Dermatology Pharmacology I 2026 PDF

Dr. Lincoln McGinnis Pharmacology I Class of 2026 Dermatology PRESBYTERIAN COLLEGE INSTRUCTIONAL OBJECTIVES ARC-PA Standard(s) B1.02, B1....

Dr. Lincoln McGinnis Pharmacology I Class of 2026 Dermatology PRESBYTERIAN COLLEGE INSTRUCTIONAL OBJECTIVES ARC-PA Standard(s) B1.02, B1.03, B1.04, B1.06, B1.07, B2.02, B2.03, B2.05, Instructional Objectives General – Know Vehicles of administration for dermatology medications – Know classes of dermatology medications and medications within each class – Know medications used for common dermatologic diseases – Decide appropriate route of administration by medical condition Instructional Objectives For the list of dermatologic conditions (see next slide) students are to: – Know medications typically used to treat the condition – Know clinical pearls relating to the use of each medication – Know key components of patient education – Know key safety issues, adverse reactions, and warnings – Know mechanism of action for each medication – Decide when it is appropriate to use each medication – Know identify if the medication has a Black Box warning and the implications of such a warning. – Find common dosages for the medication – Be able to construct a written prescription for each medication with patient information, prescription, dose, instructions, refills, provider identification, and signature. Instructional Objectives – Pruritis – Sunscreen agents – Atopic dermatitis medications – Psoriasis medications – Viral skin infection medications – Bacterial skin infection medications – Fungal skin infection medications – Parasitic skin infection medications – Hair loss (Trichogenic) agents – Acne medications – Dermatologic antineoplastic agents (Actinic Keratosis) Morphology  Diagnosis/Etiology  Treatment Pigmented Infectious diseases Barriers – Viral – Scaly Condyloma acuminatum Sunscreen agents – Sunshade agents Vesicular Herpes simplex Molluscum contagiosum Anti-inflammatory Weepy or encrusted Varicella-zoster virus infections – Topical corticosteroids Pustular Verrucae – – Bacterial Systemic steroids Figurate (“shaped”) Cellulitis Anti-infectives erythema Erysipelas – Impetigo Topical antibacterial Bullous – Fungal medications Papular Candidiasis – Topical antifungal Dermatophyte infections medications Pruritus (not – Parasitic – Topical anti-parasitic morphologic) Lice medications Nodular, cystic Trauma Scabies – Topical antiviral Photodermatitis Inflammatory medications – Systemic antimicrobials Morbilliform Neoplastic Anti-neoplastic agents Erosive A General Pathway to Integrating Dermatology Pharmacology Clin Pathophysiology of Dermatologic Treatment and Med Prognosis Disease Dermatologic Pharm Medications General Categorized by Principles Class Categorized by Disease YOU Integration Master topic block specific information for information PANCE Dermatologic pharmacology Emollients Eucerin / Aquaphor / Lubriderm Acne (topical Agents) Benzoyl Agenda Peroxide Acne (topical Agents) Clindamycin (Cleocin) General Acne (topical Agents) Isotretinoin (Accutane) Acne (topical Agents) Tretinoin (Retin-A) Actinic Keratosis Fluorouracil (Efudex) Principles Actinic Keratosis Actinic Keratosis Atopic Dermatitis Diclofenac (Solaraze) Imiquimod (Zyclara) Tacrolimus (Protopic) Categories of Atopic Dermatitis Pimecrolimus (Elidel) Burn preparations Silver Sulfadiazine (Silvadene) Psoriasis Acitretin (Soriatane) Psoriasis Calcipotriene (Dovonex) Topicals (Antiviral) Acyclovir Medications (Zovirax) Topicals (Antiviral) (Abreva) Docosanol Medications by Topicals (Antiviral) Podophyllin (Podofin) Topical (Antibacterials) Bacitracin Topical (Antibacterials) Mupirocin (Bactroban) Categories of Topical (Antibacterials) Metronidazole (Metrogel) Topical (Antibacterials) Neosporin Diseases Topical (Anti-fungals) Clotrimazole (Lotrimin) Topical (Anti-fungals) Ketoconazole (Nizoril) Review Topical (Anti-fungals) Selenium sulfide (Selsun Blue) (Lamisil) Syllabus Topical (Anti-fungals) Terbinafine Topical (Keratolytic) Salicylic acid (Compound W)  Two Strategies to Learn Dermatologic Pharmacology Categories of Medications Categories of Diseases Barriers and Emollients Pruritis Sunscreen Agents Sunscreen agents Anti-inflammatory Atopic dermatitis medications – Topical Corticosteroids – Oral corticosteroids Psoriasis medications – Oral Antihistamines Topical antiviral medications Anti-infective Topical antibacterial medications – Topical Antibiotics Topical antifungal medications – Oral Antibiotics – Topical anti-parasitic medications Topical Antifungals – Trichogenic agents Topical Antivirals – ECTOPARASITICIDES Acne Medications Trichogenic medications Dermatologic antineoplastic Retinoid and Vitamin A and D agents (Actinic Keratosis) Analogs Keratolytic & Destructive DERMATOLOGIC KISS Principles of Dermatology Dermatology in four lines: – If it’s dry, wet it; – If it’s wet, dry it; – If you think you know what it is, you don’t need to touch it! – If you don’t know what it is, biopsy it. Actual General Principles – Superficial  Deep Therapy – Escalation of Therapy Escalation of Therapy First Therapy/ Simple Second Therapy/ More Third