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Pharmacologic Therapy For severe acne

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1.Antiandrogens 2.Isotretinoin 3.Topical and oral antibiotics

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PH 38 (CLINPHARM 2) - Leaderboard

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PH 38 (CLINPHARM 2) - Details

Levels:

1) ACNE VULGARIS View
2) PSORIASIS View
3) SKIN DISORDER AND CUTANEOUS DRUG REACTIONS View

Questions:

60 questions

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Pharmacologic Therapy For severe acne

1.Antiandrogens 2.Isotretinoin 3.Topical and oral antibiotics

Pharmacologic Therapy For severe acne

1.Antiandrogens 2.Isotretinoin 3.Topical and oral antibiotics

Pharmacologic Therapy For severe acne

1.Antiandrogens 2.Isotretinoin 3.Topical and oral antibiotics

Formation of comedones, papules, pustules, nodules, and/or cysts as a result of obstruction and inflammation of pilosebaceous units develops on the face and upper trunk often affects adolescents

Acne Vulgaris

The onset of acne vulgaris during puberty occurs at a younger chronologic age more in a. girls b. boys

A. girls

In puberty, acne is often more severe in __ in about 15% of cases, which is tenfold greater a. girls b. boys

B. boys

ACNE VULGARIS FOUR MAJOR ETIOLOGICAL FACTORS

1 Increased sebum production 2 Hormonal influences 3 Bacterial colonization of the duct with Propionibacterium acnes 4 Production of inflammation in acne sites

Increased glucocorticoid secretion =>

Potentiation of the effects of androgens

Foods that are perceived to exacerbate acne

1 Chocolate 2 Cola drinks 3 Milk 4 Milk products

THE PATHOGENESIS OF ACNE 4 stages

1.Increased follicular keratinization 2.Increased sebum production 3.Bacterial lipolysis of sebum triglycerides to free fatty acids 4.Inflammation

Acne results from this primary lesion of both noninflammatory and inflammatory acne

Obstructed sebaceous follicle aka microcomedone

Acne Vulgaris Pathophysiology (step by step)

1 Acne results from obstructed sebaceous follicle (microcomedone) 2 Cells adhere to each other; forms dense keratinous plug 3 Sebum becomes trapped behind keratin plug 4 sebum solidifies; forms OPEN or CLOSED comedone 5 Pooling of sebum increases Anaerobic Bacterium Propionibacterium acnes; generate T cell response; results to inflammation

1 first clinically visible lesion of acne. It takes 5 months to develop. 2 plug extends to upper canal and dilates opening; either oxidized lipid and melanin (black color) or to the impacted mass of horny cells

1 Closed comedone, or whitehead 2 OPEN comedone or black head

Acne that is characterized by open and closed comedones is termed as?

Noninflammatory Acne

Both recruitment of polymorphs into the follicle during the inflammatory process and release of P. acnes-generated chemokines lead to what formation? Bursts into the Dermis

Pus formation

1 Propionibacterium acnes also produces enzymes which increase the permeability of the follicular wall, leading to: 2 Nodules, and cysts and may lead to __

1 Rupture, releasing keratin, hair, lipids and irritating free fatty acids into the dermis 2 scarring

TYPES OF ACNE

1 Blackheads 2 Whiteheads 3 Papules 4 Pustules 5 Nodules 6 Cysts

ACNE VULGARIS Nonpharmacologic Therapy

1.Cleansing 2.Proper shaving 3.Comedone extraction 4.Ultraviolet light 5.Prevention of Cosmetic Acne

Pharmacologic Therapy For mild to moderate acne

1.Topical retinoids 2.Salicylic acid 3.Benzoyl peroxide 4.Sulfur 5.Resorcinol

Pharmacologic Therapy For moderate to severe acne

1.Benzoyl peroxide 2 Topical antibiotics (Clindamycin/Clindamycin + Benzoyl peroxide) 3 Oral antibiotics (erythromycin, tetracycline, or minocycline) 4 Retinoids (tretinoin, adapalene, and tazarotene, and azeleic acid).

