Pharm Derm Exam 1 Flashcards
ABCDE
For Any Neoplasm
Asymmetry Borders Color Diameter Evolving / elevation
Types of benign tumors
Dermal tumors - acrochordon Cysts Vascular tumors (cherry hemangioma) Tumors of subcutaneous fat (lipoma) Hyperkeratotic reactions to chronic friction (callus/corn)
Premalignant neoplasms
Actinic keratosis appear over the exposed areas of the body as a result of actinic radiation
(solar)
Actinic Keratoses Treatments
Fluorouracil
imiquimod
ingenol mebutate
5 fluorouracil
Efudex (5%)
(Antimetabolite)
Cream or solution
a topical chemotherapy
most common treatment of most common precancer
(actinic keratoses)
Superficial basal cell carcinoma when conventional therapy is impractical
Preg Cat X
Adverse
Pain or burning at application site, pruritis, irritation, hyperpigmentation
5 fluorouracil MOA
Inhibits thymidylate synthetase and incorporates into DNA as an abnormal nucleotide
imiquimod
Aldara (5%) Cream
Actinic keratoses on face or scalp
Immune response modifier that is a Toll like receptor 7 agonist that activates immune cells
ingenol mebutate
Picato
Actinic Keratoses
Cell Death inducer
Actinic Keratoses Treatment options
Lesion directed
Surgery
Cryotherapy
Dermabrasion
Field directed Topical Fluorouracil imiquimod ingenol mebutate
or photodynamic therapy
Bowens disease Treatment
Surgical excision curettage electrodessication Photodynamic therapy Cryotherapy Topical fluorouracil Topical imiquimod
Keratoacanthomas
Conventional surgical excision is the treatment of choice for solitary Keratoacanthomas
Basal cell carcinoma topical treatment
Fluorouracil
imiquimod
Squamous cell carcinoma
If Low recurrence
Treatment
If low risk of recurrence Treatment Surgical excision Mohs surgery Curettage and electrodessication Cryotherapy Photodynamic therapy Radiation therapy (non surgical candidates)
pembrolizumab
Keytruda
Human programmed death receptor 1
PD -1 Blocking antibody
for unresectable metastatic melanoma
Embyro Fetal toxicity
pembrolizumab
MOA
releases the “brake” allowing T cells to act
protein receptor is the “brake”
pembrolizumab (keytruda)
Warnings and precautions
Immune mediated adverse reactions
Immune mediated adverse reactions
Pneumonitis, colitis, hepatitis, hypophysis, nephritis, hyperthyroidism, hypothyroidism
Administer corticosteroids based on severity of reaction
Withhold or discontinue keytruda depending upon severity of reaction
pembrolizumab (keytruda)
Warnings and precautions
Embryofetal toxicity
Keytruda may cause fetal harm
Advise females of reproductive potential to use highly effective birth control during treatment with keytruda and for 4 months after the last dose.
