Tx of Common Skin Disorders, Varicella, and Zoster IZs Flashcards
1
Q
Acne Vulgaris Pathogenic Factors
A
- excess sebum production
- keratinization→excess sloughin leads to blocked flow of sebum →black head (open comedo)
- bacterial gorwth
- inflammation
2
Q
Development of Acne
A
- bacteria proliferation (propionibacterium acnes [normal skin anaerobe]) + Sebum + keratinzation → inflammation → white head (closed comedo)
3
Q
Keratolytic Agents
A
- tx acne: apply BID
- 1st line:
-
Benzoyl Perodixe: promotes shedding of epidermis for mild, non-inflammatory acne
- SE: drying and peeling, hypersensitivty esp in asthmatics
-
Benzoyl Perodixe: promotes shedding of epidermis for mild, non-inflammatory acne
- 2nd line:
-
sulfure: less effective
- has an odor
- can cause brown scaling = Resorcinol
- can cause salicylate intoxication with chronic use
-
Salicyclic Acid: readily abosrbed
- 3% & 6% reak down horny layer of skin
- 40% can be used to remove warts, calluses, and corns
-
sulfure: less effective
4
Q
Retinoids
A
- treatment of acne, examples: Tretinoin, (adapalene (more expesnive b/c less side effects), tazarotene) [same side effects but not as sever as Tretinoin]
-
1st line: for mild to moderate comedonal and inflammatory acne
- stimulate the turnover of epithelial cells
- unclog blocked pores
- have anti-inflammatory properties
- inhibit monocyte chemotaxis and neutrophils
- Can be used with topical abx and benzoyl peroxide
- SE: transient erythema, irritation, dryness, pealing photosensitivity
- AVOID: children under 12 years old and pregnancy
- Pt Education: symptoms may worsen in first few weeks, but should see improvement in 3-4 months
5
Q
Topical Antibacterials for Acne
A
- directly suppress P. acnes (anaerobic normal flora)
- 1st line for mild to moderate inflammatory acne
- examples:
- Clindamycin 1%
- erythromycin 2% QD-BID
- SE: dryness, erythema, itching
- examples:
- can be added with benzoyl peroxide to decrease resistance and improve symptoms
6
Q
Azelaic Acid
A
- Mechanism of Action:
- anti-bacterial
- anti-inflammatory
- stabilize keratinization
- Indications:
- for pts who cannot toleralte benzoyl or topical retinoids
- mild to moderate acne
- Side Effects:
- erythema
- skin irritation: should avoid occlusive dressings
- may cause hypopigmentation
- 20% cream apply BID, should see improvement in 1-2 months
7
Q
Dapsone Gel
A
- Mechanism of Action: (type of abx)
- anti-microbial
- anti-inflammatory
- for mild-moderate acne
- SE:
- dryness, erythema, oiliness, peeling
- Apply BID, if no improvement after 12 weeks (3 months) , re-evaluate treatment
8
Q
Acne Treatment: Oral Abx
A
- treatment for moderate to severe acne (especially after failed topicals)
- prevent acne lesions from developing
- using takes about 6-10 weeks to see improvement, maximal effects at 6 months
- 1st line:
- doxycyline, TCN, minocycline (Don’t Touch Me)
- 2nd line:
- erythromycin (inhibits 3A4), clindamycin,
- isotretinoin (not an abx)
- (Every Child’s Ill)
9
Q
Oral Acne Treatment: Isotretinoin
A
- only indicated for severe acne that is unresponsive to other POs and topicals
- can cause remission of acne for several years
- **requires online registery program iPledge**
- category X drug
-
2 negative pregnancy tests prior to start
- 1 negative test each month during treatment
- SE:
- dry skin and mucus membranes
- muscle and joint pain
- elevated liver enzymes and triglycerides
- depression
- teratogenicity (inhibits fetal development)
10
Q
teratogen
A
inhibits fetal development
11
Q
Oral Acne Treatment: Oral concraceptives
A
- 2nd line treatment for moderate to severe acne in females
- yaz, estrostep, ortho tri-cyclen
- oral contraceptives reduce the production of androgens in the ovaries →decreased production of sebum
- SE:
- nausea/vomiting
- weight gain
- breast tenderness
- breakthrough bleeding
- Venous thromboembolism (especially in heavy smokers)
- caused by the estrogen in the pill
12
Q
Contact Dermatitis: irritant vs allergic
A
-
irritant:
- will have rxn with 1st time exposure
- casuses damage to epidermis → erythema
- examples:
- soaps, detergents, cosmetics, solvents, acid, mild or strong
- alkali, mild or strong
-
Allergic:
- need to have an initial sensitivity
- triggered by an immune response
- examples:
- plant resins, poison ivy, poison oaky, sumac
- metals (nickel or gold in jewelry)
- latex and rubber
- cigarette smoke
- local anesthetics (lidocain or benzocaine)
13
Q
Atopic Dermatitis
A
- aka eczema
- signs:
- crusting and oozing
