Atopic Dermatits 2024 Handout - PDF format.pdf

Xerosis & ATOPIC Dermatitis Kaelen Dunican, PharmD, RPh  Objectives: Given a case, design an appropriate, patient specific treatment plan for managing atopic dermatitis and xerosis.  Describe the typical presentation of atopic dermatitis.  List the pharmacologic category, brand/ generic nam...

Xerosis & ATOPIC Dermatitis Kaelen Dunican, PharmD, RPh  Objectives: Given a case, design an appropriate, patient specific treatment plan for managing atopic dermatitis and xerosis.  Describe the typical presentation of atopic dermatitis.  List the pharmacologic category, brand/ generic name, and dosing frequency of medication used to treat atopic dermatitis (see “drug tables”).  Identify exclusions to self care of atopic dermatitis.  Identify the most appropriate and second line medication options based on the severity of atopic dermatitis and other patient specific parameters (ex: location of the condition, patient / provider specific requests, precautions / contraindications for use, cost of medication).  Identify the potency of common topical corticosteroids.  Compare advantages and disadvantages of low/medium and high/very high potency corticosteroids.  Determine the most appropriate potency based upon the patient case.  Utilize the “fingertip method” to determine the days supply of a prescription for a cream or an ointment.  Differentiate between topical dosage forms and determine the most appropriate option (cream or ointment) based upon the patient case.  List nonpharmacologic strategies for atopic dermatitis.  Discuss counseling point for medications for atopic dermatitis.  Describe appropriate application / administration of medication.  List treatment expectations – onset and duration of action, dosing, and common side effects.  Identify any drugs with Black Box Warnings and recognize the associated contraindication. Schedule F: May 24, 2024 Derm - Atopic Dermatitis & Xerosis (Exam #2) W: May 29, 2024 Exam #1 @3pm Contingency Block (make up for July 4th) W: May 29, 2024 Derm -Contact Dermatitis (Allergic & Irritant) Th: May 30, 2024 Derm – Psoriasis (during IPC3 class block) Insect Bites & Stings F: May 31, 2024 Lice & Scabies M: June 3, 2024 Alopecia, Warts, & Minor Foot Disorders W: June 4, 2024 @3pm Exam #1 Remediation F: June 7, 2023 Acne Case simulation assessment #2 M: June 10, 2024 Burns & Wound Care W: June 12, 2024 Menstrual Disorders (Exam #3) F: June 14, 2024 Exam #2 Tips for studying derm…  Know basic presentation of each condition key patient characteristics/ location/ signs & symptoms  Know brand / generics and know what each drug is indicated for  “Derm Exam Resource” worksheet (B/G names only)  Study basic treatment algorithms first line / second line / alternate options  Study non-pharm options  Exam material will focus on lecture content OTC & Rx: Topical Corticosteroids Low Potency (Class 6 & 7) OTC 0.5% & 1%: Cortaid, Cortizone, Hydrocortisone Lanacort (Least potent) Rx 2.5%: Hytone Apply Alclometasone Aclovate BID “HAFD the strength” Fluocinolone Synalar (LOW POTENTY) acetonide Desonide DesOwen Rx: Topical Corticosteroids Medium Potency (Class 3 - 5) Fluticasone Cutivate propionate Hydrocortisone Westcort valerate Mometasone Elocon Apply BID furoate “For Her Majesty VAL, a Betamethasone Valisone MEDIUM rare T-Bone steak” valerate* MEDIUM POTENCY Kenalog* *potency varies depending on strength Rx: Topical Corticosteroids High Potency (Class 2) Amcinonide Cyclocort Fluocinonide Lidex Apply BID “The -CINONIDEs and Halocinonide Halog DI- rhyme with HIGH” Diflorasone Psorcon diacetate Rx: Topical Corticosteroids Very High Potency / Super- potent (Class 1) Betamethasone Diprolene diproprionate Apply BID Temovate “My BETA fish, NATE is VERY HIGH-ly aggressive” Halobetasol Ultravate propionate Rx: Calcineurin Inhibitors Topical Calcineurin Inhibitors (TCI) Generic: Brand: Dosing frequency: Protopic Apply BID (topical) Tacrolimus ointment (BIW application may be Pimecrolimus cream Elidel appropriate for maintenance) Rx: JAK Inhibitors Janus kinase (JAK) Inhibitors