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)
Topical corticosteroids ex based on classification
Very high potency:
Class I
Betamethasone dipropionate ointment
Comments:
-Used for very severe lesions and on thickened skin when max penetration is needed
-DO NOT USE ON FACE
-Avoid using super potent agents for >2 weeks
Limit to no more than 50g per week
High potency class 2
Betamethasone dipropionate Lotion (Diprolene)
Comments:
-Used for very severe lesions and on thickened skin when max penetration is needed
-DO NOT USE ON FACE
-Avoid using super potent agents for >2 weeks
Limit to no more than 50g per week
Mild potency classes 3-5
**Betamethasone dipropionate lotion (Diprolene)
Comments:
-Used on most skin surfaces for exacerbations
-Moderate anti-inflammatory effect
-Safer for longer usage than high potency
Low potency
Classes 6-7
-Hydrocortisone (Cortaid)
-Desonide (Desonate)
Comments:
-Use on face, groin, genitals, axilla
-Mild anti-inflammatory effect
-Safest for long-term maintenance use
Topical Calcineurin Inhibitors
MOA: blocks pro-inflammatory cytokine genes
Primecrolimus and tacrolimus
CAN BE USED ON ANY AREA
-Equivalent to mid-potency corts
-No risk of atrophy
-Few side effects - burning
$$$
Topical Calcineurin inhibitors stats
Now considered 2nd line treatment
-Intermittent use only
-Recent concern regarding long-term use
-Risk of malignancies
-Risk of resp infect in children <2 yrs
Crisaborole 2% ointment
Phosphodiesterase- Inhibitor (non-steroidal)
Alternative to TCS and TCIs
-steroid phobia
Mild or moderate AD
BID for 28 days
$619-$735
Ruxolitinib
Opzelura 1.5% cream
-Mild to moderate atopic dermatitis
-Not well controlled with other therapies
-MOA: JAK inhibitor
Mediates signaling of cytokines
-Apply a thin layer BID up to 20% BSA
-Short term use
-Max of 60g per week
Avoid in immunocompromised pts
Upadacitinib
Rinvoq
-Moderate to severe atopic dermatitis
Not well controlled with other therapies
-MOA: JAK inhibitor
Mediates signaling of cytokines and growth factors
-15 mg - 30 mg PO once daily
Well tolerated
Higher Rates of major CV events and thrombosis
Dupilumab
Dupixent
-First biologic indicated for mod-severe AD
Not well controlled with other therapies
MOA: Human monoclonal antibody against IL-3 receptor alpha
Inhibits signaling of IL-4 and IL-3 (Th2 cytokines)
-600mg initially, then 300mg SC q2 Weeks
-Well tolerated
$37,00 per year
-Specialty pharmacy - expanded indication
Tralokinumab -Adbry - recently approved
Acne - General information
Definition: A chronic inflammatory disease of the sebaceous glands and hair follicles of the skin characterized by comedones, papules, and pustules
Affects 90% of the adolescent population
-Corresponds to increased androgen production
80% of patients with acne are between 12-30 years old
-Males more severe during puberty
-Females more severe during adulthood
Factors that exacerbate acne
Oil based cosmetics
Emotional stress
Irritation/Physical pressure
Drugs
-Androgenic steroids
-Corticosteroids
-Lithium
-Anti-epilepitcs (phenytoin)
-Tuberculostatic drugs
-OCs
Pathophysiology of acne
Keratinous obstruction of sebaceous follicle outlet
-Traps sebum
-Comedone - hair follicle plugged with sebum, keratin and dead skin
-Bacterial colonization in trapped sebum
Pathophysiology bacteria
Propionibacterium acnes - naturally colonize the skin and sebaceous glands
-Proliferates in sebum environment
-Bacteria converts TG to FFA which irritates local cell resulting in inflammation
Patho can be divided by two classes
Non-inflammatory
1. white heads
2. Black heads
Inflammatory
1. Papules
