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oral antibx that can be used for acne
- tetracycline
- doxycycline
- minocycline
- use for moderate to severe inflammatory acne
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how can you prevent antibx resistance when using antibx for acne tx?
combine antibx tx with benzoyl peroxide
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what do you do If the patient has not responded after 3 months of therapy with an oral antibiotic
- Increasing the dose
- Changing the treatment or
- Refer to a dermatologist
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SE of oral antibx for acne:
- GI upset-
- epigastric burning
- N/V/D
- photosensitivity
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what are the major SE of
-tetracycline
-doxycycline
-minocycline
- Tetracycline: GI upset, photosensitivity·
- Doxycycline: GI upset, photosensitivity·
- Minocycline: GI upset, vertigo, hyperpigmentation
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CI of oral antibx for acne:
- pregnancy
- children < 8 yrs
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what do you need to pt counsel on when rxing
- If taking for acne, it is okay to take them with food and dairy products for tolerability of GI side effects·
- Take with full glass of water; avoids esophageal erosions·
- It takes 2-3 months to see improvement
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Topical antifungals
Fungistatic:
Fungicidal:
- Fungistatic: stop fungi from growing
- Fungicidal: kill the fungi
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what are 2 conditions that wont respond to topical antifungals?
- hair infections
- nail infections
- they require systemic tx
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Ex of Imidazoles (fungistatic):
& what are they useful to treat?
- Clotrimazole (Rx & OTC),
- Sulconazole
- Miconazole (OTC)
- Oxiconazole
- Ketoconazole (Rx & OTC),
- Econazole
- useful to tx candida & dermatophytes
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Ex of Allylamines & benzylamines (fungicidal):
& what are they used to treat?
- Naftifine,
- Terbinafine (OTC)
- Butenafine
- better for dermatophytes, but not candida
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Polyenes (fungistatic in low concentrations):
& what is it used to treat?
- Nystatin
- better for candida, but not dermatophytes
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Advantages of topical antifungals:
- preferred for most superficial fungal infections of limited extent
- Relatively low cost
- Acceptable efficacy
- Ease of use
- Low potential for side effects, complications, or drug interactions
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Topical therapies that inhibit keratinocyte proliferation are used in the treatment of psoriasis include:
(Vitamin D analogs)
- Calcipotriene (calcipotriol) (Dovonex)
- Calcitriol
- Calcipotrine/betamethasone dipropinate (Taclonex)
- Coal tar (stains everything!)
- Tazarotene
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Calicpotriene (calcipotriol)
- Inhibits keratinocyte proliferation
- Most common side effect is skin irritation
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Calcitriol
- Inhibits keratinocyte proliferation
- Stimulates keratinocyte differentiation
- Inhibits T-cell proliferation
- On more sensitive areas, less skin irritation than calcipotriol
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Adverse effects of:
Calcipotriene (Dovonex)
Calcipotrine/betamethasone dipropinate (Taclonex)
- skin irritation
- burning
- itching
- dryness
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Coal Tar:
disadvantages and what can it be combined with
- Antiproliferative effect
- Disadvantages: stain clothing/hair/skin; messy; increases photosensitivity
- Can be combined with salicylic acid to penetrate thick plaques
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Tazarotene 0.05% & 0.1%
used for:
disadvantages:
can be combined with:
- Topical retinoid used for acne, rosacea, psoriasis
- Disadvantages: skin irritation; teratogenic; increases photosensitivity
- Can be combined with a Class II corticosteroid to reduce irritation
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What would you prescribe for severe psoriasis? and what is imp to remember about this drug?
- Soriatane (Acitretin)
- teratogenic!!
- Soriatane is the active metabolite of Tegison (etretinate).
- Tegison is no longer on the market
- Soriatane is eliminated faster from the body. Tegison takes several YEARS...Soriatane takes only several MONTHS.
- If a pt drink alcohol while on Soriatane, some of it will be converted back to tegison, which then lingers in the body
- Warn women NOT to drink alcohol while taking Soriatane...and for two months after stopping the drug. No cough syrups,
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Bexarotene (Targretin) is mainly indicated for what?
for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma in patients who are refractory to at least one prior systemic therapy.
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indication for Tretinoin (topical)
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indication for adalapene
acne
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indication for Tazarotene
- fine facial wrinkles
- mottled facial pigmentation
- psoriasis
- acne
- sun damaged skin
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indication for Isotretinoin (oral)
severe nodular (cystic) acne
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indication for Acitretin(oral)
severe psoriasis
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what is the MC cause of tx failure in acne pts? and what can you do to prevent it?
- lack of adherence
- pt education! use moisturize with it to prevent redness and flakey
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Keratolytics
break down keratin in the skin
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drugs of keratolytics
- salicyclic acid (diff [] are in diff products)
- lactic acid
- urea
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indication for keratolytics
- Hyperkeratolytics conditions...
- warts
- psoriasis
- Hyperkeratosis: thickened epidermis, due to increased amounts of keratin, a fibrous protein found in skin, hair and nails.
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MOA of keratolytics
- Decrease the thickness of the stratum corneum
- Stratum corneum is the outermost layer of the epidermis. This layer contains keratin as well as dead squamous cells.
- The stratum corneum prevents water evaporation & provides strength.
- Exact MOA is unclear:
- May solubilize desmosomes, structures attached to keratin that impart strength
- May work by changing the pH, resulting in activation of endogenous hydrolytic enzymes
- May bind water thus softening the stratum corneum.
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SE of keratolytics
- Local:
- skin itching
- redness
- tenderness
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Which keratolytic can be systemically absorbed?
Salicyclic acid
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Imiquimod:
modifies immune response in the skin
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Imiquimod drug:
Imiquimod (Aldara)
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Indication of imiquimod:
- Actinic keratosis (neoplasm thought to be form sun exposure)
- Basal cell carcinoma
- Genital & peri-anal warts (dosing is diff for this indication)
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Imiquimod MOA:
- Modifies immune response in the skin via an increased inflammatory response in the dermis. Abnormal cells are eradicated in the amplified inflammatory conditions
- Binds to toll-like receptors on B cells
- Causes release of a variety of inflammatory mediators
- Results in increased immune cell activity
- In addition, direct apoptosis activity with tumor cells
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what is the max duration of tx for actinic keratosis?
16 weeks
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what is the max duration for tx of superficial basal cell carcinoma?
6 weeks
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what is the max duration of tx for genital and perianal warts?
16 weeks
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what are some things you would counsel your pt on when using imiquimod?
- Use sunscreen and avoid or minimize exposure to natural or artificial sunlight during imiquimod treatment.
- Localized hypopigmentation or hyperpigmentation has been reported & it may be permanent in some patients
- Apply the cream at bedtime, leave the cream on the skin for the prescribed period of time, and not bathe or get treatment area wet until the following morning (6–10 hours after application).
- Do not to use occlusive dressings. Cotton gauze dressing can be used, if needed; cotton underwear can be worn if the genital and perianal area is being treated.
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Picato (for actinic keratosis), imiquimod & Solaraze can all cause what?
- Considerable skin inflammation
- There are diff kinds so you do have more options
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