Generic: Brand: Dosing frequency: Ruxolitinib cream Opzelura Apply BID (topical) Abrocitinib Cibinqo PO daily Upadacitinib ER Rivoq PO daily  Rx: Other Pharmacologic Dosing Generic: Brand: Category: Frequency: Crisaborole ointment Eucrisa Topical Apply BID phosphodiesterase-4 Roflumilast cream Zoryve (PDE-4) inhibitor Apply once daily Dupilumab Dupixent “Biologic” / monoclonal antibody Inject SC q2weeks (blocks IL-4 and IL- Tralokinumab Adbry 13) Mupirocin ointment Bactroban Topical antibiotic Apply BID-TID OTC: Baths and Cleansers Pharmacologic Generic: Brand: Dosing frequency: category: Cleansers Mild, non-soap Use as a cleanser in Cetaphil cleanser place of soap Glycerin (TEA- Stearate, and Neutrogena Soap triethanolamine) Baths Use in warm bath, soak for 15-20 minutes Colloidal oatmeal Aveeno Oatmeal Colloidal oatmeal once-BID; pat skin dry (+/- mineral oil) Bath after bath to leave a film of oatmeal OTC: Moisturizers Pharmacologic Generic: Brand: Dosing frequency: category: Moisturizers / Emollients Petrolatum Aquaphor Moisturizer/ emollient/ Lanolin protectant Apply 3 to 4 times a day (maybe more Added to many Ceramide frequently if washing products Moisturizer/ area more) Eucerin, emollient Lubriderm, Nivea Humectants and Alpha Hydroxy Acids Mild keratolytic & Urea humectant Apply 3 to 4 times a Ammonium lactate/ AmLactin, Lac- day Alpha hydroxy acid Lactic acid Hydrin OTC & Rx: Antihistamines Pharmacologic Generic: Brand: Dosing Frequency: Category: Topical Diphenhydramine Antihistamine Apply BID Oral Diphenhydramine 25-50 mg QHS Hydroxyzine Vistaril pamoate TID-QID PRN Antihistamine (typically QHS due to Hydroxyzine secation) Atarax hydrocloride Dermatitis: Definitions Dermatitis: Nonspecific term for numerous disorders Characterized by erythema and inflammation Xerosis: Dry skin Eczema: Group of inflammatory skin disorders, often of unknown etiology Atopic Dermatitis (AD): Form of eczema ( “atopic eczema”) Chronic condition: flares and remits throughout lifetime What is the “hallmark” symptom of atopic dermatitis? A. Burning B. Plaque formation C. Pruritus D. Tissue destruction True or false: Atopic dermatitis usually presents in infants and young children. A. True B. False Differentiating dermatitis Signs & Patient Appearance Location symptoms Adults: skin creases 50% of patients Red, inflamed, (flexure surface – diagnosed in 1st Atopic lesions depend on Pruritus (a antecubital and popliteal year of life whether acute, hallmark fossae), neck, & hands dermatitis (typically 2- 3 subacute or characteristic) Children: face (cheeks, months) chronic neck, forehead) & 85% by age 5 extremities More common Rough, scales, Pruritus Anywhere; usually on Xerosis in older patients fissures Loss of flexibility limbs Papules, small vesicles over Contact inflamed skin At site in contact with Anyone Itching/ burning dermatitis Irritant CD often allergen or irritant causes scaling & fissures Which one of the following “derm terms” is defined as: a solid elevation of up to 0.5cm. A. Excoriation B. Lichenification C. Papule D. Vesicle Clinical presentation of AD  A pruritic skin disorder, with the following:  Onset at younger than 2 years  History of skin crease involvement (including cheeks in children less then 10 years old)  History of generally dry skin  Personal history of atopic disease: asthma +/- allergic rhinitis  Or history of any atopic disease in a first-degree relative in children younger than 4  “Atopic triad” = asthma, allergic, rhinitis, & atopic dermatitis  Visible flexure dermatitis  dermatitis of cheeks / forehead and other outer limbs in children less than 4  AD flares and “The itch that rashes” remits; it is a chronic condition that TRIGGER/ XEROSIS Itch is never “cured” Rash Scratch 3 Clinical Forms of AD  Acute:  intensely pruritic,  red papules possibly vesicles over red skin  excoriated, may see clear exudate which may lead to crusts  Subacute:  red, excoriates papules  scratching leads to plaques that can be scaly  Chronic:  lichenified plaques Atopic Dermatitis Triggers  Food:  Eggs, milk, peanut, soy, wheat, nuts, strawberries  