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review Flashcards

1
Q

hemorrhoids

- name 5 types of ingredients in combination pdts

A
  • Combination products include:

 local anesthetics

  • benzocaine, dibucaine, pramoxine
  • Offers temporary relief of symptoms by blocking nerve transmission
  • Is relatively safe if used for up to 7 days
  • Low absorption unless the skin is abraded

 Astringents
- Zinc sulfate, witch hazel
 Produce a drying effect, which helps to relieve symptoms, especially itching and burning
 Form a protective layer by coagulating proteins in skin cells of the perianal skin or lining of the anal canal
 Zinc can be used internally or externally on hemorrhoids, while witch hazel should only be used externally

 anti-inflammatory agents/corticosteroids
Hydrocortisone
- Rx available in combination products
- Onset can take up to 12 hours but effect lasts longer than other therapies

 Protectants

  • glycerin, petrolatum
  • Form a physical barrier on the skin to prevent irritation, itching, pain, and burning
  • May have a lubricating effect
  • Very safe!

 Vasoconstrictors - phenylephrine

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2
Q

hemorrhoids - common OTCs
2 types

new NHPs

A

Preparation H - creams and ointments
- has protectants, vasoconstrictor (limit bleeding short term with phenylephrine) and sometimes anesthetic
Anusol - creams, suppositories, ointments
- has zinc sulfate, sometimes anesthetics

Hemoval: unknown MOA, may strengthen vessel walls, increase tone, suppress inflamm mediators

  • reduce pain, edema, bleeding
  • 600mg PO TID x 4 days then 600 mg PO BID x 3 days
  • AE: abdominal pain, diarrhea, headache, nausea

Venixxa

  • citrus bioflavonoid - antiplatelet/coagulant effects
  • reduce frequency, duration, intensity of symptoms for grade I or II acute internal hem, chronic too
  • acute: 3 tabs BID for 4 days, then 2 tabs BID for 3 days
  • chronic 1 tab BID
  • AE: allergy, GI, discomfort, dizziness, headaches, malaise
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3
Q

pregnant woman preferred pdts for hem

A

astringents, protectants

refer if no relief in 1 week for all

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4
Q

Non pharm management of eructation?
bloating?
flatulence?

A

 Avoid gulping air, eat meals slowly
 Adjust poorly fitting dental apparatus
 Reduce consumption of gas-producing/releasing substances

 Avoid large meals, overeating
 Eat less and earlier in the day
 Avoid dietary and pharmaceutical triggers

 Smaller, more frequent meals
 Exercise
 Eat foods low in FODMAPs (Fructans, fructose, galacto oligosaccharides lactose, mannitol, sorbitol)

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5
Q

Gas pharm treatment

Alpha-D-galactosidase (Beano)

  • dose?
  • used for?
  • do not consume with __________
A

150–450 GaIU PO with the first bite of food
(300–1200 GaIU/day)

Effective in reducing flatus and abdominal discomfort associated with ingestion of non-absorbable carbs
 Do not consume with hot foods
 inactivates enzymes
 Adverse effects: rare allergic reactions

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6
Q

Gas pharm treatment

Bismuth subsalicylate (Pepto-Bismol)

  • dose
  • used for?
  • AE
A

524 mg QID PO (maximum 8 doses/day)
 Binds sulfide gas, effective for short term relief of intestinal gas
 Do not recommend at high doses or as long term therapy to avoid salicylate toxicity
 Adverse effects: constipation, diarrhea, nausea, tongue discoloration, grey/black stool, vomiting
- Don’t recommend bismuth for over 3-4 weeks

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7
Q

Gas pharm treatment

Lactase (Lactaid)
- used for?

A

 Can prevent flatulence in patients with lactase deficiency if taken with or prior to ingestion of lactose
 Dose varies based on amount of lactose ingested

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8
Q

Gas pharm treatment

Laxatives

use?

A

 Reduce symptoms of intestinal gas associated with constipation

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9
Q

Gas pharm treatment

probiotics

use?

A

 Some data has shown a reduction in both short-term and long-term symptoms of abdominal distension, bloating, gas
 Many available options on the market, not always consistent in quantity and type of bacterial species combined

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10
Q

Gas pharm treatment

Simethicone (Ovol, Gas X)

  • dose
  • use
A

80–160 mg per meal PO
 Prevents bubbling of liquids in stomach, not absorbed in GI tract
 No clear benefit in reduction of symptoms of intestinal gas but used for treatment of flatulence and abdominal bloating

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11
Q

name 6 pharm treatments for gas

A 
beano
bismuth sub
lactase
laxatives
probiotics
simethicone

activated charcoal, peppermint, garlic, ginger - insufficient evidence
antibiotics may be for bac overgrowth
baclofen: muscle relaxant for eructation, more evidence needed

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12
Q

hem when to refer?

gas when to refer?

