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Topical Meds Flashcards

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1
Q

The success of derm therapies is dependent on what factors?

A
  • correct dx
  • type of lesion being tx
  • med being used
  • vehicle
  • method used to apply the med
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2
Q

Whay may happen if the correct med is used but the wrong vehicle is used?

A
  • respone to therapy may be delayed, inadequate or even worsened
  • ex: using a glucocortiocid gel on hand eczema and fissures will cause increased pain and stinging due to alcohol base of gel
  • ex: tx a moist lesion with an oitment may cause folliculitis secondary to its occlusive properties
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3
Q

What is the vehicle (aka base)?

A
  • substance in which the active ingredient is dispersed
  • vehicle determines the rate at which the active ingredient is absorbed through the skin
  • sterngth of topical is dependent on vehicle
  • components of the base (may cause irritation or allergic response):
    solvents
    stabilizers
    emollients
    humectants
    thickening agents
    emulsifying agents
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4
Q

Use of appropriate vehicle for specific types of lesions?

A
  • both vehicle and active med need to be appropriate for the skin disease
  • if it’s wet, dry it, and if its dry, wet it
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5
Q

What would you use for acute contact dermatitis from poison ivy that has moist deep lesions?

A
  • lotions will help dry up dermatitis

- will also provide cool, soothing relief

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6
Q

What would you use for chronic psoriasis?

A
  • this is a dry lesion - use creams or ointments to help retain native moisture, provide relief to dry, itching skin
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7
Q

In general, what do you tx acute inflammation with? Chronic inflammation?

A

acute- tx with aqueous drying preparations

chronic- tx with greasier, lubricating compounds

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8
Q

Topical drug penetration into the skin is determined by what?

A
  • determined by the method of topical application

- site of application is also impt as variation in epidermal layer will alter the extent of drug absorption

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9
Q

What is tachyphylaxis? soln to this?

A
  • progressive decrease in clinical response due to repetitive application of a drug (glucocorticoids)
  • occurs when body becomes tolerant to pharmacotherapeutic effects of a particular med
  • soln: allow for drug free intervals, switch at various times to alternative agents
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10
Q

Vehicles consist of what 3 basic ingredients?

A
  • powder
  • oils
  • liquids
  • combo of these 3 ingredients in varying proportions make up most commonly used vehicles
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11
Q

Diff types of vehicles?

A
  • powders
  • solns
  • tinctures
  • lotions
  • oils
  • ointments
  • creams
  • gels
  • aerosols and sprays
  • shampoos
  • foam
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12
Q

When are powders used?

A
  • aid in absorbing moisture, decrease friction and help cover wide areas easily
  • primarily used in intertriginous areas to reduce moisture, maceration and friction
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13
Q

What are solns?

A
  • liquids with very minimal oil or solid content, but with active ingredients (ex - visine)
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14
Q

What are tinctures?

A
  • alcoholic or hydroalcoholic solns (may cause pain and irritation on erosions and abrasions)
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15
Q

What are lotions? How potent? diff types?

A
  • consist of suspension of powder in water
  • considered LEAST potent topical therapies
  • considered drying (even emollients)
  • as lotions evaporate they cool and dry
  • shake lotions - solids suspended within (calamine)
  • emollient lotions: oil disperesed in water with surfactant (vaseline intensive care lotion)
  • these are useful in hairy areas and conditions where large areas have to be tx
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16
Q

What are creams- composition? Potency?

A
  • semisolid emulsions of oil in water about equal proportion
  • penetrates the stratum corneum of the skin well*
  • cosmetically appealing
  • can cause more adverse rxns b/c of preservatives
  • Stronger than lotions but less potent than ointments
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17
Q

What do ointments consist of? Potency?

A
  • consist of water dropletes suspended in cont. phase of oil or of inert bases such as petrolatum (vaseline)
  • most lubricating and moisturizing and thus desirable for dryer lesions
  • facilitates heat retention, thery are semi-occlusive
  • **greater penetration of meds than creams
  • Most potent vehicle due to occlusive effect, but pt acceptance may be low b/c they are greasy
  • useful for dry dermatoses in non-seborrheic, non-intertriginous areas
  • not useful in hairy areas
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18
Q

What do gels consist of? Useful in what?

