Pharmacology for Dermatology Flashcards
Which of the following statements about rosacea is TRUE?
A) Rosacea is a chronic inflammatory skin disorder affecting the vascular system
B) Rosacea is most common in individuals under 20 years old
C) Rosacea is more common in men than women
D) Rosacea is primarily a type of acne
Correct Answer: A
✅ Rosacea is a chronic, inflammatory, cutaneous vascular disorder that leads to redness, flushing, and inflammatory lesions.
🔴 B is incorrect – Rosacea is most common in those aged 45–60, not under 20.
🔴 C is incorrect – Rosacea affects both sexes equally in prevalence.
🔴 D is incorrect – While often misdiagnosed as adult acne, rosacea is a distinct condition.
Which of the following is a common symptom of ocular rosacea?
A) Excessive oil production
B) Increased acne severity
C) Dryness and irritation of the eyes
D) Swelling of the lips
Correct Answer: C
✅ More than 50% of patients with rosacea experience eye involvement, leading to dryness, irritation, blepharitis, and conjunctivitis which can be apparent before skin symptoms are apparent.
🔴 A is incorrect – Rosacea does not cause excessive oil production (which is common in acne).
🔴 B is incorrect – Rosacea is not a form of acne, though they can appear similar.
🔴 D is incorrect – Lip swelling is not a primary symptom of rosacea.
Which of the following is NOT a common trigger for rosacea flare-ups?
A) Sunlight
B) Spicy foods
C) Cold water
D) Alcohol
Correct Answer: C
✅ Cold water is not a known trigger for rosacea, while heat is a common aggravating factor.
🔴 A is incorrect – Sunlight is one of the most well-known triggers for rosacea.
🔴 B is incorrect – Spicy foods and vinegar can worsen symptoms.
🔴 D is incorrect – Alcohol consumption is a frequent trigger for flare-ups.
TrIGGERS THAT CAN WORSEN ROSACEA
- Sunlight
- Heat
- Wind
- Exercise
- Hot beverages
Spicy foods, vinegar, Alcohol, Use of astringents, (alcohol- or acetone-based products), Emotional stress
Which of the following medications can worsen rosacea?
A) Calcium channel blockers
B) Antihistamines
C) Proton pump inhibitors
D) Beta-lactam antibiotics
Correct Answer: A
✅ Calcium channel blockers can worsen rosacea by causing vasodilation, leading to increased flushing.
🔴 B is incorrect – Antihistamines are not known to trigger rosacea and may even help with inflammation.
🔴 C is incorrect – Proton pump inhibitors are used for acid reflux and do not contribute to rosacea.
🔴 D is incorrect – Beta-lactam antibiotics are used for bacterial infections and do not worsen rosacea.
DRUGS THAT CAN WORSEN ROSACEA
* calcium channel blockers
* niacin (nicotinic acid)
* nitrates
* phosphodiesterase-5 inhibitors (e.g., sildenafil)
* topical corticosteroids (unless low potency or for brief periods
only)
* medications causing dry eyes (e.g., anticholinergics) could aggravate ocular rosacea
Why These Medications Worsen Rosacea
Calcium Channel Blockers – These cause vasodilation, which increases flushing and erythema in rosacea patients.
Niacin (Nicotinic Acid) – Causes flushing due to prostaglandin-mediated vasodilation, worsening rosacea symptoms.
Nitrates – Lead to blood vessel dilation, triggering redness and flushing in patients with rosacea.
Phosphodiesterase-5 Inhibitors (e.g., Sildenafil) – Induce vasodilation, which can lead to worsening flushing and erythema.
Topical Corticosteroids – Prolonged use causes skin thinning and rebound redness, making rosacea worse.
Medications Causing Dry Eyes (e.g., Anticholinergics) – These worsen ocular rosacea by reducing tear production and increasing irritation.
Which of the following is TRUE about topical brimonidine for rosacea?
A) It primarily targets inflammatory papules and pustules
B) It has no significant side effects
C) It works by constricting dilated blood vessels
D) It is used to treat telangiectatic blood vessels
Correct Answer: C
✅ Brimonidine acts by constricting dilated blood vessels, reducing facial redness.
🔴 A is incorrect – Brimonidine is used for flushing and persistent erythema, not inflammatory lesions.
🔴 B is incorrect – Brimonidine has side effects, including rebound erythema, flushing, and burning sensation.
🔴 D is incorrect – Brimonidine does not affect telangiectatic blood vessels, only general redness.
What is a potential downside of using topical brimonidine for rosacea?
A) Risk of rebound erythema
B) Permanent skin lightening
C) Increased oil production
D) Increased bacterial infections
Correct Answer: A
✅ Rebound erythema (worsened redness after stopping the medication) is a significant concern with topical brimonidine.
🔴 B is incorrect – Brimonidine does not cause permanent skin lightening.
🔴 C is incorrect – It does not affect oil production.
🔴 D is incorrect – Brimonidine does not increase bacterial infections.
Which of the following is considered a first-line treatment for inflammatory papules and pustules in rosacea?
A) Topical metronidazole
B) Oral isotretinoin
C) Topical corticosteroids
D) Beta-blockers
Correct Answer: A
✅ Topical metronidazole is considered a first-line treatment for inflammatory papules and pustules in rosacea due to its anti-inflammatory properties reducing reactive oxygen species.
🔴 B is incorrect – Oral isotretinoin is not a first-line treatment for rosacea (reserved for severe cases).
🔴 C is incorrect – Topical corticosteroids should be used with caution, as they can worsen rosacea.
🔴 D is incorrect – Beta-blockers are not first-line for treating inflammatory lesions.
What is the mechanism of action of topical metronidazole in rosacea treatment?
A) Reducing Demodex mites
B) Acting as a vasoconstrictor
C) Reducing reactive oxygen species
D) Increasing immune system activity
Correct Answer: C
✅ Metronidazole works by reducing reactive oxygen species, which contributes to inflammation in rosacea.
🔴 A is incorrect – Topical ivermectin, not metronidazole, reduces Demodex mites.
🔴 B is incorrect – Brimonidine, not metronidazole, acts as a vasoconstrictor.
🔴 D is incorrect – Metronidazole does not increase immune activity; it helps reduce inflammation.
Which of the following is TRUE about topical ivermectin for rosacea?
A) It is considered a first-line treatment
B) It is only used in severe, refractory cases
C) It primarily works by constricting blood vessels
D) It has no effect on Demodex mites
Correct Answer: A
✅ Topical ivermectin is a first-line agent for rosacea, particularly for inflammatory lesions.
🔴 B is incorrect – It is used even in mild to moderate rosacea, not just severe cases.
🔴 C is incorrect – Ivermectin does not constrict blood vessels (unlike brimonidine).
🔴 D is incorrect – Ivermectin targets Demodex mites, which may play a role in rosacea.
DRUG OPTIONS for INFLAMMATORY
PAPULES/PUSTULES
* Topical ivermectin
* Considered first-line agent
* Thought to act by decreasing the number of Demodex mites present (it is an acaricide)
* May also have immunomodulatory effects
* Beneficial effects may persist after treatment cessation
* Evidence suggests it might be superior to topical metronidazole
* Adverse effects include dry skin, pruritus, skin- burning sensation
What is a general recommendation for all patients with rosacea?
A) Avoid all topical treatments
B) Use high SPF sunscreen daily
C) Use alcohol-based astringents for skin cleansing
D) Exercise outdoors frequently in hot weather
Correct Answer: B
✅ High SPF sunscreen is recommended for all rosacea patients to prevent flare-ups from sun exposure.
🔴 A is incorrect – Topical treatments like metronidazole, azelaic acid, and ivermectin are commonly used.
🔴 C is incorrect – Astringents (especially alcohol- or acetone-based) can worsen rosacea.
🔴 D is incorrect – Heat and exercise can trigger flare-ups, so precautions are necessary.
How long does it typically take for inflammatory papules and pustules to improve with topical treatment?
