Dermatology 1 2024 PDF

Dermatology 1 Learning objectives This 2 part module will review the following topics: Define and describe various skin conditions and discuss non- prescription products used to treat these conditions Identify the mechanism of drug action, drug interactions, adverse effects, contraindicatio...

Dermatology 1 Learning objectives This 2 part module will review the following topics: Define and describe various skin conditions and discuss non- prescription products used to treat these conditions Identify the mechanism of drug action, drug interactions, adverse effects, contraindications and allergies associated with products used to treat various skin conditions Suggested Readings CTMA 2 Minor Ailments Dermatologic Conditions Acne Foot care Dermatitis/diaper dermatitis Corns Calluses Dry Skin Bunions Insect bites Plantar warts Minor Cuts & Wounds Athlete’s foot Sunburns Dandruff Lice/Scabies Pharmacist prescribing for Minor Ailments 2023  Allergic rhinitis Acne  Candida stomatitis (oral thrush) Aphthous ulcers  Conjunctivitis (bacterial, allergic and viral) Diaper dermatitis  Dermatitis (atopic, eczema, allergic and contact) Nausea and vomiting  Dysmenorrhea Pinworms  Gastroesophageal reflux disease (GERD) Vulvovaginal candidiasis  Hemorrhoids  Herpes labialis (cold sores)  Impetigo  Insect bites and urticaria (hives)  Tick bites, post-exposure prophylaxis to prevent Lyme disease  Musculoskeletal sprains and strains  Urinary tract infections (uncomplicated)  Pharmacists Most Recommended products Adult cold remedy Eczema care Laxative First aid bandages/dressings Oral arthritis pain reliever Blood glucose monitors Dry eye drops Decongestants Topical analgesic Emergency contraception Antacid/heartburn/GERD Heat analgesic patch/wrap/rub Children’s cough and cold Natural cold remedy Moisturizer/dry skin Probiotic Antinauseant Intra-vaginal antifungal Antibiotic eye and ear drops Oral gynecological antifungal Topical anti-infective Cold sore remedy Iron supplement 2021 OTC Counselling and Recommendations Survery. Pharmacy Practice + business May 2021 (Vol 8, No. 3) Summary of Common Skin Conditions Body Area Condition Face Acne, perioral dermatitis, folliculitis, bacterial skin infection, cold sores, impetigo, phototoxic reactions, contact dermatitis Genitals Lice, candidiasis, tinea cruris, psoriasis Limbs Contact dermatitis, warts, psoriasis, cellulitis Nails onychomycosis Scalp Tinea capitis, headlice, psoriasis, dandruff, dermatitis Trunk Shingles, tinea corporis, phototoxic reactions, tinea versicolour  What is the Role of Pharmacy Technicians in Dermatological Care? Gathering lifestyle information (eg smoking, diet, exercise) Identify disease triggers (eg psoriasis and smoking) Discuss insurance coverage and screen for nonadherence Ensure moisturizers are always in stock Organize in-house patient education sessions and invite different practitioners (eg dermatologist) Use open ended questions such how do you use this medication Andrade R. A Primer on Dermatology. Tech Talk CE March 2020 Acne Increased sebum production, hyperproliferation of ductal epidermis, bacterial colonization of ducts, and inflammation Androgens cause sebaceous glands to increase size and activity Increased keratinization of epidermal cells and development of obstructed sebaceous follicles (microcomedones) The anaerobic bacterium Propionibacterium acnes causes T-cell-mediated inflammation Acne characterized by open and closed comedones is termed noninflammatory acne Inflammatory lesions—including pustules, nodules, and cysts—may form that lead to scarring Risk factors: family history, adolescence, elevated testosterone levels  Acne Goals of therapy Alleviate symptoms by reducing the number and severity of lesions Slow the progression of signs and symptoms Limit disease duration and recurrence Prevent long-term disfigurement associated with scarring and hyperpigmentation Avoid psychological suffering CTMA 2 Compendium of Therapeutics for Minor Ailments. 