Med classes- Skin Quiz 2 Flashcards
What are the 2 layers of the skin and what do they do? *
- Epidermis: is the protective layer—its outer most surface (the stratum
corneum) contains lipids & keratin - Dermis: lies between the epidermis and SQ fat layer—it is composed of
connective tissue and contains sweat glands, sebaceous glands, hair follicles and vessels
Key factors in a skin exam
-Perform in well-lit room
-Use hand-held light for illumination
-Wood’s lamp helpful for fluorescing certain types of lesions
-KOH (potassium hydroxide) and/or 5% acetic acid prep may be needed for certain pathogens
-With ANY suspicious lesion, skin cancer must be ruled out
What to know about steroids on the face*
-Use lowest strength possible,
starting with a potency that is less than the standard dosage
-NO fluorinated steroids on the face or perineum—can cause striae and
permanent thinning of the tissue
Why does the “vehicle” choice matter in terms of skincare? *
What would you use each for
-Therapeutic effect can depend on whether the vehicle is water or oil based
-Ointment= use for dry, thick, scaly (Psoriasis, eczema, con= greasy, staining, not suitable for hair)
-Cream= generalized use (con= more frequent application, less occlusive)
-Lotion= more water based, less greasy (Better for large, hairy, inflamed areas, cooling effect, fast absorption)
-Cons= less hydrating, may contain ETOH which causes stinging
-Gel= acne, scalp, rosacea (good for oily skin)
Cons= drying, irritation
-Foam: Hair or scalp (good absorption, but expensive)
-Solution: Good for oily skin, scalp Cons=can be drying
-Powder: Absorbent dry (good for fungal infections, reduces moisture and macerations, limited penetration)
What are the two main types of UV radiation? *
What is the effect of each on the skin?
- UVB [bad]: are the rays that burn us, cause wrinkling and skin cancers
- UVA can cause some wrinkling and with many decades of “lead time” may manifest itself as BCC, melanoma, SCC, and DNA damage later in life
-NOTE: Small amounts of UV exposure daily can help maintain our bone and teeth stability
Derm Terms to know*
- MED—minimal erythemal dose—minimum amount of UV radiation that produces evident erythema
after one exposure - SPF—describes the amount of UVB protection (i.e., protection against sunburn) that a sunscreen provides. SPF values are not related to time but rather to the amount of UV exposure [MED on protected skin ÷ MED on unprotected skin]; gives direction for how long one will be protected before burning
- Broad Spectrum—effective against both UVA & UVB radiation; these protect against sunburn, skin cancer
and photoaging - Water Resistant—sunscreen is effective for 40-80 minutes while a person is swimming [or is sweating]
Sunblock (Mineral) *
Sunblock:
-Usually contains Zinc oxide/Titanium dioxide
-Block ALL sun rays, not just protect from sun’s burning rays
Per chat:
-Works by reflecting/ scattering rays
-Works as physical blocker
-Thicker, may have a white cast
-Better for use on sensitive/ reactive skin
Sunscreen*
Need to double check what she’s looking for for SPF
-Per chat:
-Contains chemical ingredients like avobenzone, oxybenzone, octisalate, and homosalate.
-Absorbs UV rays chemically
-Works by chemical filter
-Usually lightweight/ transparent and can be used for all skin types
-Use of sunscreens with SPFs of >16 for 5 years will decrease malignant melanoma risk by 50%
-Educate your patient about what an SPF of a 2, 20, 15, 30 would mean…for a person who burns in 1 minute in the sun without sunscreen
-Recommended Use: 3 tablespoons every 120 minutes
Special considerations for sunscreen*
-Apply sunscreen, then wait 30 minutes to apply insect repellant
-Use a broad-spectrum sunscreen with an SPF of at least 15 (per FDA) or 30 (per the American Academy of Dermatology and Health Canada)
-Limit time in the sun, especially between 10AM and 2PM when the sun’s rays are the strongest
-Apply sunscreen 15 minutes before sun exposure for best effectiveness
-Reapply sunscreen at least every two hours, as well as right after sweating or swimming
-Use a lip balm with SPF 30 or higher to protect the lips
-For infants less than 6 months—use small amounts of SPF 15 or less sparingly
-Sunscreen expires 36 months after date manufactured date
Glucocorticoids: How they work on the skin*
-Occlusive dressings can significantly increase absorption and may also increase side effects
-Applying topical steroids to wet skin may improve effectiveness
-Total dose for very high potency steroids should generally not exceed 50 grams per week because of the potential for adrenal suppression
-Used to reduce inflammation, itching, and redness in skin conditions like eczema, psoriasis, and dermatitis.