A) 1–2 weeks
B) 4–8 weeks
C) 6 months
D) They do not respond to treatment
Correct Answer: B
✅ Inflammatory lesions in rosacea typically improve within 4–8 weeks of topical treatment.
🔴 A is incorrect – 1–2 weeks is too soon to see full effects.
🔴 C is incorrect – Most cases do not require 6 months for improvement.
🔴 D is incorrect – They do respond to treatment, particularly with topical metronidazole, azelaic acid, or ivermectin.
DRUG OPTIONS – INFLAMMATORY
PAPULES/PUSTULES
* Treatment duration will depend upon the severity of symptoms, but improvement can generally be expected in 4–8 weeks
* Topical treatment may need to be continued indefinitely
* Relapse is to be expected upon discontinuation
* Well tolerated but may cause local irritation
Why is low-dose doxycycline sometimes preferred over standard-dose doxycycline in rosacea?
A) It has better antibacterial effects
B) It causes more gastrointestinal side effects
C) It has similar efficacy with fewer gastrointestinal effects
D) It leads to permanent rosacea remission
Correct Answer: C
✅ Low-dose doxycycline has similar anti-inflammatory benefits with fewer gastrointestinal side effects.
🔴 A is incorrect – It is used for anti-inflammatory effects, not antibacterial properties.
🔴 B is incorrect – Low-dose doxycycline reduces, not increases, GI side effects.
🔴 D is incorrect – Rosacea is a chronic condition, and no treatment leads to permanent remission.
DRUG OPTIONS – INFLAMMATORY
PAPULES/PUSTULES, tetracycline and doxycycline
* Oral tetracycline or doxycycline
* Oral antibiotics have been shown to be effective and may be added to topicals when the response is inadequate or the condition is moderate to severe
* The rationale for the use of antibiotics resides with their anti-inflammatory benefits, rather than their antimicrobial properties
* Generally used for up to 3 months and then reassessed
* Low-dose (subantimicrobial) doxycycline is available and appears to have similar efficacy but less gastrointestinal effects
* May be an option for patients in whom gastrointestinal effects of standard-dose doxycycline are of concern
* May also have less risk of antimicrobial resistance
What is a major concern when using oral isotretinoin for rosacea?
A) Liver toxicity
B) Teratogenicity
C) Increased bacterial resistance
D) Increased risk of fungal infections
Correct Answer: B
✅ Isotretinoin is highly teratogenic, requiring strict pregnancy prevention measures.
🔴 A is incorrect – Liver toxicity is a concern but not as critical as teratogenicity.
🔴 C is incorrect – Isotretinoin does not cause bacterial resistance.
🔴 D is incorrect – It does not significantly increase fungal infections.
DRUG OPTIONS – INFLAMMATORY
PAPULES/PUSTULES
* Low-dose isotretinoin
* Teratogenicity is a major concern
* Adverse effects include cheilitis, dry skin, mucocutaneous effects, myalgia, possible psychiatric effects
* Rare cases of benign intracranial hemorrhage when combined with tetracyclines
* Generally reserved for cases where other treatments fail
What is the preferred treatment for mild ocular rosacea?
A) Oral isotretinoin
B) Topical corticosteroids
C) Artificial tears and eyelid hygiene
D) Phosphodiesterase-5 inhibitors
Correct Answer: C
✅ Mild ocular rosacea is best managed with artificial tears and good eyelid hygiene.
🔴 A is incorrect – Oral isotretinoin is reserved for severe cases and is not used for ocular rosacea.
🔴 B is incorrect – Topical corticosteroids can worsen rosacea.
🔴 D is incorrect – Phosphodiesterase-5 inhibitors are not used for rosacea.
Which rosacea medication should be discontinued at least one month before pregnancy?
A) Doxycycline
B) Azelaic acid
C) Isotretinoin
D) Metronidazole
Correct Answer: C
✅ Isotretinoin must be stopped at least one month before pregnancy due to teratogenic risks.
🔴 A is incorrect – Tetracyclines clear from the body within a week, so they do not need to be stopped a month in advance.
🔴 B is incorrect – Azelaic acid is considered safe in pregnancy.
🔴 D is incorrect – Metronidazole has minimal absorption and is considered safe.
PREPREGNANCY CONSIDERATIONS for dermatitis medications
* Oral isotretinoin must be stopped at least 1 month prior to becoming pregnant
* Small amounts of isotretinoin are found in semen; however, safety reporting has not indicated any risk of harm to a fetus due to paternal exposure to isotretinoin, and special precautions are not required
* Tetracyclines are cleared from the body within 1 week of discontinuation
Why are tetracyclines contraindicated in the second and third trimesters of pregnancy?
A) They cause birth defects
B) They cause permanent enamel hypoplasia and dental staining
C) They cause maternal high blood pressure
D) They lead to increased fetal heart rate
Correct Answer: B
✅ Tetracyclines can cause dental staining and enamel hypoplasia in the baby.
🔴 A is incorrect – They do not cause major birth defects like isotretinoin does.
🔴 C is incorrect – They are not associated with maternal hypertension.
🔴 D is incorrect – They do not significantly affect fetal heart rate.
Tetracyclines use for MANAGEMENT OF ROSACEA DURING PREGNANCY
* Tetracyclines are considered contraindicated as second- and third-trimester exposure can cause dental staining and enamel hypoplasia in the baby
* Can also temporarily inhibit fetal bone development, but the effect is rapidly reversible on discontinuation of the drug, and no permanent effects have been observed
* Inadvertent exposure during the first few weeks of pregnancy is unlikely to cause harm
- Which of the following is the preferred treatment for mild ocular involvement in rosacea?
A) Oral doxycycline or tetracycline
B) Good eyelid hygiene and artificial tears
C) Topical cyclosporine eye drops
D) High-dose systemic steroids
Correct Answer: B) Good eyelid hygiene and artificial tears
✅ B is correct: Mild ocular involvement can be managed with proper eyelid hygiene and artificial tears.
❌ A is incorrect: While oral doxycycline or tetracycline is sometimes recommended, evidence supporting their use is minimal.
❌ C is incorrect: Topical cyclosporine eye drops are reserved for severe or persistent cases.
❌ D is incorrect: High-dose systemic steroids are not recommended for ocular rosacea, as they can worsen symptoms.
DRUG OPTIONS - OCULAR
* Mild ocular involvement can be managed with good eyelid hygiene and the use of artificial tears
* Experts recommend oral doxycycline or tetracycline despite minimal evidence to support its use
* Severe/persistent involvement should be referred to an ophthalmologist and topical cyclosporine eye drops may be considered
Which statement about metronidazole topical treatments for inflammatory papules/pustules in rosacea is TRUE?
A) There is a significant difference in efficacy between 0.75% and 1% formulations.
B) Topical treatments are only available as gels.
C) Both 0.75% and 1% gel or cream formulations are equally effective.
D) Topical treatments should never be used long-term.
Correct Answer: C) Both 0.75% and 1% gel or cream formulations are equally effective
✅ C is correct: Studies show no significant difference in efficacy between the two strengths or vehicles.
❌ A is incorrect: There is no clinically significant difference in effectiveness between 0.75% and 1% formulations.
❌ B is incorrect: These treatments are available as both gels and creams.
❌ D is incorrect: Topical treatments may need to be continued long-term, as rosacea is a chronic condition.
Which of the following is NOT a recommended treatment option for phymatous rosacea (phyma)?
A) Oral doxycycline or tetracycline
B) Topical retinoids
C) Oral low-dose isotretinoin
D) High-potency topical corticosteroids
Correct Answer: D) High-potency topical corticosteroids
✅ D is correct: High-potency topical corticosteroids are not recommended for phyma and can actually worsen rosacea symptoms.
❌ A, B, and C are incorrect: These are all potential treatment options, though evidence supporting their use is limited.
