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Derm Preps

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					Pharmacology—Derm Preps

Dermatology
     The rule of thumb for dermatological conditions:

   1) If it’s wet or oozing, make it dry
   2) If it’s dry, make it wet or moist

Diaper Rash
        Diapers act like occlusive dressings. The primary reason for diaper rash is urine
and feces in the diaper. Ammonia in urine will increase the pH, which will increase fecal
lipases and proteases. This causes skin damage. Systemic antibiotics may also
predispose the child to diaper rash due to superinfection. A yeast type infection is t he
most common (candida albicans). Bacterial type infection is the 2nd most common cause
and is usually due to S. aureus and group A S. pyogenes

      How can we prevent diape r rash?
   1) Keep the area clean and as dry as possible
         a) Use powder or cornstarch
         b) Frequent diaper changes
         c) Diaper should be loose fitting and ventilated
         d) Change to cloth, if necessary
         e) Remove diaper and leave off as time permits
         f) Wash with water or mild cleanser like Cetaphil
         g) Use cool air to dry buttocks

   2) Protective Barrier
          a) A & D ointment—emollients (protective)
          b) Vaseline—emollients (protective)
          c) Zinc oxide—drying agent
          d) Desitin—contains zinc oxide and emollient
          e) Some contain protectant, drying, anti- microbial, and vitamins

   3) Topical steroids are used to mask symptoms
         a) Do little to treat rash – only for anti- inflammatory
         b) Cause adrenal suppression

Treatment

Candidiasis:
       Use a topical antifungal. Nystatin (Mycolog) comes in a cream, powder, or
ointment. There is also a combination of Nystatin and Triamcinolone (Mycolog II),
which also comes as a cream or ointment. Clotrimazole (Lotrimin) comes as a cream.
Clotrimazole and Betamethasone (Lotrisone) comes as a cream.
Bacterial:
        Usually caused by S. aureus. Use systemic antibiotics to treat, such as oral
antibiotics, penicillins, macrolides, and cephalosporins.

Butt Paste
        Butt paste contains zinc oxide and can contain aquaphor, A & D ointment, or
Vaseline. The name of this is called Cholestryamine (Questran). This binds to uric acid
and keeps the pH at normal levels. The zinc and A & D provide a protective barrier.
This is not for prevent but for treatment.

Poisons
        Poisons include poison ivy, poison s umac, and poison oak. They are an
example of type IV hypersensitivity. If you are sensitive to one, you are sensitive to all
three.
        Rhus dermatitis is a delayed hypersensitivity reaction that occurs 12-72 hours
after exposure. 10-15% of the population is immune to this. Urus hiol is the chemical
secreted by bruised plants and causes the reaction.
        There are two types of exposure:

Primary Exposure: occurs with direct contact to bruised portion of the plant that exudes
the urushiol.

Secondary Exposure: occurs with contact to exposed pets, contaminated clothing, and
smoke from burning plants.

        It is not transmitted via fluid vesicles or blisters. It is self- limiting, usually
resolving with 14-20 days. It subsides on its own in 90% of patients. The symptoms are
severe itching, irritation, and a burning sensation. Secondary infection can be caused by
scratching because bacteria enter the broken skin.

Treatment Goals
        We must protect damaged skin and relieve pain and itching to prevent secondary
infection. Wash the area immediately with soap and alcohol to remove the urushiol.
Solvents can be poured on the affected area but are not favorab le because they can
possible remove the skin and cause a secondary exposure. Tecnu is an outdoor skin
cleanser that can be used. An alcohol pad should not be used.
        Barrier products such as Betoquatam (Ivy Block) can be used, which will
decrease dermatitis. Zanfel, an OTC wash, is not recommended because it is not proven.