A

refer if no relief in 1 week for all

longer than 1-2 weeks

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13
Q

Permethrin 1% (Nix, Kwellada-P)

Class
Schedule
MOA
Precautions
Contraindication
Directions for use
Side effects
Efficacy
Resistance
A

Class: synthetic pyrethroid
Schedule: II
MOA: Disrupts Na channel → delayed repolarization of membrane potential → respiratory paralysis
Precautions: not for children <2 mos

Contraindication: Allergies to ragweed/chrysanthemum

Directions for use
Wash hair with conditioner-free shampoo
Apply permethrin 1% to damp hair.
Leave on for 10 mins then rinse
Retreat in 7 days
(2 bottles may be needed for thick/long hair)

Side effects: transient irritation (redness, swelling), ocular toxicity, burning, stinging, rash, tingling, numbness uncommon

Efficacy: 96-100%, good ovicidal activity (70-80%)

Resistance: 99% of North American lice may have genes that are consistent with resistance (insectide MOA)

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14
Q

Pyrethrins with Piperonyl Butoxide (R&C)

Class
Schedule
MOA
Precautions
Contraindication
Directions for use
Side effects
Efficacy
Resistance
A

Class: Insecticide extracted from chrysanthemum
Schedule: II
MOA: Disrupts Na channel → delayed repolarization of
membrane potential → respiratory paralysis
- Piperonyl butoxide inhibits pyrethrin breakdown

Precautions: Avoid contact with eyes or mucosal tissues

Contraindication: Allergies to ragweed/chrysanthemum, petroleum pdts

Directions for use
Apply to DRY hair
Leave on for 10 mins then lather and rinse with water
Repeat in 7 days

Side effects: Mild irritation, Potential for contact dermatitis due to petroleum distillates used in formulation

Efficacy: • 45% after 1st application. 94% after 2nd application, may have some ovicidal activity

Resistance: 99% of North American lice may have genes that are consistent with resistance (insectide MOA), potential cross-resistance with permethrin

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15
Q

Isopropyl myristate 50% w/w
cyclomethicone 50 % (Resultz)

Class
Schedule
MOA
Precautions
Contraindication
Directions for use
Side effects
Efficacy
Resistance
A

Class: Non-insecticide
Schedule: II
MOA: Dissolves louse exoskeleton → dehydration →
death

Precautions: Not recommended in children < 2 years
• Avoid contact with eyes
• Formulation is volatile and flammable

Contraindications: none

Directions for use
Apply to DRY hair
Leave on for 10 mins then lather and rinse with water
Repeat in 7 days

Side effects: Local irritation (mild redness and itching)

Efficacy: 57-93%, no ovicidal activity

Resistance: Unlikely (physical mechanism of action)

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16
Q

Dimeticone 50% (Nyda)

Class
Schedule
MOA
Precautions
Contraindication
Directions for use
Side effects
Efficacy
Resistance
A

Class: Non-insecticide
Schedule: II
MOA: Suffocation through blockage of spiracles
• Gut rupture from inhibition of water excretion

Precautions: Not recommended in children < 2 years
• Avoid contact with eyes
• Formulation is volatile and flammable

Contraindications: none

Directions for use
Spray on DRY hair and massage until hair is
completely wet
Leave solution on hair
After 30 mins comb hair with fine-toothed comb
Leave on for at least 8 hrs before washing
Repeat treatment in 8-10 days

Side effects: Mild skin/scalp irritation
• Irritation if in contact with eyes

Efficacy: 97% cure rate
• 1 in 3 more patients lice free compared to permethrin
• 100% Ovicidal activity but 2nd application still
recommended due to imperfect application

Resistance: Unlikely (physical mechanism of action)

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17
Q

Tea tree oil” antimicrobial/antiseptic

Mayo/olive oil: suffocate louse

Vaseline/cetaphil cleanser: suffocate louse

A

natural treatments all have no evidence for lice

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18
Q

pregnancy and lactation

pharm treatments for lice

A

compatible with permethrin 1% and pyrethrins with piperonyl butoxide

no data for isopropyl myristate cyclomethicone or dimeticone

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19
Q

Scabies - Permethrin 5% (Nix, Kwellada-P)

Which line of treatment?
Schedule
Precautions
Contraindication
Directions for use
Side effects
A

Drug of choice, most effective scabicide
Schedule: II

Contraindication: Allergies to ragweed/chrysanthemum

Directions for use
Take a tepid bath/shower and towel dry
Apply to ENTIRE body from neck down including
fingernails, waist and genitalia (entire head and neck in infants and young children)
Put on clean clothing
Wash off after 8-14 hrs
Second administration 1 week later often routinely prescribed but may not be necessary

Side effects: Pruritus, edema, erythema

Precautions: Preferred treatment in those > 2 months of age

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20
Q

Scabies - Crotamiton 10% (Eurax)

Which line of treatment?
Schedule
Precautions
Contraindication
Directions for use
Side effects
A

2nd line, useful anti-pruritic

Schedule: II

Directions for use
Apply to ENTIRE body from neck
down including fingernails, waist
and genitalia (entire head and
neck in infants and young
children)
Repeat in 24 hrs
Wash off after 48 hrs

Side effects: local irritation

Precautions/Contra: Not recommended in patients with exudative or vesicular dermatitis, resistance reported

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21
Q

Scabies - Sulfur 5-10%

Which line of treatment?
Schedule
Precautions
Contraindication
Directions for use
Side effects
A

2nd line, recommended for
children < 2 months

Schedule: I

Directions for use
Apply to all skin areas
QHS x 5-7 days (3 days
in infants)
Wash off in the morning

Side effects: local irritation, dermatitis w/ repeated applications
Precautions/Contra: Allergies to sulfur *strong smell and can stain clothing