A
  • transparent semisolid emulsion that liquefies on contact with skin, drying as a thin, greaseless, non-occlusive film
  • consist of hydrophillic base with water or acetone (avoid acetone on sensitive skin)
  • combines the best therapeutic advantages of ointments with best cosmetic advantages of creams
  • considered drying and are used in seborrheic areas (face, chest)
  • used for exudative inflammation (poison ivy) and in scalp and hair bearing areas where other vehicles mat the hair
  • useful for tx acne (Retin-A)
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19
Q

Use of aerosols and sprays? Downside?

A
  • sprays: alcohol based solns, pressurized and delivered as an aerosol
  • considered to be drying
  • wasteful: much of active med doesn’t reach the skin
  • most frequently used in the scalp
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20
Q

Use of foams? Downside?

A
  • pressurized collections of gaseous bubbles in matrix of liquid film
  • easy to spread and apply especially to scalp
  • they are complex to make and can be more expensive
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21
Q

Use of shampoos? Big educational point for pts?

A
  • used primarily for seborrheic dermatitis of the scalp
  • the active ingredient is mixed with shampoo
  • educational pt: shampoo must usually be left on for 5-7 minutes after application for the med to be effective b/f being rinsed off
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22
Q

What does strength of topical med depend on? Exceptions?

A
  • dependent on vehicle
    in general:
    -ointment of topical corticosteroids are more potent than creams
    -creams are usually more potent than lotions
  • exceptions - retin-A in gel form and solns are more effective and more irritating than cream form
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23
Q

Most potent to least potent vehicles?

A
  • oitment/gel - most potent
  • cream - potent
  • lotion - least potent
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24
Q

What covers more body surface: cream or ointment?

A
  • ointment will cover an area 5-10% larger
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25
Q

MOA of topical clucorticoids?

A
  • pass through stratum corneum and cause vasoconstriction, decrease inflammation and inhibit cellular proliferation
  • more potent the steroid the more vasoconstriction, less inflammation and less proliferation
  • vasoconstriciton of normal skin can be quantified and serves as a parameter by which topical steroids are ranked in potency
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26
Q

Indications for topical glucocorticoids?

A
  • TOC for most inflammatory conditions
  • pruritic eruptions (dermatitis)
  • hyperplastic disorders (psoriasis)
  • infiltrative disorders (sarcoid)
  • used on a rash when not fungal or viral
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27
Q

Pros to topical corticosteroid use?

A
  • broad applicability in tx of numerous diseases
  • rapid action with small dose
  • ease of use: no odor or pain
  • lack of sensitization
  • prolonged stability
  • compatible with most other topical meds
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28
Q

Adverse rxns of topical corticosteroids - suppression of hypothalamic pituitary system? Especially what drugs?

A
  • paricularly class 1 agents
  • adults applying a potent steroid in excess of 50-100 g wk (10-20 g in small kids) for more than 2 wks may cause suppression
  • Clobetasol (strongest) known to cause suppression with only 2 grams
  • risk is greatest with more potent steroids, with damage to stratum coneum or in thin skin such as kids
  • except in infants, the mildest of steroids (hydrocortisone), is unlikely to result in systemic complications
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29
Q

local adverse rxns of topical corticosteroids?

A
  • comon in any steroid use when used for longer than 2 wks
  • burning, itching, or dryness are usually due to vehicle
  • atrophy and telangiectasias are frequent in potent steroids or application to thin skin
  • irreversible stretch marks: esp on legs, arms and abdomen
  • skin fragility and easy brusing may occur in chronic use
  • steroid rosacea (eruption of acne)
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30
Q

Dosage considerations of topical steroids?

A
  • there is a marked regional variation in steroid penetration
  • anatomic regions with a thin epidermis are significantly more permeable to topical steroid than thick skinned areas
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31
Q

Specific regional differences in percutaneous absorption?