Acne treatments Based on MOA
Inflammation
Oral isotretinoin
Oral tetracycline
Topical retinoids
Azelaic Acid
Acne treatments Based on MOA
C. Acnes proliferation
Benzoyl peroxide
Topical and oral antibiotics
Azelaic acid
Acne treatments Based on MOA
Increased sebum production
Oral isotretinoin
Hormonal therapies
Acne treatments Based on MOA
Follicular Hyperproliferation and abnormal desquamation
Topical retinoids Oral Retinoids Azelaic acid Salicylic acid hormonal therapies
Retinoic acid
most common adverse effects
The most common adverse effects of topical retinoic acid are erythema and dryness that occur in the first few weeks of use
But these can be expected to resolve with continued therapy
Isotretinoin
Accutane
Sever recalcitrant nodular acne unresponsive to conventional therapy (eg. systemic ABX)
Not for children
Preg Cat X
Severe birth defects
Must register patients in Ipledge
Avoid tetracyclines (increased risk of pseudomotor cerebri)
Adverse
Dry skin, eyes, nose, mouth, lips
REMS
To inform patients about the serious risks associated with drug X
To minimize potential drug drug and disease drug interactions
To prevent the risk of fetal exposures to drug X
Isotretinoin (what is does)
Used for acne vulgaris
improve through reducing sebum production inhibiting growth of cutibacterium acnes and inhibiting comedogensis
Multiple side effects include
tetragenicity, mucocutaneous disorders, myalgia
Not for use with pregnancy
Not for use with tetracyclines
(Idiopathic intracranial hypertension (pseudo cerebri)
Oral ABX for acne
Tetra Doxy minocycline Sarecycline Erythromycin Bactrim Azithro
Topical combination Med
Benzoyl peroxide 5% / clindamycin 1%
Local ski irritation, may bleach skin or clothing
Hormonal agents for acne
Spironolactone
contraindicated in pregnancy
Azelaic acid
Azelex
Antibacterial / anti keratinizing agent
Sulfacetamide Topical 10%
Wash or lotion
Contra
sulfa allergy
Adverse
SJS
Erythema multiforme (HSV) (target lesions)
Folliculitis
Most common pathogen S. aureus
Other common pathogens Pseudo, malassezia, demodex mites
Mild s. aureus folliculitis usually resolves on its own
persistent S. aureus folliculitis = topical ABX
Topical mupirocin, clinda are preferred
Mupirocin MOA
inhibits bacterial protein synthesis by reversible binding and inhibiting isoleucyl transfer RNA synthetase
with subsequent inhibition of the incorporation of isoleucine into bacterial proteins
Brimonidine
Topical Mirvaso 0.33% gel
for persistent (non transient) facial erythema of rosacea
Pregnancy Cat B
Alpha 2 agonist (direct vasoconstriction of vessels)
Interactions
Caution with Beta blocker, antihypertensives and cardio glycosides
Topicals for rosacea
Topical Metronidazole
(metrogel, metrocream, metrolotion, noritate)
Topical doxy = Oracea
Topical Ivermectin = Soolantra
Topical azelaic acid = Finacea
Rosacea Patient Education
Avoidance of triggers of flushing
gentle skin care,
sun protection
Rosacea and tetracycline
Not to be used in children under nine
Erythema infectiosum
5th disease
There is no specific therapy and usually no indication for symptomatic treatment
Human parvovirus B19 infections
Hand foot and mouth Disease
clinical syndrome with
oral enanthem
macular, maculopapular, vesicular rash on
hands and feet
children and adults
coxsackie b
First seen in 1957 - toronto
Management is supportive
Measels
Prevention is key MMR vaccine
There is a role for Vitamin A
Supportive therapy includes antipyretics, fluids, treatment of bacterial super infections
(pneumonia, otitis)
When to use ribavirin in Measles
under 12
over 12 with pneumonia on vent
immuno suppressed patients
Alopecia areata
chronic, relapsing, immune mediated inflammatory disorder affecting hair follicle resulting in non scarring hair loss
Tx: topical, intralesional, systemic agents, devices
few clinical trials so response varies widely
Alopecia areata treatment
scalp intralesional injections of corticosteroids
topical corticosteroids in children or those unable to tolerate intralesional injection
with extensive alopecia areata or alopecia totalis who don’t respond to treatment
