Dry Skin, Atopic Dermatitis, and Scaly Dermatoses 2024 Student PDF

1 Dry Skin, Atopic Dermatitis, and Scaly Dermatoses Vanessa Lesneski PharmD, BCPS, CPh  2 Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition,...

1 Dry Skin, Atopic Dermatitis, and Scaly Dermatoses Vanessa Lesneski PharmD, BCPS, CPh  2 Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition, Chapter 33 Required Reading Dipiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th edition. Chapter 119.  3 Explain the pathophysiology of Dry Skin, Atopic Dermatitis, and Scaly Explain Dermatoses Educate a patient on the disease state of Dry Skin, Atopic Dermatitis, Educate and Scaly Dermatoses Objectives Recommend Recommend appropriate therapy Counsel Counsel a patient on the therapy you recommended  4 Dry Skin  5 ▪ a.k.a. Xerosis ▪ Decreased water-holding capacity of the skin ▪ Alteration of the stratum corneum ▪ Barrier dysfunction due to reduced amounts of ceramides, free fatty acids, and cholesterol ▪ Can lead to cracked skin Dry Skin ▪ Changes to keratinocyte differentiation can also contribute to barrier dysfunction ▪ Environmental factors ▪ Extreme temperature ▪ Dry areas ▪ Frequent showering  6 Dry Skin ▪ Can occur at any age ▪ Affects more than 50% of adults older than 65 years ▪ As we age skin changes occur ▪ Thinner epithelium ▪ Decreased lipids in the stratum corneum and natural moisturizing factor ▪ Increased susceptibility to drying and bruising ▪ Systemic disorders associated with dry skin can include hypothyroidism, cholestasis, renal failure, and dehydration ▪ Dry skin is more prone to itching, inflammation, and development of secondary infections  7 Roughness Scaling Presentation of Cracking Fissuring Dry Skin Erythema Pruritus  8 Goals of Treatment Improve skin hydration Restore barrier function Educate the patient about and minimize water loss of the skin prevention and treatment  9 ▪ Moisturizers! (mixture of water and oil) ▪ Containing emollients that soften and smooth the skin ▪ Apply oil-based emollients after bathing while the skin is damp ▪ frequent reapplication during the day ▪ Room humidity can be increased with humidifier Nonpharm (portable or a humidification unit can be added to the home heating system) Therapy ▪ Stay hydrated unless contraindicated by any medical disorders ▪ Drinking WATER daily ▪ Table 33-3  10 Pharm Therapy ▪ Phospholipids and ceramides to improve barrier function ▪ Vehicle ▪ Ointment, Cream, Lotion ▪ Table33-4 ▪ Bath oils ▪ Cleansers ▪ Topical Hydrocortisone for itch  11 ▪ Mineral or vegetable oil plus a surfactant ▪ Colloidal (ground) oatmeal ▪ Low efficacy, too dilute Bath Oils ▪ Can be applied as a wet compress ▪ Watch for slippery tub with use  12 ▪ Glycerin soaps ▪ More water-soluble, ▪ Higher oil content than standard soaps (castor oil addition) ▪ Closer to a neutral pH Cleansers ▪ Results in a less drying soap than traditional soaps ▪ Lacking in data but well accepted by people with skin disorders ▪ Cetaphil or Phisoderm- mild cleansers in place of soap  13 ▪ 60-80% water ▪ Emollients: silicone, dimethicone oils, and petrolatum ▪ Soften and smooth the skin ▪ Fills space between the desquamating skin scales with oil droplets through which moisture cannot readily escape ▪ Emulsifiers- Keep water and lipids in one continuous phase ▪ polysorbates and potassium cetyl sulfate ▪ Humectants- increase moisture retention ▪ Glycerin, Urea, Lactic acid, propylene glycol, alpha hydroxy acids Moisturizers ▪ Vitamins ▪ Lipids ▪ ceramides or pseudoceramides ▪ Natural moisturizing factors ▪ Lactate, urea, ammonia, uric acid, glucosamine ▪ Plant oils ▪ Derived from avocado, coconut, almond, peanut, safflower, sunflower, olive  14 Vehicle Selection Butters, gels, oils, ointment, lotions, and creams Difficult to spread- creams, ointments, and butters Ointment is a water in oil emulsion Petroleum jelly Lotions and Creams- oil in