Integumentary Flashcards
Topical antibiotics
Benzoyl peroxide
Indication & Pharmacodynamics
first line for mild acne
- Antibacterial activity against P.acnes - Release of active or free radical oxygen capable of oxidizing bacterial production
Topical antibiotics
Benzoyl peroxide
Caution/contraindications: pregnancy, peds, and other considerations
- Pregnancy: Safe
- Peds: OK for 12+
- Other considerations: Should not be applied at the same time as a topical retinoid; can bleach clothes and towels; Drying effect, removes excess sebum, causes mild desquamation and may cause photosensitivity
Topical antibiotics
Erythromycin and clindamycin
Indication
Often in combination together or individually with benzoyl peroxide to reduce bacterial resistance; for mild-moderate acne
Topical antibiotics
Erythromycin and clindamycin
Pharmacodynamics
Interrupt protein synthesis at the 50s ribosomal subunit
Topical antibiotics
Clindamycin
Contraindication, what to monitor for
- Contraindicated: hx of Crohn disease, ulcerative colitis and antibitoic-associated colitis
- monitor for diarrhea - sign of colitis
Topical antibiotics
Azelaic acid
Pharmacodynamics
- Inhibits microbial cellular protein synthesis
- Decreases inflammation and the concentration of bacteria on the skin, may normalize keratinization, leading to an anti-comedonal effect, as well as decreased microcomedone formation
Topical antibiotics
Azelaic acid
Caution/contraindications: caution, interactions
- Caution: patients with darker skin pigmentation, will lighten skin irreversibly
- Interactions: Additive irritation if used with benzoyl peroxide
Salicylic acid
pharmacodynamics
exfoliant, clears comedones, mild anti-inflammatory effects
Topical retinoids
Trentoin
Pharmacodynamics
reduces cohesion between keratinized cells, acts specifically on microcomedones, causing expulsion and conversion of closed comedones to open; prevents new comedones
Can enhance penetration of other topical agents
Topical retinoids
Adapalene
pharmacodynamics
decreases microcomedone formation, modulator of cellular differentiation, keratinization and inflammatory processes
Topical retinoids
Tazarotene
Pharmacodynamics & pregnancy consideration
- normalizes epidermal differentiation, reduces influx of inflammatory cells into the skin
- Pregnancy: avoid
Topical retinoids
General caution/contraindications (5)
- All retinoids should be avoided in patients with eczema, sunburn or skin abrasions at the site of application
- Contraindicated in lactating patients
- Should not be used at the same time as topical antibiotics
- Acne may worsen before it improves, can take 6-8 weeks before benefits appear
- Sunscreen important
Topical Retinoids
adverse fx (8)
peeling, flaking dry skin, burning, erythema, pruritis, sunburn, hypo or hyperpigmentation
Oral antibiotics
Tetracyclines, azithromycin, erythromycin or Bactrim (others if tetracyclines are contraindicated)
Indication and pharmacodynamics
- Indication: moderate to severe acne, inflammatory acne resistant to topical therapies
- Pharmacodynamics: active against P.acnes, prevent future rather than existing lesions
Systemic retinoids
Isotrentoin
Pharmacodynamics, caution/contraindications: avoid, pregnancy, interaction, adverse fx (12)
- Pharmacodynamics: reduces sebum production by reducing sebaceous gland size, normalizing follicular keratinization and indirectly reducing P.acnes and its inflammatory sequela
- Caution/contraindications
- Avoid: patients at risk for osteoporosis
- Pregnancy: avoid
- Interactions: alcohol
- Adverse effects: cheilitis, dry skin and fragility, hypertriglyceridemia, elevation of glucose levels, headache, lethargy, fatigue, arthralgia, myalgias, visual disturbances, GI reactions
What combination of medications are indicated for:
- non-inflammatory comedonal acne
- inflammatory papulopustular acne
- severe inflammatory acne
- Non-inflammatory comedonal acne: topical retinoid or benzoyl peroxide
- Inflammatory papulopustular acne: topical combination therapy of topical antibiotic or retinoid plus benzoyl peroxide
-
Severe inflammatory
- Oral antibiotic combined with topical combination therapy of topic antibiotic or retinoid plus benzoyl peroxide (or all three)
- Oral isotretinoin
Topical corticosteroids
indications (2)
dermatitis, psoriasis
Topical corticosteroids
pharmacodynamics (3)
- anti-inflammatory, antipruritic, vasoconstrictive properties
- depress the formation, release and activity of endogenous chemical mediators of inflammation (histamines, prostaglandins)
- inhibit migration of macrophages and leukocytes into the affected area by reversing vascular dilatation and permeability - reduction of edema, erythema and pruritis
There are several preparations of topical corticosteroids. What are each typically recommended for?