use topical immunotherapy
Number of potency categories of topical steroids
7
Group 1 is highest potency
Group 7 is lowest potency
(hydrocortisone 2%)
Topical steoirds in skin disease
anti inflammatory
anti mitotic
immunosuppressive
topical is safer than systemic
side effects can still occur especially with super potent
Side effects of higher potency topical corticosteroids
Cutaneous atrophy
telangiectasias
striae
others acneiform eruptions purpura hypopigmentation glaucoma
Onychomycosis causes
Dermatophytes
particular trichophyton rubrum is most common cause
Yeast (candida) and non dermatophyte molds can also cause onychomycosis
First line for mild to moderate dermatophyte onychomycosis
Terbinafine (lamisil)
Terbinafine
Lamisil
Allylamine antifungal
Onychomycosis of toenail or fingernail due to tinea unguium
Contra
Chronic or active liver disease
LFT’s prior to start and during treatment
Discontinue if Liver injury
Preg Cat B
Adverse
Liver enzyme abnormalities
Hepatotoxicity
Acute paronychia causes
S. Aureus, Strep pyogenes are most common
periungal tissues
minor mechanical or chemical trauma that disrupt the nail fold barrier
Acute paronychia treatment
without abscess
topical ABX and warm water/antiseptic soak (eg iodine)
multiple times a day
usually an anti-staph antibiotic like mupirocin or triple antibiotic ointment
Soaks should be 15 mins
With abscess
I&D with culture and cover MRSA
Melasma Tx
There is no standard therapy for melasma
Photoprotection (prevention) strict photoprotection, sun avoidance, sun protective clothing, sunscreens
vitiligo tx
No cure
Treatments can stop progression
and help repigmentation
for rapidly progressing non-segmental vitiligo oral glucocorticoids rather than ultraviolet is first line
Vitiligo goals of treatment
Stabilization of active disease
repigmentation
treatment is slow and variable
Tacrolimus
Protopic (immunomodulator)
Atopic derm
Warning
Long term safety of topical calcineurin inhibitors has not been established
Black box
Skin malignancies, lymphoma
Tacrolimus MOA
Calcineurin inhibitor
Inhibits T lymphocytes and pro inflammatory cytokines in inflamed dermis
Seborrhic keratosis
Well demarcated, round or oval lesions with a dull
verrucous surface and typical stuck on appearance
Seborrhic keratosis treatments
Cryotherapy = most common
flat fair lesions
Curettage / shave excision
submit specimen to pathology
(no 15 scalpel, 1% lido)
Electrodessication
use with 1% lido
Cherry hemangioma
only treat if patient is bothered by them
cosmetic
new lesions may appear
no way to prevent this
Telangiectasias
Lasers provide quick effective therapy
particularly for multiple telangiectasias
large areas with telangiectasias
or lesions that have failed to resolve after electrocautery
CREST
Calcinosis (deposits on hand)
Raynauds
Esophageal dysfunction
Sclerodactyly (thick skin on fingers)
Telangiectasias
Bullous pemphigoid treatment
Decrease blister formation and pruritis
Promote healing of blisters and erosions
Improve quality of life
Topical steroids
Systemic steroids
Doxy
pemphigus vulgaris treatment
systemic glucocorticoids
rituximab
Rituximb
rituxan
CD20 directed cytolytic monoclonal antibody
moderate to severe pemphigus vulgaris
Warning Fatal infusion related reactions severe mucutaneous reactions Hep B reactivation Progressive multifocal leukoencephalopathy
Interaction
Live vaccine
Erythema multiforme
target like lesions
commonly from infection (HSV)
If HSV oral antivirals don’t work
Topical corticosteroids and oral antihistamines
SJS / TEN
Sever mucocutaneous adverse reactions
most commonly triggered by medications
Fever, extensive necrosis and detachment of dermis
SJS = 10% BSA
TEN >30% BSA
SJS / TEN = 10-30% BSA
Supportive care is tx = nutrition ,eyes, electorlytes, fluids, temp, pain control etc
Common drugs of SJS
SATAN Sulfa Allopurinol Tetracycline Anticonvulsants NSAIDS
Antiepileptics =
carbamazepine lamictal, phenytoin, phenobarb
Widow bite treatment
usually respond to narcotics, benzos
and hen necessary, antivenom
wound care tetanus opioids (pain) benzos (muscle spasms) Antiemetic (N/V)
