Common Skin Conditions

Select an initial or alternative drug therapy treatment plan for a patient with mild, moderate or severe papulopustular inflammatory or non-inflammatory acne

• Comedonal Non-inflammatory Acne treatment

  • GOAL: decrease keratinocyte & sebum blockage

  • Pharmacological agents that target defect in keratinization ← drugs of choice

  • Combo Tx (retinoid + benzoyl):

    • Topical retinoid: Adapalene

      • Alternatives: 

        • Tazarotene

        • Tretinoin

      • Targets hyperkeratinization 

    • Benzoyl peroxide - keratolytic

      • Azelaic acid is alternative - normalized keratinocyte activity, anti-androgen, anti-inflammatory

• Mild-Moderate Inflammatory Acne treatment

  • Target: Reduction of C. acnes

  • First line:

    • Fixed dose combo of adapalene + benzoyl peroxide

    • Fixed dose combo of topical clindamycin + benzoyl peroxide

  • Alternative:

    • Different topical retinoid with other antimicrobial agents (ex. erythromycin) with or without benzoyl peroxide

  • Wide-spread disease (over large area):

    • Combo of systemic antibiotic with benzoyl peroxide OR

    • Combo of systemic antibiotic with fixed dose combo of adapalene + benzoyl peroxide

• Severe Papulopustular acne/Nodular/Cystic acne

  • First line therapy:

    • Oral isotretinoin monotherapy

  • Second line therapy (some data supporting)

    • Alternative systemic antibiotics PLUS:

      • Fixed dose adapalene-benzoyl peroxide combo OR

      • Combo of adapalene + azelaic acid

  • Alternative therapies

    • Anti-androgen in combo with oral antibiotics

    • Topical treatments

    • Systemic antibiotics in combo with benzoyl peroxide

Topical Retinoids + azelaic + benzoyl

Topical Retinoids
Name	Side Effects	Precautions
Adapalene (Differin)	Dry skin, erythema, scaly skin, photosensitivity	Inc. risk of skin toxicity with irritating products Sensitivity to sun Risk of skin erosion with waxing  Fetal harm potential
Tretinoin (retinoic acid and vitamin A)	Dry skin, erythema, contact dermatitis, burning sensation, hypo/hyperpigmentation of skin. photosensitivity, skin irritation	Inc. risk of sunburn (wear sunscreen, avoid sun exposure while using) Fetal harm
Tazarotene (Tazoraz)	Dry skin, erythema, pruritis, skin irritation, stinging of skin, peeling, photosensitivity	Avoid use with drying agents Fetal harm (pregnancy test within 2 weeks of use)

Name	Side Effects	Precautions
Azelaic Acid Activity against all 4 pathogenic mechanisms of acne	Burning sensation Pruritis Stinging of skin	Can cause hypopigmentation of skin

Name	Side Effects	Precautions
Benzoyl peroxide Keratolytic Antibacterial	Contact dermatitis Erythema Dry skin	Avoid contact with eyes, mucus membranes May bleach hair or fabric Skin peeling can occur (adjust dose)

Topical Combos

Topical Combos
Name	Side Effects	Precautions
Clindamycin phosphate/benzoyl peroxide (Benzaclin) -1st line-	Irritation, burning sensation, dry skin, erythema, peeling, sunburn	Avoid with products containing erythromycin Use cautiously with other products that dry or irritate skin
Adapalene/benzoyl peroxide -1st line-	Application site irritation Contact dermatitis Dry skin Erythema Skin irritation Stinging of skin	Avoid use of products that also dry skin Exposure to UV light should be minimized Scaling, sunburns, irritation may limit use
Clindamycin phosphate/tretinoin -Alternative Agent-	Irritation, burning, dermatitis, dry skin, erythema, scaly skin, stinging of skin	Increased risk of sunburn Natural or artificial sunlight → sunburn

Systemic Antibacterials

Systemic Antibiotic Agents
Name	Side Effects	Precautions
Minocycline	Dizziness Headache Photosensitivity Acute hepatitis (rare) Pigment deposition in the skin, mucous membranes and teeth	Serum-sickness like rxn  Dose related dizziness, neurologic effects usually subside with use
Doxycycline	Photosensitivity Diarrhea Nasopharyngitis Hepatotoxicity (rare)  Pigment deposition in the skin, mucous membranes and teeth	Avoid isotretinoin use concomitantly (inc ICP) Sunlight or UV exposure inc photosensitivity Discontinue if erythema occurs

Oral Isotretinoin, hormone

Oral Isotretinoin
Dose	Side Effects	Precautions	Additional Notes
Goal: Reach a cumulative dose of 120mg/kg over 4-6 months	Photosensitivity Anemia Increased LFTs Thrombosis of blood vessels Neutropenia Thrombocytopenia Optical neuritis Depression, aggressive behavior, injury d/t suicide attempt, psychotic disorder, suicidal thoughts	Avoid use of tetracycline, vitamin A supplements and St John’s Wort Risk of scarring may occur with hair removal procedures, may continue up to 6 months post therapy Contraindications: Pregnancy, high risk of birth defects → BOXED WARNING	iPLEDGE REMS program Screen with serum or urine pregnancy test at initiation to enter program Counsel pt on required 2 forms of contraception simultanesoly for at least 1 month prior to initiation 30-day mandatory waiting period When authorized: Order pregnancy test at least 30 days after registration Lab testing Pregnancy test monthly Fasting lipid panel CBC CMP

Name	Side Effects	Precautions
Spironolactone	Gynecomastia (moobs) Erectile dysfunction Hyperkalemia	Gynecomastia is usually dose dependent and reversible when therapy stops

**NOTE: Hormone therapy is not combined with each other (spironolactone + oral contraceptive)

• Can be combined with systemic ABX and topicals

Maintenance + nonpharm

• Maintenance Therapy:

  • First line: topical retinoids

    • Adapalene, tazarotene, tretinoin

  • Alternative:

    • Azelaic acid

  • Continue hormonal therapy if effective

  • Long term therapy with antibiotics is NOT recommended

• Non-Pharm Treatment

  • Gentle cleansers

  • Sunscreen

  • Non-comedogenic makeup

  • Hygiene

  • Moisturizers

  • Avoid scratching, picking, popping

Select an appropriate drug therapy plan for a patient with mild, moderate or severe urticaria due to allergic reactions.

• First-generation anti-histamines

  • Anticholinergic effects

  • Lipophilic, cross BBB

  • Careful in older adults 

• Second-generation anti-histamines

  • Safer in older adults

  • No sedation

• Systemic Glucocorticoids

  • Not necessary for isolated urticaria, may be needed if angioedema is present

  • Prednisone (or equivalent): 30-60mg daily with tapering dose over 5-7 days

• When to refer:

  • Suspicion of anaphylactic rxn

Antihistamines
Name	Side Effects	Precautions
Diphenhydramine (1st gen)	Xerostomia Dizziness Sedation	Anticholinergic effects in elderly may be prominent Rebound activation in children and elderly
Hydroxyzine (1st gen)	Xerostomia Prolonged QT interval Somnolence	Avoid use in older adults d/t anticholinergic effect
Certrizine (2nd gen)	Xerostomia HA Minor sedation
Loratidine (2nd gen)	Xerostomia HA Minor sedation

Select an appropriate drug therapy for a patient with rosacea

• Treatment of vascular features

  • Laser and intense pulse light

• Treatment of facial erythema

  • Vasoactive alpha-2 adrenergic receptor agonists

    • Topical brimonidine

    • Topical oxymetazoline

• Treatment of papules and pustules

  • Topical metronidazole, topical ivermectin, azelaic acid