They work by modifying the immune response and reducing skin inflammation.
Glucocorticoides: ADE *
-Acneiform eruptions, dermatitis, local infections, hypopigmentation
-In children, applying potent steroids to large BSA can cause systemic toxicity—depression of HPA axis and growth retardation
-Skin changes such as atrophy (thinning), telangiectasias (red or purple clusters on the skin from dilated capillaries), and striae
-Though mild atrophy usually resolves after stopping the steroid, telangiectasia and striae are less likely to resolve with discontinuation.
Acne Vulgaris *
What is it? Subcategories?
Patho: Excess sebum, Comedones, Propionibacterium acnes overgrowth, Inflammation
-How its classified:
-Comedones, pustular/papular and nodular
-Disease further subdivided as→
-Mild—comedonal, pustular/papular
-Moderate—pustular/papular, small nodules [up to 1 cm]
-Severe—nodular, cystic/pustular [also called acne conglobate]
Retinoids*
MOA/ADE
-Derivatives of Vitamin A
-Influence cell proliferation, immune function, inflammation & sebum production
-These agents are comedolytic and anti-inflammatory
MOA: mediated through nucleic
retinoic acid receptors
ADE’s: irritation, dryness, skin peeling, photosensitivity, dry MM &
eyes
Tretinoin (Prototype drug for retinoids) vs other retinoids*
-Tretinoin: 1 st generation agent
-Other agents:
-Isotretinoin—1 st generation
agent—category X agent (must be prescribed by licensed providers—I Pledge Program)
-Oral agent
-Used in scarring acne and in
severe disease
-Adapalene / Tazorac—3rd
generation agent—less irritating
-1st line for comedonal and
inflammatory acne
First line acne treatments *
- Benzoyl peroxide:
-1 st line for mild to moderate acne with NO inflammation
-MOA: antiseptic against P acnes and opens pores
ADE’s:—dry skin, peeling, irritation, eyebrow discoloration - Salicylic Acid:
-MOA: exfoliates to clear comedones; mild antiinflammatory activity and is keratolytic at high concentrations
-Usually for mild disease
-ADE’s: peeling, dryness, local irritation - Azelaic Acid:
-Antibacterial against P acnes and it has antiinflammatory actioins
-Used in mild to moderate inflammatory acne
-ADE: skin irritation
Antibiotics for acne*
-P acnes is a gram + rod associated
-For moderate to severe acne with inflammatory lesions, topical or oral antibiotics can inhibit this bacteria’s
growth (Erythromycin and Clindamycin are available and used)
-Topical antibiotics best when combined with Benzoyl peroxide or
retinoids
-Topical Dapsone [a sulfonamide] is available (MOA is unknown)
ADE: methylhemaglobinemia (PERMANENT DONT GIVE)
-Moderate to severe acne requires ORAL antibiotics— Doxycycline [preferred] or Minocycline
How to know which acne treatment to use *
For mild acne:
-If mainly comedones—treatment of
choice is topical retinoid
-If mainly is papular/pustular—treatment of choice is topical retinoid + benzoyl peroxide [BPO] OR topical retinoid + BPO/antibiotic combination
For moderate acne:
-For papular/pustular disease—topical retinoid + oral antibiotic & BPO (or OCP)
-For nodular disease— topical retinoid + oral antibiotic & BPO [or
BPO/antibiotic]
-Alternative—Isotretinoin orally
For severe disease:
-For nodular—oral antibiotic and topical retinoid + BPO (can add
OCP)
-For cystic/pustular—oral
Isotretinoin [Accutane]
-Alternative is high dose
oral antibiotic and topical
retinoid + BPO (& OCP)
Isotrentinoin important warnings*
-Requires prescribers be trained and registered— have a federal ID number
-Category X pregnancy
-The iPLEDGE program is a mandatory, FDA-regulated initiative for isotretinoin prescribing to prevent fetal exposure. Key components include:
-Monthly doctor visits for pregnancy tests and counseling (Check LFT’s/ cholesterol)
-Strict rules for contraception (two forms of birth control or abstinence).
