Skin Conditions

UWorld eyes ears nose skin - 3

Drugs that can discolor skin & body fluids/secretions - Brown

levodopa

methyldopa

entacapone (이것도 PD med - Sinemet이랑 같이쓰는 COMT)

Drugs that can discolor skin & body fluids/secretions - Brown/Yellow

Nitrofurantoin

Drugs that can discolor skin & body fluids/secretions - Black/Green

Iron

Drugs that can discolor skin & body fluids/secretions - Orange/Yellow

Sulfasalazine

Drugs that can discolor skin & body fluids/secretions - Yellow-Green

Proopofol

Drugs that can discolor skin & body fluids/secretions - Red-Orange

Phenazopyridine

Rifampin

Drugs that can discolor skin & body fluids/secretions - Red

Anthracyclines (e.g. doxorubicin)

Drugs that can discolor skin & body fluids/secretions - Blue

methylene blue

mitoxantrone (chemotx)

Drugs that can discolor skin & body fluids/secretions - Blue-Gray

amiodarone

BPO

• Use: Mild (solo), Moderate, Severe Acne (with other combos) → 약간 backbone 같은 느낌이던데

• can bleach clothes and hair

Topical Retinoids

• Tretinoin (Retin-A, Retin-A Micro, REnova, Atralin, Altreno, Avita)

• Adapalene (Differin) gel 0.1% (OTC)

• Use: mild (solo), moderate, severe acne (in combo w/ BPO)

• Teratogenic → avoid in pregnancy & BF (topical 이여도)

  • Tazarotene = CI in pregnancy

• Photosensitivity → Apply pea-sized amount QHS 20 min after washing face 저녁세안 후 20분 후에

  • If irritation/redness occurs → reduce dose or decrease frequency

  • Retin-A Micro & Avita = less irritation d/t slower release

• May worsen initially → takes 4-12 weeks to work

Oral Retinoid capsules - Isotretinoin (Amnesteem, Absorica, 예전에 accutane)

• ONLY for Severe, Nodular/Cystic Acne

• Teratogenic!!

• REMS (iPLEDGE) 조건:

  1. Pt sign informed consent form about birth defects

  2. (2) Negative pregnancy tests before starting

  3. ONLY dispensed by a REGISTERED pharmacy

  4. 1-Month supply Rx

  5. Written w/in 7 days + Yellow Sticker

  6. Pt continues to use 2 forms of birth control (e.g. condom + pill)

     • PROGESTERONE-ONLY pills NOT ALLOWED

• Do NOT get pregnant 1 mo before & after (당연히 during 도 포함) tx

• Do NOT use other Vitamin A supplements, TC (also teratogenic, minocycline이 Abx로 쓰이거든), Progestin-only contraceptives, and SJW → 걍 이거 혼자만 사용.

Azelaic acid

Azelex, Finacea used for acne and rosacea

Clascoterone

Winlevi

• topical androgen receptor inhibitor cream

• used for tx of mild acne > 12yo

Oral Abx - Minocycline (Minocin, Solodyn)

• XR formulation → only for > 12yo (bone growth/color 때문에)

• TC이니까 “EIGHT Photos“

  • Esophageal irritation

  • Itracranial htn

  • GI ADE - N/V/D

  • Hyperpigmentation of teeth/bone

  • Teratogenic

  • Photosensitivity

Acne Tx Algorithm

• acne bacteria = C. acnes

• white → black heads (mild)

• → papule → pustule → cyst (mod-severe)

HSV-1 Cold Sores

• kiss, share drink로 spread

• prodrome 때 apply하는게 best

• lysine = natural product used for prevention & tx

+음.. PO 는 Acy/Valacy/Famci 있고, 이 약들쓰는 HSV-1, 2, HSZ (Herpes Zoster/Shingles) = 다 tx duration 7-10 days

OTC

• Docosanol (Abreva)

  • 5 TIMES DAILY until gone

RX

• Acyclovir (Zovirax) topical oint/cream

  • 5 TIMES DAILY x 4 days

Dandruff = white, itchy dead skin flakes

1st line = OTC

• Ketoconazole 1% shampoo (Nizoral A-D)

  • twice weekly x 8 weeks

• Selenium Sulfide (Selsun)

• Pyrithione Zinc (Head & Shoulders)

• Coal Tar (T/Gel)

2nd line = Rx

• Ketoconazole 2% shampoo (Nizoral)