Aeroallergens: dust mites, cat dander, mold, pollen  Airborne irritants: tobacco smoke, air pollution,  Cosmetics and Fragrances  Psychological stress  Exposure to temperature extremes (hot or cold)  Excessive hand washing or bathing/showering  Tight fitting or irritating clothing (wool or certain synthetics)  Dyes and preservatives  Exclusions to Self-Care Non-Pharm Medication Referral to provider/ Establish that the patient is an Non-Rx when? (Y/N) appropriate self care candidate N Y N Skin appears to be infected STAT Signs and symptoms of infection: fever, purulent discharge/ exudate, pustules, discolored crusting, odor N Y N Involvement of groin or perianal area STAT  Non-Pharmacologic Treatment with Referral Non-Pharm Medication Referral to provider/ Establish that the patient is an Non-Rx when? (Y/N) appropriate care candidate Y Soon, for Involvement of large area of body (5-10% BSA) 1% Y more Y effective therapy 0.5% Y For more Involvement of large area of body (>10% BSA) N effective Y therapy Infants < 2 years of age Y N Y SOON Involvement of face N Y Y 1% 0.5% Successful self-care treatment includes… Identify and eliminate triggers Skin hydration Appropriate pharmacotherapy General treatment algorithm Severe Systemic immunosuppression Mild - Moderate Topical steroids Topical Calcineurin Inhibitors PDE-4 Baseline: Basic Topical JAK inhibitors therapy Moisturize Non-pharm Goals of Treatment Itch TRIGGER/XEROSIS Rash Scratch Non-Pharmacologic Interventions:  Avoid triggers (see triggers slide)  Clothing  Cotton  Use mild detergent / no fabric softener  Double rinse  Short fingernails  Avoid alcohol-containing topical products Non-Pharmacologic Interventions:  Bathing recommendations:  Brief shower/baths (3-5 minutes)  Bathe/shower 2-3 times per week  Sponge bath on other days  Use non-soap cleansers (Cetaphil, Neutrogena)  Apply scent-free moisturizer liberally immediately after bathing (while still damp)  Lukewarm / tepid water (not more than 30 above body temperature) Emollients and Moisturizers  Lotions, creams, and ointments containing: water, mineral oil, petrolatum, lanolin  Which is most lipophilic? Which is thickest? Thinnest?  Lotion:  Cream:  Ointment:  MOA: fill space between desquamating skin scales  When to use an ointment, cream, or another dosage form…  Emollients and Moisturizers  Administration:  Apply topically TID-QID maybe more often if on Moisturizers / Emollients hands Petrolatum Aquaphor  Maximize hydration by applying immediately after bathing while skin still damp Lanolin  Ointments are occlusive:  Better hydration Added to many Ceramide  Associated with increased absorption products  ADRs: Eucerin,  Fragrances responsible for most side effects (SE) Lubriderm,  Allergy to ingredient or excipient (lanolin) Nivea  Treatment expectations: temporary relief of dry skin  Goal prevent flare Urea  MOA: mildly keratolytic and increases water uptake in the stratum corneum, also binds to skin protein to increase elasticity  Administration: Apply topically BID-QID  10% for simple dry skin  20-30% for more resistant dry skin  Lotions: remove scales & crusts  Emollient ointments: more effective at rehydrating  SE: may cause stinging, burning, and irritation particularly on broken skin Ammonium lactate/ Lactic Acid  An alpha-hydroxy acid available in 2-12%  MOA: increases hydration of skin may also act as an modulator of epidermal keratinization  May be added to urea  Administration: Apply topically BID Bath products: oils  Mineral or vegetable oil plus a surfactant  Can “make your own” 1tsp in ¼ cup warm water  MOA: lubricate the skin  Administration: use in bath or apply as a wet compress  SE:  Slippery (caution slips and falls)  Hard to “wash” off  Treatment expectations: minimal efficacy Bath products: colloidal oatmeal  Starch, protein, +/- oil  MOA:  Lubricate, soothe, and antipruritic  Administration: use 1 packet (30 grams) in warm bath, soak for 15-20 minutes QD-BID; pat skin dry after bath to leave a film of oatmeal  SE: Slippery (caution slips and falls)  Treatment expectations: may be helpful for some Hydrocortisone  MOA: likely suppresses cytokines associated with inflammation and itchiness  Used for minor skin irritations, inflammation, and pruritus  Strengths available OTC: _____ & _____  Administration: Apply sparingly to affected area BID (up to 4 times daily)  OTC maximum duration = 7 days (self care use) Hydrocortisone  Ointment versus cream for AD  SE:  Local side effects are uncommon due to low potency  OTC=low concentration minimal systemic absorption  What may increase absorption?  