review Flashcards
hemorrhoids
- name 5 types of ingredients in combination pdts
- 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
hemorrhoids - common OTCs
2 types
new NHPs
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
pregnant woman preferred pdts for hem
astringents, protectants
refer if no relief in 1 week for all
Non pharm management of eructation?
bloating?
flatulence?
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)
Gas pharm treatment
Alpha-D-galactosidase (Beano)
- dose?
- used for?
- do not consume with __________
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
Gas pharm treatment
Bismuth subsalicylate (Pepto-Bismol)
- dose
- used for?
- AE
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
Gas pharm treatment
Lactase (Lactaid)
- used for?
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
Gas pharm treatment
Laxatives
use?
Reduce symptoms of intestinal gas associated with constipation
Gas pharm treatment
probiotics
use?
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
Gas pharm treatment
Simethicone (Ovol, Gas X)
- dose
- use
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
name 6 pharm treatments for gas
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
hem when to refer?
gas when to refer?
refer if no relief in 1 week for all
longer than 1-2 weeks
Permethrin 1% (Nix, Kwellada-P)
Class Schedule MOA Precautions Contraindication Directions for use Side effects Efficacy Resistance
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)
Pyrethrins with Piperonyl Butoxide (R&C)
Class Schedule MOA Precautions Contraindication Directions for use Side effects Efficacy Resistance
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
Isopropyl myristate 50% w/w
cyclomethicone 50 % (Resultz)
Class Schedule MOA Precautions Contraindication Directions for use Side effects Efficacy Resistance
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)
Dimeticone 50% (Nyda)
Class Schedule MOA Precautions Contraindication Directions for use Side effects Efficacy Resistance
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)
Tea tree oil” antimicrobial/antiseptic
Mayo/olive oil: suffocate louse
Vaseline/cetaphil cleanser: suffocate louse
natural treatments all have no evidence for lice
pregnancy and lactation
pharm treatments for lice
compatible with permethrin 1% and pyrethrins with piperonyl butoxide
no data for isopropyl myristate cyclomethicone or dimeticone
Scabies - Permethrin 5% (Nix, Kwellada-P)
Which line of treatment? Schedule Precautions Contraindication Directions for use Side effects
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
Scabies - Crotamiton 10% (Eurax)
Which line of treatment? Schedule Precautions Contraindication Directions for use Side effects
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
Scabies - Sulfur 5-10%
Which line of treatment? Schedule Precautions Contraindication Directions for use Side effects
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
when should itch resolve for scabies
4 wks
corns vs callus
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
red flags for corns/calluses
- Doubt in diagnosis
- Immunocompromised patients (e.g., diabetes)*
- Signs of gangrene
- Discoloration of skin, necrosis, moderate to severe pain without palpation - Peripheral vascular disease*
- Over 65 years old
- Malnourished*
- *Due to impaired wound healing; should see podiatrist /foot care specialist
Corns and Calluses – Non-Pharm (3)
- High-risk (immunocompromised) individuals should
have their feet examined regularly by a foot care
specialist - 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 - 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
Corns and Calluses – Pharm (1)
Keratolytics – salicylic acid (12 – 40%)
-Overall, little evidence for effectiveness but may speed up the process
Corns and Calluses Monitoring
- Clinical improvement in 10-14 days after initiating salicylic acid treatment.
- Foot should be inspected at least twice-weekly until healing is complete
plantar warts
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
Plantar Warts – Non-Pharm (4)
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
Plantar Warts – Pharm
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
Common and plane warts description (proper name, contagious? age groups)
- 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
Common and plane warts management - pharm
- 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
red flags for seb derm
Diagnosis in doubt Treatment failure Widespread area of involvement Systemic symptoms present Immunocompromised Sudden onset in young patient
dandruff goals of therapy
seb derm goals of therapy
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
pharm - seb derm/dandruff
what is first line therapy?
pdt name
MOA?
what is an alternative 1st line?
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
pharm - seb derm/dandruff
what are 2 second line therapies?
pdt name
MOA?
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
Name 3 keratolytics (may be added to other topical therapies)
- Salicylic acid – helps detach flakes / allows penetration of other agents
- Sulfur – antifungal, antibacterial, and keratolytic effect
- 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
Anti-inflammatories (3) for dandruff/seb derm
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
How can the compound efficacy be ranked? dandruff/seb derm
Efficacy of compounds can be ranked:
Ketoconazole, ciclopirox and moderate-potency corticosteroids
Calcinuerin inhibitors or hydrocortisone
Selenium sulfide
Zinc pyrithione
Keratolytics
Coal tar
NHPs - have an idea
evidence?
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
sweating/odour goals of therapy? (4)
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
red flags sweating (2)
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
pharm for sweating
antiperspirants
ingredient?
MOA?
strength?
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
pharm for sweating
deodorants
ingredient?
MOA?
strength?