2nd Edition Canadian Pharmacist Association, Ottawa Acne: Aggravating Factors Factors aggravating acne Hormones Skin products that contain oil (cosmetics) Occupational irritants (kitchen grease, coal tar) Pressure from physical factors (helmets, tight collars, headbands, rough fabrics) Environmental irritants (heat, humidity) Stress Drug induced acne: hormone therapy, antiepileptic drugs, tuberculosis drugs, chemotherapy drugs, lithium, antibiotics Acne: Nonpharmacological Treatment Cleansing no more than 2 x daily with mild soap to remove surface oils Mechanical exfoliation: Polyester cleansing sponges (eg Buf-puf) Shaving with electric razors Comedone extraction May prevent progression to inflammation UV light Not routinely advised Low glycemic load diet Control stress Stop using oil containing cosmetics, moisturizers and sunscreens Acne: Pharmacological Treatment Benzoyl peroxide Salicylic acid Antibiotics Retinoids Sulfur containing preparations Corticosteroids Labelling for benzoyl peroxide found at: https://www.canada.ca/en/health- canada/services/drugs-health-products/public-involvement- consultations/natural-health-products/guidance-document-drug-facts- table-non-prescription-drugs.html#a12 Acne: Pharmacological Treatment Medicated soaps/washes Contain topical antiseptics or peeling agents Peeling agents (salicylic acid, sulfur) Antibacterial agents (Benzoyl peroxide, chlorhexidine, clindamycin) Contact time > 15 seconds to 5 minutes Vehicles Gels (oil free mixtures of water or alcohol) vs lotions or creams Lotions less drying than gels, creams are more emollient Acne: Pharmacological Treatment Exfoliants (peeling agents) Induced continuous peeling and drying by irritating skin Resorcinol 1-2% - bactericidal and fungicidal Salicylic agents (2-3%) - may increase absorption of other therapeutic agents Sulfur 2-10% - keratolytic and antibacterial action Glycolic acid – humectant that increases water content of stratum corneum Topical Rx retinoids (tretinoin, adapalene, tazarotene) - teratogenic Acne: Pharmacological Treatment Benzoyl peroxide (eg Benzagel) Antibacterial properties – anaerobic activity, bactericidal against gram positive and gram-negative bacteria, yeasts and fungi Derivative of coal tar used alone or in combination with other treatments OTC strength creams> Who shouldn’t use the product lotions, gels, sprays, foams Anybody with allergies to hydrocortisone, or other corticosteroids Anybody with viral infections (chicken pox and herpes simplex) Untreated tuberculosis, fungal or bacterial skin infections Hydrocortisone– Hyderm Warnings Don’t use dressings or bandages unless recommended by a doctor Don’t apply in or near the eyes Prolonged use may cause thinning of the skin Not to be used for long term therapy as it may cause: Slow wound healing and thinning of the skin Pharmacist Minor Ailment Prescribing Prescription Corticosteroids Lowest potency Medium potency Desonide Beclomethasone dipropionate Hydrocortisone 2%, 2.5% 0.025% Betamethasone valerate 0.05%, 0.1% Clobetasone buyrate 0.05% Flucinolone acetonide 0.01% Hydrocortisone valerate 0.2% Triamcinolone acetonide 0.1%, 0.5% Dermatitis Topical-anti-infectives Oral Antihistamines Topical anti-infectives to reduce risk of Helps with pruritus skin infections because of Itch scratch cycle complicates atopic compromised physician barrier. dermatitis S. aureus is found in more than 90% of First generation antihistamines atopic dermatitis cases (diphenhydramine)cause drowsiness Topical anti-infectives not generally and may help with sleep recommended due to increased risk of Second generation antihistamines contact dermatitis (loratadine, desloratadine) help with Treatment with antifungal agents is atopic dermatitis along with other less effective than treatment with atopic conditions like allergic rhinitis topical steroids Topical antihistamines cause contact dermatitis Dermatitis (Diaper) Acute, inflammatory contact dermatitis of buttocks, genitalia, perineal regions, lower abdomen, or thigh folds of infant or toddler resulting from direct fecal and moisture contact with skin in occlusive environment Erythematous rash; vesicles and oozing erosions