Limited prescription fills (usually for 30 days).
Rosacea *
Etiology
-Chronic acne-like inflammation of central area of face, yet no comedones are present
-Etiology:
-Cutaneous vascular disorder of capillaries
» Increased reaction to heat causes “flushing”
» Ocular symptoms may include blepharitis, conjunctivitis
-Incidence/Demographics:
-Common in fair skinned, middle aged to elderly people
What is Rhinophyma *
-Severe form of rosacea seen almost exclusively in men >40 years
-Irreversible hypertrophy of
the nose– is a result of chronic
inflammation
What meds do we give for rosacea *
-Sodium Sulfacetamide with Sulfur
(Usually prescribed as a daily wash)
-Topical Metronidazole (This agent is considered DOC and is safe in pregancy)
-Azelaic acid ( Effective for papules,
pustules, erythema but does not
deter telangiectasias, Safe in pregnancy)
-Oral Doxycycline (Can give erythro)
What is Actinic Keratosis and how do you treat it? *
-Discrete, dry, scaly lesions occurring on sun exposed skin of susceptible adults (color ranges from light tan to brown with or without reddish tinge)
-Precursor to squamous cell carcinoma [SCC]
-Etiology: Recurrent or prolonged sun-exposure in fair skin
-Common in elders from photoaging of skin (More common in males)
-Topical Therapies:
-Cryotherapy, curettage, photodynamic therapy, facial resurfacing, chemical peels
-5 Flourouracil:
-MOA—inhibits DNA & RNA synthesis
-Side effects—redness, crusting, intense stinging
-Imiquimod:
-ADE: redness, crusting, intense stinging
Atopic dermatitis and how you treat it*
-Global term that may be referring to atopic dermatitis [eczema] or allergic contact dermatitis
-Causes profound pruritus—often termed “the itch that rashes”
-Chronic disorder; genetic linked, made worse by stress, hormonal variation
-These people often have marked allergies to food, meds, pollens, etc
-Lesions often appear in first year of life
-Treated with a regimen of emollients, topical steroids, +/- topical immune modulators
Calcineurin Inhibitors:
- Tacrolimus ointment
-Pimecrolimus cream
-BOTH Used as steroid sparing agents in chronic eczema
-Both have BLACK BOX WARNINGS for skin malignancies and lymphoma
-Neither to be used in children under the age of 3 years
Verruca (warts) Defined *
-Small, usually painless growths on the skin caused by [HPV]; generally harmless—they can itch or hurt
if on plantar aspect of the feet
-Different types of warts:
-common warts: are usually on hands, but can appear anywhere
-Flat warts—often found on face and
forehead; common, in children, rare in adults
-Genital warts (also known as condyloma):seen on genitals, in pubic area, and in between the thighs, but can appear inside vagina & anal canal
-Subungual and periungual warts: appear around the fingernails and toenails
-Plantar warts: are found on soles of feet
Treatment of warts*
-OTC wart removal products: patients should try and file wart down after bathing before applying the agent
-Salicylic acid topically: many OTC formulations
-Other prescription agents—Podophyllin or Imiquimod
-Other treatments—surgical removal, cryotherapy, electrocautery or laser
Alopecia *
-Trichogenic agents are used
to treat androgenic alopecia
[male pattern baldness]
-Minoxidil (PROTOYPE) —used to
halt hair loss in both men & women
-MOA unknown; thought to act by shortening the rest phase of the hair cycle; must be used continuously
-Finasteride—5 alpha reductase
inhibitor that blocks conversion of
testosterone to 5 [DHT]
-High levels of DHT cause the
hair follicle to atrophy; this
agent lowers scalp and serum
DHT levels
-Adverse effects—decreased
libido, decreased ejaculation, ED
-Approved for men, should not
be used or handled in pregnancy as it can cause hypospadius in male fetus
Hydroquinone (PROTOTPYE)*
-Topical skin whitening agent (inhibits the tyrosinase enzyme
required for melanin synthesis)
-Used to reduce pigmentation—along with topical retinoids
- 4% preparation is best agent
-Adverse effects—local skin
irritation
NOTE Rebound Hyperpigmentation may occur if it is used without breaks, the skin may develop resistance, and pigmentation can return more intensely after discontinuation.