A
  • sole of foot: 0.14%
  • palm: 0.83%
  • forearm: 1%
  • scalp: 3.5%
  • forehead: 6%
  • cheek: 13%
  • genitalia: 42% (holy schnikes!)
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32
Q

What increases absorption of steroids?

A
  • increased with increased skin hydration
  • should be applied to moist skin after bathing to achieve optimal penetration and efficacy
  • inflamed skin has increased penetration
  • ointments allow for better percutaneous drug absorption (exception - betamethasone dipropionate (cream))
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33
Q

7 classes and 4 groups of topical steroids?

A
  • super potent (class I)
  • potent (class II-III)
  • intermediate (class IV-V)
  • mild (class VI-VII)
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34
Q

Selecting the right steroid?

A
  • depends on condition

- best to start with lowest potency agent needed and use it for short of a time as possible

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35
Q

When should super potent steroids be used?

A
  • for severe dermatoses over non-facial/non-intertriginous areas
  • useful over palms and soles
  • ex:
    psoriasis
    severe atopic dermatitis
    severe contact dermatitis
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36
Q

When are intermediate to potent strength steroids used?

A
  • mild-moderate non-facial/non intertriginous dermatoses
37
Q

When are mild to intermediate strength steroids be used?

A
  • should be considered when large areas are tx b/c of likelihood of systemic absorption
38
Q

When should mild strength steroids be used?

A
  • for tx eyelid and genital dermatoses
39
Q

SEs of mild strength steroids?

A
  • rarely cause SEs, but intermittent therapy may be preferable to cont therapy for long term tx of large skin areas
40
Q

SEs of potent to intermediate strength steroids?

A
  • rarely cause SEs if used for less than 6-8 wks, except on face and intertriginous areas
41
Q

SEs of super potent strength - Duration of use?

A
  • shouldn’t exceed 3 wks if possible

- persistent lesions on small areas may be tx for longer time?

42
Q

Tx duration dependent on location?

A
  • facial, intertriginous, and genital dermatoses should be tx for short 1-2 wk intervals since these areas are most susceptible to atrophy, telangiectasia and acneiform eruption
  • application to highly permeable areas also increases systemic absorption and is also why duration of tx should be limited to these areas
  • topical steroid should be d/c when skin condition has resolved
  • if cont. tx needed - pt should be monitored for development of adverse effects and/or tachyphylaxis
43
Q

Use of topical steroids in kids?

A
  • use low potency (class IV-VII)
  • kids under 12 shouldnt use potent or super potent steroids
  • exception fo severe dermatoses:
    short courses of more potent (class I-III) for up to 2 wks
    psoriasis, severe atopic dermatitis
  • use for short durations and for appropriate inflammatory conditions
44
Q

Should combo antifungal/glucocorticoids be used?

A
  • No!!!
  • usually a KOH scraping would diff 2 conditions
  • these are super expensive compared to topical steroids and OTC antifungals
  • steroid prep in combos are potent, increasing risk of cutaneous side effects
45
Q

Topical antibacterials used in derm?

A
  • Mupirocin (bactroban)
  • neomycin
  • gentamycin
  • silver sulfazine
46
Q

Benefits of topical antibacterials?

A
  • tx a wide variet of potential pathogens
  • no risk of ototoxicty or nephrotoxicity from aminoglycoside topicals
  • drug concentration can be very high
  • drugs are in more direct contact with organisms
  • combos of various antibacterials are synergistic
  • topical use helps to retard the emergence of resistant organisms
47
Q

Bactroban (Mupirocin):
Effective against what bugs?
Used for?

A
  • ointment and cream
  • effective against most staph (even MRSA) and strep
  • a few gram negative organisms are susceptible (E. coli, H flu, N. gonorrhea)
  • **only topical antibacterial that may be used to tx impetigo due to staph aureus and or strep pyogens
  • no contact desensitization
48
Q

Neomycin:

Effective against? Why don’t derms use it?

A
  • ointment or cream
  • effective against:
    gram (-) (except pseudomonas) and is 50x more active against staph than bacitracin
  • most derms avoid neomycin b/c has greater incidence of allergic contact sensitivity than any other topical abx (this may be hidden b/c it frequently appears as though original cutaneous disease were unaffected by tx)
  • So don’t use it!
49
Q

Use of gentamycin?