- signs:
14
Q
Non-Pharmacologic Treatment of Contact Dermatitis
A
- relieve pruritis
- maintain the hydration of the skin
- colloidal oatmeal baths
- cool soapless showers
- cool moist compressed TID
- emollients: mineral oil or petrolatum
15
Q
Pharmacological Treatment of Contact Dermatitis
A
- astringents
- topical steroids
- PO steroids: widespread areas and sxs
- antihistamines
- topical immunosuppressants
16
Q
Astringents
A
- treatment for contact dermatitis
- have drying effects → decreases oozing and relieves itching
- causes vasoconstriction → anti-inflammatory
- examples:
- aluminum acetate
- calamine lotion; zinc oxide
- witch hazel
- 15-30 min BID-QID
- no longer than 7 days
- SE:
- drying, tightening of skin
17
Q
Topical Steroids
A
- relieve redness, inflammation, itching and pain
- Vehicles:
- ointment
- creams
- lotions
- gels
- foams/mousses/ shampoo
- Want to provide optimal dosing: titrating amount to minimum that still gives relief
- chronic application can lead to tolerance and tachyphylaxis
-
ultra-high potency: no longer than 3 weeks continuously
- need to gradually taper to prevent rebound
- 3 weeks on 1 week off dosing schedule
-
ultra-high potency: no longer than 3 weeks continuously
18
Q
Oral Antihistamines for Pruritus
A
- diphenhydramine
- hydroxizine
19
Q
Topical Immunosuppressants
A
- pimecrolimus (Elidel) cream:
- apply BID on anyone over 2 years
- no longer than 6 weeks
- avoid occlusive dressing
- Tacrolimus ointment:
- apply BID
- can cause burning, erythema, pruritus
- 3rd line
- For SEVERE activation of immune symptoms
20
Q
Tinea Infections
A
- fungal infections where the fungus lives in keratinous layers of the nail or skins
- types of lesions: rings, scales, single or multiple areas
- circular ring lesions: ringworm
- examples:
- tinea pedis
- tinea manuum
- tinea cruris
- tinea corporis
- tinea versicolor
- tinea barbae
- tinea capitis
- onychomycosis (tinea unguium)
21
Q
tinea pedis
A
- involves plantar surface and interdigital spaces of foot
22
Q
tinea manuum
A
- infection of the interdigital and palmar surfaces
23
Q
tinea cruris
A
- presents with follicular papules and pustules on the mdeial thigh and inguinal fold
- ringed lesions may extend from the inguinal fold over to the adjacent inner thigh
24
Q
tinea corporis
A
- presents with circular scaly patch with enlarged border
25
tinea versicolor
* characterized by skin depigmentation but can present as hyperpigmentation
* especially dark-skinnned patients
26
tinea barbae
* infection of beard area
27
tinea capitis
* infection of the head and scalp
28
Onychomycosis
* aka tinea unguium
* infection of nail plate and bed
29
Steroid Ointments
* more lubrication
* occlusion which improves absorption
* **helpful for thick, dry hyperkeratotic lesions**
* **not good for hairy areas**
* may cause maceration and folliculitis (in "skin rubbing areas" like the groin and the armpits)
* they can be greasy which can cause an unpleasant sensation which may decrease compliance
30
Steroid Creams
* mix of water suspended in oil
* good lubrication but **less potant than same medications in ointments**
* often contain preservatives which may lead to allergic reactions, stinging, irritation
* used for exudative inflammation (i.e. poison oak)→ has drying effects
* does NOT provide occlusive effects
31
Steroid Lotions
* these are the LEAST greasy and occlusive
* good for **hairy areas**
* contains alcohol which has a drying effect → excellent for oozing lesions
32
Steroid Gels
* for **exudative inflammation** (i.e. poison oak)
* dries quickly
* good for use on **hairy areas or scalp**
33
Steroid Foams/Mousse/Shampoo
* spreads easily in hairy areas
* good penetration
34
Diaper Dermatitis Treatment
* Protectants:
* occlusive barrier
* cream/ointment
* promote healing
* zinc oxide, petrolatum, witamins, A&D Lanolin, topical cornstarch
* Topical Steroids
* Anti-fungals
* diaper rashes that last \>48-72 hours at high risk of fungal infection
* nystatin crea
* clotrimazole
* miconazole
* BID-QID
* Anti-bacterial
35
Lanosterol
* stabilizes fungal membranes
* precursor to Ergosterol
36
Recurrent Vuvlovaginal Candidiasis
* Fluconazole 150 mg PO Q3days x 2
* Topical azoles x 14 days
* consider non-albicans infections (C. Glabrata and C.tropicalis)
* Resistant to fluconazole and itraconazole
* tx:
* 1st line: **terconazole**
* 2nd line: vaginal borric acid capsules 2 weeks BID
* **Difficult** to treat:
* high levels of estrogen
* don't want to harm the fetus.
