-
rate limiting step for absorption
Hydration of the skin and damage to the stratum corneum
-
Preferred Characteristics of Topical
Preparations
- Low molecular mass (< 600 Da)
- Adequate solubility in oil and water
- High partition coefficient
- - hydrophobic we want
- - hydrophilic are more systemic
-
two types of transdermal systems
- membrane controlled reservoir - don't cut
- monolithic matric patches
-
transdermal systems place in therapy
Useful for patients with compliance issues and those who are unable to take oral medications
-
Transdermal Systems: Counseling
Points
- Apply to clean, dry, hairless skin
- Heat exposure increases absorption
- Remove old patch before applying new patch
- Disposal
-
ointments place in therapy
- Useful for thickened lesions or thicker areas of skin such as palms and soles of feet
- Can also be used as emollients to form protective barriers
greasy and difficult in hairy areas
-
list potency of topical vehicles
- ointment - most O in W
- gels - O in W alcohol base
- cream - O in W
- lotion - P in W
-
creams place in therapy
Can be used in same areas as ointments with less penetration, also good for areas with skin folds
-
lotion place in therapy
- Useful for hairy areas and can be used over large portions of the body
- Used to treat skin irritation and pruritus
-
gels place in therapy
Useful in treating acne and conditions in hairy areas
dry in a non-greasy film
-
Dispersion of finely divided solid particles of a drug in a liquid medium
vasoconstrictive properties
suspensions
-
powders place in therapy
Useful for treating mycoses of the skin, hair, and nails
-
aerosols place in therapy
- Useful in treating hairy areas
- If intended for the face, spray on hands to apply
no mechanical irritation of the skin from application
-
foams place in therapy
Useful in treating problems on the scalp and other hairy areas
easy application increases patient acceptance
-
vehicle for Smooth, nonhairy skin, thick
hyperkaratotic lesions
ointment
-
vehicle for hairy area
solution or foam
-
vehicle for palms/soles
ointment
-
vehicle for infected areas
solution
-
Low-potency steroids
Safest for long-term use; large surface area, face, genitals, skin-folds and for children
-
Medium-potency steroids
Used on the trunk, arms and legs
-
High potency steroids
reserved for thickest skin areas such as palms and soles
Can also be used for resistant conditions or in less severe cases for a shorter duration
-
Approximate FTUs needed
0.5 grams men & 0.4 grams women
- Head and neck = 2.5
- Trunk (front or back) = 7
- One arm = 3, one hand = 1
- One leg = 6, one foot = 2
-
why must you determine if a person has a fungal infection if giving a topical steroid
Immunosuppressant effects of topical steroids can prevent resolution of fungal infection, so they should be avoided
Do not use combination of antifungal agent and steroid
-
inflammatory, erythematous rash
dermatitis
-
Acute inflammatory dermatitis of buttocks, genitals, and perineum
diaper dermatitis
-
Erythematous patches, erosion of skin, vesicles, and ulcerations
diaper dermatitis
-
diaper dermatitis TX
- Frequent diaper changes
- Lukewarm water with mild soap
- Occlusive agents as a barrier
- Zinc oxide, titanium dioxide, petrolatum
-
Overproduction of skin cells and sebum
Also overgrowth of skin yeast
seborrheic dermatitis
-
Pruritus, erythematous papules, and vesicular lesions
atopic dermititis
-
Thickened plaques, accentuated skin markings (lichenification), and fibrotic papules
atopic dermatitis
-
Thicker, paler, scaly, erythematous, and
excoriated plaques
atopic dermatitis
-
Atopic Dermatitis Treatment nonpharmacologic
- Avoid potential allergens
- Bathe in lukewarm water, 5 minutes daily or twice daily
- Air dry or lightly towel dry
- Avoid irritating soaps with dyes, fragrances, detergents
- Apply emollient (ointment or cream) after bathing
- Use other moisturizers at least twice daily
- Keep fingernails short to avoid scratching
- Wear clothing made of cotton
- Avoid wool and synthetic fibers
- Avoid pillows and bedding with feathers, down, or animal
- fibers
-
Atopic Dermatitis Treatment
- Emollients and disease state
- education
- Acute control of pruritus and
- inflammation
- Topical corticosteroids or topical
- calcineurin inhibitors (TCIs)
- Maintenance therapy
- At earliest sign of flare use TCI or
- intermittent topical corticosteroids
- Severe, refractory cases
- Phototherapy, potent steroids,