therapy/ Most Cost Complex complex Compliance Cost—usually intermediate Cost—usually higher Complications Compliance Compliance Complications Complications Cure Rate Cure Rate Cure Rate Simple to Complex Principles of Dermatologic Therapy Bathing Topical Therapy – Anti-infectives – Corticosteroids – Emollients & Barriers – Drying agents – Topical antipruritic – Keratolytics and immunomodulators Systemic Drugs – Antihistamines and antidepressants – Systemic corticosteroids – Systemic immunomodulators – Systemic Anti-infectives Bathing Soap should be used only in the axillae and groin and on the feet by persons with dry or inflamed skin. Soaking in water for 10–15 minutes before applying topical corticosteroids or emollient enhances their efficacy (Soak and Smear). Vehicles of Administration for Dermatology Medication Topical medications usually consist of active ingredients incorporated in a vehicle that facilitates cutaneous application. Important considerations in vehicle selection – Solubility of the active agent in the vehicle; – The rate of release of the agent from the vehicle; – The ability of the vehicle to hydrate the stratum  Vehicles of Administration for Topical Medication Foams (cosmetically elegant): spread readily, easier to apply; Gel (jelly-like): may more expensive. USE for hairy areas; inflammation Creams: e.g. (vanish when contain alcohol, rubbed in): less greasy, greaseless, least drying effects; not occlusive, occlusive; dry quickly can sting, more likely to USE for acne, exudative Foams cause irritation (preservatives/fragrances). inflammation (e.g. acute Creams contact dermatitis); on Gels USE for acute exudative scalp/hairy areas without inflammation, intertriginous matting areas Sprays: Aerosols Sprays Oils: less stinging than (rarely used), pump lotions or solutions. USE for sprays Oils the scalp, especially for people with coarse or very curly hair Oral Solutions (pourable liquid): less greasy, less Solutions Ointments: (e.g. occlusive; may contain Vaseline): lubricating, alcohol (drying effect on oozing lesion); Ointments occlusive; greasy. USE for smooth, non-hairy skin; penetrate easily, little dry, thick, or residue. USE for hairy hyperkeratotic lesions. areas AVOID on hairy and intertriginous (when skin Pharmacologic Response to Topical Medication Major variables that determine pharmacologic response to drugs applied to the skin 1. Regional variation in drug penetration 2. Concentration gradient 3. Dosing schedule Pharmacologic Response to Topical Medication--Regional Regional variation in drug penetration: – Scrotum, face, axilla, and scalp are far more permeable than the forearm and may require less drug for equivalent effect A.S.S. Face Axilla Scalp Scrotum Donkey gargoyle Strasbourg, France South exterior, Cathedrale Notre Dame, Strasbourg, France Pharmacologic Response to Topical Medication Concentration gradient: – Increasing the concentration gradient increases the mass of drug transferred per unit time – Resistance to topical corticosteroids can sometimes be overcome by use of higher concentrations of drug Dosing schedule: – The skin acts as a reservoir for many drugs – The “local half-life” may be long enough to permit once-daily application of drugs with short systemic half-lives. – example, once-daily application of corticosteroids appears to be just as effective as multiple applications Pharmacologic Response to Topical Medication Vehicles and occlusion: – An appropriate vehicle maximizes the ability of the drug to penetrate the outer layers of the skin – Physical properties (moistening or drying effects), vehicles may themselves have important therapeutic effects. – Occlusion (application of a plastic wrap to hold the drug and its vehicle in close contact with the skin) is extremely effective in maximizing efficacy https://www.doctors.net.uk/_datastore/ecme/mod1227/Drug_dosage_Table1.pdf Basic & Clinical Pharmacology, 15e > Dermatologic Pharmacology Bertram G. Katzung BARRIER MEDICATIONS EMOLLIENTS - DRY SKIN - Emollients (Eucerin, Lubriderm, Cetaphil) Safety, SE, & emollients Pearls & Patient Ed Warnings Most emollients can Store away from Uses be used safely and children / infants to effectively with no avoid poisoning from side effects. However, ingestion Dry Skin burning, stinging, Some may redness, or irritation contain may occur. If any of sunscreen these effects persist or worsen, tell your doctor or pharmacist promptl y. Mechanism of Action Increase the skin's hydration by providing moisture and reducing evaporation  BARRIER MEDICATIONS SUNSCREENS & SUNSHADES - UV LIGHT [UVB]- Sunscreens Safety, SE, & sunscreen Pearls & Patient Ed Warnings The ratio of the Reduces UV minimal erythema Uses dose with sunscreen exposure, not to the minimal completely block erythema dose products claiming without sunscreen is the SPF. to be water SPF values of 15 or resistant must higher help protect indicate whether against not only sunburn, but also skin they remain cancer and early skin effective for 40 aging minutes or 80 minutes while Mechanism of Action swimming or preparations are designed to absorb UV light--the ultraviolet B (UVB) wavelength