Site of application  Area of application  Occlusion  Do not use on infected skin may mask infection  Continued use may lead to tachyphylaxis Self care with hydrocortisone? If yes, ointment or cream? Fingertip Method 0.5 g = 2% BSA 1g = 4% BSA AD is a 28 year old woman with atopic dermatitis behind both knees (approx. 1 hand-print each). You recommend hydrocortisone 1% cream BID. How long will a 15 gram tube last? A. 5 days B. 7 days C. 10 days D. 15 days E. 30 days Antipruritics: Local Anesthetics & Counterirritants  Local Anesthetics:  Avoid large quantities for prolonged use, particularly on raw or blistered skin  Apply to affected area TID-QID  Caution: may be sensitizing in some people  Role in AD?  Counterirritants:  Camphor & menthol: cooling sensation  Role in AD? Which antihistamine is most likely to work for pruritus? A. Diphenhydramine B. Loratadine C. Fexofenadine D. Pseudoephedrine E. Dextromethorphan Antipruritic: Antihistamines  Topical antihistamines:  Compete with H-1 receptors and topical anesthetic, but ? if histamine plays a role with atopic dermatitis  Max duration=7 days because of significant sensitizing potential  Role in AD?  Oral antihistamines:  Antipruritic effect may be from sedation  Precautions?  Role in AD? Prescription Therapy for Atopic Dermatitis General treatment algorithm Severe Systemic immunosuppression Mild - Moderate Topical steroids Topical Calcineurin Inhibitors Baseline: Basic PDE-4 therapy Topical JAK inhibitors Moisturize Non-pharm Topical Corticosteroids (TCS) ADRs  More common ADRs:  Cutaneous atrophy  Telangiectases  Resolves (after months)  Other/Serious ADRs:  Striae, acne, refractory rosacea, hypopigmentation, alopecia or hypertrichosis, glaucoma  Systemic ADRs  ADRs of topical steroids... 51 Systemic ADRs  Numerous serious ADRs (see next slide)  Adrenal suppression and iatrogenic Cushing’s  Increased risk with:  Long duration of use  Higher potency  Increased dose, use on larger BSA  Decreased skin integrity  Thin skin (face, genital area, intertriginous areas, younger patients)  Broken skin Systemic ADRs with corticosteroids Choosing a TCS  Based on severity and location  No optimum regimen for flare-up  Short burst of high potency TCS  Lowest potency trial and increase if needed  Applied twice a day until flare improves  If experience frequent flares may apply once or twice a week chronically Low and Medium Potency Corticosteroids Lower Potency Hydrocortisone (Least potent): OTC Cortaid, Cortizone, Rx Hytone Alclometasone: Aclovate Fluocinolone acetonide: Synalar Desonide: DesOwen Medium/ Mid- Potency Betamethasone valerate: Valisone Fluticasone propionate: Cutivate Hydrocortisone valerate: Westcort Mometasone furoate: Elocon Triamcinolone acetonide: Kenalog Lower Potency Corticosteroids Advantages: LESS SE LOW: can be applied to face, genitals LOW / MEDIUM MEDIUM: can be applied to intertriginous areas Potency Disadvantages: Lower efficacy, may take longer to control flare High and Very High Potency Corticosteroids High Potency Amcinonide: Cyclocort Fluocinonide: Lidex Halocinonide: Halog Diflorasone diacetate: Psorcon Very High Potency / Superpotent Clobetasol propionate: Temovate Halobetasol propionate: Ultravate Betamethasone dipropionate: Diprolene Higher Potency Corticosteroids Advantages: More effective at controlling flare Can be applied to thicker skin and High lichenified areas /Very High Disadvantages: Potency Higher incidence of SE Avoid face, genitals, intertriginous areas Topical Calcineurin Inhibitors (TCI)  Tacrolimus ointment  Brand