Recluse bite Treatment
Symptomatic and supportive care
wound care
Causes dermal necrolysis
no antivenom
dont use dapsone
Rocky mountain spotted fever bacteria
Rickettsia Rickettsi
Ehrlichiosis
Rash is uncommon
Doxy for all ages
Lyme disease bacteria
Borrelia burgdorferi
Lyme disease treatment
doxy 100mg BID 10-14 days
Erythema migrans
Misc insect bite treatment
antihistamines
if severe, can use prednisone
Empiric MRSA coverage
IV Vanc
PO Bactrim
Non purulent cellulitis treatment
Empiric therapy for
beta hemolytic strep
MSSA
Possibly for MRSA
Use cefazolin IV
or Cephalexin PO
5 days of treatment for uncomplicated infection
can be extended to 14 days if severe
purulent cellulitis treatment
I&D
Cover with ABX for MRSA
Erysipelas vs cellulitis
treat empirically for beta hemolytic strep
will have more delineated borders compared to cellulitis
superficial dermis
superficial lymphatics
(Cellulitis is deeper)
Erysipelas treatment
Mild = oral penicillin or amoxicillin
if allergic
use cephalexin
if cant tolerate
use clinda, Bactrim or linezolid
Impetigo
Usually from S. Aureus
Topical Mupirocin TID x 5 days
and
Retapamulin BID x 5 days
If numerous lesions, use oral ABX
dicloxacillin and cephalexin x 7 days
If MRSA suspected, use Bactrim, clinda, doxy
Candidiasis
Intertrigo or intertriginous dermatitis
common inflammatory condition in the skin folds
Moist erythema, malodor, weeping, pruritis, tender
Candidiasis treatment
Daily cleaning with mild cleanser, hair dyer to dry (cool)
treat for DM if appropriate
Dermatophyte infections
Tinea pedis
tinea corporis
tinea cruris
tinea capitis
Tinea versicolor is not a dermatophyte
It is a yeast
Ketoconazole
Nizoral shampoo
Tinea versicolor
Azole antifungal
Tinea pedis
Tinea corporis
Tine Cruris
Treatment
Topicals azoles allyamines butenafine ciclopirox tolnaftate
Severe: use oral: terbinafine itraconazole fluconazole griseofluvin
Tinea pedis
Tinea corporis
Tine Cruris
Severe
Treatment
Severe: use oral:
terbinafine
itraconazole
fluconazole
griseofluvin
Tinea capitus treatment
Griseofulvin
terbinafine
both are first line
Do nots for anti fungals
Nystatin doesn’t work (only for candida)
Dont use ketoconazole for tinea infections
(box warning, hepatotoxicity)
Dont treat without confirming first
KOH, Culture, acid schiff test for onychomycosis
Dont use topicals only on tinea capitus
can use in combo
Lindane toxicity (kwell)
Lindaneis an organochlorine insecticide that inhibits neurotransmission in parasitic arthropods.
Neurologic toxicity resulting in seizures and death has been reported in humans following topical lindane therapy.
Most of these events have occurred after prolonged or repeated application of lindane but, in rare cases, have followed a single application.
Lindane
Kwell
Only use as last resort for lice
Black box
lindane shampoo should only be used as a second-line treatment in patients who cannot tolerate or have failed other therapies for the treatment of scabies or lice.
Lindane is contraindicated in patients with skin disorders that may lead to increased systemic absorption (eg, atopic dermatitis, psoriasis).
Scabies treatment
Topical permethrin
cure rate over 90%
Vulvo vaginal warts
40% will resolve without treatment
Herpes simples treatment
Anitvirals
Acyclovir
Valcyclovir
Famciclovir
Herpes simples treatment
Acyclovir dose
400mg 3-5 x day
children 12-15mg/kg/day divided in 2 doses
prophylactic
400mg BID
Herpes simples treatment
Valcyclovir dose
500mg TID
prophylactic
500mg QD
Herpes simples treatment
Famciclovir dose
250mg TID
Prophylactic
250mg QD or 125 BID
Acyclovir Class
Nucleoside analogue
Zovirax cream
Varicella Zoster
fever
vesicular rash
antihistamine
cut fingernails
Tylenol
(not ASA - Reyes)
if under 12, no antivirals (self Limiting)
If antivirals are needed, valcyclovir (fewer doses)
The goals of antiviral therapy
for varicella zoster
Promote more rapid healing of skin lesions,
Lessen the severity and duration of pain associated with acute neuritis,
and potentially reduce the incidence or severity of chronic pain,
referred to as post herpetic neuralgia.