37
Vulvocandidiasis during pregnancy
* this is difficult to treat during pregnancy due to:
* high levels of estrogen
* potential harm to the fetus
* fluconazole can cause congenital limb deformities if 400-800mg Q day are used during 1st trimester
* Vaginal antifungals that can be used:
* **clotrimazole**
* 1-2 weeks is the preferred treatment
38
Impetigo--superficial infection tx
* scabby, crusty eruption usually caused by poor hygiene and crowding
* **\*\*common bugs\*\*:**
* beta-hemolytic streptococci
* **group A strep**
* **Staph aureus**
* tx:
* mild: **Mupirocin (Bactroban) topical ointment**
* **penicillinase-stable penicillins**
* **1st gen cephalosporins**
* Alternative:
* clindamycin
* macrolide
39
Treatment of Scabies
* Sarcoptes scabiei
* **Permethrin (Elimite)** 5% cream
* apply to whole body from neck down for 8-14 hours
* Alternatives:
* **Crotamiton (Eurax)** 10% cream or lotion
* Q24hours x 2
* **Ivermectin (Stromectol)**
40
Shingrix: Ingredients, Indications, Administration
* Ingredients:
* lyophilized **varicella zoster virus glycoprotein E (gE) antigen**
* Indications:
* **immunocompetent \>50 years old**
* not indicated for prevention of primary varicella infection
* Administration:
* **IM 2 doses (0.5mL each) at 0 and 2-6 months later**
* Contraindications:
* severe allergic reaction
* just received a dose
* or just delay vaccine if:
* pregnant or breastfeeding
* *currently* have a shingles episode
41
pneumonic to remember topical acne therapies
* KRAAD:
* Keratolytics
* benzoyl peroxide 1st line
* ASA 2nd line
* Sulfur 2nd line
* Retinoids
* Antibacterials
* Azelaic Acid
* Dapsone gel →mostly severe cases
42
Retinoid Examples and what they can be used with
* Tretinoin (once daily before bed)
* Adapalene
* more expensive because less side effects
* Tazarotene
* last line agent
* same SEs but **MORE** severe
* Can be used with topical abx (clindamycine and erythromycin) and benzoyl peroxide
43
Low Potency Steroids
* **Hey Fluorence, Design This Mask/Mouth**
* Hydrocortisone 1-2.5%
* Fluocinolone 0.01%
* Desonide 0.05%
* Triamcinolone **(0.1%-0.025%)**
* Mometasone 0.1%
44
High Potency Steroids
* **Best DonuTs And CHips**
* Betamethasone
* Desoximetasone
* Triamcinolone (**0.5% → medium to high**)
* Augmented Betamethasone
* Clobetasole
* Halobestasol
45
Ultra-High Potency Topical Steroid Considerations
* titrate to minimum frequency
* no longer than 3 weeks
* 3 weeks on 1 week off
* otherwise results in **tachyphylaxis** (tolerance)
* SEs:
* steroid atrophy
* secondary infections
* delayed wound healing
* hypopigmentation
* rebound flare
* cataracts (if too much in blood stream)
46
Oral Antihistamines used for Pruritus
* diphenhydramine
* hydoxyzine (Atarax/ Visteril) → also used for anxiety
47
Imidazoles
* type of Azole (slightly different structure than triazoles)
* **I Make The Canadian Eat Ketoh**
* Imidazoles
* Miconazoles
* Tioconazoles
* Clotrimazole
* Econazole
* Ketoconazole
48
Triazoles
* type of azole (interferes with ergosterol synthesis because blocks fungal P450 enzymes)
* **Try Flying Past That Insane Vortex**
* Triazoles
* Fluconazole
* Posaconazole
* Terconazole
* Itraconazole
* Voriconazole
49
Echinocandins
* antifungal drug that blocks the cell wall synthesis
* inhibit beta-glucan synthesis
* **Caspofungin -- IV**
50
Allyamine
* antifungal drug that inhibits the epoxidation of Squalene which leads to high squalene levels and results in cell death
* **Terbinafine**
* **Butenafine**
51
Systemic Therapy for Tinea Infections
* Fluconazole