Treating GRAM POSITIVE skin infections Topically*
-Bacitracin: used most often for prevention of skin disease after burns and scrapes (small area)
Impetigo*
-Mupirocin—protein synthesis inhibitor; Useful for treating impetigo and other serious gram +
-Retapamulin– protein synthesis inhibitor approved for the treatment of impetigo
*CRUSTY
Onychomycosis *
Terbinafine [Lamisil] PROTOTYPE DRUG
-Active against most all strains of dermatophytes
-Oral form is DOC for onychomycosis (topicals don’t work)
-Topical [cream usually] treats tinea
pedis, corporis, cruris
-Concentrates in breast milk
- ½ life in tissues is 200-400 hours
-Avoid in patients with liver dysfunction
-ADE’s:—diarrhea, dyspepsia,
nausea, headache, elevated LFTs
-Cicloprirox
-Agent inhibits transport of essential elements that allow DNA, RNA and protein synthesis
-Only topical antifungal active against ALL dermatophytes and all strains of Candida
-Used for tinea pedis, corporis & cruris, cutaneous candidiasis and tinea versicolor
-Not used for vaginal candidiasis
Treating GRAM NEGATIVE skin infections Topically*
-Polymyxin B—cyclic hydrophobic peptide that disrupts the bacterial cell membrane of gram - pathogens
-Commonly combined with Neomycin** & Bacitracin in
triple antibiotic [TAO] products
-Gentamycin
**Allergic dermatitis and other sensitivities common with Neomycin
Treating skin infections systemically*
-Augmentin [or high dose Amoxicillin]
-Cephalexin
-Doxycycline
If MRSA suspected—Trimethoprim/Sulfa or Doxycycline
-Clindamycin or Rifampin if infection severe
-Fluoroquinolones might be an option—depending on your
geographical area—Levofloxacin or Moxifloxacin
Ectoparasitic infections of the skin*
-Parasites that live on animal skin [where they obtain their nutrition] and can jump “species” and infect humans
-Pediculosis—lice
-Scabies—mite
Agents we use in these infections—Lindane, Permethrin, Synergized pyrethrins with piperonyl butoxide
Antiparasitic agents*
-Lindane—cyclohexane derivative
-Available as cream or shampoo; kills lice & scabies
-Permethrin—synthetic pyrethroid that is neurotoxic to lice and scabies
(Preferred over Lindane, as Lindane can cause neurotoxicity)
-Ivermectin—given orally, is an alternative therapy for lice and
scabies
-Synergized pyrethrins with piperonyl butoxide—OTC product used to treat head and pubic lice [Rid]
-Pyrethrins are pesticides
Fungal infections of the skin*
-These are infections that are limited to the hair follicle and epidermal layer of the skin and nails
-Dermatophytosis: Do not invade dermis because of keratin dependency (aka ringworm)
-Candidiasis: More common in patients with comorbidities
Treating fungal infections *
-Yeast infections—candida species
-Non-yeast fungal infections—dermatophytes [tinea]
-Tinea appears as rings or round red patches with clear centers (often called “ringworm”)
How do we treat fungal infections?*
-Squalene Epoxidase Inhibitors
-“fine”
-These agents block the biosynthesis of ergosterol— which is needed in the fungal cell membrane
Agents in Class:
- Naftifine, Butenafine
Griseofulvin*
-Antifungal
-This agent disrupts the mitotic spindle and inhibits fungal mitosis
-Older agent (has been replaced for the most part by Terbinafine, but still used for dermatophytes of scalp
and hair)
-Agent is fungostatic—so duration of treatment is long—500 mg po daily 6 to 12 months for nails
-Absorbed from GI tract, enhanced by high fat meal
-It increases the metabolism of anticoagulants
-Contraindicated in pregnancy and patients with porphyria
Imidazoles*
-“Azole’s”