DRUG OPTIONS - PHYMA
* Not a lot of evidence to support drug options
* Possible options
- Oral doxycycline or tetracycline
- Topical retinoids
- Oral low-dose isotretinoin
Which topical medication is considered safe for use during pregnancy?
A) Topical azelaic acid
B) Topical metronidazole
C) Topical retinoids
D) A and B
Correct Answer: D) A and B (Topical azelaic acid and metronidazole)
✅ A and B are correct: Both are minimally absorbed and considered safe for use during pregnancy.
❌ C is incorrect: Topical retinoids do not have established safety data for pregnancy.
MANAGEMENT OF ROSACEA DURING PREGNANCY
* Topical therapy for rosacea is favoured
* Topical azelaic acid is minimally absorbed and considered
safe for use in pregnancy
* Minimal absorption occurs with topical metronidazole, and it is considered safe for use in pregnancy
* Safety data has not been established with other topical therapies
Which statement about oral isotretinoin and pregnancy is TRUE?
A) Pregnancy must be avoided 1 month before, during, and 1 month after therapy.
B) Oral isotretinoin is safe for use in pregnancy.
C) Small amounts of isotretinoin in semen pose a high risk to a fetus.
D) Patients taking isotretinoin do not need to follow a pregnancy prevention program.
Correct Answer: A) Pregnancy must be avoided 1 month before, during, and 1 month after therapy
✅ A is correct: Isotretinoin is teratogenic, so strict pregnancy prevention measures are required.
❌ B is incorrect: Isotretinoin is NOT safe for use in pregnancy.
❌ C is incorrect: Small amounts in semen do not pose a significant risk to a fetus.
❌ D is incorrect: Patients must follow a pregnancy prevention program to avoid fetal exposure.
Which statement is TRUE about rosacea management during breastfeeding?
A) Topical azelaic acid and metronidazole are considered safe.
B) Tetracyclines are completely safe for long-term use.
C) Oral isotretinoin is recommended for severe cases.
D) There is strong evidence supporting the use of all topical therapies.
Correct Answer: A) Topical azelaic acid and metronidazole are considered safe
✅ A is correct: These topical treatments are safe due to limited systemic absorption.
❌ B is incorrect: While tetracyclines pass into breast milk in low amounts, long-term use should be avoided.
❌ C is incorrect: The safety of oral isotretinoin during breastfeeding has not been established, so it is not recommended.
❌ D is incorrect: Not all topical therapies have established safety data for breastfeeding.
MANAGEMENT OF ROSACEA DURING BREASTFEEDING
* Very similar to the recommendations for drug options during pregnancy
* Topical azelaic acid and metronidazole are both considered safe to use while breastfeeding due to limited systemic absorption and/or low transfer into breast milk
* No safety data available for other topical therapies
Which of the following medications is NOT commonly associated with pruritus?
A) Amiodarone
B) Beta-blockers
C) Statins
D) Vitamin C
Answer: D) Vitamin C
MEDICATIONS ASSOCIATED WITH PRURITUS
- Angiotensin-converting enzyme
inhibitors (ACEi) - Angiotensin receptor blockers (ARBs)
- Amiodarone
- Antimalarials (chloroquine, others)
- Beta-blockers
- Calcium channel blockers
- G-CSF
- Heparin
Hydrochlorothiazide Interleukin-2 Macrolides
Opioids Penicillins Statins
Stimulants (cocaine, MDMA, ADHD medications)
Targeted cancer therapies, i.e.. monoclonal antibodies and derivatives, small molecule inhibitors
Trimethoprim/sulfamethoxazole
Which treatment option should be avoided when managing pruritus?
A) Emollients
B) Topical antihistamines
C) Topical corticosteroids for inflammatory skin conditions
D) Menthol and camphor
Answer: B) Topical antihistamines
Explanation: Topical antihistamines do not work well for pruritus and can cause contact dermatitis.
A) Emollients are recommended to alleviate itch due to xerosis.
C) Topical corticosteroids are appropriate when pruritus is caused by an inflammatory skin condition with erythema.
D)Menthol and camphor are used as counterirritants, making option B the correct answer.
Which systemic therapy is recommended for pruritus in the elderly with neurogenic conditions?
A) Montelukast
B) Gabapentin and pregabalin
C) Sedating antihistamines
D) Topical capsaicin
Answer: B) Gabapentin and pregabalin are recommended for pruritus in elderly patients with neurogenic conditions such as peripheral neuropathy.
Explanation:
A) Montelukast are more for chronic urticaria in addition to NON-sedating histamines
C) Sedating antihistamines should generally be avoided if possible, especially in the elderly.
D) Topical capsaicin is useful for neurogenic pruritus but is not systemic.
Which of the following corticosteroid vehicles is best for use on smooth, non-hairy skin?
A) Lotion
B) Gel
C) Ointment
D) Cream
**Correct Answer: C) Ointment
✅ C is correct: Ointments are ideal for smooth, non-hairy skin because they are lubricating, semi-occlusive, and provide better absorption. E.g. Petrolatum like
- Lubricating, semiocclusive, greasy, does not sting
- Useful for smooth, non-hairy skin and for dry, thick, or hyperkeratotic lesions
**
❌ A is incorrect: Lotion is alcohol-based and often stings, making it less suitable for dry skin.
- Pourable alcohol-based liquid
- Less greasy, less occlusive, often stings
- Good for hairy areas
❌ B is incorrect: Gel is alcohol-based and dries quickly, which may cause irritation and is less suitable for dry areas.
- Alcohol based so may sting, is least occlusive, dries quickly
- Good for acne and on the scalp/hairy areas without matting
❌ D is incorrect: Cream is less greasy but can sting and cause irritation due to preservatives/fragrances.
- Vanish when rubbed in
-Less greasy, not occlusive
- Good for intertriginous areas
What is a key factor in determining the benefit of emollients for treating pruritus and dermatitis?
A) The concentration of the emollient.
B) The frequency of routine use.
C) The presence of inflammation in the affected area.
D) The vehicle type (ointment, cream, etc.).
Correct Answer: B) The frequency of routine use.
✅ B is correct: The most predictive factor for the benefit of emollients is frequent and routine use, particularly when applied twice daily (BID) and after bathing.
❌ A is incorrect: The concentration of the emollient is not as important as the frequency of use for effectiveness.
❌ C is incorrect: Inflammation is addressed by corticosteroids, not emollients.
❌ D is incorrect: While vehicle type affects absorption, the frequency of use is the most critical factor for emollient effectiveness.
Which of the following is true regarding the use of corticosteroids?
A) Super-high potency corticosteroids should be used for mild dermatoses.
B) Low-potency steroids are appropriate for use on facial areas and thin skin.
C) The vehicle does not affect the potency of a corticosteroid.
D) Ointments are less effective than creams in treating pruritus.
Correct Answer: B) Low-potency steroids are appropriate for use on facial areas and thin skin.
✅ B is correct: Low-potency corticosteroids are the preferred choice for sensitive areas with thinner skin, such as the face and genital areas.
❌ A is incorrect: Super-high potency steroids are used for severe dermatoses, not mild ones.
❌ C is incorrect: The vehicle does affect corticosteroid potency (e.g., ointments have better absorption than creams).
❌ D is incorrect: Ointments are more effective than creams for treating dry, thick lesions because of better absorption.
CORTICOSTEROIDS
* Low potency steroids can be used on large areas and thinner skin
- Face, eyelid, genital, intertriginous areas
* The vehicle can change the potency of the corticosteroid
* Ointments allow for better absorption
- E.g., Mometasone furoate ointment is high potency while the
cream is medium potency
Which of the following is NOT required for a corticosteroid prescription?
A) Generic name
B) Vehicle
C) Drug expiration date
D) Concentration
✅ Correct Answer: C) Drug expiration date
Explanation: A corticosteroid prescription requires the generic name, vehicle, concentration, directions (Sig), amount, and refills. The expiration date is not typically included in a prescription but is provided by the manufacturer or pharmacy.