range from 280 to 320 nm, sweatingVariable Most commonly are p-aminobenzoic acid (PABA) and its esters, the benzophenones, and the dibenzoylmethanes. ! Sunshades Safety, SE, & sunshade Pearls & Patient Ed Warnings Apply as directed Uses Mechanism of Action Zinc oxide or titanium oxide containing compounds opaque materials such as titanium dioxide that reflect light, called sunshades Summary: Sunscreen and Sunshades Safety, SE, & UVB blockers Pearls & Patient Ed Warnings component of a The regular use of Uses comprehensive sunscreen is sun protection efficacious in temporary approach along reducing photoprotectio with minimizing photocarcinogenes n from the sun exposure and is and photoaging acute and using (Mancebo et al., chronic effects photoprotective 2014). of sun gear exposure Mechanism of Action Blocks UVB  MEDICATIONS ANTI-INFLAMMATORY AGENTS- Glucocorticoids: Anti-inflammatory & Immunosuppressive Glucocorticoids dramatically reduce the manifestations of inflammation and suppress some immune functions. – suppressive effects on inflammatory cytokines and chemokines and on other mediators of inflammation. – profound effects on the concentration, distribution, and function of peripheral leukocytes – inhibiting the functions of tissue macrophages and other antigen-presenting cells. Adverse Effects – used for short periods (Goodman AccessMedicine 1% gel & Gilman's: RXR-α, RXR-β, The Pharmacological X Basis of Therapeutics, +++ Pharmacology 13e > Dermatological Tretinoin Topical (Retin-A) Safety, SE, & Topical retinoid Pearls & Patient Ed Warnings Topical gel is Serious Reactions Uses flammable! Do – skin rxn, severe not smoke until it Common Reactions Acne, topical dries and use – peeling Acne vulgaris extreme caution – xeroderma Wrinkle Call if skin – burning/stinging irritation becomes – erythema reduction – pruritus severe or no – blistering improvement in 8- – photosensitivity 12 weeks Mechanism of Action Exact mechanism of action unknown; binds to retinoic acid receptors, stimulating epithelial cell turnover (retinoid) Systemic Retinoids RECEPTOR DRUG DOSING RANGE t1/2 SPECIFICITY Isotretinoin No clear receptor 0.5–2 mg/kg/d 10–20 h affinity Etretinate RAR-α, RAR-β, 0.25–1 mg/kg/d 80–160 d RAR-γ Acitretin RAR-α, RAR-β, 0.5–1 mg/kg/d 50 h RAR-γ Bexarotene RXR-α, RXR-β, 300 mg/m2/d 7–9 h RXR-γ AccessMedicine >Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 13e > Dermatological Pharmacology Isotretinoin (Accutane) Retinoid, Safety, SE, & Pearls & Patient Ed systemic Warnings Brand no longer Pregnancy available in US… Contraindicated Uses however, commonly do not use in female discussed for this class pts who are or may Acne, severe of meds. become pregnant; extremely high birth recalcitrant defect risk if Should be prescribed by nodular a dermatologist in a pregnancy occurs while taking any closely monitored isotretinoin even for environment. short time periods; any fetus exposed Numerous very serious during pregnancy adverse reactions may be affected Mechanism of Action Exact mechanism of action unknown; inhibits sebaceous gland function and differentiation, reduces sebum secretion (retinoid) Calcipotriene [Calcitrene] Vitamin D Safety, SE, & Pearls & Patient Ed analogue Warnings Hypercalcemia and Dosage forms: hypercalciuria may Uses OINT: 0.005% develop when the Calcipotriene is cumulative weekly dose topical exceeds the applied twice daily recommended 100 vitamin D to plaque psoriasis g/week limit and analogue that on the body, often resolves within days of discontinuation is used in the in combination Calcipotriene also treatment of with topical causes perilesional psoriasis, corticosteroids. irritation and mild photosensitivity plaque. Mechanism of Action Calcipotriene exerts its effects through binding to vitamin D response elements on DNA, increasing expression of genes that modulate epidermal differentiation and inflammation  MEDICATIONS - KERATOLYTIC & DESTRUCTIVE AGENTS- Salicylic Acid Safety, SE, & Keratolytic Pearls & Patient Ed Warnings Active metabolite of It is advisable to limit both the total amount of Uses aspirin salicylic acid applied and (acetylsalicylic the frequency of Salicylic acid has acid), application. Salicylism and been extensively Topical bar/cream death have occurred wash/foam following topical used in application. dermatologic wash/medicated therapy as a pads Topical use may be keratolytic Topical lotion associated with local agent. OTC limit 2% for irritation, acute Acne inflammation, and even face Warts ulceration Mechanism of Action The mechanism by which it produces its keratolytic and other therapeutic effects is poorly understood. The drug may solubilize cell surface proteins that keep the stratum corneum intact, thereby resulting in desquamation of keratotic debris. Benzoyl Peroxide, topical Safety, SE, & Acne vulgaris Pearls & Patient Ed Warnings Cause the cells of Benzoyl peroxide is a Uses the epidermis to potent contact shed more readily sensitizer and this Benzoyl peroxide and help prevent adverse effect may penetrates the occur in up to 1% of pores from clogging stratum corneum or acne patients. follicular