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22
Q

when should itch resolve for scabies

A

4 wks

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23
Q

corns vs callus

A

Inspect the foot and footwear

  • Central radix (cone) over bony areas
  • Affected area may be yellowed
  • Skin ridges pass through corns but around plantar warts

callus

  • Similar in appearance to corns, but better defined
  • No central radix
  • On soles or balls of feet
  • Even thickness
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24
Q

red flags for corns/calluses

A
  1. Doubt in diagnosis
  2. Immunocompromised patients (e.g., diabetes)*
  3. Signs of gangrene
    - Discoloration of skin, necrosis, moderate to severe pain without palpation
  4. Peripheral vascular disease*
  5. Over 65 years old
  6. Malnourished*
    - *Due to impaired wound healing; should see podiatrist /foot care specialist
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25
Q

Corns and Calluses – Non-Pharm (3)

A
  1. High-risk (immunocompromised) individuals should
    have their feet examined regularly by a foot care
    specialist
  2. Manage footwear – most common, effective option
    - Change footwear entirely
    - Use orthotic devices to provide arch support and evenly distribute bodyweight
    - Protect affected area with cushioning
  3. Debridement
    - Pumice stones can be used after feet have been soaked for 10 minutes (oils can be applied to further soften these areas)
    - Files / emery boards can be used on dry feet
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26
Q

Corns and Calluses – Pharm (1)

A

Keratolytics – salicylic acid (12 – 40%)

-Overall, little evidence for effectiveness but may speed up the process

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27
Q

Corns and Calluses Monitoring

A
  • Clinical improvement in 10-14 days after initiating salicylic acid treatment.
  • Foot should be inspected at least twice-weekly until healing is complete
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28
Q

plantar warts

A

Benign, contagious tumors – verrucae plantaris
- Can cause embarrassment and pain
- Most common in children and young adults
- Contagious
– Caused by HPV strains infiltrating the skin via cut or micrabrasions transmitted via contact with another lesion or contaminated surfaces
Found on soles of feet
- This is were micro-abrasions are more likely to allow inoculation
- May occur singly or in clusters
- Generally skin-colored and contain thrombosed capillaries that appear as black dots in the center of the lesion
Often symptomless
- But can have pain with pressure
- Grow inward due to walking

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29
Q

Plantar Warts – Non-Pharm (4)

A

Should be referred to a podiatrist, physician, or dermatologist
1. Cryotherapy with liquid nitrogen (-196ºC)
- Considered first-line; requires multiple treatments
- SE: pain, blistering, and scarring
2. Dimethyl ether and propane (at-home option, -57ºC))
- Also freezes the wart creating a blister
underneath it causing it to fall off
3. CO2 laser therapy / pulsed die laser
- Destroy tissue and vasculature respectively
4. Other
- Hyperthermic therapy – soaking in 44ºC water

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30
Q

Plantar Warts – Pharm

A

Salicylic acid – 5-40%
- MOA: keratolytic and drying agent. Topical chemicals
trigger inflammatory response and can stimulate the body to attack the virus and destroy infected tissue
- SE: low scarring potential, but can take months to be
effective. Because of location of foot, liquid preparations are preferred over pastes or ointments, as the latter may spread to healthy skin due to pressure of walking

f/u every 4 wks - if it persists after 12 wks refer

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31
Q

Common and plane warts description (proper name, contagious? age groups)

A
  • Benign, contagious tumors cause by HPV strains
  • Children and young adults are most commonly affected
  • Same means of transmission and similar incubation as with plantar warts
  • Common Warts:
     Most often seen on the knees, fingers, hands and around the nails
  • Plane Warts:
     Most often seen on face and neck
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32
Q

Common and plane warts management - pharm

A
  • Salicylic formulations not to be used on the face, neck and genital area. Can recommend for hands.
  • Virucidal Therapy*
  • Antiproliferative Therapy*
  • Immunological therapy*
     Cimetidine has been used in the treatment of warts
     MOA: Increasing cell-mediated immunity by blocking T-suppressor cells on H2 receptors
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33
Q

red flags for seb derm

A 
 Diagnosis in doubt
 Treatment failure
 Widespread area of involvement
 Systemic symptoms present
 Immunocompromised
 Sudden onset in young patient
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34
Q

dandruff goals of therapy

seb derm goals of therapy

A

 Reduce or eliminate scales and flaking
 Prevent recurrence by improving scalp hygiene
 Eliminate or reduce environmental triggers

 Control (not cure) symptoms
 Reduce fungus and resulting scaling/inflammation
 Relief symptoms (e.g., pruritis)
 Education importance of control through good hygiene
 Eliminate or reduce environmental triggers

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35
Q

pharm - seb derm/dandruff

what is first line therapy?
pdt name
MOA?

what is an alternative 1st line?

A

Antifungals – first-line in both conditions
 Nizoral® – ketoconazole (first line therapy)
 MOA: fungistatic, helps with inflammation
 SE: minimal irritation
 Use 2-4x week
 Widely studied; good response in 4 weeks
also an antifungal cream for other areas

 Stieprox® – ciclopirox shampoo – Rx (alternative to ketoconazole)
 MOA: cytostatic (slows fungal growth)
 Use: 2-3x week
 SE: well tolerated, minimal irritation
- costly but also 1st line
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36
Q

pharm - seb derm/dandruff

what are 2 second line therapies?
pdt name
MOA?

