Pharmacotherapy of Common Skin Diseases Dermatologic Therapy Lecture
- Slides: 56
Pharmacotherapy of Common Skin Diseases
Dermatologic Therapy Lecture Outline I. III. Acne Vulgaris and Rosacea Psoriasis Eczema
Acne Vulgaris and Rosacea Defined: Chronic papulopustular eruption affecting the pilosebaceous units of the face and trunk. Types: Comedonal, Papulopustular, Nodulocystic, Conglobata, Fulminans, Rosacea. Primary Lesion: red papule/nodule, pustule, comedones (white and black heads). Keys to Dx: Age, Flushing?
Acne Pathophysiology The Formation of the Comedo Early microcomedo: sebaceous canal distends with sticky corneocytes. Late microcomedo: colonization with Propionibacterium acnes. Mature closed comedo (white head): densely packed corneocytes, solid masses of P. acnes, few small hairs. Open comedo (black head): sticky corneocytes, bacteria, oxidized lipids
The Fate of the Closed Comedo Closed comedo (“Time bomb of acne”) Rupture and Inflammation Potent chemoattractant for neutrophils Open Comedo
Acne: Natural History Comedonal: closed and open comedones Papular: + red inflamed papules Papulopustular: + pustules Nodulocystic: + inflamed nodules/cysts
Acne Vulgaris Therapeutic Agents Classes of topical agents Retinoids: tretinoin, adapalene (micro gels, creams, solutions)- comedolytic, shrink sebaceous glands Should not be used in pregnant women Antibiotics: – Clindamycin & Erythromycin (solution, gel, pads, lotion)- antibacterial – Sulfur-containing products (lotion, cream)antibacterial Benzoyl Peroxide (cream, gel)- antibacterial, comedolytic
Acne Vulgaris Therapeutic Agents Classes of oral agents Antibiotics Retinoid (Isotretinoin) Spironolactone – Uncommonly used Oral contraceptives (low progesterone) – Yasmin, Orthotricyclen – Only for adjunctive therapy
Acne Vulgaris Therapeutic Agents Oral Antibiotics Tetracycline: 500 mg bid - tid (Photosensitivity, GI upset- empty stomach) Doxycycline: 100 mg qd - bid (Photosensitivity, $$) Minocycline: 100 mg qd (Dizziness, skin pigmentation, $$$) Erythromycin: 500 mg bid-tid (GI upset) Trimethoprim/sulfamethoxazole: 800/160 mg (1 DS tab) bid (Photosensitivity, renal effects)
Acne Vulgaris Therapeutic Agents Oral Isotretinoin Nodulocystic acne or refractory acne 1. 0 mg/kg/d with food for 16 to 20 wks. Teratogenicity, extreme xerosis, increased liver function tests & triglycerides, etc. March 1, 2006: FDA i. Pledge Begins – To prevent use in pregnant women – Pt, MD, & Pharmacist must register with FDA – All women of child bearing age must list 2 forms of contraception to register No evidence to support increased risk of depression and suicide
Acne Vulgaris Therapy Comedonal Acne Topical tretinoin cream or gel at bedtime * Apply a small amount (pea-sized) to affected regions of face. * Apply to dry face, not wet. * Try applying every other night if irritating Consider adding a topical antibiotic or topical benzoyl peroxide in the morning.
Acne Vulgaris Therapy Papular Acne As per Comedonal Acne Add oral antibiotic if moderately severe or if chest and back are involved. * Continue oral antibiotic for at least 6 to 8 weeks then slowly decrease daily dose to avoid flare-ups. * Do not abandon a given therapy until a 6 week trial has been completed.
Acne Vulgaris Therapy Papulopustular/Nodulocystic Acne As per Papular Acne If severe consider Isotretinoin * Recommend Dermatology referral. * All other acne treatment is stopped. * Contraceptive counseling important. Oral contraceptives are safe with isotretinoin.