openings Highly concentrated unchanged and is formulations may converted Benzoyl peroxide is an metabolically to lead to oxidant and may benzoic acid within hyperpigmentation rarely cause bleaching the epidermis and and an increased of the hair or colored dermis. risk of skin irritation. fabrics. Mechanism of Action mechanism of action of benzoyl peroxide in acne is related to its antimicrobial activity against P acnes and to its peeling and comedolytic effects. Fluorouracil Topical (Efudex) Safety, SE, & Antineoplastic Pearls & Patient Ed Warnings systemic toxicity, life- May harm fetus – do threatening not use if pregnant or Uses application site rxn breastfeeding erythema actinic keratosis xeroderma basal cell CA, The response to superficial scaling treatment begins with crusting erythema and Fluorouracil is available in multiple burning progresses through formulations containing 0.5%, 1%, stinging vesiculation, erosion, 2%, 4%, and 5% concentrations (Carac, pruritus superficial ulceration, Efudex, Fluoroplex, pain necrosis, and finally Tolak). edema reepithelialization. Mechanism of Action Inhibits DNA and RNA synthesis Fluorouracil Topical (Efudex) Actinic Keratosis Fluorouracil Topical 5% cream Apply to affected area every 12 hours Diclofenac (Solaraze) Safety, SE, & Keratolytic Pearls & Patient Ed Warnings A topical 3% gel Cardiovascular Risk Uses formulation of the NSAIDs incr. risk of nonsteroidal anti- serious and potentially inflammatory drug moderate fatal cardiovascular thrombotic events, effectiveness incl. MI and stroke; Adult Dosing. in the Dosage forms: GEL: risk may occur early in treatment of 3% tx and may incr. w/ actinic duration of use; actinic keratosis keratoses. contraindicated for [apply bid x60-90 CABG peri-operative days] pain Mechanism of Action exact mechanism of action in actinic keratosis unknown; inhibits cyclooxygenase, reducing prostaglandin and thromboxane synthesis PODOPHYLLUM RESIN & PODOFILOX Safety, SE, & Genital Warts Pearls & Patient Ed Warnings condyloma acuminata, external Application should [apply qwk prn] Uses be restricted to In treating cases of large wart tissue only, used in the treatment of condylomas, it is advisable condyloma acuminatum to limit application to to limit the total and other verrucae. sections of the affected area to minimize systemic amount of Pure podophyllotoxin absorption. medication used (podofilox) is approved for use as either a 0.5% The patient is instructed to and to prevent solution or gel (Condylox) for wash off the preparation 2– severe erosive 3 hours after the initial application by the patient in the treatment application, because the changes in irritant reaction is variable. of genital condylomas. adjacent tissue. Mechanism of Action Podophyllotoxin and its derivatives are active cytotoxic agents with specific affinity for the microtubule protein of the mitotic spindle; arrests mitosis, resulting in cytotoxicity Immunomodulators IMIQUIMOD external genital and perianal warts in adults, actinic keratoses on the face and scalp, and biopsy-proven primary superficial basal cell carcinomas on the trunk, neck, and extremities – external genital and perianal warts in adults, 5% cream (Aldara) applied to the wart tissue three times per week and left on the skin for 6–10 hours prior to washing off with mild soap and water continued until eradication of the warts is accomplished, but not for more than a total of 16 weeks actinic keratoses twice-weekly applications of the 5% cream on the contiguous area of involvement or nightly applications of the 2.5% or 3.75% cream biopsy-proven primary superficial basal cell carcinomas on the trunk, neck, and extremities. – five-times-per-week application of 5% cream to the tumor, including a 1 cm margin of surrounding skin, for a 6-week course of therapy TACROLIMUS & PIMECROLIMUS macrolide immunosuppressants that have been shown to be of significant benefit in the treatment of atopic dermatitis IMIQUIMOD (5% cream, Aldara) Immunomodula Safety, SE, & Pearls & Patient Ed tor Warnings actinic keratoses Adverse effects Uses consists of twice- consist of local weekly applications of the 5% cream on the inflammatory the treatment of external genital and contiguous area of reactions, perianal warts in involvement or nightly including pruritus, adults, actinic keratoses on applications of the erythema, and the face and scalp 2.5% or 3.75% cream superficial erosion. biopsy-proven The cream is removed primary superficial basal cell after approximately 8 carcinomas on the hours with mild soap trunk, neck, and and water. extremities. Mechanism of Action stimulate peripheral mononuclear cells to release interferon alpha and to stimulate macrophages to produce interleukins-1, -6, and -8, and tumor necrosis factor-α (TNF-α). Tacrolimus (Protopic) and Pimecrolimus (Elidel) Safety, SE, & immunosupress Pearls & Patient Ed Warnings ants Tacrolimus 0.03% The most common side effect of both drugs is a Uses ointment and burning sensation in the pimecrolimus 1% applied area that Both are improves with continued cream are use. indicated for short-term and approved for use The US Food and Drug