A

 Selsun® blue – selenium sulfide
 MOA: fungistatic on scalp, keratolytic
 Do not use > 3x/week
 SE: irritation of broken skin; may affect hair dye or damage jewelry
Skin needs enough exposure - 5 mins and rinse it out and repeat one more time

Head and Shoulders® products – zinc pyrithione
 MOA: cytostatic and keratolytic properties
 Use: 2-3x week
 SE: may discolor hair

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37
Q

Name 3 keratolytics (may be added to other topical therapies)

A
  1. Salicylic acid – helps detach flakes / allows penetration of other agents
  2. Sulfur – antifungal, antibacterial, and keratolytic effect
  3. Coal tar – reduces swelling, inflammation, and itching, but minimal antifungal activity
     SE: messy, staining, and unpleasant odor
    - fallen out of favour

Sebcur has coal tar and salicylic acid
Denorex has coal tar

38
Q

Anti-inflammatories (3) for dandruff/seb derm

A 
Topical corticosteroids (TCS)
 Reduce pruritus and inflammation
 Generally, have patient stay on corticosteroid for 2-3 weeks until antifungal exerts its action then withdraw TCS
 Intended for temporary use
 e.g., hydrocortisone 1%
 Scalp solutions available
Topical calcineurin inhibitors – second line option
 Prescription-only
 e.g., tacrolimus or pimecrolimus
- NO side effects, prescription only
- for thin skin only

Oral antifungals – for severe or refractory cases

For seb derm as areas can be inflamed and in other places which is added to antifungal

39
Q

How can the compound efficacy be ranked? dandruff/seb derm

A

Efficacy of compounds can be ranked:
 Ketoconazole, ciclopirox and moderate-potency corticosteroids
 Calcinuerin inhibitors or hydrocortisone
 Selenium sulfide
 Zinc pyrithione
 Keratolytics
 Coal tar

40
Q

NHPs - have an idea

evidence?

A

limited evidence, few studies, pdts not qlty controlled

Tea tree oil
 Terpinen-4-ol may have activity against M. furfur
 Solutions of 5-10% used as topical antifungals
 Effective and tolerated in dandruff treatment vs. placebo
- 5% shown effective

Quassia amara 4% gel
 Antifungal and anti-inflammatory properties
 Compared to topical ketoconazole and ciclopirox, may have advantage in efficacy over 4 weeks

Heartsease and oat straw
 Effective for mild seborrheic dermatitis

Solanum chrysotrichum leaf extract
 No difference in efficacy vs. ketoconazole

41
Q

sweating/odour goals of therapy? (4)

A

 Control socially undesirable body odour
 Control underarm wetness due to physiologic sweating
 Reduce quantity of sweat excreted due to hyperhydrosis
 Prevent complications of hyperhydrosis
Especially of the feet: odour, blisters, infection

42
Q

red flags sweating (2)

A

Consider referral for
 Recent increase or onset of sweating
 Sweating in an unusual or unexplainable pattern
 e.g., only at night or in the absence of exercise, unusual location

if sweating is excessive and affects qlty of life, not controlled by standard antiperspirants classify as primary of secondary hydrosis

if primary, treat with stronger aluminum conc and use nonpharm measures

if secondary, treat underlying medical condition/change med

43
Q

pharm for sweating

antiperspirants
ingredient?
MOA?
strength?

A

Work best for axillary sweating, but can be applied anywhere.

MOA: Sweat glands are mechanically plugged, causing sweat to thicken and clump; this signals the body to stop perspiring. Over time, application of antiperspirants may destroy secretory cells, so decreased application is required.

“Regular” vs. “clinical” strength
 Aluminum salts like aluminum zirconium (e.g., Speed Stick®) create more superficial blockages and should not create irritation with once or twice daily application
 Aluminum chloride 6.25% – 20% (e.g., Drysol®) may provide deeper and more effective blockages, but may be more irritating

44
Q

pharm for sweating

deodorants
ingredient?
MOA?
strength?

A

Do not prevent sweating

MOA: Mask odour with fragrance or by reducing bacterial population

Contain ingredients such as “alum” (a water purifier) or crystals of potassium or ammonium alum. Some contain vinegar, sodium bicarbonate, and isopropyl alcohol.

Those marketed for the feet may contain the above, or zinc salts and corn starch
 e.g., Crystal Body Deoderant®, Dr. Scholl’s Foot Powders®

45
Q

2 other pharm for sweating

  1. Block the release of acetylcholine from cholinergic neurons in eccrine glands
     Approved for 1º hyperhydrosis of the axillae, but could be used on other sites as well
     Results possible within 2 weeks, with effect lasting 4-12 months
  2. Commonly used for overactive bladder
     Has anticholinergic effects
    has side effects
A

al salts, then electrophoresis, then botox

botox – onabotulinumtoxinA

oxybutynin

46
Q

red flags for bites and stings

goals

A
  • <2 years of age - pro judgement
  • extensive local rxn ? 10 cm in diameter persisting several days
  • multiples bites/stings
  • sting to mouth, tongue
  • history of rxn to previous bites/stings (anaphylaxis)
  • immunocompromised and lesion remains after 7 days with no improvement

 Prevent bites and stings
 Prevent diseases or reactions caused by bites and
stings
 Ensure patient receives appropriate care when
warranted (In the case of more serious reactions)
 Provide symptomatic relief of localized reactions

47
Q

insect repellents

examples?

