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CDM 3 Exam 2 > Lecture 5 - Dermatology 2 > Flashcards

Lecture 5 - Dermatology 2 Flashcards

1
Q

tell tale sign of psoriasis

A

erythematous papule and plaques with silver scale

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2
Q

Psoriasis risk factors

A

Genetic predisposition
Environmental Triggers, infection, stress
Medications
Smoking
Obesity & higher BMI in adults and children
Vitamin D deficiency

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3
Q

exacerbating factors for psoriasis

A

Drugs = BB< lithium, antimalarial meds, ACEi, NSAIDs
Infections, bacterial and viral
Alcohol abuse

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4
Q

Exacerbating comorbidities for psoriasis

A

CVD
Malignancy
Diabetes
HTN
Metabolic syndrome
IBD

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5
Q

Patients with psoriasis are at increased risk for…..

A

CV events

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6
Q

Clinical presentation of plaque psoriasis

A

symmetrically distributed plaques
*sharply defined margins raised above surrounding normal skin
Tick, silvery scale is usually present
Auspit’z sign
1-10cm in diameter
typically asymptomatic, may have itching

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7
Q

Nail psoriasis

A

most often noted after onset of disease
involvement of nail Matrix or nail bed
nail pitting
Leukonychia
typically req system therapy or sublingual injections

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8
Q

How is severity of psoriasis assessed?

A

Based on %% of body surface area

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9
Q

Desired outcomes of psoriasis?

A

minimize or eliminate signs of psoriasis
Alleviate pruritus if present
Reduce frequency & flare ups
Avoid/minimize ADE
cost effective therapy
approve QOL

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10
Q

Non-pharm psoriasis therapy

A

Stress reduction
Using moisturizers
Oatmeal baths
sunscreen 30+ SPF
Avoidance of irritants
Avoidance of offending agents

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11
Q

Psoriasis: topical corticosteroid therapy

A

Mainstay of therapy
Location, age, plaque thickness taken into consideration
usually BID

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12
Q

Lower potency Topical steroid used for….

A

infants and lesions on the face, intertriginous areas (rub together) and area with thin skin

ex. Hydrocortisone 0.5-2.5% cream

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13
Q

Mid-high potency topical steroid used for….

A

most areas generally recommended

ex. Betamethasone valerate 0.12% ointment

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14
Q

Ultra-High potency topical steroid use for….

A

very thick plaques or recalcitrant disease

ex. Clobetasol 0.05% cream

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15
Q

Treatment of choice for mild-mod psoriasis…..

A

Topical corticosteroids

less ADR, QD-BID

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16
Q

Topical Vit D analogs info

A

inhibit keratinocyte proliferation and enhancement of keratinocyte differentiation

immunosuppressive properties

comparable to group 3 steroids, but more $$ & irritating

Calcitriol < Calcipotriene irritation

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17
Q

Vitamin D analog Safety

A

Photosensitivity and inc risk of UV-induced skin tumors
Acute psoriatic eruption of scalp can occur
topical solution and foam are flammable
Safe in peds

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18
Q

Vitamin D analog tolerability

A

Hypercalcemia is concern w/ higher doses (>100g/week)
can worsen psoriasis, cause skin irritation

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19
Q

Topical Vitamin D analog efficacy

A

Calcipotriene as effective as TCS but more ADR
Greatest efficacy when combo w/ betamethasone

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20
Q

Vitamin D analog clinical pearls

A

used in combo w/ TCS
inactivated by UVA, apply after not before exposure

BID application, not more than 30% BSA

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21
Q

Tazarotene info

A

Retinoid

limited absorption, but irritation is major issue and limits use

irritation is dose dependent

therapeutic benefit can persist up to 12weeks after stopping

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22
Q

Tazarotene safety

A

Preg X
Photosensitivity

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23
Q

Tazarotene Tolerability

A

Inc sensitivity to environmental factors
Skin burning, stinging, irritation

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24
Q

Tazarotene efficacy

A

50% improvement in symptoms at 12 weeks in 50% of treated pts

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25
Q

Tazarotene clinical pearls

A

used with TCS for inc efficacy and tolerability
use lower strength cream and combo with moisturizer
alternate days to reduce irritation

used QD

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26
Q

Other treatment options for psoriasis

A

Anthralin = V irritating, have to do short contact regimen

Coal Tar = stain and small, used at night

Salicylic Acid = avoid combo w/ calcipqotriol, phototherapy, > 20% BSA, renal impairment, children