water emulsion  15 Scaly Dermatoses  16 ▪ Includes dandruff, seborrheic dermatitis, and psoriasis Chronic scaly ▪ Involves the uppermost layer of skin (epidermis) dermatoses ▪ Primary manifestation is scaling of the skin, with inflammation, erythema, and pruritus  17 ▪ Mild inflammatory disorder of the scalp ▪ Flaking and itching- Scalp scaling, the sloughing of small white or gray loosely bound flakes ▪ Results in excessive scalp scaling ▪ Hyperproliferative disorder- Accelerated epidermal cell turnover and abnormal keratinization ▪ Resulting in mild inflammation, flaking, and pruritus Dandruff ▪ Involves the presence of Malassezia yeast, disruption in skin proliferation, differentiation, and barrier function ▪ Milder form of the seborrheic dermatitis ▪ No gender difference ▪ Bald spots are usually dandruff-free This Photo by Unknown Author is licensed under CC BY-SA  18 ▪ Sebaceous secretions, skin permeability, and fatty acid penetration also may play a role ▪ Factors, such as stress, extreme temperatures, hormone levels, skin moisture may exacerbate dandruff Dandruff symptoms ▪ Cause damage to the stratum corneum and worsening dandruff  19 ▪ Reduce the epidermal turnover rate of the scalp skin by Dandruff reducing the number of Malassezia fungi on the scalp ▪ Minimize the cosmetic embarrassment of visible Treatment scaling Goals ▪ Minimize itch  20 ▪ Shampoos daily or every other day with nonmedicated shampoo often is sufficient to control mild to moderate dandruff ▪ Shampoo with pyrithione zinc or selenium sulfide ▪ Massage the medicated shampoo into the scalp and leave Dandruff on the hair for 3–5 minutes before rinsing ▪ Use the medicated shampoo daily for 1 week, then 2–3 Treatment times weekly for 2–3 weeks, and thereafter once weekly or every other week ▪ Nonprescription ketoconazole shampoo ▪ An antifungal with anti-Malassezia activity  21 ▪ Similar to dandruff but exhibit more inflammation ▪ Involves area with dense distribution of sebaceous glands (scalps, eyebrows, glabella, beard area, cheeks, etc.) ▪ Accelerated cell turnover and enhanced sebaceous gland activities give rise to skin changes consisting of prominent yellow, greasy scales and erythema Seborrheic Dermatitis  22 Goals: 1. Reduce inflammation 2. Reduce epidermal turnover rate 3. Minimizing visible erythema and scaling 4. Minimizing itch Treatment Treatment: 1. Regular use of medicated shampoo (pyrithione zinc and selenium sulfide) Leave on affected area for 3-5 minutes before washed Use daily for 1-2 weeks then reduce to 3-4 times per week for 4 weeks 2. Corticosteroid ointment Shouldn’t use more than 2 times per day and no more than 7 days  23 ▪ They are used to decrease the rate of epidermal cell replication ▪ Pyrithione zinc reduce yeast count in the scalp and skin FDA recommends concentration of 0.3 to 2% for dandruff and 0.95 to 2% for seborrheic dermatitis ▪ Selenium sulfide works similar to pyrithione zinc, but Cytostatic must be rinsed from hair thoroughly as discoloration Agents may result Concentration of 1% is approved for treatment of dandruff and seborrheic dermatitis ▪ Coal tar arrests excessive skin cells proliferation Concentration of 0.5 to 5% is available in market for self- treatment of dermatologic disorders  24 ▪ Ketoconazole 1% is active against most pathogenic fungi that cause scaly dermatoses ▪ Keratolytic agents (salicylic acid and sulfur) can be used in dandruff and seborrheic dermatitis to loosen and lyse keratin aggregates → removal from scalp in smaller particles Antifungal Topical salicylic acid is useful for psoriasis when thick scales are present Agents Salicylic acid 1.8 to 3% is approved for self-treatment of dandruff, seborrheic dermatitis and psoriasis Sulfur 2 to 5% is approved for self-treatment of dandruff only  25 ▪ Atopic: ▪ A predisposition (genetic) to develop an allergic reaction (allergic rhinitis or asthma) with