A

 Products containing a Pest Control Product (PCP) registration number on the label
 Can be used in pregnancy and breastfeeding with the exception of citronella

 DEET (N,N-diethyl-m-toluamide) - offensive smell,
- low conc for greater than 6 mos, high conc older than 12

 PMD (P-menthane 3,8-doil)
- MOA unknown, under age of 3

 Icaridin / Picaridin
- conceals attractants, changes ability of bugs to smell

 Oil of citronella
- offensive taste of smell, not for under 2

 Soybean oil
- all ages safe, conceal attractants, cools skin surface temp

48
Q

Name 6 types of pharm treatments for bites/stings

A

analgesics: acetaminophen, ibuprofen
antihistamines: first or second gen (1st more side fx, shorter DOA

astringents/protectants: calamine, zinc oxide, less appealing

anesthetics: benzocaine, lidocaine, pramoxine
counterirritants: camphor or menthol, cooling, anti-itch, pain-relieving
corticosteroids: hydrocortisone 0.5% or 1%, max 7 days, no Rx unless child under 2

other (ammonia/baking soda After Bite): local cooling and anti-pruritic

49
Q

what are the types of burn?

A

1st degree
 Affect the epidermis only
 Causes: sunburn, low-intensity heat
 Presentation: dry, pink, blanches with pressure,
some pain but no edema, skin remains intact
 Healing: 3-7 days without scarring

2nd degree (superficial partial thickness)\
 Affect the epidermis and upper dermis
 Causes: scalds, flame, dilute chemicals
 Presentation: moist, weeping, blanches with
pressure, extreme pain, small blisters
 Healing:3-7 days, some pigment changes,
generally no scarring

2nd degree (deep partial thickness)
 Affects the epidermis and deep dermis, including hair
follicles and sweat glands
 Causes: scalds, oil/grease, flame, prolonged
exposure to dilute chemicals
 Presentation: wet/waxy or dry, variable color (red/white), blisters, no blanching with pressure, pain only with pressure
 Healing: >21 days with possible scarring and contractures (tightening of tendons/muscles)

3rd degree (full thickness)
 Affects the epidermis and deep dermis, including hair
follicles and sweat glands
 Causes: scalds, oil/grease, flame, prolonged
exposure to dilute chemicals
 Presentation: wet/waxy or dry, variable color (red/white), blisters, no blanching with pressure, pain only with pressure
 Healing: >21 days with possible scarring and contractures (tightening of tendons/muscles)

50
Q

red flags for burns

A
  • refer for deep partial-thickness or full-thickness burns
     >10% TBSA for adults or >5% TBSA for children
     Any size of burn that is more serious*
     Any burn involving thin skinned areas or individuals
    presumed to have thin skin (face, ear, eyelid)
     Burns on hands/feet or circumferential burns (circumference of digit/extremity/torso)
     Concomitant trauma (e.g., electrocution)
     Chemical burns (may progress), electric or inhalation burn
     Possible inhalation injury
  • < 5y or >60 y
  • monitor if there is underlying medical condition that can delay healing
51
Q

pharm for burns

A

 Usual doses of acetaminophen or ibuprofen (or opioids)
 Avoid ASA, as may promote bleeding from deep wounds
 Lidocaine/benzocaine/pramoxine often marketed for burns, but little evidence for use and may sensitize
 Camphor/menthol/phenol could have cooling effect, but also little evidence for use

 Colloidal oatmeal (Aveeno® products) and other topical moisturizing products for itch
 Oral diphenhydramine (Benadryl®, cetirizine (Reactine®), or hydroxyzine (Atarax® - Rx), may be beneficial if itching is bothersome

 Suggest the use of sunscreen as burned skin is susceptible to damage
 Honey – anti-microbial and anti-inflammatory properties may improve healing by 4-5 days
 Aloe vera – inconclusive evidence, may cause some irritation
 Tetanus vaccine – for partial- or full-thickness burns

52
Q

name 4 healing phases for wounds

A
  1. Hemostasis phase – begins within minutes, release of inflammatory mediators assists with clot formation, etc.
  2. Inflammatory phase – lasting ~4 days, WBC migration prevents infection
    and begins repair process.
  3. Maturation phase – also within 4-5 days, collagen forms early scar tissue to close and strengthen the wound.
  4. Proliferative phase – lasting ~24 days, the wound remains red and raised but starts contracting.
  • collagen can continue to strengthen the wound for up to 2 years depending on the type of wound
53
Q

red flags for wounds

A

Wounds that continue to bleed despite application of
pressure:
 Wounds that expose fat, muscle, or bone
 Visible foreign material despite irrigation
 Gaping / large wounds (>2cm)
 Deep puncture wounds

 Wounds from animal bites
 Wounds causing severe pain
 Chronic wounds or those at risk of delayed healing due to wound / patient factors
 Signs of infection

54
Q

pharm for wounds

Topical Antibacterials
Oral Antibiotics

A

Prophylaxis – generally not recommended unless there is a high risk of infection

Treatment – for superficial, mildly infected wounds
 e.g., Polysporin® cream or ointment – OTC
 e.g., fucidin acid (Fucidin® - Rx) or mupirocin (Bactroban® - Rx)
 All are applied BID to TID, may cause localized irritation
 Should be used only as long as is necessary

 oral antibac Indicated for human/animal bites, deep wounds, or those persisting >2 weeks despite proper care

55
Q

how does acne form?