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27
Q

Using topical calcineurin inhibi for psoriasis

A

not FDA approved
Not as effective so not really used

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28
Q

Excimer Laser

A

Faster responses
Can cause tanned spots on skin
high doses of UVA light to certain spots

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29
Q

Biologic agents used in which psoriasis patients

A

moderate to severe plaque type
good short/long term

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30
Q

Enbrel (Etanercept)

A

Approved for PsA and moderate to severe psoriasis

Give 50mg SQ BIW for 1st 12weeks, then 25/50mg QW

efficacious children 4-17 dosed 0.8mg/kg (50mg max) QW

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31
Q

Humira (Adalimmab)

A

rapid and efficacious control of psoriasis and PsA, can see improvement in 1st week

dose: 80mg SQ once, then 40mg SQ QOW

effective alternative for pts who fail to respond to Enbrel

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32
Q

Remicade (Infliximab)

A

more efficacious than Entanercept

Given Iv infusion over 6 weeks, then every 8 weeks

Rapid response

Rare but serious ADE = highest risk for TB, Bacterial/viral/invasive fungal infection, Fatal cases of hepatosplenic T-cell lymphomas

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33
Q

Cimzia (Certolizumab Pegol)

A

Dosed QOW
Mild ADR = nasopharyngitis & URI
$$$
relatively safe in pregnancy

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34
Q

TNF Alpha-inhibitors efficacy

A

Adalimumab = dec after 12 weeks
Etanercept = going from BIW -> QIW = less therapeutic effect
Infiximab = greatest dec symptoms shortest time

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35
Q

TNF-alpha inhibitor clinical pearls

A

combo w/ methotrexate = lower likelihood of resistnace
$$$$$
Dont sue w/ live vaccines as immune response can be compromised

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36
Q

Otezla (Apremilast)

A

PDE-4 inhibitor, inhibit TNF-a production
ADR mental = depression, suicidial ideation, mood changes = probs dont use
Titrate up to 30mg BID, reduce dose if CrCl < 30

37
Q

Otezla (Apremilast) Efficacy & Peals

A

appears to be less effective than TNF-a inhibitor
Oral admin w/ minimal DI and ADR GI concern

38
Q

IL-17 inhibitors

A

Cosentyx (Secukinumab)
Taltz (Ixekizumab)
Siliq (Brodalumab)

39
Q

IL-12/23 inhibitors

A

Stelara (Ustekinumab)
Tremfya (Guselkumab)
Illumya (Tildrakizumab)
Skyrizi (Risankizumab)

40
Q

Cosentyx (Secukinumab) info

A

Possible anaphylaxis and inc in infection rate

Greater efficacy for mod/severe plaque psoriasis than ustekinumab
Less long-term efficacy than guselkumab

Dosed: QW for 4 weeks, then Q monthly

41
Q

Taltz (Ixekizumab) info

A

Dosed Q2 wks for 12 wks, then Q4wks

SE: neutropenia

More efficacy than etanercept

42
Q

Siliq (Brodalumab)

A

Dosed: QWkly X 3, then Q2weeks

REMS for suicidal ideation & Box warning**

higher likelihood of complete remission than ustekinumab

SE: arthralgia, suicidal ideation, cryptococcal meningitis, candida infections

43
Q

Stelara (ustekinumab) info

A

efficacy persistent over time
May worsen PsA for some pts
More major CV events reported**

44
Q

Tremfya (Guselkumab)