Treatment of Mild and Moderate Cases
        Can use soaks, baths, and mild dressings. Colloidal oatmeal (Aveeno) can be
used as a bath and provides transient relief. Aluminum acetate (Burrow’s solution) is
used in the form of moist dressings and it reduces itch. It is a mild astringent. It is a
drying agent and compresses vesicles and blisters. The aluminum acetate absorbs the
resin of the urushiol. For facial lesions, you can use wet d ressings. You should not use
lotions because they are difficult and painful to remove once dry.
        Topicals can also be used. These include Calamine (calamine, Fe oxide, Zn
oxide). The calamine is an astringent and the Fe/Zn oxides are drying agents. Local
anesthetics (Caladryl = calamine + pramoxine) can be used. This is a mild, local
anesthetic and is taken orally. Antihistamines, such as Benadryl, may sensitize skin.
Topical Benadryl is generally not effective. Diphenhydramine is another topical
antihistamine that does not penetrate the skin and may irritate even further. If you need
to relieve itch, you must take an oral antihistamine. Camphor, menthol, phenol, and
EtOH promotes the drying of vesicles. Camphor and menthol are cooling agents, while
the phenol and EtOH are antibacterial. Aluminum acetate solutions can also be used.
You do not want to use ointments while vesicles are present and weeping. They form a
barrier sealing the moisture in. The vesicles must be able to dry. Ointments s hould only
be used for very dry lesions. You might want to use a mild-moderate potent topical
steroid for a localized area.

Treatment for Severe Cases
         Severe cases are for widespread or eye involvement. Antihistamines are used for
anti- itch and must be taken orally. Diphenhydramine should be taken 25-50mg, four
times a day, as needed. Adverse reactions can be sedation and there can be
anticholinergics side effects. Glucocorticosteroids are anti- inflammatory and are used for
severe Rhus dermatitis. The drug of choice here is Prednisone, which should be taken
orally for 7-21 days and must be tapered off if taken for more than two weeks.
Antibiotics should be used if the scratch becomes infected. You must treat for staph,
which is the most common skin disease. Cephalosporins and penicillins are the best for
this because they provide increasing resistance to MRSA. Steroid injections can also be
used.

Acne
        Acne is stimulated by testosterone and metabolite dihydrotestosterone, which
cause sebaceous glands to grow and produce sebum, leading to white heads and black
heads. Its pathogenesis is multi- factorial and bacterial (P. acnes). Irritants that cause it
can be touching your face, makeup (lanolin and emollients trap dirt), and foods (certain
individuals). It is the one of the most common dermatological conditions that people
seek clinical help for.

General Treatment Guidelines
        You must cleanse the skin twice a day with a mild cleanser and pat dry. Use a
coarse cloth or other sponges to exfoliate the skin. An astringent can close pores and
helps prevent dirt from entering. You can use medication as necessary.

Treatment
        Benzoyl Peroxide (Benzac, Benzagel, Clearasil, and Stridex) is category C. It
causes desquamation, increasing cell turnover and promoting healing. It may be
bacteriostatic or cidal. It can cause drying because of its alcohol base, more so in the gel
preparations. Drying could cause an enhanced therapeutic response. The cleansers and
washes may have decreased therapeutic effects. Peeling can also occur. You should not
apply this around the mouth, eyes, or lips. Stinging and bleached clothing (use white
pillow cases) can also occur. 2% of the general population is hypertensive, so you must
start with a low dose and increase as tolerated.
        Salicylic Acid (Clearasil pads) has 0.5-2% potency. It is a keratolytic, which
helps remove the upper layer of dead cells. It is a drying agent and also causes peeling.
        Retinoids – Vitamin A Derivatives increase epithelial cell proliferation and
reduces comedo formation. ADRs include photosensitivity, erythema, scaling, dryness,
itching, crusting, and pigmentation changes (bleaching). People who take these should
avoid the sun by using SPF 30-45 and also use sunscreens that prevent against UVA.
        Adapalene (Differin) (C) is a retinoid- like compound that binds to different
retinoid type receptors. ADRs – similar to other retinoids, local skin irritation, not show
to be tertaogenic in rodents but also no human studies have been performed.
        Erythromycin (Eyderm), Erythromycin + benzoyl peroxide (Benzamycin), and
Clindamycin (Cleocin T) are the most common topical antibiotics used for acne.
Clindamycin can come as a gel, cream, lotion, solution, or disposable pads. When
combined with benzoyl peroxide it is Duac Gel. ADRs for all include burning, stinging,
drying, peeling, and erythema.
        Oral antibiotics can also be used. However, there is an increased risk of
resistance due to the chronic usage. Tetracyclines include Doxycycline and Minocycline.
These are the most popular and are the best for acne. Erythromycin can also be used.
ADRs include N/V/D, vertigo (minocycline), and contraceptive failure of birth control
pills. Oral antibiotics are reserved for more severe acne. They must be used for at least
one month.
        Estrogen drugs should only be used in females. Increased estrogen helps
counterbalance the high testosterone levels which cause acne. Estrogen can be taken
alone or in an estrogen/progesterone combinatio n. When using the combination, we
prefer to have high estrogenic activity and low androgenic activity. Tricycline brands are
good for this. ADRs include PMS- like symptoms, bloating, and weight gain. They can
be used for women over 18 years old and those not planning pregnancy.