CORTICOSTEROID PRESCRIPTIONS Example
* Generic name
* Vehicle
* Concentration
* Sig (Directions)
* Amount
* Refills
- Mometasone furoate ointment 0.1% apply to affected body areas daily
- 15 grams refills 3
What is the primary reason calcineurin inhibitors are often used as first-line therapy for facial or intertriginous areas?
A) They have a faster onset of action than corticosteroids
B) They lack the skin-thinning effects of corticosteroids
C) They have a stronger anti-inflammatory effect than corticosteroids
D) They are safer than all other topical therapies
✅ Correct Answer: B) They lack the skin-thinning effects of corticosteroids
Explanation: Calcineurin inhibitors (tacrolimus, pimecrolimus) are often used as first-line therapy for the face and intertriginous areas because they do not cause skin atrophy, which is a common side effect of corticosteroids.
Wrong choices:
A) Incorrect—They do not necessarily have a faster onset.
C) Incorrect—They are not stronger than corticosteroids.
D) Incorrect—They have a black box warning for lymphoma and skin cancer.
CALCINEURIN INHIBITORS
* Two available in Canada Tacrolimus ointment Pimecrolimus cream
* Considered second-line therapy but often used clinically as
first-line therapy for the face or intertriginous areas
* No additive benefit when used in conjunction with corticosteroids
* Black box warning pertaining to lymphoma and skin cancer
What is a potential adverse effect of crisaborole?
A) Skin atrophy
B) Application site pain
C) Increased risk of lymphoma
D) Hyperpigmentation
✅ Correct Answer: B) Application site pain
Explanation: Crisaborole is a PDE4 inhibitor approved for mild-moderate atopic dermatitis (AD). It has been associated with application site pain, upper respiratory infections (URI), and worsening dermatitis.
Wrong choices:
A) Incorrect—Skin atrophy is a concern with corticosteroids, not crisaborole.
C) Incorrect—The black box warning for lymphoma applies to calcineurin inhibitors, not crisaborole.
D) Incorrect—Crisaborole does not cause hyperpigmentation.
CRISABOROLE
* PDE4 inhibitor
* The only one approved in Canada at the moment
* Approved for use on all body areas in mild-moderate AD
* No head-to-head studies exist to objectively determine comparative efficacy to corticosteroids and calcineurin inhibitors
* Current studies suggest enhanced benefit over vehicle
DLQI: - 5.2 vs – 3.5
* Common AE: application site pain, URI, worsening dermatitis
Which systemic therapy is a biologic that targets IL-4 and IL-13 signaling?
A) Azathioprine
B) Methotrexate
C) Cyclosporine
D) Dupilumab
✅ Correct Answer: D) Dupilumab
Explanation: Dupilumab is a biologic (subcutaneous injection) that reduces IL-4 and IL-13 signaling, which are key in type 2 allergic responses in atopic dermatitis.
Wrong choices:
A) Azathioprine is an immunosuppressant, not a biologic.
B) Methotrexate is primarily used for RA and some cancers, not IL-4/IL-13 inhibition.
C) Cyclosporine is used to prevent organ rejection, not target IL-4/IL-13.
SYSTEMIC THERAPIES
* Dupilumab
* Biologic (subcutaneous injection)
* Anti IL-4 receptor antibody
* Reduces IL-4 and IL-13 signaling
* Both are key interleukins involved in type 2 allergic responses, IgE class switching, changes to the epidermal barrier, dermal inflammation and remodeling
* Has the potential for marked reductions in SCORAD, EASI, DLQI
Why is increased risk of HSV infection a notable adverse effect?
IL-4 and IL-13 play a role in immune responses against viral infections, including herpes simplex virus (HSV).
By inhibiting these cytokines, dupilumab can weaken the body’s ability to fight HSV, leading to an increased risk of cold sores (HSV-1) and herpes simplex keratitis.
Clinical studies have reported higher rates of HSV infections (including eczema herpeticum) in patients using dupilumab.
What is a notable adverse effect of dupilumab?
A) Increased risk of HSV infection
B) Skin thinning
C) Organ toxicity
D) Increased risk of skin cancer
✅ Correct Answer: A) Increased risk of HSV infection
Explanation: Dupilumab has been associated with HSV (herpes simplex virus) infections, conjunctivitis, headache, injection site reactions, and nasopharyngitis.
Wrong choices:
B) Incorrect—Skin thinning is a steroid-related effect, not dupilumab.
C) Incorrect—Organ toxicity is a concern with cyclosporine.
D) Incorrect—The black box warning for skin cancer applies to calcineurin inhibitors, not dupilumab.
What is the best approach for flare prevention after achieving remission in atopic dermatitis?
A) Continue daily use of corticosteroids
B) Stop all treatment and restart if symptoms return
C) Apply topical therapy at the first sign of a flare
D) Use topical calcineurin inhibitors daily indefinitely
✅ Correct Answer: C) Apply topical therapy at the first sign of a flare
Explanation: Flare prevention involves ongoing daily moisturizer use and intermittent topical therapy (1-2 times weekly) to prevent flare-ups.
Wrong choices:
A) Incorrect—Daily corticosteroid use is stopped after remission.
B) Incorrect—Stopping all treatment and waiting for symptoms to return can lead to worse flare-ups.
D) Incorrect—Daily calcineurin inhibitor use is not recommended after remission.
FLARE PREVENTION
* Once in remission, the standard is to stop daily topical corticosteroid or calcineurin inhibitors
* Ongoing daily use of moisturizer is recommended to prevent flare ups.
* Evidence varies for different topical drug therapy regimens
- 1-2 times weekly seems sufficient for most patients
* Topical therapy should be initiated at the first sign of flare
Which of the following is TRUE regarding corticosteroid use in pregnancy?
A) Only high-potency corticosteroids are safe to use
B) Placental metabolism minimizes fetal exposure
C) All topical corticosteroids are contraindicated
D) Systemic corticosteroids are the preferred treatment
✅ Correct Answer: B) Placental metabolism minimizes fetal exposure
Explanation: Low- to mid-potency topical corticosteroids are considered safe during pregnancy because placental metabolism reduces fetal exposure.
Wrong choices:
A) Incorrect—High-potency corticosteroids are not preferred due to higher systemic absorption.
C) Incorrect—Topical corticosteroids are not completely contraindicated.
D) Incorrect—Systemic corticosteroids are not the preferred treatment.
Corticoid steroid use in PREGNANCY
* Reliance on nonpharmacologic options preferred
* Topical low and mid-potency corticosteroids are the main treatment option
- Placental metabolism dramatically minimizes corticosteroid exposure in the developing fetus
* Calcineurin inhibitors are safe to use due to low bioavailability when applied topically
Why are calcineurin inhibitors NOT recommended for nipple dermatitis while breastfeeding?
A) They have high systemic absorption
B) There is a black box warning for lymphoma
C) Infant ingestion risk is unknown
D) They cause significant skin thinning
✅ Correct Answer: C) Infant ingestion risk is unknown
Explanation: Calcineurin inhibitors (tacrolimus, pimecrolimus) should not be used on the breast area because the risk of infant ingestion is unknown.
Wrong choices:
A) Incorrect—They have low systemic absorption, which is why they are safe for other areas.
B) Incorrect—The black box warning is for long-term use, not breastfeeding.
D) Incorrect—They do not cause significant skin thinning, unlike corticosteroids.
- Similar recommendations as with pregnancy
- Calcineurin inhibitors are ok when used outside of the breast area
- Nipple dermatitis is common
- Calcineurin inhibitors should not be used here
- Topical corticosteroids cleaned from the area prior to
breastfeeding are ok
What is the most common symptom of topical corticosteroid withdrawal?
A) Skin peeling
B) Hives
C) Erythema, burning, or stinging
D) Papulopustules
Correct Answer: C) Erythema, burning, or stinging
✔ Explanation: These symptoms occur in more than 90% of cases and are the hallmark of topical corticosteroid withdrawal.