Administration (FDA) intermittent in children older mandates a black box long-term than 2 years of warning regarding the therapy for mild age, although all long-term safety of to moderate topical tacrolimus and atopic strengths are pimecrolimus because of approved for adult animal tumorigenicity dermatitis. data. use Mechanism of Action Both agents inhibit T-lymphocyte activation and prevent the release of inflammatory cytokines and mediators from mast cells QUESTIONS? Medications – Dry Skin [Xerosis cutis is the medical term for abnormally dry skin.] Dry skin is the first cause of itch that should be sought, since it is common and easily treated. Emollients provide barrier protection and moisterizer – OTC, safe, usually 1-3 times daily – Aquaphor – Aveeno – Cetaphil – Eucerin – Lubriderm – Neutrogena – Urea Emollients (Eucerin, Lubriderm, Cetaphil) Safety, SE, & Pearls & Patient Ed Warnings Most emollients can Store away from Uses be used safely and children / infants to effectively with no avoid poisoning from side effects. However, ingestion Dry Skin burning, stinging, Some may redness, or irritation contain may occur. If any of sunscreen these effects persist or worsen, tell your doctor or pharmacist promptl y. Mechanism of Action Increase the skin's hydration by providing moisture and reducing evaporation Sunscreens Safety, SE, & Pearls & Patient Ed Warnings The ratio of the Reduces UV minimal erythema Uses dose with sunscreen exposure, not to the minimal completely block erythema dose products claiming without sunscreen is the SPF. to be water SPF values of 15 or resistant must higher help protect indicate whether against not only sunburn, but also skin they remain cancer and early skin effective for 40 aging minutes or 80 minutes while Mechanism of Action swimming or preparations are designed to absorb UV light--the ultraviolet B (UVB) wavelength range from 280 to 320 nm, sweatingVariable Most commonly are p-aminobenzoic acid (PABA) and its esters, the benzophenones, and the dibenzoylmethanes. ! Sunshades Safety, SE, & Pearls & Patient Ed Warnings Apply as directed Uses Mechanism of Action Zinc oxide or titanium oxide containing compounds opaque materials such as titanium dioxide that reflect light, called sunshades  - S TIS N TI IO A AT M IC ER D E CD M PI TO A - Atopic dermatitis (also known as eczema) Distinct presentations in people of different ages and races. Diagnostic criteria: must include – pruritus, – typical morphology and distribution (flexural lichenification, hand eczema, nipple eczema, and eyelid eczema in adults), – onset in childhood, and chronicity. Also helpful: – (1) personal / FHx of atopy (asthma, allergic rhinitis, atopic dermatitis), – (2) xerosis-ichthyosis, – (3) facial pallor with infraorbital darkening, – (4) elevated serum IgE, and – (5) repeated skin infections. Atopic dermatitis (also known as eczema) Treatment General Measures Local Treatment – Corticosteroids—adjust according to severity It is vital that patients taper off corticosteroids and substitute emollients as the dermatitis clears to avoid side effects of corticosteroids. – Tacrolimus ointment (Protopic 0.03% or 0.1%), pimecrolimus cream (Elidel 1%), and crisaborole (Eucrisa 2%) can be effective in managing atopic dermatitis when applied twice daily. These noncorticosteroid medications do not cause skin atrophy or striae, avoiding the complications of long-term topical corticosteroid use. They are safe for application on the face and even the eyelids but are more expensive than generic topical corticosteroids. Systemic and Adjuvant Therapy – Systemic corticosteroids are indicated only for severe acute exacerbations. – Due to the chronic nature of atopic dermatitis and the side effects of long-term systemic corticosteroids, ongoing use of these agents is not recommended for maintenance therapy. MEDICATIONS - PSORIASIS- Psoriasis common benign, chronic ESSENTIALS OF DIAGNOSIS inflammatory skin disease Silvery scales on bright red, well- with both a genetic basis demarcated plaques, usually on and known environmental the knees, elbows, and scalp. Nails: pitting and onycholysis triggers. Injury or irritation of (separation of the nail plate from normal skin tends to induce the bed). lesions of psoriasis at the Mild itching is common. site May be associated with psoriatic Psoriasis has several arthritis. variants Increased risk of cardiovascular – Plaque type events, type 2 diabetes mellitus, – Eruptive metabolic syndrome, and – generalized lymphoma. Psoriasis Treatment Limited Disease high-potency to ultra–high-potency topical corticosteroid cream or ointment; It is best to restrict the ultra–high-potency corticosteroids to 2–3 weeks of twice-daily use Calcipotriene ointment 0.005% or calcitriol ointment 0.003%, both vitamin D analogs, are used twice daily for plaque psoriasis. Moderate Disease UV phototherapy or systemic agents Generalized Disease outpatient narrowband UVB (NB-UVB) three times weekly Methotrexate Acitretin, a synthetic retinoid The tumor necrosis factor (TNF) inhibitors etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira) are effective in pustular and chronic