Isotretinoin (Accutane)
         Oral retinoids can also be used. Isotretinoin (Accutane) is the main drug in this
group. It is in category X. Taken 0.5 – 0.75 mg/kg/day, twice daily divided dose for 15-
20 weeks. Accutane reduces the size of the sebaceous gland and regulates cell
proliferation/differentiation.
         ADRs include dry skin and mucous membrane, headache, depression,
hyperlipidemia, increase LFT’s, alopecia, myalgia, hematologic ADRs, ocular ADRs,
photosensitivity, and increased suicide risk. The patient’s CBC and cholesterol levels
should be monitored. It is the best treatment for severe cases. Patients need to sign
informed patient consent prior to receiving and cannot be/get pregnant and need to
undergo two negative pregnancy tests prior to treatment and continue to use two forms of
birth control while they are taking the drug. There is decreased night vision and a risk of
cataracts.
         Photosensitivity is also common, occurring in 5-10% of patients. They should
stay out of the sun for prolonged periods of time and use UVA protection. Phototoxicity
is common in patients. The UVA light rays are absorbed and cause skin damage. There
is a rapid onset and the patients get exaggerated sunburns.
Drugs that Cause Acne

A) Hormones:
      1) Gonadotropins
      2) Anabolic steroids
      3) Corticosteroids

B) Anti-Epileptic drugs

C) TB drugs
      1) INH
      2) Rifampin

D) Miscellaneous
      1) Lithium
      2) Cyclosporine
      3) Iodine

Psoriasis
        Psoriasis has no cure. Treatment is aimed to reduce severity. Palliative treatment
is aimed to reduce the risk of secondary infection. Comes in acute and chronic phases
        Acute psoriasis is characterized as severely erythematous lesions. The treatment
aims to soothe irritation and use non- medicated topicals like Aquaphor, Cold Cream,
Lac-hydrin, and Eucerin.
        Treatment for chronic psoriasis is topical glucocorticoids. They produce anti-
inflammatory, anti-pruritic, vasoconstriction, and immunosuppressive results.

Chronic Psoriasis Treatment

Topical Glucocorticoids – start with super high potency (class one or two) twice a day
for 2-3 weeks. After high potency treatment, change to pulse treatment (2 days on then 5
days off) or change to lower potency steroid. Halogenated steroids improve absorption
and should not be used on the face, perineum, or mucous membranes. Non-fluorinated
steroids can be used on the face, eyelids, perineum, and mucous membranes.
        Several ADRs involve thinning of the skin, tearing of the skin (due to thinning),
bruising, acne, hypopigmentation – blanching due to vasoconstriction, infection –
immune system suppressed, and contact dermatitis.
        Super potent steroids should not be used on children or elderly due to increased
systemic absorption. In children, the skin is not keratinized and in the elderly the skin is
thin. Super potent steroids should be avoided in the flexural areas like the groin, axilla,
popliteal, and antecubital fossa. These areas tend to be warm and moist, therefore there is
added absorption. If super potent steroids are used, minimize them to less than two
weeks or switch to a lower potency. These steroids can also inhibit the HPA axis.

Coal Tar (Zetar, Neutragena T) – comes as an ointment, lotion, soap, or shampoo. It
can be used alone or with low potency steroids. Preferably applied at night and washed
off in the AM. May be used with UVB light therapy. There are many non-compliance
problems because it is cosmetically non-appealing. It stains the clothes, bedding, and
hair.
         ADRs include irritation, photosensitivity, folliculitis, scaling, itching, and
inflammation.