❌ A) Skin peeling → Incorrect, because peeling occurs at the end of a flare, not as the most common symptom.
❌ B) Hives → Incorrect, because hives are less common and more associated with the recovery phase.
❌ D) Papulopustules → Incorrect, though present in 80% of cases, they are slightly less common than erythema, burning, and stinging.
Topical corticosteroid withdrawal SYMPTOMS
* Erythema, burning or stinging are most common and are present in
more than 90% of cases
* Papulopustules are present in over 80% of cases
* Pruritus is present in 45% of cases and can be severe
* Skin peeling often occurs at the end of a flare
* Hives and excessive sweating can occur and are often signs of
recovery
* Many other symptoms have been described, including edema, lymphadenopathy, “red sleeve sign,” “headlight sign,” dermal thickening of extensor surfaces
Which factor increases the risk of developing topical corticosteroid withdrawal?
A) Short-term use (less than 4 weeks)
B) Use of low-potency corticosteroids
C) Application to the face or genitals
D) Use of topical corticosteroids for insect bites
Correct Answer: C) Application to the face or genitals
✔ Explanation: These areas have thinner skin, which increases absorption and risk of withdrawal symptoms.
❌ A) Short-term use (less than 4 weeks) → Incorrect, because risk increases with prolonged use, not short-term use.
❌ B) Use of low-potency corticosteroids → Incorrect, because higher potency corticosteroids have a greater risk.
❌ D) Use of topical corticosteroids for insect bites → Incorrect, because occasional use for insect bites is unlikely to cause withdrawal.
Topical corticosteroid RISK FACTORS
* Those with atopic dermatitis are most at risk
* Apparent equivalence between men and women when topical steroids are used for inflammatory skin conditions
- Topical steroids used for cosmetic reasons inflate the proportion of
females affected overall
* Application to the face or genitals increases risk
* Risk increases with potency of drug and duration of use
* Signs of skin damage from topical steroid use often predict the development of steroid withdrawal
What is the main concern with long-term corticosteroid use on the face and skin folds?
A) Increased risk of infection
B) Dermal atrophy
C) Hyperpigmentation
D) Increased hair growth
Correct Answer: B) Dermal atrophy
✔ Explanation: Long-term use of corticosteroids, especially high-potency ones, can thin the skin, leading to dermal atrophy.
❌ A) Increased risk of infection → Incorrect, because although long-term corticosteroid use can suppress immunity, the main concern in sensitive areas is thinning of the skin.
❌ C) Hyperpigmentation → Incorrect, because while possible, it is not the primary concern.
❌ D) Increased hair growth → Incorrect, because this is more associated with systemic steroids.
Why do corticosteroids cause dermal atrophy?
Corticosteroids cause dermal atrophy because they inhibit the synthesis of collagen and reduce the amount of glycosaminoglycans (such as hyaluronic acid) in the skin. Collagen is a major structural component of the dermis, and its reduction leads to thinning of the skin. Corticosteroids also suppress the fibroblasts, which are responsible for collagen production. Over time, this thinning and weakening of the skin can lead to visible signs like easy bruising, delayed wound healing, and a more fragile skin surface.
Which treatment option is recommended for pruritus in topical steroid withdrawal?
A) Oral gabapentin
B) Oral antihistamines
C) Topical corticosteroids
D) Topical retinoids
Correct Answer: B) Oral antihistamines
✔ Explanation: Antihistamines help relieve pruritus, which is present in 45% of cases and can be severe.
❌ A) Oral gabapentin → Incorrect, because this is more commonly used for burning pain, not pruritus.
❌ C) Topical corticosteroids → Incorrect, because this condition occurs due to corticosteroid use; stopping them is the goal.
❌ D) Topical retinoids → Incorrect, because these can irritate the skin further.
Topical Corticosteroid Withdrawal TREATMENT
* Some studies suggest continued abrupt discontinuation
* Other studies suggest tapering the topical corticosteroid
* Possible treatment with topical calcineurin inhibitors
* Oral antihistamines may help with pruritus
* Oral gabapentin may help with burning pain
* Sleeping aids and anxiolytics may be appropriate in some cases
Which topical drug class is commonly prescribed off-label for psoriasis, especially on the face and skin folds?
A) Calcineurin inhibitors
B) Vitamin D derivatives
C) High-potency corticosteroids
D) Tar-based products
Correct Answer: A) Calcineurin inhibitors
✔ Explanation: These do not cause dermal atrophy, making them useful for delicate areas like the face and skin folds.
❌ B) Vitamin D derivatives → Incorrect, because they cause irritation and should not be used in skin folds.
❌ C) High-potency corticosteroids → Incorrect, because these should not be used in delicate areas due to atrophy risk.
❌ D) Tar-based products → Incorrect, because these are mainly used for the scalp and guttate psoriasis.
Which systemic psoriasis treatment requires caution with live vaccines?
A) Apremilast
B) Methotrexate
C) Biologics
D) Acitretin
Correct Answer: C) Biologics
✔ Explanation: All biologics indicated for psoriasis suppress the immune system, increasing infection risk and requiring avoidance of live vaccines.
❌ A) Apremilast → Incorrect, because it does not significantly suppress the immune system.
❌ B) Methotrexate → Incorrect, because while it affects immunity, it is not as strongly contraindicated with live vaccines as biologics.
❌ D) Acitretin → Incorrect, because it is a retinoid and does not impact live vaccine administration.
SYSTEMIC AGENTS - BIOLOGICS
* Adverse effects are similar across all biologics indicated for psoriasis
* Administration of live vaccines during therapy should be avoided for all biologics indicated for psoriasis
Which systemic agent is commonly used for psoriasis but must be avoided in pregnancy?
A) Methotrexate
B) Apremilast
C) Cyclosporine
D) Roflumilast
Correct Answer: A) Methotrexate
✔ Explanation: Methotrexate is teratogenic and contraindicated in pregnancy due to its effects on folate metabolism.
❌ B) Apremilast → Incorrect, because while it has side effects, it is not a strong teratogen.
❌ C) Cyclosporine → Incorrect, because while it has risks, it is not as strongly contraindicated in pregnancy as methotrexate.
❌ D) Roflumilast → Incorrect, because this is a PDE4 inhibitor with minimal systemic toxicity.
SYSTEMIC AGENTS -
IMMUNOSUPPRESSIVES
* Methotrexate
* Commonly used and cost-effective agent for psoriasis
* Can be a safe and effective treatment with appropriate patient selection (avoid in pregnancy, presence or risk of liver disease, active or chronic infection including hepatitis B or C, tuberculosis) and monitoring (CBC, liver enzymes, renal function)
Psoriasis SYSTEMIC AGENTS
* When topical agents do not achieve the desired benefit or when psoriasis is quite severe, systemic agents are indicated
* Oral retinoids
* Biologics
* Immunosuppressants
Which is a notable adverse effect of acitretin?
A) Increased risk of intracranial pressure with tetracyclines
B) Increased risk of hypertension
C) Increased risk of hypoglycemia
D) Increased risk of osteoporosis
Correct Answer: A) Increased risk of intracranial pressure with tetracyclines
✔ Explanation: Acitretin + tetracyclines can cause pseudotumor cerebri, a condition of increased intracranial pressure.
❌ B) Increased risk of hypertension → Incorrect, because this is more associated with cyclosporine.
❌ C) Increased risk of hypoglycemia → Incorrect, because acitretin does not impact blood sugar regulation.
❌ D) Increased risk of osteoporosis → Incorrect, because this is more linked to systemic corticosteroids, not acitretin.
SYSTEMIC AGENTS -
IMMUNOSUPPRESSIVES
* Acitretin
* Adverse effects include joint and muscle pain, mucosal dryness,
hepatoxicity requiring liver function monitoring, hyperlipidemia
* Alcohol consumption increases conversion of acitretin to a long
half-life metabolite etretinate.