2. Pustules
3. Ruptured Contents
Secondary Lesions
Excoriations
Erythematous macules
Hyperpigmented macules
Scars
Treating complication
Dermabrasion
Chemical peels
-70% glycolic acid
Laser resurfacing
$$$
Goals of therapy
Long-term control
-Relieve discomfort
-Improve skin appearance
-Minimize physiological stress
Prevent scars
MOA of acne therapy
-Antimicrobial
-Anti-inflammatory
-Decrease sebum production
-Keratolytic
Compounds that break down the outer layers of the skin; decrease the thickness; and promote sloughing
-Salicylic acid; urea; alpha-hydroxy acids
Comedolytic
-A product or medication that inhibits the formation of comedones
-Tretinoin; aldapalen; azelaic acid
Treatment - all patients
Follow a regular skin cleansing regimen using a mild facial soap BID
Minimize the use of products that cause irritation or stinging (aftershave, alcohol based cleansers)
Use tepid, not hot water to clean affected areas
NO QUICK FIX - weeks to months
Tx of **Comedonal, noninflammatory acne (mild) **
-First line:
** Topical retinoids**
-Alt:
Benzoyl peroxide (BP)
Azelaic acid (lower strengths
Tx of Mild-moderate papulopustular inflammatory acne
First line:
-Adapalene + BP or
-Clindamycin +BP
Alt:
-Alternative retinoids
-Adapalene + Oral antibiotics (OA)
Tx: Severe papulopustular or moderate nodular acne
First line
Oral isotretinoin
Alt:
OA + Adapalene
OA + adapalene +BP
OA + Azelaic acid
OA + Oral antiandrogens
Oral antiandrogens + topicals
Tx of nodular or conglobate acne
First line
Oral isotretinoin
Alt:
-OA + Azelaic acid
Other topical agents or oral antiandrogens can be substituted for AA
Maintenance therapy acne
First line
Adapalene
Alt:
-Tazarotene
-Tretinoin
-Azelaic acid
-Benzoyl peroxide
Topical therapy: Adapalene (Differin)
Formulation:
-Gel
-Cream
-Solution
MOA:
-Retinoid
-Regulate epithelial cell growth
Daily at hs
Burning/stinging
Topical therapy: Tazorotene (Tazorac)
Formulation:
-Cream
-Gel
MOA:
-Retinoid
Daily
start lower strength
very drying
category X
Topical therapy: Tretinoin (Retin-A)
Formulation:
-Cream
-Gel
-Solution
MOA:
-Retinoid
Daily at hs
sting, burn
Dryness
Photosensitivity
4-6 weeks until improvement
Topical therapy: Azelaic acid (Azelex)
Formulation
-Cream
MOA:
Antibacterial
Keratolytic
Adjunct
Well tolerated
Topical therapy: Benzoyl Peroxide (Oxy-10)
Formulation:
-Gel
-Cream
-Lotion
MOA:
-Antibacterial
-Comedolytic/keratolytic
-Anti-inflammatory
BID
-Dry skin/irritation
Can bleach skin/hair
Start lower strength
Avoid contact with clothin
Topical therapy: Clindamycin (Cleocin T)
Formulation:
-Gel
-Solution
-Lotion
MOA:
Topical Antibiotic
Daily or BID
Topical therapy: Erythromycin (Generic)
Formulation:
-Gel
-Solution
Topical Antibiotic
BID
Expires in 30 days
Topical therapy: Clindamycin +BP (BenzaClin DUAC)
Formulation:
-Cream
Topical antibiotic
Limits resistance
Adverse effects of topical agents
Adapalene has the least
Tretinoin has the most
Erthema
Scaling
Burning
Flare
Resistance HEAVY in antibiotics ONLY
Combination productions
Clindamycin + Benzoyl Peroxide
-Duac
Adapalene + Benzoyl Peroxide
-Epiduo Forte
Most combo products are expensive!! Most insurances will not cover combo, but may cover individual ingredients
Oral antibiotics
**Minocycline; Doxycycline; Erythromycin; Azithromycin; TMP/SMX
Decreased bacteria and inflammation
-weeks to see improvement
MOST EFFECTIVE WHEN INFLAMMATION PRESENT
-Risk of allergy, photosensitivity, GI upset, thrush
-Risk of resistance developing
(Limit to 6-8 weeks if possible)
Oral Anti-androgen therapy: Hormone tx
Low dose oral contraceptives
Spironolactone