elevated levels of IgE due to exposure to an antigen (especially inhaled or ingested) ▪ Often called eczema or just plain “dermatitis” ▪ AD is a form of eczema (eczema=inflammatory Atopic skin disorders of unknown origin) Dermatitis ▪ Inflammatory skin disorder (epidermis and dermis) ▪ Lots of itching ▪ Red, swollen, papular, and crusty ▪ Disease consists of periods of flares and remission  26 ▪ 50% are diagnosed within first year of life ▪ 85% before 5 yoa ▪ Worldwide prevalence is increasing ▪ More so in developed countries ▪ 80% of AD patients have asthma and AD Stats allergic rhinitis too ▪ “Atopic march” or “atopic triad” A lot of patients do not seek medical help and self-treat  27 CD External factors cause Contact Dermatitis vs. Atopic Dermatitis AD Internal predisposition cause  28 ▪ Genetic basis ▪ Exogenous triggers manifest expression ▪ Gene-gene & gene-environment interactions ▪ Multiple genes involved Pathophysiology ▪ 2 groups ▪ Genes coding for epidermal or epithelial structural proteins ▪ Genes coding for features of immune system ▪ Twin studies support a genetic component  29 ▪ Cytokines and Chemokines are expressed ▪ Cytokines: IL-4, IL-13, tumor necrosis factor ▪ Mutation in the filaggrin (FLG) gene is associated with AD ▪ A mutation leads to changes in the skin barrier ▪ Deficient skin barrier characteristic of AD ▪ Including an increased penetration of allergens, a Pathophysiology decrease in skin barrier proteins, higher peptidase activity, and lack of protease inhibitors ▪ 35 known mutations ▪ Atopic skin has a decreased ability to retain moisture ▪ Due to a decrease in concentration of lipids and ceramides  30 ▪ Acute AD: ▪ Rash (red, very itchy, papules or vesicles on top of red skin) ▪ Itching ▪ Scratching leads to more irritation (chafed, raw skin and possibility of bacterial infection) Presentation- 3 ▪ Subacute AD: forms ▪ Red, excoriated papules and plaques ▪ Chronic AD: ▪ Thickened plaques or scales ▪ Secondary infections are common ▪ Bacterial (Staphylococcus aureus) & Viral (herpes simplex, Molluscum contagiosum)  31 ▪ Behind knee ▪ Inside of elbows ▪ Behind ears ▪ Cheeks Common ▪ Buttocks locations for ▪ Hands rash ▪ Feet UpToDate. Distinguishing atopic dermatitis from chronic plaque psoriasis in children.  32 Presentation https://www-uptodate-com.lecomlrc.lecom.edu/contents/treatment-of-atopic-dermatitis- eczema?search=atopic+dermatitis&source=search_result&selectedTitle=3%7E150&usage_type=default&display_rank=2  33 Presentation ▪ Major indicators: ▪ Selected minor indicators: ▪ Pruritus ▪ Early age of onset ▪ Characteristic rash in locations typical of ▪ Dry skin that may also have patchy scales the disease or rough bumps ▪ Chronic or repeatedly occurring ▪ Increased serum IgE symptoms ▪ Numerous skin creases on the palms ▪ Personal or family history of atopic ▪ Hand or foot involvement disorders (eczema, hay fever, asthma) ▪ Inflammation around the lips ▪ Nipple eczema ▪ Susceptibility to skin infections ▪ Positive allergy skin tests No reliable diagnostic test or biomarker  34 ▪ Relieve the symptoms – stop the itch, scratch, itch cycle ▪ Maintain skin hydration and barrier function Treatment ▪ Prevent/minimize exacerbations Goals ▪ Prevent/minimize adverse events from treatments ▪ Prevent and treat any secondary infections  35 ▪ Identify and try to eliminate triggers ▪ Lukewarm baths & air-dry skin ▪ Bath additives ▪ Non-soap cleansers, hypoallergenic, fragrance-free ▪ Moisturizers immediately after bathing and throughout the day ▪ At least twice daily Self-Care – Non- ▪ “Soak and Smear:” Apply moisturizer directly afar bath without towel drying Pharm ▪ Keep fingernails short & prevent scratching ▪ Use soft cotton fabrics for clothing & sheets ▪ Gentle detergent, 2 rinse cycles ▪ Bleach bath ▪ Increase room humidity and keep air temperature “cool” ▪ Wet-wrap therapy ▪ Use sunscreen  36 Triggers ▪ Soaps, detergents ▪ Excessive hand or skin washing ▪ Cosmetics, fragrances, and astringents ▪ Dyes and preservatives ▪ Extreme temperatures ▪ Environmental & animal allergens ▪ Aeroallergens (e.g., dust mites, cat dander, molds, grass, ragweed, pollen) ▪ Airborne irritants (tobacco smoke, air pollution, traffic exhaust) ▪ Stress ▪ Food allergens (e.g., egg, milk, peanut, soy, wheat, nuts) ▪ Electric blankets ▪ Tight-fitting or irritating clothes (wool or synthetics)  37 Self-Care – Hydrate Skin ▪ Moisturizers divided into 3 categories: 1) Occlusives – layer that prevents/slows water loss 2) Humectants – Increase water-holding ability of stratum corneum 3) Emollients – Smooth skin surface by filling space with oil droplets ▪ Use at least twice a day for preventive and maintenance ▪ Natural moisturizing factors (NMFs), ceramides or pseudoceramides, aid in preventing epidermal water loss via “barrier repair therapy” ▪ Higher water content in lotions can have a drying effect and their use should be avoided ▪ Ointments may have more effective dermal penetration, but greasy ▪ Patient preference  38 ▪ Topical corticosteroids (TCS) the DOC ▪ Consider severity, site, & duration of use ▪ Low Potency ▪ Use for the face Pharmacologic ▪ Long-duration Options ▪ Medium Potency ▪ Body ▪ Short-duration/exacerbation ▪ High & Ultra-High Potency ▪ Short-duration/exacerbation  39 ▪ Apply twice daily ▪ Can respond to once daily application ▪ Discontinue therapy once symptoms are controlled ▪ Taper off steroid: ▪ BID to QD to QOD to twice weekly to off TCS Tidbits ▪ After discontinuing steroid, continue to use a moisturizer ▪ Patients with frequent reoccurrences may benefit from long-term use of twice weekly application  40 ▪ Second-line therapy ▪ MOA: Prevent T-cell activation and the inflammatory cascade of cytokines via calcineurin inhibition Pharmacologic ▪ Available as: Options-Topical ▪ Tacrolimus ointment (Protopic) Calcineurin ▪ 0.03% - Approved for ages 2-15 Inhibitors ▪ 0.1% - Approved for ages 16 and older ▪ Pimecrolimus cream (Elidel) ▪ 1% - Approved for ages 2 and older ▪ Not for patients with weak or compromised immune systems  41 ▪ BLACK BOX: have been associated with cases of lymphoma and skin malignancy ▪ Use sunscreen- broad spectrum SPF 30 or higher ▪ Approved for short-term OR noncontinuous chronic use in AD ▪ Application limited to involved areas & smallest amount possible Topical ▪ Ok for all body locations Calcineurin ▪ Typically used after acute control from TCS Inhibitors ▪ Most common side effect: Temporary burning feeling at application site ▪ Avoid use in immunocompromised ▪ No monitoring necessary ▪ Frequent relapses consider 2-3 times weekly for maintenance  42 ▪ Consider 1st-generation antihistamines at bedtime ▪ Help with pruritus ▪ Help with sleep disturbance due to Pharmacologic itching and discomfort Options ▪ Diphenhydramine (Benadryl) most common ▪ 25 mg every 4 to 6 hours as needed ▪ or 50 mg every 6 to 8 hours as needed  43 Pharmacologic Therapy Summary Systemic therapy, Topical phototherapy, calcineurin new options Topical inhibitors Corticosteroids (TCIs) Moisturizers (TCs)  44 ▪ Additional second-line option ▪ More like 3rd line ▪ May help decrease dose of steroids ▪ Avoid in patients who experience flares from sunlight ▪ Avoid in patients using topical calcineurin inhibitors ▪ Treatment Phototherapy ▪ Ultraviolet light ▪ Ultraviolet light + photochemotherapy ( drug or topical ointment) ▪ UVA, UVA1, BB-UVB, & NB-UVB ▪ Side effects: Skin redness and pain ▪ Long-term effects: Premature aging & skin cancer ▪ MUST wear eye protection  45 ▪ Not well-studied ▪ Anti-proliferation and anti-inflammatory properties ▪ Side effects: Photosensitivity, acne-like eruptions, folliculitis, burning, stinging ▪ Dosage forms: Lotion, cream, ointment, shampoo, gel, solution Pharmacologic ▪ Application: Once to twice daily ▪ Advantages: Well tolerated and inexpensive Options – Coal ▪ Disadvantages: Tar ▪ Smells bad https://goo.gl/images/Bk1C2Y ▪ Can stain skin, clothes, etc. ▪ Not recommended on acutely inflamed skin ▪ Additional irritation ▪ Risk of cancer with long-term use? ▪ Efficacy?  