Pitfalls of Therapy for Acne Vulgaris Not waiting 6 -8 weeks to establish a response to starting therapy. Ignoring the impact of cosmetics, skin cleansers, hair lubricants, picking, OCPs, occupational exposures, stress, and hormones on a patient’s acne. Poor patient education on how to counteract the drying effects of topical therapy.
Acne Rosacea Therapeutic Considerations NO COMEDONES: No place for topical comedolytics (tretinoin, benzoyl peroxide). P. acnes bacteria not important: Topical erythromycin and clindamycin not helpful. Vascular instability leads to flushing.
Therapy of Acne Rosacea Topical metronidazole cream or gel bid If moderately severe add oral antibiotics * Tetracycline , Doxycyline, Minocycline * Erythromycin Topical sulfur containing lotions/creams are occasionally helpful.
Pitfalls of Acne Rosacea Therapy Not waiting 6 -8 weeks to establish a response to starting therapy. Ignoring the impact of cosmetics, skin cleansers, skin care products, topical steroids, stress, and other triggers on a patient’s rosacea.
Psoriasis
Psoriasis Defined: A chronic eruption of scaly plaques on the extensor surfaces that may involve the scalp and nails. Types: Vulgaris, Guttate, Pustular, Erythrodermic, Scalp, Palmoplantar, Nail. Primary Lesion: well-defined plaque with thick silvery scale. Keys to Dx: Distribution; Pitting of nails.
Plaque-type Psoriasis Vulgaris
Plaque-type Psoriasis Vulgaris
Guttate Psoriasis
Scalp Psoriasis
Palmoplantar Psoriasis
Erythrodermic Psoriasis
Pustular Psoriasis
Pustular Psoriasis
Pitted Nails of Psoriasis
Psoriatic Nail Disease
Clinical features of psoriatic arthritis
Clinical features of psoriatic arthritis
Histopathology of psoriasis
Psoriasis: Pathophysiology Etiology unknown: possible genetic, environmental, physical factors? Main defect: rapid turnover of epidermal maturation (differentiation). ***Normal epidermal transit time = 30 days ***Psoriasis epidermal transit time = 7 -14 days T cell mediated cytokine release (eg. TNFa)
Psoriasis: Therapeutic Modalities Topical steroid creams and ointments Topical calcipotriene cream and ointment Topical tazarotene (retinoid) gel Topical tar containing ointments Phototherapy (UVB & PUVA) Oral methotrexate, acitretin (retinoid), or cyclosporine Injectable biologic response modifiers – etanercept, efalizumab, adalimumab, infliximab,
Topical Steroid Potency Rankings I= Strongest, VII= Weakest Class I* -Betamethasone diproprionate 0. 05 % oint (Diprolene) -Clobetasol propionate 0. 05% oint & cream (Temovate) Class II* -Flucinonide 0. 05% oint (Lidex) -Amcinonide 0. 1% oint (Cyclocort) *NEVER ON FACE OR SKIN FOLDS Class III -Triamcinolone acetonide 0. 1% oint (Aristocort) -Amcinonide 0. 1% cream (Cyclocort) -Halcinonide 0. 1% oint (Halog)
Topical Steroid Potency Rankings I= Strongest, VII= Weakest Class IV -Hydrocortisone valerate 0. 2% oint (Westcort) -Halcinonide 0. 1% cream (Halog) Class V -Triamcinolone acetonide 0. 025% oint (Aristocort) -Betamethasone valerate 0. 1% cream (Valisone) Class VI -Desonide 0. 05% oint & cream (Desowen) -Triamcinolone acetonide 0. 025% cream (Aristocort) Class VII* -Hydrocortisone 0. 5%, 1%, 2. 5% oint and cream * Safe for the face and skin folds
Partially cleared psoriasis
Limited Plaque Psoriasis Therapy Topical Steroids * Class I or II for short term (14 days) control. * Class III-IV for daily maintenance therapy. Topical calcipotriene 0. 005% cream/ointment (Dovonex) * Apply twice daily +/- topical steroids Topical tazarotene 0. 1%, 0. 05% gel (Tazorac): Should not be used in pregnant women. * Apply once daily +/- topical steroids Topical tar containing ointments * short contact therapy to bid applications
Eczema Defined: Inflamed, pruritic skin (dermatitis) not due, exclusively, to external factors (allergens, sunlight, cold, heat, fungus, etc. ). Types: Atopic, Asteatotic, Hand, Nummular, Stasis (Dermatitis). Primary Lesion: ill-defined scaly red patch. Keys to Dx: Rule out external factors as the sole cause of the eruption.