Psoralens – Included in this group is Methoxsalen (Oxsoralen). It comes PO or lotion.
UVA light treatment is followed two hours after it is applied. This combination is
referred to as PUVA therapy.
        ADRs include pruritus, dry skin, and loss of pigmentation, nausea in 10% of
patients, blistering, and painful erythema. There is a very potent drug- food interaction so
patients should avoid furocoumarin-containing foods, such as limes, figs, parsley, celery,
cloves, lemon, mustard, and carrots.
        Psoralen treatment is not used alone. They are believed to inhibit DNA synthesis
so it will suppress cell division. Lotion is given in a bath prior to UV light. There are
extremely photosensitive effects. Patients should stay away from the sun for 24 hours
before and 48 hours after. Specifically, patients should avoid sunlight for 8 hours after
oral treatment and 12-48 hours after topical treatment.

Retinoids - Etretinate (Tegison)is taken orally. It normalizes the expression of keratin
and suppresses chemotaxis. It decreases stratum corneum cohesiveness. The half- life for
this drug is 100 days (can be found in plasma 2-3 years after discontinuation.
        ADRs include LFT abnormalities, alopecia, exfoliation, hyperlipidemia, myalgia,
and arthralgia. Birth control should be utilized 1 month before and during therapy. Birth
control must also be used for 3 years after. When combined with PUVA, it is called RE-
PUVA.
        Acitretin (soriatane) is taken orally. It is very much like etretinate. Its half- life is
49 hours.
        Tazarotene (tazorac) is topical.

 Miscellaneous – Methotrexate is taken orally and is an anti- metabolite. It is a chemo
drug. It affects metabolism, therefore decreasing cell proliferation and suppresses
inflammation. It is used orally 1 week in low doses. ADRs include GI, liver, and
pulmonary toxicity, hematologic disorders, and cytotoxic.
        Cyclosporine A (Neoral) is an immunosuppressant and prevents rejection after
transplants.
        Topical immune modulators are very commonly used. They include
Tacrolimus (Protropic) and Pimecrolimus (Elidel). There are indications for atopic
dermatitis and eczema, but not psoriasis. Recently, the FDA added a black box warning
– potential cancer risk and should be reserved for after topical steroids fail or other
treatments don’t work and should not be used for children under two years old. Should
also not be used chronically.

Non-FDA Approved – IV immune modulators, like Etanercept (enbrel), are used for
rheumatoid arthritis and juvenile rheumatoid arthritis. Sirolimus (Rapamune) is an
immunosuppressant that is used for organ transplants.
Miscellaneous – Cacliprotriene (Dovonex) is topical and is good for mild to moderate
psoriasis. Its effects equal class II and III steroids. It is a vitamin D analog; therefore it
has no steroid SE. SEs it does have, however, include local skin irritation and skin
reactions. Should not be used on the face, eyelids, perineum, or skin folds.
        Anthralin (Drithocreme) is topical and is used for short term treatment. It is
applied for one hour or less and then washed off. SEs include staining and irritation on
un- involved skin. There is permanent brown color staining of clothing and bathroom
fixtures with this product. It is also used for alopecia areata (non-FDA). Has an irritant
property, so may stimulate the follicle to grow hair.
        Keratolytics soften the keratin layer of skin. Also enhances absorption of other
agents. Phenol and Salicylic acid are used and are mixed with Aquaphor, cold cream,
emollients, and coal tar.

Phototherapy – Sunlight, photochemotherapy (PUVA) and phototherapy (UVB light
therapy) can be used to treat psoriasis.

Rosacea
       Rosacea is chronic, long-term, inflammatory skin disease. It is characterized by
redness/swelling on the face due to swelling of the blood vessels.
       Treatment is usually topical, coming in the form of creams, lotions, ointments,
and gels. They consist of antibiotics, sulfur lotions, Azelaic acid, and benzoyl peroxide.

Treatment

Topical Antibiotics – Metronidazole (Metrogel, Metrocream) is the treatment of choice
for rosacea. It is also an anti-protozoal agent.
        Clindamycin (Cleocin T) and Erythromycin can also be used but are not as
effective as other topical antibiotics.
        Sulfur products such as Novacet and Sulfacet can be used but should be avoided
in sulfa allergy.

Topical Azelaic Acid – this is an antibacterial, comdeolytic, and anti- inflammatory drug.
A small study showed that it is as effective as Metrogel. It consists of two parts: Finacea
Gel 15%, which is used to treat the rosacea; Azelex or Finevin 20%, is used to treat the
acne. Finacea is less acidic, so it is used for rosacea.
       ADRs include local skin irritation.