A
  • increased androgen production -> increased sebaceous gland size and activity -> increased sebum production
  • increased keratinization of the epithelial cells cause obstruction of the follicle forming a dense plug
  • Sebum becomes trapped and accumulates forming a comedo
  • Comedo contains oily sebum, keratinized cells, bacteria
  • Sebum continues to be produced -> comedo continues to grow
  • C. acnes hydrolyzes the sebum triglycerides into free fatty acids
  • Fatty acids increase keratinization feeding into the cycle of more
    microcomedones
    -> Increase of C. acnes leading to T cell response and inflammation
    polymorphonucleocytes move to follicle and bacteria release chemokines - formation of pus
56
Q

What are some red flags with acne? (7)

A
  • Acne is drug-induced or due to a known
    endocrinopathy (e.g., polycystic ovarian syndrome
    as it may be suspected with hirsutism, weight gain)
  • Systemic symptoms are present (fever, malaise)
  • Psychological assessment is required
  • Acne at a very young age (may need endocrinology
    consult)
  • Moderate to severe acne requiring prescription
    therapy (asses your competency to manage acne)
  • Acne that is nonresponsive to initial therapy
  • Presence of scarring, especially if moderate to
    severe
57
Q

What are the 4 goals of therapy for acne?

A
  1. Clear existing lesions
  2. Prevent new lesions
  3. Treat early to minimize scarring, hypo/hyperpigmentation
  4. Minimize psychological impact
58
Q

Non-pharm for acne

A
  1. Address contributing factors and introduce lifestyle/self-care measures
  2. Do not pick and touch lesions
  3. Cleansing
     No more than twice daily
     Suggest cleansers that are mild and unscented
     Do not scrub skin
  4. Cosmetics
     Use oil-free make-up, try to avoid multiple layers
     Wash off at night!
     Hairspray can clog pores, discontinue if possible or wear a headband over exposed skin.
  5. Educate on stress management
  6. Encourage a well balanced diet
  7. Cationic (C) bond strips
     Activated by water, dirt/oil is anionic, strip adheres to this molecules and removes it when strip peeled off
     Temporary improvement in appearance of skin but limited permanent change
  8. Comedone Extraction
     Efficacy may be enhanced if pretreated with a peeler (i.e. glycolic acid, salicylic acid)
59
Q

Topical Benzoyl Peroxide details

when to use
strength
MOA
Vehicles
Administration
Response time
AE
A

When to use: First line for mild-moderate acne as monotherapy, combination

Strength:

  • 2.5-5% most common
  • BPO > 5% no more effective and more irritating
  • Unscheduled: strength <5%
  • Schedule I: >5%, combination product with a topical antibiotic or retinoid

Mechanism of action: Antibacterial: oxidation of bacterial proteins. Eliminates C. acnes on the surface of the skin and sebaceous follicle. Effective in the prevention of bacterial resistance.
- Mildly comedolytic

Vehicles: Gel, cream, solution, lotion, wash, soap
• Avoid recommending washes, soaps -> little contact time with the face = least effective

Administration: Apply topically to entire affected area
To minimize irritation, start with applying for 15 mins 1st night, 30 mins 2nd night, increase to over night eventually

Response time: • Rapid bactericidal effects may start seeing a decrease in inflamed lesions ~5 days. See optimal improvement 8-12 weeks

Adverse effects • Dryness, peeling, erythema, burning, bleaches clothing, smell that lingers (body odor)

Other counseling • Decrease irritation at initiation by decreasing frequency (eg. apply every 2-3 days, various regimens)
• Sunscreen during the day, BP at night
• Can bleach hair/ clothing
• PRACTICAL TIP: use at night to avoid staining of clothes

Examples: Non-prescription
• Neutrogena On-the-Spot (2.5% benzoyl peroxide)
Prescription
• BenzaClin gel (benzoyl peroxide 5% clindamycin 1%) - Rx

60
Q 
Salicylic acid details
when to use
strength
MOA
Vehicles
Administration
Response time
AE
A

Schedule U: in topical preparations in concentrations <40%

Mechanism of action: Mildly comedolytic Keratolytic, mildly antibacterial, mildly antiinflammatory

Available strengths: 0.5-3.5% daily-BID
Vehicles: Gels, toners, cleansers, washes, pads

Adverse effects: Drying, burning, stinging, erythema, pruritus, peeling

Other
• Well tolerated
• Less potent than equal
strength benzoyl peroxide
• 8-12 weeks time to effect
61
Q

Glycolic acid details

schedule
strength
MOA
Vehicles
Administration
Response time
AE
A

Schedule: U

Mechanism of action: Mildly comedolytic, causes desquamation

Available strength: 2-15% (40% used as a peel)

Vehicles:
• solution, gel, lotion, cream;
• apply once to BID

Adverse effect:
Burning, stinging, erythema, dryness, pruritus

Other:
• At higher concentrations used for chemical peels
• 6-7 weeks time to effect

62
Q

zinc acetate or zinc gluconate details

schedule
strength
MOA
Vehicles
Administration
Response time
AE
A 
Schedule: U
Mechanism of action: Absorb excess sebum
Available strengths: n/a
Vehicles: cleansers
Adverse effects: burning, stinging
Other:
• Well tolerated
• Time to effect? Assess for improvement @ 4-8 weeks
63
Q

Resorcinol details

A

Schedule: U
Mechanism of action: Keratolyltic (mild) and
bactericidal and fungicidal
Available strengths: 1-2% (+ sulfur, salicylic acid)
Vehicles: Variety of formulations
Adverse effects:
• Burning, stinging (Do not apply to large areas of skin or broken skin)
• Can pigment skin in darker individuals

Other: • Needs protective packaging because reactive to light and O2.
• Time to effect? Assess @ 4-8 weeks