- Ointments are more occlusive and potent: good for dry and scaly lesions
- Creams less occlusive and potent: good for oozing lesions on intertriginous areas
- Lotions are least potent: good for hair bearing areas
Topical corticosteroids
caution and contraindications: area to avoid, pregnancy, peds
- Area to avoid: Do not use high-potency agents on face, groin or axilla
- Pregnancy: caution, only if benefits outweigh risks
- Peds: OK but need lowest strength
Topical corticosteroids
adverse fx (4)
- Local skin irritation, increase risk for secondary infections; tolerance may occur in prolonged use
- Adrenal function and growth should be monitored in children who require moderate to high potency steroids (growth can be stunted)
Topical calcineurin inhibitors
Pimecrolimus (Elidel) and Tacrolimus (protopic)
What are the indications of each?
Pimecrolimus: mild-moderate atopic dermatitis
Tacrolimus: moderate to severe atopic dermatitis
Both: Resistance to steroids, sensitive areas like face, skin folds, steroid induced atrophy or long-term uninterrupted topical steroid use
Topical calcineurin inhibitors
Pimecrolimus (Elidel) and Tacrolimus (protopic)
Pharmacodynamics
suppresses cellular immunity by inhibiting T cell activation by binding to intracellular proteins including calcineurin dependent proteins - results in inhibition of inflammatory cytokines and mediators from mass cells
Topical calcineurin inhibitors
Pimecrolimus (Elidel) and Tacrolimus (protopic)
Caution/contraindications: when to avoid, black box warning, pregnancy, peds
- Avoid: immunosuppression, site of active cutaneous viral infection
- Black box warning: long-term safety concern due to rare cases of malignancy
- Pregnancy - caution; lactation - avoid
- Peds: avoid
Topical calcineurin inhibitors
Pimecrolimus (Elidel) and Tacrolimus (protopic)
Adverse fx (7)
burning, pruritis and tingling, headache, fever, flu-like symptoms, acne and folliculitis
Topical antihistamine and antipruritics
Diphenhydramine
Pharmacodynamics
- provides local relief of itching and swelling due to effects on H1 receptors; suppresses formation of edema and pruritis - closed skin reaction
- May also provide a local anesthetic quality by blocking transmission of nerve impulses
Topical antihistamine and antipruritics
Diphenhydramine
Indications
local reaction to insect bites, stings, minor skin cuts and burns and rashes
Topical antihistamine and antipruritics
Diphenhydramine
Caution/contraindications: when to avoid, other considerations, pregnancy, peds & Adverse fx (1)
- Avoid: use greater than 7 days
- Other considerations: Increased risk of systemic effects if applied to large surface area
- Pregnancy - safe; lactation - caution
- Peds: OK 2+
- Adverse fx: May cause skin irritation
Topical antihistamine and antipruritics
Doxepine
Pharmacodynamics
Histamine blocking action of H1 and H2 receptors inhibiting activation of histamine receptors
Topical antihistamine and antipruritics
Doxepine
Indications
short-term management of moderate to severe pruritis
Topical antihistamine and antipruritics
Doxepine
Caution/contraindications: caution, avoid, pregnancy, peds, other considerations & Adverse fx (1)
- Caution: elderly
- Avoid: untreated narrow-angle glaucoma and urinary retention (medication has anticholinergic fx)
- Pregnancy - safe; lactation - avoid
- Peds: avoid
- Other considerations: do not occlude; if excessive drowsiness occurs decrease body surface area treated or reduce number of applications
- Adverse fx: Burning and stinging sensation when applied