A
  • ointment or cream
  • greater activity against pseudomonas
  • more active against staph and GABHS
50
Q

Use of silvadene: silver sufadiazine? What does it cover against? CI in what pts? What may it cause in burn pts?

A
  • 1% cream
  • bacteriocidal against gram + (including staph aureus), gram negatives (pseudomonas) and candida albicans
  • DON’T use in pts with sulfa allergies
  • may cause leukopenia in burn pts with large surface area burns
  • use: 2nd/3rd degree burns and chronic ulcers
51
Q

MOA of polyene class of antifungals? What drugs are in this class?

A
  • bind with sterols in fungal cell membrane - ergosterol
  • this changes the temp of cell membrane from a more fluid to a more crystalline state
  • the result is leakage of ions and small organic molecules leading to cell death
  • animal cells contain cholesterol instead of ergosterol and so are much less susceptible to damage
  • drugs:
    Nystatin (mycostatin)
    Amphotericin B (fungizone)
52
Q

Use of Nystatin?

A
  • ointment, cream
  • used in tx of Candida infections of skin and mucous membranes
  • oral preps are poorly absorbed from GI tract and will thus rid the oral and GI mucosa of candida but have no effect on systemic or cutaneous infections
53
Q

Use of amphotericin B (fungizone)?

A
  • 3% cream, lotion or ointment
  • used topically to tx superficial Candida albicans
  • ineffective against dermatophytes (ringworm) and tinea versicolor
  • drug is yellow-orange and may stain clothes and skin
54
Q

MOA of Allyamine class of antifungals? drugs?

A
  • inhibit squaline epoxidase
  • an enzyme necessary for ergosterol synthesis
  • drugs:
    terbinafine (lamisil)
    Naftitine (Naftin)
55
Q

Use of Terbinafine (lamisil)?

A
  • OTC
  • 1% cream
  • used for dermatophytes (Tinea Pedis)
56
Q

Use of Naftifine (Naftin)?

A
  • Rx only
  • 1% or 2% cream, gel, powder
  • used in topical tx of tine corporis, cruris, and versicolor
57
Q

MOA of Imadazole class? Drugs?

A
  • inhibits the enzyme- lamosterol 14 alpha-demethylase
  • enzyme necessary for converting lanosterol to ergosterol
  • lack of ergosterol disrupts fungal membrane leading to inhibition of fungal growth
  • Drugs:
    clotrimazole (lotrimin, Desenex)
    miconazole (Micatin, monostat)
    ketoconazole (Nizoral)
58
Q

Use of clotrimazole?

A
  • lotrimin, mycelex: OTC
  • cream, soln
  • used to tx tinea corporis, tinea pedis, tinea cruris, tinea versicolor
59
Q

Use of Miconazole?

A
  • Monistat, Micatin: OTC
  • 2% cream, lotion, vaginal supps
  • same spectrum as clotrimazole
  • used to tx vaginal infections due to candida albicans, also tx tinea pedis, tinea cruris, tinea corporis and tinea versicolor
60
Q

Use of ketoconazole?

A
  • Nizoral - Rx only
  • 2% cream - ued in tx of tinea infections and tinea versicolor and candida
  • 2% shampoo: used in tx of seborrheic dermatitis, there is an OTC shampoo that isn’t Rx strength
61
Q

Use of Econazole (Spectazole)?

A
  • Rx only
  • 1% cream
  • same spectrum of activity as Clotrimazole
  • used to tx tinea carpers, tinea pedis, tinea cruris, tinea versicolor
62
Q

Application of Imidazole antifungals?

A
  • once or twice daily application to affected area will generally result in clearing of superficial dermatophyte infections in 2-3 wks
  • 3-4 applications to affected area will effectively tx intertriginous candidiases (use powder)
  • topical won’t clear up nail infection
  • seborrheic dermatitis should be tx with 2x daily applications of ketoconazole until clinical clearing is obtained
63
Q

what is MOA of ciclopirox Oxamine (Loprox)? Used for?