plaque psoriasis and are also effective for the associated arthritis. Acitretin [Soriatane] Vit A Safety, SE, & Pearls & Patient Ed Derivative Warnings Patient Agreement/Informed Pregnancy Contraindicated Consent for Female Pts; do not use in female pts who are or may become pregnant during tx or for at least 3y Uses prescriber must counsel pt qmo during tx and q3mo x3y after after D/C; exposure may lead to major fetal abnormalities incl. meningomyelocele, meningoencephalocele, mult. synostoses, facial D/C about contraception and use in the behaviors assoc. w/ incr. dysmorhpia, syndactyly, absent terminal phalanges, malformations of hip, ankle, and forearm, low-set pregnancy risk ears, high palate, decr. cranial volume, cutaneous cardiovascular malformation, and skull/cervical manifestations of vertebrae alterations Avoid ingestion of additional psoriasis [severe sources of exogenous vitamin A Women of Child-Bearing Potential--only consider tx psoriasis in (in excess of RDA); in women w/ severe psoriasis unresponsive or not candidate for other tx; prescribe only if pregnancy adults] females of childbearing excluded and pt meets set criteria: potential should not ingest 2 initial negative pregnancy tests then ethanol and ethanol-containing negative pregnancy tests qmo during tx and Not for the products during therapy and for q3mo for >3y after D/C, use of 2 effective forms of contraception (avoid progestin-only treatment of 2 months after the last dose of forms) 1mo prior to tx start, during tx, and for >3y after D/C, and signed acitretin. acne. Mechanism of Action Binds to and activates retinoid X receptors (RXR) and retinoic acid receptors (RAR) to inhibit the expression of the proinflammatory cytokines and abnormal keratinocyte differentiation). Resulting actions are anti-inflammatory and antiproliferative, and keratinocyte differentiation is normalized in the epithelium. Calcipotriene [Calcitrene] Vitamin D Safety, SE, & Pearls & Patient Ed analogue Warnings Hypercalcemia and Dosage forms: hypercalciuria may Uses OINT: 0.005% develop when the Calcipotriene is cumulative weekly dose topical exceeds the applied twice daily recommended 100 vitamin D to plaque psoriasis g/week limit and analogue that on the body, often resolves within days of discontinuation is used in the in combination Calcipotriene also treatment of with topical causes perilesional psoriasis, corticosteroids. irritation and mild photosensitivity plaque. Mechanism of Action Calcipotriene exerts its effects through binding to vitamin D response elements on DNA, increasing expression of genes that modulate epidermal differentiation and inflammation The role of topical antibiotics in the treatment of minor skin infections Most minor skin infections are self-limiting and resolve without the use of an antibiotic (with standard skin hygiene advice). The decision to treat will be determined by several factors, including the extent and severity of infection, the patient’s co- morbidities and socioeconomic status (e.g. living environment). Not all patients with a skin infection require an antibiotic If an antibiotic is required, topical antibiotics are only appropriate for patients with minor, localized areas of impetigo https://bpac.org.nz/BPJ/2014/October/topical-antibiotics.aspx Acyclovir [Topical] Topical; Safety, SE, & Pearls & Patient Ed (HSV/VZV) Warnings Adverse local reactions Dosage forms: to acyclovir and Uses OINT: 5%; CRM: 5% penciclovir may include pruritus and mild pain mucocutaneous HSV, Topical formulations with transient stinging or immunocompromised pts burning. produce high [apply 6x/day x7 days] concentrations in Topical acyclovir cream herpetic lesions, but is substantially less recurrent herpes labialis effective than oral (cold sores), systemic therapy for primary HSV immunocompetent pts concentrations are infection. It is of no undetectable by this benefit in treating [apply crm 5x/day x4 recurrent genital herpes. days] route. Start: at sx onset Mechanism of Action inhibits DNA polymerase; incorporates into viral DNA Acyclovir [Oral, systemic] [Zovirax] Antiviral, Safety, SE, & Systemic Pearls & Patient Ed Warnings (HSV/VZV) Dosage forms: CAP: 200 Serious Reactions hallucinations mg; TAB: 400 mg, 800 mg; Uses SUSP: 200 mg per 5 mL psychosis encephalopathy seizures HSV encephalitis genital HSV, coma genital HSV, immunocompetent pts immunocompetent pts leukopenia orolabial HSV, thrombocytopenia [1st episode, mild- immunocompetent pts neutropenia (neonates) moderate infection] HSV infection, Common Reactions immunocompromised [recurrence] Nausea, vomiting pts [suppression] diarrhea varicella (chicken pox) Dose: 400 mg PO bid; headache *herpes zoster malaise ophthalmicus Alt: 200 mg PO 3-5x/day; Dizziness Info: reassess tx need at 1y Mechanism of Action inhibits DNA polymerase; incorporates into viral DNA Doconazole [Abreva (OTC)] Safety, SE, & Pearls & Patient Ed Warnings Appropriate use: For Hypersensitivity: external use only; do not Severe allergic Uses apply to inside of mouth or around eyes. Apply at reactions (eg, hives, facial swelling, Cold sore/fever the first sign of cold