A

SE: tinea, HSV infection

effective pts who had inadequate responses to ustekinumab

45
Q

Alumna (Tildrakizumab)

A

Dosed: week 0/4 nd then every 12

superior to etanercept

antibody development w/ minimal impact on efficacy

46
Q

Skyrizi (Risankizumab)

A

Dosed week 0/4 and then every 12

greater efficacy than ustekinumab and adalimumab

higher likelihood of antibody development effecting efficacy

47
Q

IL inhibitor general info

A

All shown efficacy over etanercept but $$

48
Q

Acitretin info

A

oral retinoid
utilized for sever psoriasis
can be used with UVB or PUVA therapy or topical calcipqotriol
Less effective used alone
Efficacy dose dependent, 50mg optimal
Bunch of ADRs, BW

49
Q

Acitretin pregnancy info

A

Category X
pregnancy contraindicated for 3 years after D/c

No blood donations from men/women for atleast 3 years after

50
Q

Acitretin in females of child-bearing age

A

two negative preg test
repeat test monthly during therapy, Q3 months 3yrs after therapy
2 forms of Birth control starting 1 month before and 3 years after therapy
cant drink during therapy and 2 months after D/c

51
Q

Acitretin in females of child-bearing age

A

two negative preg test
repeat test monthly during therapy, Q3 months 3yrs after therapy
2 forms of Birth control starting 1 month before and 3 years after therapy
cant drink during therapy and 2 months after D/cMethotrexate info

52
Q

Methotrexate info

A

Should be given with folic acid sup daily**
more effective than acitretin, similar to cyclosporine w/ less ADR
given Weekly

BW, Preg X, and 6 months females and 3 months before conception…both have to use contraception
CI in Breastfeeding too

53
Q

Mild-moderate psoriasis treatment algorithm

A
  1. Mild to mod TCS
  2. trial of topical Vit D analog or retinoid alone or w/ TCS..combo recommended
  3. Trial of phototherapy or oral systemic agent
  4. consider moderate-severe disease therapy

Step down therapy to lowest therapy that maintains control of symptoms

54
Q

Moderate to severe psoriasis treatment algorithm

A
  1. high-V high potency TCS + vitamin D analog/retinoid
  2. Add systemic agent ( IL/TNF-a I) to topical therapy or consider trial of phototherapy
  3. inc systemic agent potency or use 2 systemic agents in addition to topical therapy
  4. use BRM an other agents as needed

Step down therapy to lowest therapy that maintains control of symptoms

55
Q

Exampels of BRM

A

Biologic Response modifiers

Acitretin, Methotrexate, Cyclosporine

56
Q

Two main fungi that cause human disease

A

Dermatophytes
Candida albicans

57
Q

Risk factors to mycotic infections of skin, hair and nails

A

prolonged exposure to sweat
maceration
intertriginous folds
sharing personal belongings
occlusion of the skin
close living quarters
immunodeficiency and suppresion
diabetes
obesity
poor hygiene
trauma
warm or humid climate

58
Q

Tinea pedis

A

Athletes foot
usually 3/4 or 4/5th toes
usually seen in 1 foot and respond to topical therapy

59
Q

Treatment for mild/acute cases of tines pedis

A

cream generally
Terbinafine better than azaleas
Treat for 1-6 weeks
avoid nystatin**

60
Q

oral treatment of tinea pedis

A

oral treatments

terbinafine 250 QD for 2 weeks
Itraconazole 200mg BID X 1 week
fluconazole 150mg weekly for 2-6 weeks

61
Q

Tinea unguium

A

aka onychomycosis

fungal infection of nail, more common toe nails

62
Q

Risk factors for Tinea Unguium

A

> 40yrs old
Family history
Immunodeficiency
Psoriasis
Diabetes
PVD
Tinea pedis
Sporting activities

63
Q

Distal sublingual onychomycosis (DSO)

A

most common
T.rubum common cause
nail plate, bed and maybe matrix effected

white, yellowish or brown discoloration

64
Q

White superficial onychomycosis (WSO)