name: ______________  Pimecrolimus cream  Brand name: ______________  More lipophilic than tacrolimus (stays in skin)  TCI advantages over topical corticosteroids:  Long term use not associated with skin atrophy  Can be used on any area of body  Can be used for prolonged periods (although episodic is recommended) Topical Calcineurin Inhibitors  Applied BID (BIW for maintenance)  Most common adverse effect: transient mild to moderate stinging and burning  May also cause transient worsening of skin conditions  FDA BBW (Black Box Warning): rare malignancies including skin and lymphoma  Causal relationship not firmly established…  Avoid in patients with weakened/ compromised immune system (HIV, on chemotherapy) BBWs are  Must wear sunscreen CORE knowledge Phosphodiesterase-4 inhibitors MOA: Agents:  Selective phosphodiesterase  Crisaborole (Eucrisa): 2% 4 (PDE-4) Inhibitors topical ointment  Role in therapy:  Apply topically BID  Mild to moderate AD  More common  May be used on sensitive  Roflumilast cream areas (face, genitals) (Zoryve) 0.15% topical  Alternative to TCS or TCIs cream  Side effects (SE): localized  Apply topically once a day pain, burning and stinging  Newly approved for AD – original approval for 0.3% cream for psoriasis Janus kinase (JAK) inhibitors  MOA: suppress cytokine signaling – help with itching and inflammation  Topical: Ruxolitinib (Opzelura) Cream  Role in therapy: Indicated for mild to moderate AD for short term use when other topical agents fail  Oral:  Abrocitinib (Cibinqo) tablets  Upadacitinib ER (Rivoq) tablets  Role in therapy: Indicated for moderate to severe / refractory AD  BBW: serious infections, increased rate of all cause mortality, lymphomas/ malignancies, major CV events, thrombosis Monoclonal antibodies  MOA: Inhibit interleukin-4 (IL-4) and interleukin 13 (IL-13) =key inflammatory cytokines in AD -> reduces inflammation  Dupilumab (Dupixent®): SQ q2 weeks  Tralokinumab (Adbry ®): SQ q2 weeks  Role in therapy:  Moderate to severe AD when other agents fail; can be used with or without TCS  ADRs: injection site reactions, conjunctivitis, corneal inflammation, oral herpes infection and eosinophilia Other options?  Topical therapy:  Coal tar  Phototherapy  Tapinarof cream (Vtama) – see psoriasis lecture  CAM:  Probiotics?  Other:  Intranasal mupirocin  Diluted bleach baths  Systemic therapy  Apremilast (Otezla®) – limited role for AD (see psoriasis lecture)  Systemic corticosteroids  Cyclosporine  Interferon  Azathioprine  Methotrexate  Mycophenolate mofetil  Nemolizumab Sometimes I wish I could just scratch my skin right off! IG is a 24 year old female with a past medical history of asthma and seasonal allergies. She explains the skin on the back of her knees is dry and intensely itchy and has gotten progressively worse over the past week. The affected area is ~2 hand-prints behind each knee. Upon inspection the skin appears red, inflamed, and excoriated. She states that she had lots of skin rashes when she was a kid and she seems to go through this every summer when it gets really hot and humid out and at times when she is under a lot of stress. What OTC would you recommend for IG? A. Cortaid® topical cream B. Diphenhydramine topical gel C. Lanacort® topical ointment D. Urea topical lotion How to apply? Treatment expectations Key counseling points  Which Rx would you recommend for IG? A. Aclometasone ointment B. Crisaborole ointment C. Desonide cream D. Halocinonide cream E. Ruxolitinib cream How to apply? Treatment expectations Key counseling points Self assessment…  How would your recommendation change if she preferred a non- steroid option?  What if she had a PMH of HIV?  What else may make you choose an alternative option?  What could you add on to help her sleep at night? Fingertip Method The affected area is ~2 hand-prints behind each knee. If applied BID, how long will a 60 gram tube last? A. 5 days B. 7 days C. 10 days D. 15 days E. 30 days What would you recommend for IG?  Agent (brand, generic, route of administration & frequency)  Treatment expectations  Key counseling points