may be present in severe cases May be infected by Candida species and present with confluent red plaques, papules, and pustules Goals of therapy Relieve symptoms. Remove precipitating factors. Prevent recurrences. Avoid adverse treatment effects. Improve quality of life. Dermatitis (diaper) Nonpharmacological treatment Frequent diaper changes Air drying (remove diaper for as long as practical) Gentle cleansing with non-soap cleansers and lukewarm water Dermatitis (diaper) Pharmacological treatment May apply zinc oxide for astringent and absorbent properties and to provide effective moisture barrier Apply topical imidazole antifungal agents for Candida (yeast). Discontinue therapy when rash subsides and continue barrier product to prevent recurrence May use very low potency topical corticosteroid (hydrocortisone 0.5– 1%) for short periods (1–2 weeks) in severe inflammatory cases Commercial diaper wipes containing fragrance or alcohol should be avoided Dry Skin The skin is composed of 3 main layers: epidermis (which includes the stratum corneum), dermis and subcutaneous/hypodermis layer The term “dry skin” (also known as xeroderma or xerosis) is commonly used to describe skin that may be rough to the touch and have mild scaling, flaking or peeling of the upper layers, and is often very itchy, with possible cracking if severe enough Related to water loss from skin surface  Goals of Therapy Alleviate the unpleasant feel of rough, scaly skin Restore skin hydration and reduce transepidermal water loss Facilitate repair of the barrier function and maintain the integrity of the stratum corneum Relieve itching associated with dry skin Educate the patient on self-treatment to prevent further damage CTMA 2 Compendium of Therapeutics for Minor Ailments. 2nd Edition Canadian Pharmacist Association, Ottawa Patient Assessment Managed generally with nonprescription therapy by improving skin hydration and addressing contributing factors Factors: Swimming in chlorinated pools Use of harsh antibacterial soaps Overexposure to sun/exposure to UV radiation Normal skin aging Low humidity Medical conditions: hypothyroidism or skin conditions (atopic dermatitis) Medications: anticholinergics, chemotherapy, retinoids Consequences of Dry Skin Cosmetic Issues Cracks Itchiness Irritation Bleeding Pain Open to bacterial and fungal infections Dry Skin Nonpharmacologic Treatment Nonpharmacologic Therapy Tepid show water Avoid harsh or perfumed soaps Add bath products at end of bath or after bath Apply moisturizer after bathing Avoid caffeine, alcohol that may contribute to dehydration if ingested in large quantities or used on regular basis Avoid products that might sensitize skin (eg lanolin, fragrances) Maintain adequate fluid intake Dry Skin Pharmacologic Treatment Occlusives Humectants Physically block surface of stratum Draw water from the dermis to the corneum to prevent further water epidermis and from the loss, which promotes barrier repair. environment (providing humidity is Minimizes water loss to the external environment. 70–80%) into the stratum corneum.& retains water EG Beeswax, dimethicone, lanolin, mineral oil, paraffin, petrolatum, EG Alpha-hydroxy acid (AHA), soybean oil, zinc oxide glycerin, glycolic acid, lactic acid, Side effects: contact dermatitis, propylene glycol, sodium greasy hyaluronate, sorbitol, urea Side effects: stinging and burning on open skin Dry Skin Pharmacologic Treatment Emollients Bath oils Fill the spaces between cells in the Provide a layer of oil on the skin stratum corneum, sealing moisture that prevents moisture into the skin, which makes it feel evaporation. smoother and softer. Eg Coal tar, colloidal oatmeal, liquid Eg Castor oil, cocoa butter, paraffin ceramides, coconut oil, fatty acids, Side effects: safety hazard lanolin, lipids, mineral oil, palm oil, vitamins A and E, wool fat Side effects: skin sensitivity Dry Skin Pharmacologic Treatment Barrier Repair Agents Normalize skin barrier by replacing ceramides; decreasing transepidermal water loss (TEWL); decreasing triggers for inflammation. Eg. Ceramides/cholesterol/free