Valcyclovir dose vs acyclovir
Zoster
1000mg TID
x 7 days
vs
800mg 5 times a day for 7 days
Zoster transmission
Patients with herpes zoster can transmit VZV to individuals who have not had varicella and have not received thevaricella vaccine.
Until the rash has crusted, patients should be advised to keep the rash covered, if feasible, and to wash their hands often to prevent the spread of virus to others.
They should also avoid contact with pregnant women who have never had chickenpox or the varicella vaccine, premature or low birth weight infants, and immunocompromised individuals.
Molluscum contagiosum Tx
Cryotherapy
curettage
cantharidin
Verrucae
Warts
HPV 6 and 11 = Anogenital warts
Common, plantar or flat warts (verrucae ….)
topical salicylic acid
cryotherapy
most common treatments
plantar warts less likely to respond
Contact dermatitis treatment
avoid offending agent
treat skin inflammation
restore epidermal barrier function
prevent further exposure
Dorsum of hands, finger tips, finger webs
common sites
Emollients and topical corticosteroids used empirically
Used in combo
Exanthematous drug eruptions
treatment
stop drug
topical corticosteroids (high potency-grp 1-3)
BID x 1 week
oral antihistamines PRN for pruritis
don’t use systemic corticosteroids for uncomplicated reaction
Eczema Treatment
The goals of treatment are
to reduce symptoms (pruritus and dermatitis),
prevent exacerbations,
and minimize therapeutic risks.
Atopic Dermatitis Treatment
mild to moderate atopic dermatitis
topical corticosteroids and emollients.
For patients with mild atopic dermatitis, we suggest a low-potency (groups 5, 6,7) corticosteroid cream or ointment (eg,desonide0.05%,hydrocortisone2.5%).
Topical corticosteroids can be applied once or twice daily for two to four weeks.
We suggest that patients with atopic dermatitis involving the face or skin folds that is not controlled with topical corticosteroids be treated with a topical calcineurin inhibitor (ie,tacrolimusorpimecrolimus)
Lichen planus treatment
We suggest high potency or super high potency topical corticosteroids as initial treatment of localized cutaneous lichen planus on the trunk or extremities
Intralesional corticosteroids can be useful in patients with hypertrophic lichen planus.
Pityriasis rosea
In 50 to 90 percent of cases, the eruption begins with a “herald” or “mother” patch,
a single round or oval, sharply delimited, pink or salmon-colored lesion on the chest, neck, or back.
mild itching = medium-potency topical corticosteroids.
Severe PR who desire treatment to accelerate improvement of the skin manifestations
oralacyclovirrather than oralerythromycin.
Psoriasis
limited plaque psoriasis
topical corticosteroids and emollients
moderate to severe plaque psoriasis
phototherapy if feasible and practical.
Coal tar
Scytera
To relieve symptoms of psoriasis
Inhibits excessive skin cell proliferation
keratolytic
anti itchy
anti inflammatory
Biologics and psoriasis
The drugs block certain cells or proteins that play a role in psoriasis.
They keep them from going into overdrive.
While that helps with inflammation and other issues, it also lowers your body’s defenses.
TNF concerns
Tumor necrosis factor blockers
There is a concern that all TNF-alpha inhibitors have the potential to activate latent infections such as tuberculosis, and increased rates of infection have been seen in patients with rheumatoid arthritis treated withetanercept,infliximab, andadalimumab.
Etanercept
Enbrel
Tumor Necrosis Factor Blocker
Mod - severe plaque psoriasis
not for under 4
Contra
Sepsis
IL 23 blocker
Ustekinumab
Guselkumab
Risankizumab
Tidrakizumab
IL 17 blocker
Secukinumab
Ixekizumab
Bimekizumab
IL 17A blocker
Brodalumab
Biologics for psoriasis Drugs and class
TNF alpha blockers Etanercept (enbrel) Adalimumab (Humira) Infliximab (Remicade) Certolizumab