64
Q

name 5 acne ingredients

A 
benzoyl peroxide 2.5-5% 8-12 wks
salicylic acid 0.5-3.5% BID 8-12 wks
glycolic acid 2-15% BID 6-7 wks
zinc acetate/gluconate cleansers 4-8 wks
resorcinol 1-2% (+sulfur, salicylic acid) 4-8wks

monitor 4-8 wks
check in a few days after start of therapy (may take 2-4 months for results)

65
Q

Xerosis - Pathophysiology-what are the contributing abnormalities (5)

A
  1. There is an overall reduction in the lipids in the stratum corneum
  2. Ratio of ceramides, cholesterol and free fatty acids may be altered.
    - Most skin barrier disorders are characterized by a decreased ceramide content which leads to a defect in the epidermal layer.
  3. Abnormal filaggrin (protein that bind to keratin fibers in the epidermal cells) expression
    - This results in corneocyte deformation (flattening of surface skin cells), which disrupts the
    organization of the extracellular lipid (fat).
  4. There may be a reduction in proliferation of keratinocytes.
    - Keratinocyte subtypes change in dry skin with decrease in keratins K1, K10 and increase in K5, K14.
  5. too much involucrin (protein) may be expressed early, increasing cell stiffness
66
Q

What is the Immune response for dermatitis? (think of the skin diagram)

A
  • Immune activation by resident innate immune cells leads to type 2 inflammation, led by inflammatory cytokines IL-4, IL-13, and IL-31.
  • Type 2 inflammation mediates barrier disruption, promotes further inflammation, and increases itch, leading to acute skin lesions.
  • Chronic disease is characterized by intensification of the effect of type 2/Th2 cytokines as well as involvement of Th1 inflammation, resulting in lichenification of the skin
  • Innate immune cells and proteins are always present and read to mobilize to fight microbes
  • Th1 and Th2 is off balance
67
Q

allergic rhinitis/conjunc, allergic bronchial asthma, AD

A

atopic syndrome, diathesis, triad

68
Q

Atopic Dermatitis - Presentation

locations?

A

Infantile (<2yr): scalp, cheeks, outer elbows, middle chest, knees, diaper area

Childhood (2yr-puberty): neck, inner elbows, behind knees, feet

Adult: hands and feet

there is mild, moderate and severe AD
Start prescription therapy if there is morbidity

69
Q

Irritant Contact Dermatitis - Pathophysiology and Contributing Factors

A
  • Nonallergic reaction resulting from activation of the innate immune system by the direct cytotoxic effect produced by exposure to any substance.
  • Occurs when chemicals or physical agents damage the surface of the skin faster than the skin is able to repair the damage.
  • Irritants remove oils and moisture from the outer epidermal layer, allowing chemical irritants to penetrate more deeply and cause further damage by triggering inflammation.

agg factors

  • Inflamed skin
  • Burn
  • Skin infection
  • Pressure or friction on the skin
  • Excessive perspiration
  • Extremes in temperature
  • Occlusion of skin
70
Q

why is breastfeeding protective for diaper derm?

A

feces less copious, less alkaline, less caustic

71
Q

Diaper Dermatitis - Presentation

A

From slight to severe
Slight : faint pinkness
Mild: area of pinkness and few raised bumps
Moderate: definite pinkness in large area with small definite redness and scattered raised bumps
Moderate to severe: intense redness, peeling raised bumps, few fluid containing bumps
Severe: intense redness over large area of multiple raised bumps with fluid containing bumps

mod to sev - start to refer

72
Q

Allergic Contact Dermatitis - Pathophysiology

A

Delayed or T cell–driven hypersensitivity immune reaction mediated by lymphocytes that have been previously sensitized
The incubation period after initial sensitization is 5–21 days and 12–48 hours after subsequent re-exposure, but the reaction may continue to develop for several weeks.

73
Q

AD red flags

A
  • Concomitant skin infection
  • Large body surface area is involved, open wounds that are oozing or blistering
  • Systemic symptoms present (fever, malaise, pain)
  • Patient is psychologically distressed and requires an assessment
  • Patient needs a prescription drug product?
  • Assess you competency as a prescriber
  • Patient is experiencing side effects from prescribed treatment
  • Treatment failure (after you assess adherence)
  • Ambiguity on diagnosis
74
Q

AD Goals of Therapy (4)

A
  • Restore barrier function
  • Provide symptomatic relief while decreasing skin lesions
  • Implement proactive measures focusing on preventing or decreasing the number of flares or exacerbations
  • Increase symptom free periods and empower patient/caregiver with strategies to manage skin condition
  • Decrease impact on quality of life and psychosocial distress due to condition
75
Q

what are the different types of moisturizers? (5)

A 
occlusive agents
humectants
emollients
bath products
barrier repair products
76
Q

Moisturizer: Occlusive agents

A

Form a layer on the skin that inhibits moisture evaporation. Used in conjunction with hydration.
Examples: mineral oil, dimethicone, petrolatum
Additional notes:
- These agent are not appealing on the face
- In very hot and humid climates, can be overly greasy and occlusive

77
Q

Humectants

A

Hygroscopic, attract water to the skin
Examples: Alpha-hydroxy acid (AHA) (glycolic acid,
lactic acid), glycerin, propylene glycol, urea
Additional notes:
- Formulations may sting if used on open wounds. People with sensitive skin may not tolerate.
- Use with an occlusive agent. Lactic acid (>12%) and urea (>10%) are keratolytic and their use is reserved for
treatment of more severe skin conditions with thick scales