fatty acids combinations Side effects: skin sensitivity Commercial Products for Dry Skin Look up 5 skin care products for dermatitis and dry skin and identify their manufacturer, dosage form, active ingredients and uses For example Dermaflex HC cream Made by Paladin Available as cream Keratolytic: urea 10% Anti-inflammatory: hydrocortisone acetate 1% Insect Bites Arthropods include spiders, scorpions, ticks, fleas, lice, caterpillars, centipedes, ants, bees, wasps, mosquitoes and flies Concern due to allergic reactions or transmission of disease if arthropod is a vector Patient assessment recommendations and self management of insect bites depends on mild versus moderate symptoms Eg Deer tick and Lyme disease that cause flu- like symptoms, and can lead to severe symptoms if left untreated https://www.canada.ca/en/public-health/services/diseases/lyme-disease/surveillance-lyme-disease.html  Goals of Therapy 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 for localized reactions CTMA 2 Compendium of Therapeutics for Minor Ailments. 2nd Edition Canadian Pharmacist Association, Ottawa Prevention of Insert Bites Avoid use of scented cosmetics, perfumes and hairsprays that attract insects Caution eating outside Limit time spent outdoors at dawn and dusk Avoid infested areas of tall grasses, marshes, bushy areas To protect against sticks, pants and shirts should be tight at ankles and wrists or tucked into socks and gloves Light coloured clothing makes ticks more visible for quick removal Pharmacologic Treatment: Insect Repellents DEET (N,N-dimethyl-m-toluamide Icardin (Picardin) Vapour thought to have offensive Believed to affect smell or taste to insects and repels the insect's ability to detect the mosquitoes. host by concealing attractants Effective against mosquitoes, black emitted by hosts or by changing flies, ticks, chiggers and fleas. the insect's ability to smell them. Duration of effect depends on Effective against mosquitoes, ticks concentration and black flies. ADRS: irritation, contact dermatitis, Low toxicity, nonirritating to skin toxic if ingested. Not for children < Others: oil of Citronella, soybean oil, 6 months of age metofluthrin Insert Bites Pharmacologic Treatment Treatment of pain: acetaminophen, ASA, NSAIDS Treatment of itching, inflammation: oral antihistamines such as diphenhydramine, chlorpheniramine, loratadine, cetirizine Topical antihistamines not recommended due to sensitization Topical products (local anesthetics): benzocaine, pramoxine Topical corticosteroids for itchiness, redness, and swelling. Minor Cuts and Wounds A wound is a disruption in the normal skin structure and functioning due to mechanical trauma and injury Wounds are classified as acute or chronic: Acute wounds can occur from burns, bites, abrasions, scrapes, minor lacerations and punctures, and minor surgical procedures. Acute wounds tend to heal within 3 weeks with minor treatment Chronic wounds occur when healing has been delayed or impaired due to various conditions (e.g., immunocompromised states, diabetes) or have not proceeded through the healing process correctly Wound healing occurs through regeneration or repair of the skin Wound Complications Infection Scarring Gram-negative and gram- Large deposit of collagen and positive bacteria (including glycoprotein at wound site tetanus) and fungi may be which is natural part of healing involved in wound infections. process Tetanus Vaccination Moist healing environments decrease scarring and improve wound healing (eg topical silicone gels and sheets)  Goals of Therapy Provide an environment that optimizes wound healing and prevents cosmetic deformity Prevent infection Minimize further trauma to the area Minimize patient discomfort CTMA 2 Compendium of Therapeutics for Minor Ailments. 