Pediculicides
Pyrethrin (RID) OTC
Indication & Pharmacodynamics
- Indication: lice
- Pharmacodynamics: absorbed through the exoskeleton of arthropods, causing paralysis and death
Pediculicides
Pyrethrin (RID) OTC
Caution/contraindications: when to avoid, pregnancy, peds, other considerations & Adverse fx (3)
- Avoid in chrysanthemum or ragweed allergy
- Pregnancy/lactation: compatible
- Children: OK 2+
- Other considerations: Works best on dry hair, active only when applied
- Adverse effects: localized burning, pruritis, skin irritation
Scabicides and pediculicides
Permethrin
Indication & Pharmacodynamics
- Indication: lice and scabies
- Note for scabies: first line treatment; treat all family members who have been in contact with patient
- Pharmacodynamics: absorbed through exoskeleton of arthropods, causing paralysis and death
- Residual activity against lice for up to 10 days
Scabicides and pediculicides
Permethrin
Caution/contraindications: where to avoid application, pregnancy, peds & Adverse fx (3)
- Avoid use near eyes
- Pregnancy/lactation: compatible
- Peds: OK 2 months +
- Adverse drug effects: localized burning, pruritis, skin irritation
What can be used for adults with a contraindication to permethrin?
Croamiton (Eurax)
Pediculicides
Malathion
Indication & Pharmacodynamics
- Indication: 2nd line if not able to use permethrin for lice
- Pharmacodynamics
- inhibits cholinesterase activity in vivo
- Pediculicidal and ovicidal
- Residual activity for up to 7 days
Pediculicides
Malathion
Caution/contraindications: other considerations, pregnancy, peds & adverse fx (3)
- Other considerations: Flammable
- Pregnancy/lactation: avoid
- Peds: OK 6+
-
Adverse effects
- Organophosphate poisoning and severe respiratory distress if ingested
- Localized burning, skin irritation
Pediculicides
Benzyl alcohol
Indication & Pharmacodynamics
- Indication: first FDA approved non-neurotoxin treatment for head lice
- Pharmacodynamics: stuns lice, leading to ability to penetrate respiratory mechanism, which leads to asphyxiation; used in active lice infestation
Pediculicides
Benzyl alcohol
Caution/contraindications: peds, pregnancy & adverse fx (2)
- Peds: 6 months +
- Pregnancy/lactation: ok
- Adverse effects: pruritis, erythema
Pediculicides
Ivermectin
Indication & Pharmacodynamics
- Indication: head lice
- Pharmacodynamics
- Interferes with function of nerve and muscle cells, resulting in parasite paralysis and death
- Single application of topical ivermectin is effective for eradication of head lice
Pediculicides
Ivermectin
Caution/contraindications: pregnancy, peds & adverse fx (3)
- Pregnancy/lactation: avoid
- Peds: 6 months +
- Adverse effects: dry skin, burning sensation, eye irritation
How do you choose therapy for lice/scabies? Several considerations - what do you start with? Who else needs to be considered for lice vs. scabies? What else can be done that is a non-pharm intervention?
- Start with permethrin, use ivermectin if needed
- Consider patient family members
- Lice: check for infestation and treat infected members
- Scabies: prophylactically treat members
- Sexual partners should be treated concurrently if pubic lice present
- Nit or fine-tooth comb should be used to remove any dead lice or eggs
- Clothing and bedding should be washed in hot water
Corticosteroids: what are the different classes of corticosteroid strength?
Low strength: Class 6-7
Intermediate strength: Class 4-5
High strength: Class 2-3
Very high strength: Class 1