- Significant biologic persistence potentially requiring an extension of time after discontinuation before pregnancy is advised
* Increased risk of liver damage when combined with methotrexate
* Elevated risk of increased intracranial pressure when used with tetracyclines
What is a significant adverse effect of apremilast?
A) GI side effects
B) Hepatotoxicity
C) Hyperkalemia
D) Bone marrow suppression
Correct Answer: A) GI side effects
✔ Explanation: Apremilast (PDE4 inhibitor) causes nausea, diarrhea, and weight loss, especially during dose titration.
❌ B) Hepatotoxicity → Incorrect, because this is more associated with methotrexate.
❌ C) Hyperkalemia → Incorrect, because this is a side effect of cyclosporine.
❌ D) Bone marrow suppression → Incorrect, because this is a concern with methotrexate, not apremilast.
SYSTEMIC AGENTS -
IMMUNOSUPPRESSIVES
* Apremilast
* PDE4 Inhibitor
* Significant GI adverse effects that can be minimized by titrating up to therapeutic dose over 5 days
- Other AE: URI, headache, weight loss
* Reduced levels with CYP3A4 inducers
* May be a more appropriate choice in medically complex patients where other systemic nonbiologic agents carry a greater risk of toxicity
nbUVB Phototherapy for Guttate Psoriasis
1. What is the most effective combination therapy for guttate psoriasis?
A) Salicylic acid and anthralin
B) nbUVB phototherapy with tar and salicylic acid
C) Calcineurin inhibitors and topical corticosteroids
D) Oral methotrexate and vitamin D derivatives
Correct Answer: B) Because narrowband UVB (nbUVB) phototherapy combined with tar and salicylic acid is the most effective for guttate psoriasis. Tar helps reduce scaling, and salicylic acid acts as a descaling agent.
A is incorrect because anthralin is primarily used for chronic plaque psoriasis and often irritates the skin.
C is incorrect because calcineurin inhibitors are not approved for psoriasis and are mainly used for delicate areas like the face and folds.
D is incorrect because methotrexate is a systemic agent reserved for moderate-to-severe psoriasis, not guttate psoriasis.
TOPICAL DRUG THERAPY
* Topical medium-potency corticosteroids are usually the drug of choice for psoriasis on the body or extremities
* If topical corticosteroids do not achieve the desired benefit, vitamin D derivatives, tazarotene, tar, and anthralin can be used in isolation or in combination.
* nbUVB phototherapy with tars and salicylic acid (descaling agent) is most effective for guttate psoriasis
Vehicle Considerations
2. Which vehicle is most appropriate for treating psoriasis on the scalp?
A) Ointments
B) Creams
C) Lotions or gels
D) Tar-based shampoo only
Correct Answer: C) Lotions or gels because lotions and gels are best suited for the scalp, as they are easier to apply and absorb well.
A is incorrect because ointments are greasy and difficult to wash out of hair.
B is incorrect because creams are not ideal for the scalp due to their thicker consistency.
D is incorrect because while tar-based shampoos help with scale removal, they are not a standalone treatment.
Live Vaccines & Deucravacitinib (Tyrosine Kinase 2 Inhibitor)
Which of the following statements about deucravacitinib is TRUE?
A) It is a biologic targeting IL-23
B) It has fewer side effects than apremilast
C) Live vaccines should be avoided during therapy
D) It is a PDE-4 inhibitor similar to apremilast
Correct Answer: C) because, like biologics, deucravacitinib requires caution with live vaccines.
A is incorrect because deucravacitinib is a tyrosine kinase 2 (TK2) inhibitor, not an IL-23 biologic.
B is incorrect because while it may be more effective than apremilast, it has a risk of infections (URTI, herpes simplex) and other side effects.
D is incorrect because PDE-4 inhibitors (e.g., apremilast) work differently from TK2 inhibitors.
What type of corticosteroid is best for treating acne in patients with thicker skin, such as on the palms and soles?
A) Low-potency corticosteroids
B) Moderate-potency corticosteroids
C) High-potency corticosteroids
D) No corticosteroids should be used
Correct Answer: C) High-potency corticosteroids
👉 Why? The palms and soles have thicker skin, so higher potency corticosteroids are required to penetrate effectively and treat skin conditions.
❌ Wrong Answers:
A) Low-potency corticosteroids would not be sufficient for thick skin areas like the palms and soles.
B) Moderate-potency corticosteroids might not be strong enough for these areas.
D) No corticosteroids should not be used; higher-potency corticosteroids are needed for treatment.
MODIFICATIONS FOR SKIN TYPES
* Face and skin folds
- Dermal atrophy is the biggest concern
- Lower potency corticosteroids (hydrocortisone 1%) or calcineurin inhibitors
- The frequency of application should be reduced as improvement
occurs
* Palms and Soles
- Higher potency corticosteroids are needed, given the thickness of the
skin in these areas
- Quite difficult to treat
Which of the following is most commonly used as a topical antibiotic for acne treatment?
A) Clindamycin
B) Benzoyl peroxide
C) Tretinoin
D) Adapalene
Correct Answer: A) Clindamycin
👉 Why? Clindamycin is the most commonly used topical antibiotic for acne treatment. It helps reduce bacterial growth, which is a key factor in acne development. It’s often combined with other agents like benzoyl peroxide to reduce antibiotic resistance.
Explanation of the other options:
B) Benzoyl peroxide: While it is not an antibiotic, it is often used as an antibacterial and comedolytic agent. It helps to clear existing acne and prevent new lesions by killing acne-causing bacteria and opening up clogged pores. However, it is not classified as an antibiotic like clindamycin.
C) Tretinoin: A topical retinoid that is potent and effective for treating acne but is not an antibiotic. It’s used to help prevent acne formation by promoting skin cell turnover.
D) Adapalene: Another topical retinoid, least irritating compared to tretinoin, but not an antibiotic. It helps in reducing comedones (clogged pores) and treating acne.
Which of the following medications should be used cautiously due to the risk of drug-induced lupus and hepatitis?
A) Doxycycline
B) Minocycline
C) Tetracycline
D) Azithromycin
Correct Answer: B) Minocycline
👉 Why? Minocycline has a known risk of causing drug-induced lupus and hepatitis, making it a less preferred option among the tetracycline family.
❌ Wrong Answers:
A) Doxycycline is a preferred first-line agent and has fewer severe side effects compared to minocycline.
C) Tetracycline is another tetracycline, but minocycline has a higher risk profile for lupus and hepatitis.
D) Azithromycin is a macrolide and is generally reserved for second-line use, not known for causing lupus or hepatitis.
SYSTEMIC AGENTS for Acne
* Antibiotics
- Tetracyclines first-line agents
- Doxycycline, minocycline, tetracycline
Minocycline is the worst option due to drug-induced lupus and hepatitis
* Macrolides and SMX-TMP should only be used as second-line options if tetracyclines are contraindicated or do not work
- Conservative use to minimize resistance
* Should be used in conjunction with benzoyl peroxide
What is the primary goal when treating bacterial skin infections?
A) To prevent new infections
B) To relieve symptoms and pain
C) To eradicate the infection and prevent complications
D) To increase hydration
Correct Answer: C) To eradicate the infection and prevent complications
👉 Why? The main goal of treating a bacterial skin infection is to eradicate the infection and prevent complications like abscess formation or systemic spread.
❌ Wrong Answers:
A) While preventing new infections is important, the primary goal is to address the current infection.
B) Relieving symptoms is a secondary goal once the infection is under control.
D) Increasing hydration may be beneficial, but it is not the primary goal of infection treatment.
GOALS OF THERAPY for Treating Acne
* Clear existing lesions
* Prevent new lesions
* Minimize scarring
* Reduce dyspigmentation
* Minimize psychological impact
Which antibiotic is commonly used to treat mild folliculitis?
A) Mupirocin
B) Cephalexin
C) Clindamycin
D) Tetracycline
Correct Answer: A) Mupirocin
👉 Why? Mupirocin is an effective topical antibiotic commonly used for treating mild staphylococcal folliculitis.