2nd Edition Canadian Pharmacist Association, Ottawa Wounds and Cuts Patient Assessment Superficial wounds that are small and accompanied by limited bleeding are suitable for self management Further assessment/treatment is required if: Wounds continue to bleed after 10 minutes of pressure Deep puncture wounds Gaping wounds Wounds that expose fat, muscle bones Wounds from animal bits Wounds with visible dirt Wounds causing severe pain Wounds Nonpharmacologic Treatment Self treatment of minor wounds steps 1. Cleanse wound 2. Stop the bleeding 3. Apply a dressing Cleansing and Antiseptic Agents Saline Isopropyl alcohol 70% Cleansing agent not harmful to Bactericidal in concentrations tissue 70% to 90% Hydrogen peroxide 3% Used as disinfectant for wounds An oxidizing agent that and prior to injections has antiseptic, disinfectant and Some fungicidal activity deodorant properties used to ADR: irritation and drying clean wounds Consider OTC misuse ADR: impair wound healing Cleansing and Antiseptic Agents Iodine Povidone-iodine Used as a disinfectant Used as a disinfectant and antiseptic for contaminated and antiseptic for contaminated wounds, wound bed or infected wounds and for pre- management and prevention of operative preparation of the skin infection Broad spectrum Water solution preferred ADR: contraindicated in iodine ADR: contraindicated in patients allergy, systemic absorption, may with iodine allergy, stains skins impair wound healing and clothing, may impair wound healing Topical Antibacterials Topical antibiotics Other agents on bacitracin/neomycin/polymyxin B prescription Spectrum: gramicidin: gram-positives. Silver sulfadiazine Polymyxin B: gram-negatives. Fusidic acid Ingredients are combined to provide Mupirocin (See NAPRA broad antibacterial coverage. guidelines) Resistance uncommon but can develop with prolonged use. ADR: common localized itching and burning. Bacitracin is common sensitizer Polysporin: Polymixin B, Bacitracin, Gramicidin Use: Warnings Clean affected area before Avoid contact with eyes application Don’t use over large areas of the Apply ointment 1-3 times daily body Cover with a sterile bandage cover Don’t use in deep or puncture application to prevent infection. wounds, on animal bites or serious External use only burns Don’t use for more than 7 days Who shouldn’t use the product unless directed by a doctor Anybody with allergies to any of the ingredients Interactions No specific drug interactions Foot Care for People with Diabetes 1. inspect 6. Avoid extreme cold and heat 2. bathe 7. circulation 3. moisturize 8. injuries/infections 4. Trim 9. exercise 5. Shoes and Socks 10. control Sunburn and the Skin The skin serves several important functions: Protects against minor injury Helps control body temperature & water loss Prevents invasion by microorganisms Prevents radiation damage from sun exposure  Sun Protection Factor (SPF) Sun Protection Factor Helps to explain the amount of sun blocked Scale, rating the level of protection of sunscreen products on the market Attempts to inform patients of increased allowable time of exposure before sun burn will occur (not always accurate) Products on the market range from SPF 4 to SPF 100 Suntan lotion is not the same as sunscreen UVA & B Sunrays UVA Rays UVB Rays Penetrates the dermis and Damages the stratum corneum and subcutaneous fat epidermal layer Present all day Main cause of sunburn, plays a major role in both skin cancer & photoaging Can penetrate through clouds, Acute exposure increases blood flow windows and clothing to the skin, activating inflammatory Responsible for phototoxicity, pathways thus reddened skin and photoaging and skin cancers sunburn Responsible for reactions from Strongest between 10am and 4pm, at photosensitizing drugs such as high altitudes and is intensified by tetracycline, quinolones and wind, humidity, high temperatures tricyclic antidepressants (TCAs) and reflective surfaces (water, sand, snow, concrete) Sun-Induced Skin Damage Acute Chronic Sunburn Photoaging Phototoxic reactions Pigmentary changes Sunburn like chemical reactions Actinic keratosis Polymorphic light eruption Skin Cancer – melanoma and Genetic & environment non melanoma Solar urticaria  Goals of Therapy Prevent acute sun-induced skin damage (sunburn) Prevent phototoxic reactions from medications Provide relief of pain resulting from sunburn Minimize the risk of infection in severe sunburns Prevent long-term sun-induced skin damage (including photoaging and some types of skin cancer) Reduce the visible effects of photoaging on the skin CTMA 2 Compendium of Therapeutics for Minor Ailments. 