A

t.metagrophytes most common cause
localized to surface of nail place

65
Q

Proximal sublingual onychomycosis (PSO)

A

invades nail through proximal nail fold and spreads to nail plate and matrix

uncommon in general pop, mostly immunocompromised patients

66
Q

Topical medications approved for onychomycosis

A

Jublia
Kerydan
Penlac

67
Q

Penlac (Ciclopirox 8%)

A

mild-moderate onychomycosis
Early stages of DSO
Treatment for 1yr
only superficial
Limited to 3-4 nails
used if Systemic therapy is CI

68
Q

systemic treatment of onychomycosis

A

Terbinafine or itraconazole
generally 3 months
12 weeks for toenails or 6 weeks for fingernails

69
Q

Tinea cruris

A

jock itch
scaly, erythematous margin
more common males
source of infection is almost always patients feet

70
Q

Tinea cruris txm

A

topical therapy is recommended for 1-2 weeks after system resolution

severe/resistn require oral therapy

relief of itching/burning can be facilitated by using short-term topical steroids

71
Q

Tinea corporis

A

ringworm of the body

commonly in obese, adults in warmer climates, day care kids

72
Q

Tinea corporis appearance

A

small, circular, erythematous scaly areas
may have pustules
may be itchy

73
Q

Tinea corporis treatments

A

topical agents usually

systemic for severely immunocompromised, griseofulvin preferred in children (has penicillin so if allergic cant use)

74
Q

Tinea capitis

A

Typically occurs in childhood
one or more patches of partial hair loss
more common in black females

75
Q

Tinea Capitis therapy

A

depends on causative organism

PO therapy for 4-12 wks depending on agent used

76
Q

If Tinea Capitis Microsporum Canis confirmed or unknown

A

1st = Griseofulvin (6-12weeks)
2nd = Terbinafine, itraconazole, fluconazole

77
Q

If Tinea Capitis Trichophyton tonsurans confirmed

A

1st = Terbinafine (2-4wks), 6 weeks if granule formation
2nd = Griseofulvin, itraconazole, fluconazole

Family members maybe asymptomatic = use antifungal shampoo for at least 5 min, 3 times per week

78
Q

Pityriasis Versicolor

A

Also called tines versicolor
more common in adults and those in tropical temps

79
Q

Pityriasis Versicolor therapy

A

1st line = Ketoconazole or selenium sulfide
Topical Terbinafine maybe used

Hypopigmented areas take longer to regiment

80
Q

Pityriasis Versicolor therapy duration

A

Usually 2-3 weeks

Ketoconazole = QD 2-3weeks, let sit for 5min then wash off
Selenium sulfide = apply 10min, wash off for 7 days

81
Q

systemic treatment of Pityriasis Versicolor

A

itraconazole and fluconazole are effective and preferred

keto works but dont want to work

terbinafine and griseofulvin not effective

82
Q

Goals of therapy for fungal infections

A

Reduce and or relieve symptoms
Eradicate fungus
Prevent future infections
Prevent spreading of infections

83
Q

Counseling points for fungal infections

A

reduce moisture to affected area
avoid tight fitting clothing
keep areas clean
dry areas completely
wash infected clothing separately
avoid walking barefoot in communal areas
keep nails short and clean
avoid sharing personal items
use separate towels to dry off affected area

84
Q

Exclusions for self care

A

Tinea unguium or Capitis
uncealer etiology
signs of 2ndary infection
involvement of face, genitalia, or mucous membranes
if topical doesn’t work
diabetes, systemic infection or immunodeficiency

85
Q

When to choose cream

A

better coverage because rubbed into skin

product needs to be dried before putting socks on

86
Q

When to choose powder

A

good for excessive wetness
good for skin folds where moisture accumulates

87
Q

When to choose solution

A

better coverage of affected areas like creams
dries more rapidly but more expensive

88
Q

When to choose spray

A

easy to apply, especially hard to reach
Not as effective due to no rubbing

CDM 3 Exam 2 (11 decks)

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