wheezing/difficulty sore/fever blister blister: (tingle); early treatment breathing, rash, Treatment of ensures best results. Do shock) may occur not share product with with use; discontinue cold others. Discontinue use and seek medical and contact a health sores/fever care provider if the attention blisters on the condition gets worse or immediately if an face or lips. is not healed within 10 allergic reaction days. occurs. Mechanism of Action Prevents viral entry and replication at the cellular level General guidance for use of antibiotics for skin infections Antibiotics (topical or Topical antibiotics may Oral antibiotics (not oral) rarely required be considered topical) usually indicated Furuncles (boils) Impetigo (small, Infected wounds, Carbuncles (multiple localised patches) including bites headed lesions) Occasionally considered Cellulitis --In most cases these for infected eczema can be treated with (small, localised Widespread impetigo or incision and drainage patches, not improving infected eczema with standard care) Mastitis https://bpac.org.nz/BPJ/2014/October/topical- Furuncle vs Carbuncle vs Phlegmon Overuse can lead to resistant organisms https://bpac.org.nz/BPJ/2014/October/topical- General lifestyle and hygiene measures to reduce the likelihood of skin infections. Use an emollient to treat dry skin Wash clothes, towels and sheets Ensure that skin conditions such as regularly; if a family member has a dermatitis or eczema are optimally skin infection, ideally use hot water managed and dry items in a hot clothes dryer If skin is dry or damaged, avoid soaps (although acknowledging that this is which can irritate the skin, and often not affordable for families). A prolonged exposure to hot water hot iron can be used after clothes are Where possible, store and use skin dry. products from pump or pour bottles, rather than jars Regularly wash toys using a mild Keep fingernails and toenails trimmed disinfectant – hard toys can be and clean washed in a dishwasher, soak soft Do not share personal hygiene items toys prior to washing; there is no such as hairbrushes, razors, facecloths evidence that freezing soft toys and towels, and regularly clean these reduces bacterial contamination18 items If a skin injury occurs, clean and cover Wash and dry hands after using the it to help prevent infection and toilet and before eating regularly change the dressing Avoid scratching skin lesions Avoid sharing bath/cleaning water Avoid swimming in unclean/untreated Ferguson when J.aPreventive member of strategies for recurrent the family has a water if an open wound is present staphylococcal skin infection. Med Today skin infection 2012;13:65–70. Topical Antimicrobial Agents for Infection Drugs Therapeutic Uses Clinical Pharmacology and Tips Bacitracin, Superficial bacterial skin Topical use restricted for superficial neomycin, infections infections polymyxin Not indicated in clean surgical wounds B, May cause contact dermatitis (especially gentamicin bacitracin, neomycin, mafenide) Mupirocin, Superficial skin infections Intranasal decolonization of MRSA retapamulin due to S. aureus or S. pyogenes Mafenide Adjunctive therapy for Mafenide inhibits carbonic anhydrase and acetate burn wounds can cause metabolic acidosis Silver Prevention or treatment Efficacy of silver sulfadiazine questionable sulfadiazine in partial-thickness burns or venous stasis ulcers Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 13e > BACITRACIN & GRAMICIDIN Gram + Safety, SE, & Pearls & Patient Ed Peptide Abx Warnings Bacitracin is poorly Allergic contact Uses absorbed through dermatitis occurs the skin, so frequently, and systemic toxicity is immunologic allergic The use of contact urticaria rare. bacitracin in the rarely. Bacitracin is anterior nares Do not use this compounded in an may temporarily ointment base alone product over large decrease or in combination areas of the body. colonization by Do not use it for with neomycin, pathogenic polymyxin B, or serious skin staphylococci. both. infections. Mechanism of Action Bacitracin and gramicidin are peptide antibiotics, active against gram-positive organisms such as streptococci, pneumococci, and staphylococci. MUPIROCIN (myoo PEER oh sin) [Bactroban] Gram + Safety, SE, & Pearls & Patient Ed topical Abx Warnings Alt: apply oint bid Polyethylene Glycol Uses x5 days; Content--avoid use if extensive Info: for impetigo absorption possible, pseudomonic caused by S. especially if mod- acid A aureus or S. severe renal Dosage forms: impairment (oint OINT: 2%; CRM: pyogenes; may form); acute tubular 2% cover w/ gauze; necrosis may occur Impetigo [apply reassess if no Bactroban confused oint tid x7-14 improvement in 3- with: bacitracin; days] 5 days Bactrim Mechanism of Action bacteriostatic or bactericidal, depending on susceptibility and concentration; reversibly binds to isoleucyl-tRNA synthetase, inhibiting protein synthesis (monoxycarbolic acid) Neosporin ointment Safety, SE, & Pearls & Patient Ed Warnings Each gram itching, pain, skin Uses contains rash, scaling, swelling, polymyxin B redness, or other signs of skin irritation to treat certain sulfate 5,000 IU