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®
2 other pharm for sweating
- 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 - Commonly used for overactive bladder
Has anticholinergic effects
has side effects
al salts, then electrophoresis, then botox
botox – onabotulinumtoxinA
oxybutynin
red flags for bites and stings
goals
- <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
insect repellents
examples?
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
Name 6 types of pharm treatments for bites/stings
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
what are the types of burn?
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)
red flags for burns
- 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
pharm for burns
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
name 4 healing phases for wounds
- Hemostasis phase – begins within minutes, release of inflammatory mediators assists with clot formation, etc.
- Inflammatory phase – lasting ~4 days, WBC migration prevents infection
and begins repair process. - Maturation phase – also within 4-5 days, collagen forms early scar tissue to close and strengthen the wound.
- 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
red flags for wounds
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
pharm for wounds
Topical Antibacterials
Oral Antibiotics
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
how does acne form?
- 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
What are some red flags with acne? (7)
- 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
What are the 4 goals of therapy for acne?
- Clear existing lesions
- Prevent new lesions
- Treat early to minimize scarring, hypo/hyperpigmentation
- Minimize psychological impact
Non-pharm for acne
- Address contributing factors and introduce lifestyle/self-care measures
- Do not pick and touch lesions
- Cleansing
No more than twice daily
Suggest cleansers that are mild and unscented
Do not scrub skin - 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. - Educate on stress management
- Encourage a well balanced diet
- 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 - Comedone Extraction
Efficacy may be enhanced if pretreated with a peeler (i.e. glycolic acid, salicylic acid)
Topical Benzoyl Peroxide details
when to use strength MOA Vehicles Administration Response time AE
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
Salicylic acid details when to use strength MOA Vehicles Administration Response time AE
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
Glycolic acid details
schedule strength MOA Vehicles Administration Response time AE
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
zinc acetate or zinc gluconate details
schedule strength MOA Vehicles Administration Response time AE
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
Resorcinol details
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
name 5 acne ingredients
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)
Xerosis - Pathophysiology-what are the contributing abnormalities (5)
- There is an overall reduction in the lipids in the stratum corneum
- 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. - 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). - 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. - too much involucrin (protein) may be expressed early, increasing cell stiffness
What is the Immune response for dermatitis? (think of the skin diagram)
- 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
allergic rhinitis/conjunc, allergic bronchial asthma, AD
atopic syndrome, diathesis, triad
Atopic Dermatitis - Presentation
locations?
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
Irritant Contact Dermatitis - Pathophysiology and Contributing Factors
- 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
why is breastfeeding protective for diaper derm?
feces less copious, less alkaline, less caustic
Diaper Dermatitis - Presentation
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
Allergic Contact Dermatitis - Pathophysiology
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.
AD red flags
- 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
AD Goals of Therapy (4)
- 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
what are the different types of moisturizers? (5)
occlusive agents humectants emollients bath products barrier repair products
Moisturizer: Occlusive agents
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
Humectants
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
emollients
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
Bath products
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
4 pharm options AD
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
Atopic Dermatitis - Specific Care Plan
- Mild disease: Moisturizers and patient education on
lifestyle measures - Moderate to severe disease: Moisturizers + TCS/TCI
or crisaborole + patient education on lifestyle
measures - Severe disease: All of the above +/- dupilumab,
phototherapy, other immunosupressants (out of the
scope of PMCO 1)
Irritant Contact Dermatitis- Specific Care Plan
ABCDE for diaper derm
- Obtain a good social history that helps identify
potential occupational triggers. - 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
Allergic Contact Dermatitis - Specific Care Plan
- Treatment of ACD hinges on detection of the allergen
(through “patch testing”) - Avoidance of allergen and use of topical
corticosteroids for acute flares.
Stasis Dermatitis - Specific Care Plan
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!)
viscosity agents
electrolytes
lipids
preservatives
- 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
Contact Lens Care
What drugs affect lenses or the wearer?
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
Otitis Externa
pharm treatment
Name 4 types of drugs or substances that can be used
- 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
Red flags of dyspepsia and GERD
4+ others
- Abdominal mass / swelling
- History of abdominal cancer - Dysphagia, odynophagia, or choking
- Unintentional weight loss
- Symptom onset or worsening at >50 years of age
- What are some others…?
Chest pain that resembles cardiac symptoms -Radiating
GI bleeding - Coffee-ground vomitus or black, tarry stools
Anemia - Dizzy, pale, fatigued
Tums
- 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
Diovol
- active ingredient
- dose
- SE (1)
– aluminum / magnesium hydroxide
- 30mL 1 hour pc and hs prn
- SE: Combination product intended to offset constipation / diarrhea side effects
Milk of Magnesia
- active ingredient
- dose
- SE (1)
- magnesium hydroxide
- Chew 2-4 tablets or drink 5-15mL up to QID prn
- SE: diarrhea