Oral Antibiotics – These are better for moderate to severe rosacea. They are used if
topicals fail. Treatment can be combined with topical treatment.
        Tetracyclines are the most commonly used. Erythromycin is preferred for
pregnancy because tetracyclines are category D.
        Other oral antibiotics used are Clarithromycin (Biaxin), Sulfamethoxazole/
Trimethoprim (Bactrim, Septra), Metronidazole (Flagyl).
Miscellaneous Treatments – Glycolic Acid comes as either peels or washes and creams.
It helps shrink thickened facial skin and diminish nodular rosacea. The peels are put on
the skin for 5min. and the skin will be red for a few hours. The washes and creams
enhance the peel’s effect.
        Topical Tretinoin (Retin-A) can be used. Isotretinoin (Accutane) is used for
severe cases but is not FDA approved for rosacea.

Eye Problems associated with rosacea – Oral Doxycycline, Minocycline, and
Tetracycline are taken for any eye problems the patient may have.

For Redness and Flushing – For this, anti- inflammatory meds, such as steroid creams,
are the preferred choice. Other treatment available includes electrosurgery, intense light
therapy, and vascular lasers.

Rhinophyma – Rhinophyma is an enlargement on the nose and is more common in men
than in women. Treatment for this includes dermabrasion, electrosurgery, or laser
surgery

Overall Treatment Approaches
        The overall goal is to minimize flare-ups. Rubbing, scrubbing, and massaging the
face should be avoided because it irritates the skin. Moisturizers and sun screen should
be used. SPF 15 or greater and protective clothing should also be worn. The patient
should avoid hot drinks, spicy foods, and EtOH. Skin should be protected from extreme
heat or cold because these extreme temperatures will irritate the skin and causes flare-
ups. Cosmetics, soaps, and moisturizers that contain EtOH and fragrances should be
avoided. Medication should be used as appropriate.

Eczema
        The most common symptoms of eczema are dry, red, extremely itchy patches on
the skin. They can occur on any part of the body and usually appears during infancy.
Incidence is more common in males than females.
        Prevention of eczema is very important. Techniques include moisturizing,
avoiding rapid temperature changes, reduced stress, avoiding scratchy materials (woo l),
avoiding harsh soaps and detergents, avoiding triggers like allergens, and being aware for
foods that cause outbreak.

Treatment
        The overall treatment of eczema is to prevent the scratching. Creams and lotions
should be used to moisturize. Cold compresses relieve the itching. Corticosteroids (OTC
or Rx) are anti- inflammatory and can assist. Antibiotics, either topical or oral, can be
used for infected skin. Antihistamines (OTC or Rx) will to reduce itch.
        Coal tar and phototherapy can be used for eczema. Cyclosporine A (Neoral,
Sandimune, Restasis) is only for resistant eczema. Topical immune modulators like
Tacrolimus (Protropic) and Pimecrolimus (Elidel) can also be considered.
        Treatment options for children include keeping the bedroom and p lay area dust
free, mild soaps (Cetaphil), breathable clothing (cotton), and low potency hydrocortisone.
Actinic Ke ratosis
         Actinic Keratosis is the beginning stage of skin cancer. Common lesions are
found on the epidermis and are caused from long sun exposure. Seen most commonly in
40-50 y.o that are exposed to chronic sun exposure. Areas of Florida and Southern Cal
also have high incidences of teenagers and people in their 20s. There is an increased risk
in fair skin people. Can progress to SCC. It is defined as cutaneous dysplasia of the
epidermis.

Treatment
        Cryosurgery is the most common treatment. Surgical excision and biopsy should
be performed is SCC is suspected. Retinoids, topical or oral, have also be proven
effective. 5-Fluorouracil (Efudex, Fluoroplex) is topical chemotherapy that can be
useful. Chemical peels are another option. Dermabrasion, laser skin resurfacing, and
electrosurgical skin resurfacing can also be performed.

Melanoma
       Melanoma is skin cancer of the melanocytes. It occurs when melanin produces
too much brown pigmentation. It is potentially lethal.

Treatment
        Localized melanoma should be treated with surgical excision. For higher stages
of melanoma, interferon injection, interleukin injection, and combination c hemotherapy
are used.

See Drug-Induced Photosensitivity List

				
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