not present before use skin infections (international of this medication and to prevent units), bacitracin a very large affected zinc 400 IU, and infections in area, where a neomycin sulfate significant amount of burns, minor 5 mg, in a low cuts, and medication may be melting point absorbed into the wounds. petrolatum base. body Mechanism of Action Polymyxin B sulfate - neomycin sulfate - bacitracin zinc Impetigo Soaks and scrubbing can be beneficial, especially in unroofing lakes of pus under thick crusts. Topical agents, such as bacitracin, mupirocin, and retapamulin, are first-line treatment options for infections limited to small areas. In widespread cases, or in immunosuppressed individuals, systemic antibiotics are indicated. Cephalexin, 250 mg orally four times daily, is usually effective. Impetigo: MSSA Crusted erythematous erosions becoming confluent on the nose, cheek, lips, and chin in a child with nasal carriage of S. aureus. Citation: BACTERIAL COLONIZATIONS AND INFECTIONS OF SKIN AND SOFT TISSUES, Wolff K, Johnson R, Saavedra AP, Roh EK. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology, 8e; 2017. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=2043&sectionid=154893879 Accessed: October 28, 2019 Copyright © 2019 McGraw-Hill Education. All rights reserved Seborrheic (seb-o-REE-ik) dermatitis is a common skin condition that mainly affects your scalp. It causes scaly patches, red skin and stubborn dandruff and can also affect oily areas of the body, such as the face, sides of the nose, eyebrows, ears, eyelids and chest TINEA UNGUIUM (ONYCHOMYCOSIS) Tinea unguium is a trichophyton infection of one or more (but rarely all) fingernails or toenails. The species most commonly found is T rubrum. Onychomycosis is difficult to treat because of the long duration of therapy required and the frequency of recurrences. Fingernails respond more readily than toenails. In general, systemic therapy is required to effectively treat nail onychomycosis. Although historically topical therapy has had limited value, efinaconazole 10% has been approved as a topical therapy; evidence suggests that it performs better than prior topical treatment options. Tavaborole 5% solution is also approved for the treatment of onychomycosis, but its clearance rates do not appear to be as good as those of efinaconazole. Adjunctive value of surgical procedures is unproven, and the efficacy of laser treatments is lacking, especially with regard to long-term cures. Fingernails can virtually always be cured, and toenails are cured 35–50% of the time and are clinically improved about 75% of the time. Shinkai K, Fox LP. Nail Disorders. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020 New York, NY: McGraw-Hill;. Table 70–7 Recommended Cutaneous Antifungal Therapy CONDITION TOPICAL THERAPY ORAL THERAPY Tinea corporis, localized Azoles, allylamines, benzylamines — Tinea corporis, widespread — Griseofulvin, terbinafine, itraconazole, fluconazole Tinea capitis — Griseofulvin, terbinafine, itraconazole, fluconazole Tinea pedis Azoles, allylamines, benzylamines Griseofulvin, terbinafine, itraconazole, fluconazole Onychomycosis — Terbinafine, itraconazole, fluconazole Candidiasis, localized Azoles, nystatin — Candidiasis, widespread and — Itraconazole, fluconazole mucocutaneous Tinea versicolor, localized Azoles, allylamines — Tinea versicolor, widespread — Itraconazole, fluconazole Goodman & Gilman's: The Pharmacological Basis of Therapeutics, 13e > Dermatological Pharmacology Laurence L. Brunton, Randa Hilal-Dandan, Björn C. Knollmann Azoles Butoconazole Vaginal cream, 2% Vulvovaginal candidiasis Clotrimazole Oral lozenge, 10 mg Oropharyngeal candidiasis Vaginal cream, 1% or 2% Vaginal candidiasis Cream, ointment, solution; 1% Rx: Candida albicans, pityriasis versicolor OTC: tinea Econazole Cream, 1% Tinea; cutaneous candidiasis, pityriasis versicolor Foam, 1% Tinea pedis in patients ≥ 12 years Efinaconazole Solution, 10% Toenail onychomycosis Ketoconazole 2% foam, gel; 1% shampoo Seborrheic dermatitis 2% shampoo, gel Pityriasis versicolor Cream, 2% Tinea; pityriasis versicolor, seborrheic dermatitis, cutaneous candidiasis Luliconazole 1% cream Tinea Miconazole 2% cream, lotion, ointment, powder, solution, spray Tinea Vaginal suppository, 100 or 200 mg Vulvovaginal candidiasis 2% or 4% vaginal cream Oxiconazole 1% cream, lotion Tinea; pityriasis versicolor Sertaconazole 2% cream Tinea pedis in pts ≥ 12 years Sulconazole 1% cream, solution Tinea; pityriasis versicolor Terconazole 0.4%, 0.8% vaginal cream; 80-mg vaginal suppository Vulvovaginal candidiasis Tioconazole 6.5% vaginal ointment Vulvovaginal candidiasis Clotrimazole (Lotrimin, Mycelex); Miconazole (Monistat, Micatin) Safety, SE, & Antifungal Pearls & Patient Ed Warnings Dosage forms: CRM: Irritation: 1%; SOL: 1% Discontinue if Uses sensitivity or irritation – Apply BID occurs. candidiasis, cutaneous Petrolatum-based: Pediatric: Topical tinea, multiple forms Vaginal products are Info: for tinea corporis, products are not for cruris, pedis, petrolatum-based and self-medication (OTC versicolor; best results may damage rubber use) in children