Alopecia

• Can be due to: hereditary, stress, pregnancy/postpardum, hypothyroidism, chemotx, Valproate, Lamotrigine, Tacrolimus,

• biotin, zinc, selenium, vitamin D deficiency

1. Finasteride (Propecia)

   • NOT Proscar (BPH) → don’t dispense if taking Proscar

   • 5aRi = CI in pregnancy, NIOSH HD

2. Rogaine (Minoxidil)

3. Latisse* (Bimatoprost) = for eyelash growth (아 항암치료는 눈썹도 빠지나봐 ㅠㅠ)

   • For thinning eyelashes = hypotrichosis

   • Apply nightly to the base of the upper eyelash/lid skin only. (X lower lid)

   • Do NOT use w/ other -prost’s for glaucoma.

Eczema (atopic dermatitis) Tx:

• itchy, red, dry skin rashes, crusty, scaly

• inner side of folded skin → elbows, behind knees/ears, face, buttocks, hands, feet

• usually due to triggers

1st line = mild → Hydration & Moisturizers + OTC AH to itch relief

• Aquaphor, Eucerin

2nd line = mild-moderate → topical steroids, topical CNI

• tacrolimus (Protopic)

• pimecrolimus (Elidel)

3rd line = severe, refractory → topical PDE4i, mabs, JAK

• Dupixent (Dupilumab)

• crisaborole (Eucrisa)

• Cibinqo

All - Wash hands after application

Tacrolimus - Do NOT use in children < 2 yo b/c of risk of lymphoma & skin cancer (immunosuppressants)

JAKi - infections, malignancy, thrombosis

hyperhidrosis = excessive sweating

topical anticholinergic to DRY out sweat

• glycopyrronium (Qbrexza)

Tinea

• pedis = athlete’s foot

  • public pool, showers, locker rooms

  • don’t walk around barefoot = spreading it

• corporis = ringworm body

• capitis = scalp

• cruris = jock itch

  • genitals, inner thighs, buttocks

  • use clean towels, change underwear daily

Topical antifungals

azole 이 2nd line

OTC:

1. Terbinafine (Lamisil AT), Butenafine (Lotrimin Ultra)

2. Clotrimazole, Miconazole (둘다 Lotrimin AF)

3. Tolnaftate (Tinactin)

Rx:

1. Lotrisone (Betamethasone/Clotrimazole)

2. ketoconazole

Note:

• Tx duration = 2-4 weeks even if it appears healed

• Apply 1-2 inches further in diameter 주변 더 발라

Nail infection (Onychomycosis)

• toe nails > finger nails 발톱이 더 어려움

• 20% KOH smear to confirm diagnosis

Topical = NOT ENOUGH

Need longer & more potent tx to penetrate the nails → PO Antifungals x ~years~

RX:

1. Itraconazole

   • CI in HF

   • QT prolongation

   • Hepatotoxicity

2. Terbinafine

   • Hepatotoxicity

Vaginal fungal infections

• cottage-cheese-like discharge, itchy

• high pH (alkaline, not acidic ☹) > 4.5 = Bacterial Vaginosis or Trich

RF:

• menstruating women

• high dose estrogen, hormone replacement therapy, steroids, immunosuppressant drugs, abx, douching

Mild/Moderate, Infrequent infections:

1 / 3 / 7 day treatment with vaginal cream, ointment, suppository/tabs

OTC

1. Miconazole (Monistat 3)

2. Clotrimazole

RX

1. Butoconazole (Gynazole-1)

2. Fluconazole (Diflucan) PO 150mg x 1

Severe, Recurrent VVC: > 4 times/year OR recurrence w/in 2 mos:

• Refer to HCP

**Pregnant = need longer tx = 7-10 days

+Lactobacillus or yogurt with active cultures might be helpful to reduce infection occurrence

Counseling for Topical Vaginal Antifungals (oint, cream, suppositories)

• Insert suppository/tab, cream, oint @ night before bed while lying down (안 흘러내리게)

• oil-based meds + latex condoms = decreased efficacy/weakened protection → avoid sex

• Don’t use tampons + meds @ menses

Diaper rash

OTC

• Desitin (Petrolatum/Zinc Oxide)

  • ZnO2 = desicant 뽀송뽀송하게 해서 살 짖무름이 없도록.