2nd Edition Canadian Pharmacist Association, Ottawa What is Photoaging? Photoaging is premature aging of the skin caused by repeated exposure to ultraviolet radiation (UV) primarily from the sun, but also from artificial UV sources. “Photo” is derived the Greek word “phos” which means “light”. So, aging of the skin caused by light. How to Prevent Sun Damage Non-Pharmacological Treatment Avoid the times when UVB rays are the strongest Look for shady areas Protective clothing (long pants, shirts, sunglasses) Avoid tanning beds Canadian Dermatology Association The Canadian Dermatology Association recommends that sunscreens should: Have a sun protection factor (SPF) of at least 30 Offer broad-spectrum (UVA and UVB) protection Be nonirritating, noncomedogenic and hypoallergenic Be minimally or nonperfumed  How to Prevent Sun Damage Pharmacological treatment Suncreen products Have the ability to reduce skin tanning and sunburn Reduce the occurrence of photoaging Should be used to protect the skin rather than prolong the time that can be spent in the direct sun Minimum SPF of at least 30 is recommended Potential adverse effects of sunscreens: *dependent on the product’s active ingredients – skin sensitivity (redness, itchiness), allergic dermatitis, worsening of acne due to clogging of pores, photosensitivity reactions Available as: lotions, creams, sprays, mousse and sticks Sunscreens Multiple active ingredients in many of our commercial sunscreen products Different active ingredients absorb UV radiation at different UV wavelengths Some suncreens have broad spectrum UVA and UVB while others only protect against one or the other… Recommend a broad spectrum sunscreen for BEST protection against the sun’s harmful rays Physical vs Chemical Sunscreens Physical sunscreens or “blockers” reflect and scatter UV radiation Examples: titaniumdioxide zinc oxide Chemical sunscreens absorb UV radiation Examples: PABA, homosalate Parsol 1789 = avobenzone Mexoryl XL and SX, octocrylene ADRs: skin sensitivity, allergic reactions Identify 3 different sunscreen products that contain different UVA and UVB absorbers and list their ingredients Drugs That May Cause Photosensitivity Antibiotics: quinolones, sulfonamides, tetracycline Diuretics: furosemide, hydrochlorothiazide Statins: atorvastatin, rosuvastatin Psychiatry medications: alprazolam, amitriptyline Topical retinoids: tretinoin, adapalene Systemic retinoids: isotretinoin NSAIDs: ibuprofen, naproxen Sunburn Treatment Cool compresses Analgesics = ibuprofen, naproxen & acetaminophen Topical aloe vera Moisturizing agents to reduce dry skin & peeling Topical anaesthetics (common ending “caine”)  Sunscreen Product Recalls Johnson & Johnson is recalling two types of spray-on sunscreen after testing indicated elevated levels of benzene. The recall applies to all lots of Neutrogena Beach Defense and Ultra Sheer aerosol sunscreens for both adults and children with SPF 30, 45 and 60. Health Canada says consumers should stop using these products, warning that frequent and long-term exposure to elevated levels of benzene has been linked to serious health risks including leukemia and other cancers. https://www.canadianhealthcarenetwork.ca/two-neutrogena-spray-sunscreens-recalled-over-concerns-about-benzene- levels?oly_enc_id=1249B3859912C1U How to Detect Melanoma Using the ABCDE method https://www.theweathernetwork.com/ca/news/article/detect-melanoma-with-the-abcde-method References CTMA 2 Compendium of Therapeutics for Minor Ailments. 2nd Edition Canadian Pharmacist Association, Ottawa CPMA 2 Compendium of Products for Minor Ailments. 2nd Edition. Canadian Pharmacist Association. Ottawa CTC 2019 Compendium of Therapeutic Choices. Canadian Pharmacist Association. Ottawa. NAPRA available @ www.napra.ca Health Canada, Drug Product Database, 2021  Part 1 ends here Continue on to part 2