A
  • broad spectrum hydroxypyridine anti fungal agent:
    interes with cell membrane transport and fungal respiratory process
  • 1% cream and lotion: used for dermatophytes, C. albicans and tinea versicolor
  • 8% Penlac nail lacquer: mild to moderate onychomycosis of fingernails and toes
64
Q

Use of Selenium sulfide (Selsun, Exsel)?

A
  • OTC
  • 1% and 2.5% solns
  • used to tx seborrheic dermatitis, dandruff and tinea versicolor
  • antimitotic agent, antibacterial and antifungal**
65
Q

Use of Tolnaftate (Tinactin, Cruex)?

A
  • OTC
  • believed to inhibit squalene epoxidase
  • 10% cream, powder, spray, ointment
  • antifungal effective against tinea versicolor and all dermatophyte fungi
  • ineffective against C. albicans
66
Q

Acne preps that are used topically?

A
  • azelic acid
  • benzoyl preoxidase
  • retinoids
  • topical abx
  • Dapsone
67
Q

Use of Azelaic acid?

A
  • naturally occuring in skin
  • it is believed that azelaic acid clears acne by reducing pop. of P. acnes, decreasing the abnormal shedding of skin cells and reducing inflammation
  • used to tx mild to moderate inflammatory and non-inflammatory acne
  • also proven effective in tx dark spots that develop in some acne pts with skin of color
  • well tolerated by most people and can be safely used for yrs
  • side effects may include skin dryness and lightening of the skin where applied
68
Q

Azelaic acid drug names?

A
  • Azelex
  • Finacea
  • available in: gel (more drying, has alcohol base) and cream
69
Q

Benzoyl peroxide use?

Most common SEs?

A
  • OTC
  • benzoyl peroxide works by killing P. acnes
  • it doesn’t have anti-inflammatory abilities
  • available in wide range of strengths and can be found as gel, lotion, cleanser, cream and wash:
    many acne preps include benzoyl peroxide b/c research shows that benzoyl peroxide increases the effectiveness of some meds such as erythro and clindamycin
  • when used in combo with abx - benzoyl peroxide reduces the likelihood of pt developing resistance to abx
  • MC SEs: skin irritation, potential to bleach hair and fabrics as well as possible allergic rxn
70
Q

Use of topical retinoids in acne tx?

MC side effect?

A
    • mainstay of acne tx
  • Rx to tx acne ranging from mild to moderately severe, topical retinoids are a derivative of Vit A and considered a cornerstone in acne tx
  • primarily anti-inflammatory
  • work to unclog pores and prevent white heads and black heads from forming
  • **can irritate the skin and increase sun sensitivity so it is impt to use sun protection (even in winter)
  • ad added benefit of these is that they may help diminish signs of aging, such as fine lines and wrinkles
71
Q

Retinoic acid (Retin-A)?

A
  • acid form of vitamin A
  • action decreases cohesion b/t epidermal cells and increased epidermal cell turnover
  • results in expulsion of open comedons and transformation of closed comedones to open ones
  • promotes collagen synthesis, new blood vessel formation and thickening of epidermis
72
Q

Use of Adapalene (differin)?

A
  • mild retinoid
  • 0.1% gel once daily
  • less irritating than retin-A
  • used for mild to moderate acne vulgaris
73
Q

Use of Tazarotene (Tazorac)?

A
  • retinoid
  • 0.1% gel and cream
  • used for mild to moderately severe facial acne and psoriasis
  • use only in teens older than 12
  • should be used by women of childbearing age only after contraceptive counseling
  • preg: X
74
Q

MC adverse effects of retinoids?

A
  • Erythema and dryness: occurs in first few weeks of use, but can be expected to resolve with continued therapy
  • minimize sun exposure and use protective sunscreen (some pts should d/c retinoid during summer if outside all the time)
75
Q

General guidelines for using retinoids? Pt instruction?