46 ▪ Systemic corticosteroids Pharmacologic ▪ Used for rapid suppression Options – ▪ ADR profile is not favorable Systemic ▪ Risk of flares & rebound exacerbations Therapies  47 ▪ Limited evidence ▪ Azathioprine ▪ Methotrexate ▪ Mycophenolate mofetil Pharmacologic ▪ Intravenous immunoglobulin (IVIG) Options – ▪ Biologic response modifiers Systemic ▪ Tumor necrosis factor (TNF)-α inhibitors ▪ infliximab & etanercept effective in some; ADRs ▪ Monoclonal antibodies ▪ omalizumab, rituximab, & alefacept shown to be somewhat effective  48 ▪ Class: IL-4 receptor antagonist ▪ Indication: ≥18 yoa with moderate-to-severe atopic dermatitis ▪ Dosage: 600mg SQ once, then 300mg every other week New PT Option- ▪ Side effects: Allergic reactions, eye issues (conjunctivitis, eye pruritus), injection site Dupilumab reactions (Dupixent) ▪ Key points: ▪ Administered under the skin ▪ Dispensed as prefilled syringe for self- administration ▪ Can combine with topical corticosteroids  49 ▪ Class: Phosphodiesterase-4 (PDE-4) inhibitor ▪ Indication: 2 years and older with mild-to- moderate atopic dermatitis Crisaborole ▪ Dosage: Thin layer BID AA (Eucrisa) ▪ Side effects: Allergic reactions, stinging/burning ▪ Key points: ▪ Wash hands before and after use ▪ Dispensed as 2% ointment  50 ▪ Class: IL-4 receptor antagonist ▪ Indication: moderate to severe AD where topical therapies proven ineffective Tralokinumab ▪ Dosage: 600 mg SQ once; followed by 300 mg SQ every 2 weeks (Adbry) ▪ SE: injection site reaction, conjunctivitis, increased WBC, & upper respiratory infection ▪ NO LIVE VACCINES! Increased risk of infection.  51 Biologics: Janus Kinase Inhibitors  52 ▪ Black Box Warnings (Research and fill these in!!) ▪ Serious infections: ▪ Mortality (with 1 CV risk factor): Janus Kinase ▪ Malignancies: Inhibitors ▪ Major adverse cardiovascular events: ▪ Thrombosis: ▪ Mechanism of action  53 Opzelura (Ruxolitinib) Approved Sept 2021 Janus Kinase inhibitor; Topical Selectively inhibits Janus-associated kinases (JAKs), JAK1 and JAK2. JAK1 and JAK2 These mediate signaling of cytokine and growth factors responsible for hematopoiesis and immune function; JAK-mediated signaling involves recruitment of signal transducers and activators of transcription (STATs) to cytokine receptors, which leads to modulation of gene expression Thought that the JAK-STAT signaling pathway is linked to inflammation, itch response, and skin barrier function  54 ▪ Atopic Dermatitis and Nonsegmental vitiligo ▪ Apply a thin layer to affected area(s) twice daily ▪ Application area should not exceed 20% BSA ▪ Max dose: 60 g per week or 100 g per 2 weeks Opzelura ▪ Discontinue when signs/symptoms resolve ▪ Reassess therapy if signs/symptoms have not resolved (Ruxolitinib) within 8 weeks ▪ Avoid concomitant use with other biologics, other Janus kinase inhibitors, or potent immunosuppressants (e.g. azathioprine, cyclosporine)  55 Rinvoq (upadacitinib) Approved 2019 Inhibits Janus kinase (JAK) enzymes Intracellular enzymes involved in stimulating hematopoiesis and immune cell function JAKs activate signal transducers and activators of transcription (STATs), which regulate gene expression and intracellular activity Inhibition of JAKs prevents the activation this signaling pathway  56 ▪ Ankylosing spondylitis, Atopic dermatitis, Psoriatic arthritis, Rheumatoid arthritis, Ulcerative colitis ▪ Atopic dermatitis ▪ 15 mg PO once daily, increase to 30 mg PO once daily if inadequate response ▪ Discontinue if an adequate response Rinvoq ▪ Use the lowest effective dose needed to maintain response (upadacitinib) ▪ Dose adjustment (15 mg PO daily) for renal impairment (eGFR: 15-