Pharmacologic Therapy For severe acne

1.Antiandrogens 2.Isotretinoin 3.Topical and oral antibiotics

Pharmacologic Therapy Anti-sebum agents

1 Oral Contraceptives (norgestimate + ethinyl estradiol or norethindrone acetate + ethinyl estradiol) 2.Spironolactone 3.Cyproterone Acetate 4.Oral Corticosteroids 5.Oral Isotretinoin

Pharmacologic Therapy Pharmacologic Cleansing Options:

1.Medicated Soaps and Washes

A chronic disease that waxes and wanes. It is never cured, and it is now known to be associated with multiple comorbidities including heart disease, diabetes, and the metabolic syndrome. signs and symptoms of may subside and then flare-up again T-lymphocyte–mediated inflammatory disease resulting from a complex interplay between multiple genetic factors and environmental influences.

Psoriasis

Psoriasis two peak ages of onset

20 to 30 years of age. 50 to 60 years of age.

Is CENTRAL to the clinical presentation of psoriasis

Keratinocyte proliferation

PSORIASIS TWO MAJOR ETIOLOGICAL FACTORS:

1 Genetics 2 Predisposing and precipitating factors

PSORIASIS Predisposing FACTORS

1 horse-fly bite (Koebner phenomenon) 2 viral or streptococcal infection 3 use of β-adrenergic blockers

PSORIASIS Precipitating FACTORS

1 NSAIDS 2 antimalarials 3 β -adrenergic blockers 4 withdrawal of corticosteroids

Are responsible for the EPIDERMAL HYPERPLASIA and DERMAL INFLAMMATION that is seen in psoriasis.

Interaction of dermal dendritic cells activated T cells of TH-1, TH-17 lineage with cytokines and growth factors

TYPES OF PSORIASIS

1 Plaque 2 Flexural or Intertriginous 3 Seborrheic 4 Scalp 5 Acrodermatitis of Hallopeau 6 Palm or soles 7 Erythodermic 8 Guttate 9 Generalized Pustular Psoriasis

The most common type of psoriasis; 90% of Psoriasis patients chronic autoimmune condition; characterized by patches of red, inflamed skin covered with silvery scales. patches appear on the elbows, knees, scalp, and lower back, but can occur anywhere on the body

Plaque Psoriasis

Diagnostic Tests of PSORIASIS

1.Body surface area (BSA) 2.Psoriasis Area and Severity Index (PASI) 3.Physician’s Global Assessment (static PGA) 4 Quality-of-life measures such as the Dermatology Life Quality Index (DLQI) or the Short Form (SF-36) Health Survey.

Nonpharmacologic Therapy

1.Stress-reduction strategies 2.Moisturizers 3.Oatmeal baths 4.Skin protection using sunscreens.

PSORIASIS Pharmacologic Therapy

Topical Therapies 1 Corticosteroids (mainstay for the majority) 2 Vitamin D3 Analogues (calcipotriol (calcipotriene), calcitriol (the active metabolite of vitamin D), and tacalcitol) 3 Retinoids (Tazarotene) 4 Anthralin (direct antiproliferative effect) 5 Coal Tar (one of the earliest agents) 6 Salicylic Acid (for patients with scalp psoriasis) 7 Calcineurin Inhibitors (for atopic dermatitis)

PSORIASIS Pharmacologic Therapy 1 Phototherapies and Photochemotherapy:

1.UVB 2.NB-UVB (Narrowband UVB) 3.UVA 4.PUVA (UVA + Psoralens)

PSORIASIS Pharmacologic Therapy 1 Systemic Therapies:

1.Acitretin 2.Cyclosporine 3.Methotrexate

Skin consists of

1 Outer Epidermis 2 Inner Epidermis

Epidermis parts

1 stratum basale (basal layer), 2 stratum spinosum (prickle cell layer) 3 stratum granulosum (granular layer) 4 stratum corneum (horny layer)

1 provide resilience to mechanical stress 2 provide color and protect from UV penetration 3 consist of sweat, oils, corneocytes, protein decomposition products, and transepidermal water 4 a much thicker layer that contains nerve endings and blood vessels