Ideal for females whos acne flares during menstrual cycle
-Decreases androgen
Topical hormone
-Clascoterone 1% Cream
-Androgen receptor inhibitor
May be used in males and females
Applied BID
Local erythema most common SE
Treatment: Severe acne
Isotretinoin
-Used for severe acne or when patients have failed other treatments or when it relapses soon after d/c other therapies
Vitamin A derivative
$393 - good rx
Provides resolution in 80% of cases
Reduces sebum production and shrinks sebaceous glands
Isotretinoin dosing
0.5-2mg/kg/day in 2 doses (with food) for 15-20 weeks
Acne will get worse before it gets better
-If acne flares after > 2 months off tx, a 2nd course may be used
-Effectiveness increases with higher doses
Isotretinoin Adverse effects
Skin:
-Dry skin
-Dry eyes and nose
-Dry lips
-Hair shedding
-Peeling of palms and soles
-Photosensitivity
MSK
-Back pain
-Arthralgias
-Myalgias
-Fatigue
-Risk of osteoporosis
-Delayed bone healing
Labs:
-Elevated AST/ALT
-Elevated chol and triglycerides
Other
Category X
hA
Mood changes
Night blindness
Depression/suicide
Monitoring of patients on isotretinoins
AVOID pregnancy
Do not take vitamin A sup
Use moisturizer, lip balm, and artificial tears
use sunscreen
Take with food
IPledge program
Can only dispense 30 day supply
Females must have negative pregnancy test every month to be on therapy
Tx follow up
For any pt with acne:
-2-6 months will be necessary to determine if a regimen has been successful
Lengthening acne free periods is key
Rosacea - General info
A common chronic progressive inflammatory dermatosis based on Vascular instability
Characterized by facial flushing/blushing facial erythema, papules, pustules and telangiectasia
Ages 25 and 70 years
People with fair complexions
Women > men
Chronic, persisting for years with periods of exacerbation and remission
Subtypes of Rosacea
Telangiectactic
-Visibly dilated blood vessels
-Very red skin
Papulopustular
-Resembles acne
Phytmatous
-Enlarges sebaceous glands
-Especially the nose
-More common in males
Ocular
-Watery eyes
-Bloodshot eyes
Trigger factors
Foods
Temp
Weather
Beverages
Medical conditions
Emotional influences
Physical exertion
Skin products
Drugs
-Vasodilators
-Topical corticosteroids
-Nicotinic acid
-ACE inhibitor
-Calcium channel blockers
-Statins
Tx: Lifestyle mods
Avoid triggers
-avoid excessive exposure to the sun
-Use mild soaps and cleansers
-Stress adherence to topical meds
Topical meds should be allowed to penetrate the skin for 5-10 min before applying make-up
Med treatment of rosacea
Mild
-Avoid triggers
-Topical antibiotics (metronidazole)
-Topical retinoids
Moderate
-Oral antibiotics
-Topical retinoids
Severe
-Oral isotretinoin
-Laser treatments
Tx of Rosacea; topical antibiotics and retinoids
Topical Antibiotics:
Metronidazole 1% cream; gel; lotion
Tx of choice - apply bid
-Clindamycin
Sulfur
Topical retinoids
Azelaix acid - Finacea Gel 15% antibacteral
New tx for Rosacea: Brimonidine (Mirvasco) 33%
Alpha-2 adrenergic agonist
-Tx of persistent facial erythema
Ophthalmic drops for ocular rosacea
Psoriasis basic info
Thickened red patches covered by silver-white scales
2% of us population
Onset usually prior to 40 y/o
Psoriasis classification:
Limited
-<5% BSA
Generalized
-Moderate 5-10% BSA
Severe >10% BSA
80% of pts have mild to moderate
20% have severe disease
Psoriasis Triggers
Stress
Cold environment
Injury
infection
smoking
Drugs (NSAIDs, ACE, Lithium)
Diet
Goals of therapy Psoriasis
Decrease symptoms. % of BSA affected
Improve QOL
Reduce inflammation and slow down rapid skin cell division
Prolong periods between exacerbations