Azole derivatives that have a wide
range of activity against the 4 most
common dermatophytes and Candida species
-These agents are given for tinea
corporis, cruris and pedis; oral/pharyngeal & vaginal Candida
-Prolonged topical use can cause
contact dermatitis, vulvovaginal
irritation/edema
-The only AZOLE that covers Candida glabrata is terconazole [Terazol]*
-Examples: Butoconazole, Clotrimazole, Econazole,, Ketoconazole, Miconazole,
Oxiconazole, Sertaconazole, Sulconazole, Terconazole—Terazol [vaginal] Tioconazole—Monistat [vaginal], Fluconazole—Diflucan (oral)
Psoriasis *
-Chronic, scaling papules and plaques
-Characteristic distribution is knees, elbows, scalp
-Skin lesions occur insidiously [on occasion may be acute +/-
pruritus; may be associated with acute systemic illness w fever and malaise (strep)
-Etiology: Alteration in cell kinetics of keratinocytes with shortening of cell
turnover rate, resulting in increased production of epidermal cells
- Silvery-white scaling with pinpoint
bleeding when scale removed (Auspitz sign) - Assess quality of life—ask about
pain
-Important nondrug therapies—avoid
rubbing/scratching; advise patient
to eat a healthful diet, exercise and
lose weight, stop smoking
How to treat psoriasis *
-Patients with mild to moderate disease can be managed with topicals—retinoids, Vitamin D analogues, keratolytics, topical steroids
-For more severe disease, systemic therapies—
Methotrexate, Cyclosporine, immune modulators
-If patient not a candidate for the aforementioned—
phototherapy [Methoxsalen + UVA [PUVA] OR UVB alone]
Retinoids used in psoriasis *
-Tazarotene [Tazorac]—topical retinoid for plaque psoriasis
-Acitretin [Soriatane]—2nd generation retinoid; given
PO for pustular psoriasis
-½ life of 120 days; ETOH contraindicated as it increases potency and prolongs ½ life
-Teratogenic and women must avoid pregnancy for at least 3 years after using Acitretin
-ADE: cheiliitis (cracking lip cornners) pruritus, peeling skin, hyperlipidemia
Vitamin D Analogues *
-These agents inhibit growth of keratinocytes (2nd line)
-Calcipotriene & Calcitriol
-Synthetic Vitamin D3 derivatives used topically to treat plaque psoriasis
-Can cause hypercalcemia
ADE: itching, dryness, burning irritation and erythema
Other agents used for psoriasis *
-Corticosteroids (First line)
-High potency topical steroids
for 2-3 weeks; then, use in pulse
fashion for 2 d/week
-Avoid ORAL steroids which can cause
rebound flares (tachyphlyaxis)
-Long term use of topical corticosteroids is limited by
cutaneous atrophy
-Calcineurin Inhibitors:
-Tacrolimus [Protopic]
-Pimecrolimus [Elidel]
-These agents inhibit T-cell activation/ proliferation by blocking calcineurin phosphatase. This leads to the suppression of these cells and reduced production of pro-inflammatory cytokines.
-Steroid sparing agents; used
in flexural and facial psoriasis
Systemic therapies for psoriasis *
-If unresponsive to topicals or BSA >5%:
-Apremilast
-Methotrexate (With Folic acid)
-Cyclosporine
-Worry about hepatotoxicity and myelosuppression
-TNF Alpha Blockers
-Adalimumab
-Etanercept
-Infliximab
-Interleukin IL-12 & IL 23 Blocker:
-Ustekinumab
-Interleukin IL-17A Blocker
-Secukinumab
-Worry about imunosuppression
-Phototherapy (Can be used with topicals) (can get basal cells down the road)
-PUVA [Psoralen with UVA light]
-Narrow band UVB therapy
Eczema
-Restores skin barrier, suppressing inflammation
-Topical agents:
-Emollients
-Topical steroids
-Calcineurin inhibitors
Cellulitis
-Topical Mupirocin (mild)
-Severe (cephalexin, clindamycin, vanco, ancef)
