Pharm - BP, Poison Ivy, Vitiligo

Question 1

Bullous Pemphigoid

- first line therapy

Answer 1

Topical or systemic steroids

Question 2

Bullous Pemphigoid

- what is often added to first line therapy? why?

Answer 2

• immunomodulatory therapy

- minimize ADR or augment response

Question 3

Bullous Pemphigoid

- 3 goals of therapy for

Answer 3

• Decrease blister formation and pruritis
• Promote healing of blisters and erosions
• Improve QOL

Question 4

Bullous Pemphigoid

- What should be done with blisters?

Answer 4

rupture them daily - reduces lateral extension of blister edge

Question 5

Bullous Pemphigoid

- risk factors for infection

Answer 5

• # of skin lesions

- use of immunosuppressants

Question 6

Bullous Pemphigoid

- 3 treatment phases

Answer 6

1. Control: intense therapy to suppress disease activity until no new lesions appear. Duration is weeks.
2. Consolidation: drugs and doses are maintained until complete clearance of lesions
3. Maintenance: meds gradually tapered until reach lowest dose that prevents new lesions

Question 7

Bullous Pemphigoid

- why are topical vs. systemic steroids preferred in extensive disease

Answer 7

• Better clinical outcomes in extensive BP than with systemic steroid therapy
• One-year survival rate, disease response, server complications lower versus tx with systemic steroids
• There is apparently a third reason…

Question 8

Bullous Pemphigoid

- what type of topical glucocorticoid is preferred

Answer 8

Super high potency

- clobetasol 0.05%

Question 9

Bullous Pemphigoid

- How to dose topical corticosteroids

Answer 9

• full therapeutic dose until active disease process halts: once active inflammation, new blister formation, pruritis cease for min 2 weeks and 80% of blisters are healed
• prolonged taper needed: typically lasts 4 months or longer

Question 10

Bullous Pemphigoid

- ADR of topical corticosteroids

Answer 10

• Cutaneous atrophy
• Striae
• Folliculitis
• Adrenal suppression

Question 11

Bullous Pemphigoid

- what is second line when topical corticosteroids are not feasible

Answer 11

oral systemic corticosteroids

Question 12

Bullous Pemphigoid

- The many ADR of systemic corticosteroids

Answer 12

• HTN
• Elevated blood glucose
• Osteoporosis
• Increased fx risk
• Cataracts
• Muscle wasting
• Thinning skin
• Increased bruising
• Immunosuppression
• Increased risk fo infection
• Weight gain/ increased appetite
• HPA axis suppression
• Psychological effects- depressed or elevated mood
• Changes in memory and behavior

Question 13

Bullous Pemphigoid

- why are immunosuppressive and anti-inflammatory drugs used with glucocorticoids?

Answer 13

Minimize dependence on systemic glucocorticoid therapy

Question 14

Bullous Pemphigoid

- how to dose glucocorticoid-sparing agents with glucocorticoids?

Answer 14

• Glucocorticoid-sparing drugs clinical response is slower than systemic glucocorticoids
• Begin treatment with glucocorticoid-sparing agent just prior to starting glucocorticoid taper
• Then slowly taper glucocorticoid with goal to discontinue completely and continue therapy with immunosuppressant alone

Question 15

Bullous Pemphigoid

- what are three immunosuppressive drugs

Answer 15

1. azathioprine
2. Mycophenolate mofetil
3. Methotrexate

Question 16

Bullous Pemphigoid

- Risk associated with immunosuppressants

Answer 16

• cancer

- infection

Question 17

Bullous Pemphigoid

- What baseline labs are needed before starting immunosuppressants?

Answer 17

• CBC
• Renal fn
• Liver fn

Question 18

Bullous Pemphigoid

- how to dose methotrexate

Answer 18

weekly

Question 19

Bullous Pemphigoid

- What must be added to methotrexate therapy

Answer 19

folic acid

- reduce hematologic and GI ADR

Question 20

Bullous Pemphigoid

- what is benefit to abx other than antimicrobial

Answer 20

anti-inflammatory

Question 21

Bullous Pemphigoid

- two abx used

Answer 21

• tetracyclines
• dapsone
• Use when glucocorticoid-sparing agent is required for pts with mild BP (risk of immunosuppressants outweighs the benefit)
• Also good option for pts who are not good candidates for immunosuppressants

Question 22

Bullous Pemphigoid

- what needs to be screened before using Dapsone

Answer 22

G6PD deficiency

Question 23

Bullous Pemphigoid

- what can be used to monitor response to therapy?

Answer 23

• BP 180 antibodies

- Generally correlate with clinical activity of BP

Question 24

Vitiligo

- what is first line therapy for LIMITED dz

Answer 24

• super high potency topical steroids

- modulate immune response

Question 25

Vitiligo | - Tx of choice for >10% BSA

Answer 25

- Narrowband/ NB-UVB phototherapy | - used for both stabilization and re-pigmentation

Question 26

Vitiligo | - What treatment is used for depigmentation

Answer 26

- monobenzone

Question 27

Poison Ivy | - role of decontamination after exposure

Answer 27

- After known exposure, remove any contaminated clothing and gently wash skin with mild soap and water (not rough, likely make dermatitis worse) - After 10 minutes, 50% of urushiol can be removed - After 30 minutes, 10% of urushiol can be removed - Washing within 2 hours can sig reduce likelihood and severity of dermatitis

Question 28

Poison Ivy | - Decontamination products (3)

Answer 28

- Tecnu - Goop - Dial ultra dishwashing soap * all sig reduce dermatitis when used within two hours of exposure

Question 29

Poison Ivy | - role of barrier cream in preventing exposure to poison ivy

Answer 29

- Topical preparations that are applied prior to exposure to contact allergen, attempt to prevent reaction - Organoclay compounds more effective than other preparations

Question 30

Poison Ivy | - topical treatments to relieve pruritus

Answer 30

- Oatmeal baths - Cool, wet compresses - Topicals containing menthol and phenol (calamine) - Topical astringents: aluminum acetate (Burow’s solution) or aluminum sulfate and calcium acetate (Domeboro) used under occlusion dressing - Soap mixture of ethoxylate and sodium lauroyl sarcosinate sufractants (Zanfel) * * Avoid topical antihistamines, anesthetics with benzocaine, abx with neomycin and bacitracin dt allergic potential

Question 31

Poison Ivy | - role of oral corticosteroids to relieve dermatitis sx

Answer 31

- Severe dermatitis (esp on face or genitals) may require | - If too short a course, risk rebound dermatitis (ex. 6-day medrol dose pack)

Question 32

Poison Ivy | - Oral corticosteroid example, dose, taper

Answer 32

- Prednisone - 1 mg/kg/day - Taper 2-3 weeks