❌ Wrong Answers:
B) Cephalexin is used for more extensive cases of folliculitis, not mild ones.
C) Clindamycin is another good option but typically used in more extensive cases.
D) Tetracycline is usually used for systemic infections rather than topical issues.
Which of the following is a nonpharmacologic treatment for folliculitis?
A) Use of topical antibiotics on affected areas
B) Eliminating tight-fitting clothing and reducing friction
C) Increasing the use of friction in affected areas
D) Applying steroids to reduce inflammation
Correct Answer: B) Eliminating tight-fitting clothing and reducing friction
👉 Why? Folliculitis can be exacerbated by friction, moisture, and heat, so removing contributing factors like tight clothing is an effective nonpharmacologic treatment.
❌ Wrong Answers:
A) Topical antibiotics can be used, but they are pharmacological treatments, not nonpharmacologic.
C) Increasing friction would worsen folliculitis, not treat it.
D) Steroids should not be used in treating folliculitis without proper medical evaluation.
Which medication is considered the safest topical antibiotic for treating folliculitis due to Staphylococcus aureus?
A) Clindamycin
B) Mupirocin
C) Tetracycline
D) Benzoyl peroxide
Correct Answer: B) Mupirocin
👉 Why? Mupirocin is a topical antibiotic commonly used to treat infections caused by Staphylococcus aureus, including folliculitis.
❌ Wrong Answers:
A) Clindamycin is also an option but may not be as specific as mupirocin for staph infections.
C) Tetracycline is an oral antibiotic, not topical, and is used for more extensive cases.
D) Benzoyl peroxide is used for acne, not bacterial folliculitis.
Which of the following antibiotics should be used for a patient with a carbuncle or furuncle that is likely caused by MRSA?
A) Cephalexin
B) Doxycycline
C) Amoxicillin
D) Erythromycin
Correct Answer: B) Doxycycline
👉 Why? Doxycycline is effective against MRSA and is a common second-line treatment for skin infections like carbuncles and furuncles.
❌ Wrong Answers:
A) Cephalexin is effective for staph infections but not MRSA.
C) Amoxicillin is not effective against MRSA.
D) Erythromycin is not the first choice for MRSA and is less commonly used for this purpose.
Which of the following is an important consideration when treating folliculitis caused by hot tubs?
A) Prescribing a long course of antibiotics immediately
B) Ensuring adequate chlorination of the water to prevent recurrence
C) Using oral contraceptives as a preventive measure
D) Applying topical steroids to reduce inflammation
Correct Answer: B) Ensuring adequate chlorination of the water to prevent recurrence
👉 Why? Hot tub folliculitis is often caused by Pseudomonas aeruginosa, and ensuring the water is adequately chlorinated can help prevent further outbreaks.
❌ Wrong Answers:
A) Antibiotics are typically not needed for hot tub folliculitis unless it’s severe.
C) Oral contraceptives have no role in preventing folliculitis.
D) Topical steroids should be avoided in the case of folliculitis unless directed by a physician.
What is FOLLICULITIS
* Inflammation of superficial or deep hair follicles, producing papules and pustules
* Infectious causes include
- Staphylococcus aureus (most common)
- Pseudomonas aeruginosa (hot tub–associated)
- Other gram-negative rods (sometimes after prolonged antibiotic use)
Which of the following treatments is generally avoided during pregnancy due to potential teratogenic effects?
A) Topical retinoids
B) Oral erythromycin
C) Mupirocin
D) Benzoyl peroxide
Correct Answer: A) Topical retinoids
👉 Why? Topical retinoids, like tretinoin, are teratogenic and should be avoided during pregnancy due to potential harm to the fetus.
❌ Wrong Answers:
B) Oral erythromycin is considered safe to use during pregnancy for bacterial infections.
C) Mupirocin is safe for topical use during pregnancy.
D) Benzoyl peroxide is considered safe for topical use during pregnancy
Which systemic therapy is often used to treat severe acne, but requires strict precautions due to its teratogenic effects?
A) Doxycycline
B) Isotretinoin
C) Spironolactone
D) Tetracycline
Correct Answer: B) Isotretinoin
👉 Why? Isotretinoin is highly effective for severe acne but is a potent teratogen. Strict precautions, including pregnancy tests and contraception, are required.
❌ Wrong Answers:
A) Doxycycline is effective for acne but does not carry the same teratogenic risks.
C) Spironolactone is used off-label for acne but is not teratogenic to the same degree as isotretinoin.
D) Tetracycline, while effective for acne, is not as commonly prescribed as isotretinoin for severe cases and does not require the same strict pregnancy precautions.
Which of the following is NOT recommended for acne treatment during pregnancy?
A) Benzoyl peroxide
B) Oral erythromycin
C) Topical retinoids
D) Clindamycin
Correct Answer: C) Topical retinoids
👉 Why? Topical retinoids should not be used during pregnancy due to the risk of birth defects.
❌ Wrong Answers:
A) Benzoyl peroxide is safe during pregnancy for topical acne treatment.
B) Oral erythromycin is considered safe during pregnancy for bacterial infections.
D) Clindamycin is safe for topical use during pregnancy for acne.
TOPICAL AGENTS
* Topical retinoids should not be combined with benzoyl peroxide at the same time
Benzoyl peroxide in AM and topical retinoid before bed is ok
* Other comedolytics
Azelaic acid – also reduced pigmentation
Salicylic acid – usually found in OTC cosmetic products
Glycolic acid – suitable alternative to topical retinoids
SYSTEMIC AGENTS for Acne
* Antibiotics
- Tetracyclines first-line agents
- Doxycycline, minocycline, tetracycline
Minocycline is the worst option due to drug-induced lupus and hepatitis
* Macrolides and SMX-TMP should only be used as second-line options if tetracyclines are contraindicated or do not work
- Conservative use to minimize resistance
* Should be used in conjunction with benzoyl peroxide
* Oral contraceptives
Specifically ones with minimal androgenic activity or those
that contain cyproterone acetate or drospirenone
* Spironolactone
Potassium sparing diuretic
Often prescribed off label due to its anti-androgenic effects
What is a common cause of folliculitis that is not bacterial in nature?
A) Malassezia
B) Staphylococcus aureus
C) Streptococcus pyogenes
D) Escherichia coli
Correct Answer: A) Malassezia
👉 Why? Malassezia is a type of yeast that can cause fungal folliculitis, which is not related to bacterial infection.
❌ Wrong Answers:
B) Staphylococcus aureus causes bacterial folliculitis, not fungal.
C) Streptococcus pyogenes is a bacteria that causes impetigo, not folliculitis.
D) Escherichia coli is not a common cause of folliculitis.
What is a characteristic feature of a carbuncle?
A) A single boil
B) A collection of multiple interconnected boils
C) A fungal infection of hair follicles
D) A superficial skin infection
Correct Answer: B) A collection of multiple interconnected boils
👉 Why? A carbuncle is formed when multiple furuncles (boils) merge into a large purulent mass.
❌ Wrong Answers:
A) A single boil refers to a furuncle, not a carbuncle.
C) A fungal infection is not associated with carbuncles; they are bacterial.
D) A superficial skin infection doesn’t describe the deep, interconnected nature of a carbuncle.
Which of the following is typically a nonpharmacologic treatment for folliculitis?
A) Warm compresses to accelerate rupture of furuncles
B) Antibiotics for all cases
C) Elimination of tight-fitting clothing
D) Surgical drainage
Correct Answer: C) Elimination of tight-fitting clothing
👉 Why? Reducing friction, moisture, and heat by wearing looser clothing can help prevent folliculitis, especially in intertriginous regions.
❌ Wrong Answers:
A) Warm compresses are used to treat furuncles and carbuncles, but not for all cases of folliculitis.
B) Antibiotics are not used for all cases of folliculitis, as mild cases may resolve on their own.