- cyclosporine, methotrexate, oral steroids
-
Pimecrolimus 1% (Elidel®)
- BID
- BBW
- burning at site, respiratory infection, HA
- approved for > 2yo
-
Tacrolimus (Protopic®)
- BID
- BBW
- cough, HA, fever, flu-like syndrome
-
type 1 acne vulgaris
comedones only,<10 on face only, no scarring
-
type 2 acne vulgaris
papules,10-25 on face and trunk mild scarring
-
type 3 acne vulgaris
pustules,>25 lesions, moderate scarring
-
type 4 acne vulgaris
nodules/cysts, extensive scarring
-
Tx goals of acne vulgaris
- Stop new lesions from forming
- Heal existing lesions
- Prevent/minimize scarring and
- hyperpigmentation
-
Non-pharmacologic Treatment for acne vulgaris
- Use non-drying face cleanser and do not scrub
- skin excessively
- Use oil-free cosmetics
- Use noncomedogenic cosmetic products
- Avoid occlusive dressings
- Refrain from rubbing face or picking skin
- Control stress
- Low-glycemic diet
-
first-line for mild acne
Salicylic acid (0.5-2%)—Clearasil Clearstick® Neutrogena®, Clean & Clear®
-
Benzoyl Peroxide (BPO) adverse effects
Dryness, discoloration of hair and clothing, photosensitivity
-
Treats mild-to-moderate acne in patients who do not tolerate benzoyl peroxide
azelic acid- BID
-
azelic acid AE
hypopigmentation
-
First-line for mild to moderate inflammatory acne and comedonal (non-inflammatory) acne
- topical retinoid
- tretinoin - retin A
- Adapalene - differin
- Tazarotene - tazorac
-
when do you apply topical retinoids
Apply once daily at night, due to photolability of products
-
topical antibiotics
- erythromycin
- clindamycin
- dapsone
-
first-line option in mild to moderate rosacea
- metronidazole - QD
- azelaic acid - BID
-
Presence of silvery scales with sharp,
delineated surfaces
psoriasis
-
determing therapy for psoriasis
- mild to moderate 5-10% topical therapy
- severe > 10% oral therapy
-
Cottony feeling in the mouth, loss of taste, and sometimes pain on eating and swallowing
oral candidiasis
-
Oral Candidiasis Treatment
- Prevention is best
- Topical treatment is first-line
- Initial episodes should be treated for 7-14 days
- Esophageal candidiasis should be treated for 14-21 days
-
2 topical Tx options for oral candidas
-
glaucoma risk factors
- elevated intraocular pressure
- normal 10-21mmHG
- age and sex
- >65, female
- race
- african american
- FH
- sibling or parent
-
IOP > 40 mmHg, blurred or hazy vision with halos around lights, headache, cloudy, edematous cornea, ocular pain, nausea/vomiting, abdominal pain, and
diaphoresis
angle closure glaucoma
-
Asymptomatic until substantial visual field loss
General peripheral visual field constriction, isolated blind spots, nasal visual field depression or nasal step, enlargement of blind spot, large arc-like blind spots, reduced contrast sensitivity, reduced peripheral acuity, and altered color vision
open-angle glaucoma
-
glaucoma Tx goal
- Decrease IOP to prevent long-term nerve damage and visual field loss
- 20% - 35% decrease from baseline
-
first line therapy for glaucoma
- beta blockers
- prostaglandin analogs
-
prostaglandin analog dosing
Instill 1 drop in affected eye(s) at night
-
alternative first line agent for glaucoma
- alpha2 agonist
- brimonidine (alphagan) 1 gtt TID
- >2yo
-
Used in patients with inadequate response or contraindications to first-line therapy for glaucoma
- carbonic anhydrase inhibitors
- dorzolamide - 1gtt TID, sulfa allergy
-
Watery or mucoserous discharge; burning, sandy, or gritty feeling in one eye; second eye presents similarly in 24-48 hours
viral conjunctivitis
-
Purulent discharge throughout the day; thick yellow, white, or green
bacterial conjuctivitis
-
preferred agents for contact lens wearers due to increased likelihood of Pseudomonas infection who have conjuctivitis
fluoroquinolones
-
Photophobia, pruritus, tearing, burning, watery discharge
allergic conjuctivitis
-
Pruritus, discharge, hearing loss
Pain with tragal pressure or when auricle is pulled
Edematous ear canal with discolored debris
otitis externa
-
Sneezing, nasal itching, watery rhinorrhea, nasal congestion,
and itching of throat, eyes, and ears
allergic rhinitis
-
Tx goals of allergic rhinitis
- Minimize and prevent symptoms
- None or minimal adverse medication effects
- Reasonable medication expenses
-
Considered first-line in patients with moderate-to-severe or chronic allergic rhinitis
- intranasal corticosteroids
- fluticasone - 2sprays each nostril daily
- triamcinolone - 2 sprays each nostril daily
|
|