78
Q

emollients

A

Fill in the spaces between stratum corneum, sealing moisture in the skin. Lubricate stratum corneum and slow evaporation. Most are oil in water or water in oil emulsions (the more oil, the less evaporation due to increased occlusion).
Examples: colloidal oatmeal, glycol, glyceryl stearate, shea butter and soy sterols

79
Q

Bath products

A

Provide a layer of oil on the skin that prevents moisture evaporation
Examples: colloidal oatmeal, liquid paraffin

Barrier Repair Products
Normalize skin barrier by replacing lipids; decreasing
transepidermal water loss (TEWL); decreasing response to triggers for inflammation.
Example: Ceramides/cholesterol/free fatty acids
combinations, filaggrin, silicone and/or zinc related
compounds

80
Q

4 pharm options AD

A

TCS: qs-bid + moisturizer

Topical calcineurins: protopic (tacro 1% cream), elidel (pime 0.03-0.1% ointment), bid
- inhibits T-lymphocyte activation by first bindng intracellular protein

Topical PDE4 inhibitor: eucrisa (crisabole) ointment, bid
- inhibit PDE4 which is an enzyme overactive in eczema which regulates inflamm

Systemic biologic: dupexent (dupilumab), IL-4 receptor alpha ant

f/u in 7-10 days

81
Q

Atopic Dermatitis - Specific Care Plan

A
  1. Mild disease: Moisturizers and patient education on
    lifestyle measures
  2. Moderate to severe disease: Moisturizers + TCS/TCI
    or crisaborole + patient education on lifestyle
    measures
  3. Severe disease: All of the above +/- dupilumab,
    phototherapy, other immunosupressants (out of the
    scope of PMCO 1)
82
Q

Irritant Contact Dermatitis- Specific Care Plan

ABCDE for diaper derm

A
  1. Obtain a good social history that helps identify
    potential occupational triggers.
  2. Treatment is to avoid the irritants, protect the skin
    (gloves, barrier creams, dimethicone-containing creams)
    and occasional use of topical steroids
ABCDE of Diaper Dermatitis - A's (4)
avoid agg
air, absorptive, antifungals, anti-inflamm
barriers
cleansing, compressing
diapers
education
83
Q

Allergic Contact Dermatitis - Specific Care Plan

A
  1. Treatment of ACD hinges on detection of the allergen
    (through “patch testing”)
  2. Avoidance of allergen and use of topical
    corticosteroids for acute flares.
84
Q

Stasis Dermatitis - Specific Care Plan

A 
1. Relieve the swelling
• Compression stockings
• Elevation of limbs
2. Use moderate to potent TCS
3. Patients with stasis dermatitis are particularly prone to developing allergic contact dermatitis (use inert
products!)
85
Q

viscosity agents
electrolytes
lipids
preservatives

A
  • carboxymethylcelluose
  • hyaluronic acid
  • polyethylene glycold
  • petrolatum - is viscous and is a lipid (2 roles)
  • potassium chloride
  • sodium bicarbonate
  • castor oil
  • mineral oil

common

  • benzalkonium chloride (BAK)
  • EDTA
  • Lanolin

safer

  • PolyQuad
  • Purite
  • Sodium perborate
  • oxidative preservatives, safe alternatives
86
Q

Contact Lens Care

What drugs affect lenses or the wearer?

A

oral contraceptives (Alesse): exacerbation of dry eye

antihistamines, sedatives, hypnotics (benadryl): decreased blink rate

muscle relaxants (Robax pdts, cyclobenzaprine): incomplete blinking

aspirin: ocular irritation, redness

antibiotics (nitrofurantoin, others): discoloration of lenses

ophthalmic products (BAK, decongestants like phenylephrine, tetrahydrozoline): concentrates in lenses and leads to irritation, dark discoloration with repeated use

ASA, anticholinergic drugs, isotretinoin

87
Q

Otitis Externa

pharm treatment
Name 4 types of drugs or substances that can be used

A
  • acidifying agents: acetic acid 2%
  • antibiotics: gramicidin/polymixin B drops (OTC)
  • analgesics: no antipyrine/benzocaine drops (OTC), use aceta, ibu
  • corticosteroids: dexamethasone drops (Rx)

f/u 3-5 days

88
Q

Red flags of dyspepsia and GERD

4+ others

A
  1. Abdominal mass / swelling
    - History of abdominal cancer
  2. Dysphagia, odynophagia, or choking
  3. Unintentional weight loss
  4. Symptom onset or worsening at >50 years of age
  5. What are some others…?
     Chest pain that resembles cardiac symptoms -Radiating
     GI bleeding - Coffee-ground vomitus or black, tarry stools
     Anemia - Dizzy, pale, fatigued
89
Q

Tums

A
  • calcium carbonate
  • 500-1500mg daily in divided doses (pc, hs)
  • Preferred agent in renal failure

SE: constipation, kidney stones, acid rebound,
belching, milk-alkali syndrome
- Acid rebound: calcium carbonate can stimulate gastrin release leading to more acid reflux

90
Q

Diovol

  • active ingredient
  • dose
  • SE (1)
A

– aluminum / magnesium hydroxide

  • 30mL 1 hour pc and hs prn
  • SE: Combination product intended to offset constipation / diarrhea side effects
91
Q

Milk of Magnesia

  • active ingredient
  • dose
  • SE (1)
A
  • magnesium hydroxide
  • Chew 2-4 tablets or drink 5-15mL up to QID prn
  • SE: diarrhea

Pharmacotherapy (14 decks)

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