A
  • best to start with lowest strength and if too irritating on a daily basis go to every other or every 3rd day
  • instruct pt to not put retinoid with benzoyl perixodase as BP oxidizes the retinoid (makes it ineffective)
  • retinoid can be put on at night and a combo BP with topical abx in am
76
Q

Use of topical clindamycin in acne tx?

A
  • 1% soln or gel
  • good activity against Propionibacterium acnes
  • water based gel and lotion formulations are well tolerated and less likely to cause irritation
  • allergic contact dermatitis is uncommon
  • does come in a fixed dose with benzoyl peroxidase
77
Q

Use of topical erythromycin in acne tx?

A
  • first line topical abx
  • used with benzyl peroxide to reduce resistance
  • comes in variety of forms
  • shouldn’t be used as monotherapy as high bacterial resistance
78
Q

Use of sodium sulfacetamide in acne tx? What pts need to avoid this med?

A
  • used in tx of acne vulgaris and acne rosacea
    10% lotion
    10% wash
  • DON’T use in pts with sulfa allergy
79
Q

use of Dapsone 5% for acne? skin SE if applied with benzyl peroxide?

A
  • MOA not well understood
  • both anti-inflammatory and anti-bacterial
  • applying dapsone w/ benzyl peroxide can turn skin orange
80
Q

When is Permethrin cream used? Med of choice in what pop? Directions?

A
  • OTC: lice and scabies
  • med of choice: for children
    directions:
    -apply to entire body (if for scabies)
  • leave on for 8-12 hrs
  • kills mites and eliminates the risk of contagion w/in 24 hrs
  • pruritus may continue for several days to 2 weeks after tx
  • entire family should be tx
  • all clothing and bedding washed
81
Q

When is permethrin cream rinse used? What else is used?

A
  • used to tx head lice and pubic lice
  • has to be reapplied after 14 days for the most successful tx
  • also use fine tooth comb to remove nits
82
Q

Alt meds for lice and scabies?

A
  • for older kids and adults: Lindane lotion
  • Ivermectin (Stromectol): taken by mouth in 2 doses given a week apart also is effective and is especially helpful for severe infestations in people with weakened immune system
83
Q

What are the topical immunossuppressives used?

A
  • Tacrolimus (Protopic)

- Pimecrolimus (Elidel)

84
Q

Why are Topical Calcineurin inhibitors used? When are they used? MOA?

A
  • nonsteroidal immunomodulating agents that do not have skin SEs that topical steroids do
  • 2nd line tx for mild to moderate atopic dermatitis involving the face, including the eyelids, neck and skin folds
  • MOA: inhibits effects of cytokine production but also may result in a decreased activity of T cells
  • main adverse effects: mild stinging, burning, and pruritis
85
Q

Use of Topical Calcineurin Inhibitors may increase the risk of what? What pops should these not be used in?

A
  • May increase the risk of developing lymphomas and skin cancer b/c of MOA that leads to decreased activity of T cells

pops:

  • they shouldn’t be used on kids younger than 2YO
  • they shouldn’t be used for extended periods of time and over a minimum area
  • they shouldn’t be used for extended periods of time and over a minimum area
86
Q

What are topical chemo (immuno-modifier) drugs used? and what are they used for?

A
  • 5-FU
  • Imiquimod
    Used for:
  • Skin cancer and actinic keratosis
87
Q

MOA and use of 5-FU (Efudex)? Education for pt?

A
  • MOA: intereferes with DNA synthesis, primarily in fastest growing cells
  • used to tx actinic keratosis and low grade basal cell skin cancers
  • use: apply to affected area using an applicator for 2-6 wks
  • result: burning, peeling, blistering skin, more sun sensitized - need to protect (stay out of sun)
88
Q

Imoquimod: MOA, use, and effects? When should this not be used?

A
  • MOA: immune modifier: acts at several levels of immune system and promotes apoptosis in skin cancer cells
  • tx for basal cell CA, actinic keratosis and genital warts
  • Use: apply at noc either for 2 wks or longer only 2x a week then
  • Effects: same as w/ 5-FU + systemic fatigue & flu like illness
  • if a pt has another cancer they shouldn’t use imoquimod: suppresses immune system

Dermatology (12 decks)

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