D) Surgical drainage is used in severe cases (like carbuncles), but not typically for folliculitis.
Which antibiotic is commonly used for the topical treatment of folliculitis?
A) Mupirocin
B) Amoxicillin
C) Ciprofloxacin
D) Clindamycin
Correct Answer: A) Mupirocin
👉 Why? Mupirocin is an effective topical antibiotic, especially for folliculitis caused by Staphylococcus aureus.
❌ Wrong Answers:
B) Amoxicillin is a broad-spectrum antibiotic but is not typically used topically for folliculitis.
C) Ciprofloxacin is a fluoroquinolone used for systemic infections, not typically for topical folliculitis.
D) Clindamycin can also be used but is more often prescribed for oral use in more severe cases.
What is the recommended treatment for extensive or refractory cases of folliculitis?
A) Cephalexin for 7 days
B) Mupirocin ointment
C) Oral antifungals
D) Warm compresses
Correct Answer: A) Cephalexin for 7 days
👉 Why? In extensive or persistent folliculitis, oral antibiotics like cephalexin are recommended to target the bacterial infection effectively.
❌ Wrong Answers:
B) Mupirocin ointment is for localized cases and not for extensive infections.
C) Oral antifungals are not indicated for bacterial folliculitis, which is treated with antibiotics.
D) Warm compresses are used for furuncles or carbuncles, not for extensive bacterial folliculitis.
What should be done if folliculitis is related to a hospital stay or travel, particularly when MRSA is suspected?
A) Administer oral antibiotics without culture
B) Perform a culture to identify the cause
C) Treat with antifungals immediately
D) Use over-the-counter antibiotics
Correct Answer: B) Perform a culture to identify the cause
👉 Why? If MRSA (methicillin-resistant Staphylococcus aureus) is suspected, it is essential to culture the infection first to confirm the bacteria and determine appropriate treatment.
❌ Wrong Answers:
A) Administer oral antibiotics without culture is not recommended as it may not target the right bacteria.
C) Treat with antifungals is incorrect because MRSA is a bacterial infection, not fungal.
D) Use over-the-counter antibiotics may not be effective against MRSA.
Which of the following is a common cause of nonpurulent cellulitis?
A) Group A beta-hemolytic streptococci (S. pyogenes)
B) Staphylococcus aureus (including MRSA strains)
C) Haemophilus influenzae
D) Pasteurella and Capnocytophaga
Correct Answer: A) Group A beta-hemolytic streptococci (S. pyogenes)
👉 Why? Nonpurulent cellulitis is predominantly caused by Group A beta-hemolytic streptococci, such as S. pyogenes.
❌ Wrong Answers:
B) Staphylococcus aureus is the cause of purulent cellulitis, not nonpurulent.
C) Haemophilus influenzae is linked to buccal cellulitis in children, not typically to cellulitis.
D) Pasteurella and Capnocytophaga are associated with cellulitis caused by animal bites, not nonpurulent cellulitis.
Which of the following is a nonpharmacologic approach to managing cellulitis?
A) Use of oral antibiotics
B) Elevation of the affected area
C) Immediate incision and drainage
D) Application of antifungal creams
Correct Answer: B) Elevation of the affected area
👉 Why? Elevating the affected area helps to reduce edema and promote healing.
❌ Wrong Answers:
A) Oral antibiotics are a pharmacologic treatment, not a nonpharmacologic one.
C) Incision and drainage is a procedure for abscesses, not cellulitis.
D) Antifungal creams are not appropriate for cellulitis, as it is a bacterial infection, not fungal.
What is the first-line pharmacologic treatment for nonpurulent cellulitis caused by S. pyogenes?
A) Mupirocin
B) Cephalexin
C) Fluconazole
D) Amoxicillin/clavulanic acid
Correct Answer: B) Cephalexin
👉 Why? Cephalexin, a first-generation cephalosporin, is effective against S. pyogenes and is the first-line treatment for nonpurulent cellulitis.
❌ Wrong Answers:
A) Mupirocin is a topical antibiotic and is not used for cellulitis, which often requires systemic therapy.
C) Fluconazole is an antifungal, not appropriate for bacterial cellulitis.
D) Amoxicillin/clavulanic acid is used for animal bites and polymicrobial infections, not for simple nonpurulent cellulitis.
Which factor increases the risk of fungal nail infections (onychomycosis)?
A) Hyperhidrosis
B) Cold weather
C) Dehydration
D) Decreased foot temperature
Prefix: “Onycho-“
This comes from the Greek word “onyx” meaning “nail”. It refers to the nail, particularly the finger or toenail.
Root: “-mycos-“
This comes from the Greek word “mykes” meaning “fungus”. It refers to a fungal infection.
Suffix: “-osis”
This suffix comes from Greek and typically denotes a condition or disease, often implying an abnormal or diseased state.
So, “onychomycosis” literally translates to “a fungal condition of the nail” or “nail fungus.”
Correct Answer: A) Hyperhidrosis
👉 Why? Hyperhidrosis (excessive sweating) is a known risk factor for onychomycosis, as it creates a moist environment conducive to fungal growth.
❌ Wrong Answers:
B) Cold weather is not a risk factor for fungal nail infections.
C) Dehydration may affect skin health, but it is not directly linked to fungal nail infections.
D) Decreased foot temperature is not a significant factor in fungal nail infections.
What is the most common subtype of onychomycosis?
A) Superficial white onychomycosis (SWO)
B) Proximal subungual onychomycosis (PSO)
C) Distal subungual onychomycosis (DLSO)
D) Candida onychomycosis
Correct Answer: C) Distal subungual onychomycosis (DLSO)
👉 Why? DLSO is the most common subtype of onychomycosis, accounting for about 90% of cases.
❌ Wrong Answers:
A) Superficial white onychomycosis is less common and typically affects children.
B) Proximal subungual onychomycosis is rare and often seen in immunocompromised individuals.
D) Candida onychomycosis is caused by yeast, not dermatophytes, and is less common than DLSO.
Which of the following is an effective topical treatment for mild to moderate distal subungual onychomycosis (DLSO)?
A) Oral terbinafine
B) Ciclopirox olamine 8% lacquer
C) Fluconazole
D) Itraconazole
Correct Answer: B) Ciclopirox olamine 8% lacquer
👉 Why? Ciclopirox is a topical treatment specifically used for onychomycosis, applied to the nails for an extended period to improve nail appearance.
❌ Wrong Answers:
A) Oral terbinafine is a systemic treatment, often reserved for more severe cases.
C) Fluconazole is an oral antifungal, not a topical treatment.
D) Itraconazole is also a systemic treatment, typically used when topical therapy is ineffective.
What is the primary goal of therapy for fungal nail infections (onychomycosis)?
A) Eradicate the causative organism and achieve mycological cure
B) Prevent systemic side effects
C) Reduce nail thickness
D) Apply topical treatments to the skin
Correct Answer: A) Eradicate the causative organism and achieve mycological cure
👉 Why? The primary goal is to eliminate the fungal infection and achieve mycological cure, which is confirmed through laboratory tests.
❌ Wrong Answers:
B) Prevent systemic side effects is important but not the primary goal.
C) Reduce nail thickness is a secondary goal; the main aim is to cure the infection.
D) Apply topical treatments to the skin does not address the fungal infection in the nail effectively.
Which of the following systemic treatments is considered the drug of choice for onychomycosis caused by dermatophytes?
A) Fluconazole
B) Itraconazole
C) Terbinafine
D) Griseofulvin
Correct Answer: C) Terbinafine
👉 Why? Terbinafine is the most effective and preferred systemic treatment for dermatophyte-related onychomycosis.
❌ Wrong Answers:
A) Fluconazole is less effective for dermatophytes and not the first choice for onychomycosis.
B) Itraconazole is second-line for dermatophyte infections, preferred for yeast or nondermatophyte moulds.
D) Griseofulvin is an older treatment and is less effective compared to terbinafine.