1 Keratinocytes 2 Melanocytes 3 Hydrolipid film 4 dermis

1 contains more water and is thinner for enhanced topical drug absorption 2 tends to be drier, thinner, and more friable (external insults) 3 Exposure to __ accelerates aging and skin cancer

1 Pediatric skin 2 Aged skin 3 radiation

PATHOPHYSIOLOGY: 1 Localized DRUG-INDUCED REACTIONS 2 Allergic DRUG-INDUCED REACTIONS Depend on inducing an immune response from the host Classified as:

1 Chemical vaginitis (vaginal douches, spermicides, and imidazoles) 2 Blistering Exanthematous Pustular eruptions Urticarial

Afebrile exanthematous eruption most commonly encountered. S/S: Erythematous macules and papules that may be pruritic. Lesions usually begin within 7-10 days after offending medication Resolution: 7-14 days

Maculopapular skin reaction

Aka drug reaction with eosinophilia an exanthematous eruption accompanied by fever, lymphadenopathy, and multiorgan involvement S/S: begin 1–4 weeks after starting the offending drug

Drug hypersensitivity syndrome (DRESS)

S/S: hives, extremely pruritic red raised wheals, angioedema, and mucous membrane swelling that typically occurs within minutes to hours

Urticaria and angioedema

Complex urticarial eruptions S/S: fever, rash (usually urticarial), and arthralgias, usually within 1–3 weeks after starting the offending drug.

Serum sickness-like reactions

Immune complex or cell-mediated allergic responses S/S: generalized tender/painful bullous formation with fever, headache, and respiratory symptoms, that rapidly deteriorate.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN)

Simple pustular eruptions caused by medications that induce acne (whiteheads or blackheads). onset is usually about one to three weeks.

Acneiform drug reactions

Complex pustular eruption S/S: acute onset (within days after starting the offending drug), fever, diffuse erythema, and many pustules.

Acute generalized exanthematous pustulosis (AGEP)

Hyperpigmentation

May be phototoxic or photoallergic. Drugs that induce phototoxic reactions absorb ultraviolet A (UVA) light

Photosensitivity

COMMON SKIN DISORDER

1 CONTACT DERMATITIS 2 DIAPER DERMATITIS 3 SKIN CANCER

Skin inflammation caused by irritants or allergic sensitizers Eczematous inflammation, with erythema, vesicles, papules, crusting, fissuring, or scaling

CONTACT DERMATITIS

1 contact dermatitis that occur several days later, immunologic response 2 contact dermatitis that occur few hours, organic substance

1 Allergic CD 2 Irritant CD

Acute, inflammatory dermatitis of the buttocks, genitalia, and perineal region Direct fecal and moisture contact with the skin Erythematous, and severe rashes may have vesicles or oozing erosions

DIAPER DERMATITIS / Diaper rash

1 causes red plaques, papules, and pustules in diaper rash

1 Candida species

DRUG-INDUCED REACTIONS MANAGEMENT Management & Treatment 1 IF severe case: 2 IF w/ fever: 3 IF SJS/TEN:

Termination of suspected drug 1 IF severe case: -- Corticosteroids 2 IF w/ fever: -- Acetaminophen 3 Broad spectrum antibiotics & vancomycin, IVIG

CONTACT DERMATITIS MANAGEMENT 1) 1st goal: 2) 2nd goal:

. 1 identify, withdraw, avoid offending agent using Patch Test -> gold standard 2 provide symptomatic relief while decreasing skin lesions. -> cold compresses -> topical corticosteroids

DIAPER DERMATITIS MANAGEMENT 1 Non pharmacologic 2 Drugs 3 DOC for candidal rash:

1) Frequent diaper changes Air drying Gentle cleansing 2) Zinc oxide (astringent) Petrolatum (moisture) 3 imidazole

SKIN CANCER MANAGEMENT 1 Squamous Cell Carcinoma (SCC) treatment 2 Basal Cell Carcinoma (BCC) 3 Malignant melanoma - give also drug for metastatic melanoma

. 1 surgical excision 2 may involve surgical excision; topical agents (imiquimod or antineoplastic agents, such as 5-fluorouracil) 3 antineoplastic therapy, (temozolomide) or (dacarbazine for metastatic melanoma)