant
-Non-immunologic reaction to frequent contact with everyday substances
-More common than allergic
-Reaction within a few hours
Common irritants
-Metals
-Cosmetics
-Adhesives
Contact Dermatitis - Poison Ivy
Direct exposure
-Broken plant
-Resin - 2 weeks
Indirect exposure
-Clothing, dog, smoke
-Does not spread from lesions
Prevention is key
Ivy Block
-Protectant; barrier
-Re-apply every 4 hours
Dermatitis occurs 24-48 hours after exposure
Pruritis is intense
-Secondary infections
Wash skin and nails within 10 minutes
-Wash clothing as well
Topical therapy OK if <10% BSA involved
Poison Ivy tx
Treatment options for limited rash??
-Remove source
-Calamine lotion
-Topical antihistamines
-Oral antihistamines
-Topical corticosteroids vs Oral Corticosteroids
Tx of acute dermatitis - MOA of topical corticosteroids
Anti-inflammatory
-Increase expression of anti-inflammatory genes and indirectly inhibit inflammatory transcription factors, such as NFkb, to decrease the expression of pro-inflammatory genes
Anti-Miotic
-Inhibits cell proliferation
Immunosuppressive
-Inhibition of humoral factors involved in the inflammatory response
Apply bid to qid *3-14 days
-Varies w/vehicle
-Always treat at least 1 day beyond resolution
Tx of acute dermatitis - Corticosteroids
Avoid dose packs
-Only tx for 6days; need MINIMUM tx of 10-14 days
-Do not provide tx for long enough period of time
-Start at prednisone 40-60mg per day; taper every 3 days
-Minimum of 10-14 days of tx
Tx of acute dermatitis - Systemic Therapy
Non-sedating antihistamines
-Loratadine (claritin)
-Desloratadine (Clarinex)
-Fexofenadine (Allegra)
Sedating antihistmaines
-Diphenhydramine (Benadryl)
-Cetirizine (Zyrtec)
-Hydroxyzine (Atatrax) =RX
Doxepin = RX
Atopic Dermatitis
Most common form of eczema
Usually presents in infancy
1 in 5 children
1 in 12 adults
80% mild; 20% mod-severe
Significant QOL issues
-Sleep
-Depression, anxiety, productivity
Atopic Triad
Atopic march - Often first disease of atopic allergic triad to be observed
-50-75% also develop allergic rhinitis and or asthma
Atopic Dermatitis
Allergic rhinitis
Asthma
Atopic Dermatitis
Pruritis
-Symmetrical red papules or plaques
-Scaling excoriations
Overall dryness of skin
-Redness and inflammation
-History of allergic disease
-Risk of 2nd infection
Atopic Dermatitis age presentations
Infant
-Red, papular skin rash on cheeks and skin
-Lesions often crust over time
-lesions later appear on neck, trunk and groin
-Itching often results in irritability
Child
Face, neck, flexural creases of arms and legs
-Skin often appears dry, flaky, rough, cracked, and may bleed from scratching
-Sleep disturbance is common
-Greater risk of secondary skin infections
Adult
-Hands and neck**
Flexor surfaces of the arms and legs
-Excoriation and lichenification from chronic scratching
-Intense itching; sleep disturbance; Altered QOL; depression
Atopic Dermatitis Triggers
Allergens
Chemicals
Bathing
Detergents
Soaps
Smoke
Dust
Infections
Stepwise mgmt of atopic dermatitis
Non-pcol measures
-Lukewarm/tepid baths
-Emollients
-Eliminate irritants; modify environment; avoid triggers
-Trim fingernails; Non-irritating clothing
Topical Therapy
-Topical corticosteroids (TCS)
-Topical calcineurin inhibitor therapy
-Topical JAK inhibitor
-Strength/duration of use based on severity
Systemic therapy
-Phototherapy
-Oral immunosuppressant therapy
-Oral JAK inhibitors
-Injectable biologic agents
Stepwise mgmt of moderate-to-severe atopic dermatitis
Acute flares
-Moderate to severe: medium potency TCS BID for up to 3 days beyond CL of lesions
Refractory
Refractory to topical agents or widespread lesions: Phototherapy or oral immunosuppressive therapy
Inadequate response to all therapies: consider emerging biologic agents
Maintenance therapy
Moderate to severe Basic measures plus daily application of low-potency TCS or 2-3 times weekly application of TCS or other topical anti-inflammatory agent
Written action plan
Topical corticosteroids: Choice of vehicle based upon:
Location of lesions
Type of lesion
Severity of lesion/degree of inflammation
Degree of skin penetration desired
Topical corticosteroids cont
Classified according to potency, which corresponds to anti-inflammatory activity and vasoconstrictive potency
-Very-high-high-Mid-low (Grades I to VII)
-Vehicle impacts delivery and potency of corticosteroids
-Only 2% absorbed when applied to normal intact skin
-Occlusion enhances penetration
-Increases penetration up to 10X
Topical corticosteroids SE
-Thinning of skin
-Dilated blood vessels
-Increased bruising
-Skin color changes
-Risk of HPA suppression w/long-term use of high potency agents
-Development of tolerance (tachphylaxis)