Hand eczema
Atopic dermatitis
Face involvement in atopic dermatitis
Nummular eczema
Nummular eczema
Eczema: Pathophysiology Etiology unknown: genetic and environmental factors play a strong role. Histology: Spongiosis = intercellular edema within the epidermis. Acute and chronic inflammatory cells. T cell mediated cytokine release (TH 2 type)
Atopic eczema
Therapy of Mild to Moderate Eczema Correct diagnosis! Rule out allergic or irritant contact dermatitis, dermatophyte infections, drug reactions, etc. Good skin care: Mild superfatted skin cleanser (unscented Dove, Basis, etc. ), lukewarm not hot showers, lubricate skin frequently with unscented lotions/creams.
Therapy of Mild to Moderate Eczema Topical steroids only for flares – Class I or II for short term (14 days) control of severe flares in adults. Class III or IV for children. – Class IV - VII for mild flares in adults. Class VI or VII in children. Consider topical or oral antibiotics if crusted Consider topical tacrolimus or topical pimecrolimus ($$$) for refractory disease. – Both are calcineurin inhibitors that inhibit T cell proliferation – NO SKIN ATROPHY – FDA is concerned about long term use (Skin cancers, lymphomas ? ? ? ) – Dermatologists are not concerned
Intense pruritus in atopic dermatitis
Therapy of Severe and Widespread Eczema Dermatology referral Oral or intramuscular steroids Phototherapy Oral methotrexate
- Pharmacotherapy
- Pharmacotherapy
- Pharmacotherapy workup
- Retention hyperkeratosis dermnet
- Seborrheic keratoses
- Milady chapter 8 skin disorders and diseases
- Chapter 23 lesson 2 common communicable diseases
- Non common communicable diseases
- Thin skin vs thick skin
- Thin skin vs thick skin
- Chapter 23 facials
- 01:640:244 lecture notes - lecture 15: plat, idah, farad
- Psychodynamic and humanistic therapies have in common
- Bioness bits cost
- Humanistic therapies aim to boost
- Biomedical therapy definition
- Common factors of 36 and 48
- Common anode and common cathode
- Gcf of 48 56 and 72
- Highest common factors and lowest common multiples
- Lcm of 10 and 18
- Multiples of 9 and 21
- Different types of diseases
- Management gurus and their contributions
- Protein deficiency diseases
- Natural disease
- Lifestyle modern
- Major nutritional deficiency diseases in emergencies
- Tromboflibitis
- Iceberg phenomenon definition
- Human diseases a systemic approach
- Venn diagram communicable and noncommunicable diseases
- Chapter 24 lesson 1 sexually transmitted diseases
- Periradicular disease definition
- Section 19-3 diseases caused by bacteria and viruses
- Chapter 6 musculoskeletal system
- Chapter 32 childhood communicable diseases bioterrorism
- Chapter 24 sexually transmitted diseases and hiv/aids
- Chapter 22 genetics and genetically linked diseases
- Chapter 21 mental health diseases and disorders
- Chapter 17 reproductive system diseases and disorders
- Chapter 15 nervous system diseases and disorders
- Onychomycosis milady
- 10 diseases of lymphatic system
- X linked diseases
- Whats sex linked
- Helminthic diseases
- Nutritional diseases
- Nutritional diseases
- Nutritional diseases
- King of diseases
- Flaccid gingiva
- Non communicable diseases
- Diseases spread by columbian exchange
- Chapter 10 nail disorders and diseases review questions
- Diseases spread by columbian exchange
- Sti std