RX

• clotrimazole, miconazole, nystatin

HPV Genital warts (cauliflower like warts)

imiquimod cream (Aldara, Zyclara)

Hemorrhoids

• bright red blood from ‘recent’ bleeding anus (vs. black, tarry stools from ‘old’ GIB)

Phenylephrine (Preparation H), Hydrocortisone (Anusol-HC)

• topical decongestant/vasoconstrictor = shrinks hemorrhage + reduces burning & itching

Psyllium (fiber) → to help reduce straining

Docusate → stool softener

Witch hazel (Tucks Medicated Cooling Pads) = astringent to relieve mild itching

Pinworm (Vermicularis)

• children w/ anal itching

  very contagious - wash hands frequently & treat entire household

• parasitic worms → 3 “Tape test“ to identify eggs

  • before bathroom

OTC

• pyrantel pamoate (Reese’s Pinworm Medicine)

Rx

• Albendazole, Mebendazole (Emverm)

  • Hepatotoxic, HA, Nausea

  • steroids, antiseizure meds given together

  • take w/ high-fat meal

Lice vs Scabies

• Lice = Children

• Scabies = Adults

아직 막 알에서 깨고 나온 lice 가 있을수도 있어서

Must repeat on Day 9

Lice: Topical OTC = 1st line DOC

OTC

• Permethrin 1% lotion (Nix)

• Pyrethrin/Piperonyl butoxide (RID)

• Ivermectin lotion (Sklice)

  • head lice 용

Rx

• Malathion lotion 0.5% (Ovide)

  • flammable

  • > 6 yo

Scabies

• Permethrin cream 5%

• PO Ivermectin (Stromectol)

Lice tx counseling

• after tx, use nit comb to remove nits and lice every 2-3 days

• EXCEPT Sklice, retreatment is required on Day 9.

Burns

• 1* = minor swelling, superficial

• 2* = thicker, blisters, very painful

• 3* = White or Charred, all skin layers damages

• chemical exposure, immunosuppressed, DM pts (d/t risk of amputation) → ED immediately

• Do not apply ice (more damage)

• Aquaphor ointments = minor burns to protect the skin, retain moisture & reduce scarring risk….

• Silver sulfadiazine (Silvadene; SSD) = reduce infection risk, promote healing

Cuts, Minor wounds

OTC

• Neosporin (Neomycin/Polymyxin /Bacitracin)

Rx

• Cortisporin = Neosporin + Hydrocortisone

• Mupirocin

  • good staph & strept coverage including MRSA

Poison Ivy, oak, sumac (Urushidol toxin)

Calamine lotion

Aveeno Colloidal Oatmeal

Al3+ acetate (astringent)

Lowest potency Topical Steroid available OTC

• use low potency for thin skins & skin folds (face, eyelids, genitals, armpits, groin, under boobs) & infants

• 1 fingertip (마디) unit = 0.5g

Hydrocortisone (HC) Cream 0.5%, 1%

urticaria (hives)

1. 2nd gen AH (cetirizine)

2. H2RA

   1. famotidine

   2. hydroxyzine (Vistaril)

      • can cause sedation & dry mouth

Steroid vehicle influences strength/potency:

1. ointment

2. cream

3. lotion

4. solutions

5. gel

6. spray

Very High Potency Topical Steroids (Rx)

Fluocinonide 0.1% Cream (Vanos)

Clobetasol propionate 0.05%

• Cream/Ointment (Temovate)

• Lotion/Shampoo/Spray (Clobex)

• Foam (Olux)

High Potency Topical Steroids (Rx)

Fluocinonide 0.05% Ointment

Mometasone furoate 0.1% Ointment

Betamethasone dipropionate 0.05% Cream (Diprolene AF)

High-Medium Potency Topical Steroids (Rx)

Fluocinonide 0.05% Cream

Medium Potency Topical Steroids (Rx)

Mometasone furoate 0.1% Lotion

Triamcinolone acetonide 0.1% Cream, Spray (Kenalog)

Lowest Potency Topical Steroids (OTC)

HC 0.5%, 1% cream (Cortizone-10)

Sunscreen Counseling

• UVA = aging

• UVB = burning

• broad spectrum = UVA, UVB both cover

• TTB = SPF x TTB w/o sunscreen

• SPF minimum 15-30

• Reapply every 2 hours or when washed off (swimming or sweating)

• No sunscreen is 100% waterproof - “waterproof” or “sweatproof” label is no longer permitted

  • → “Water-resistant” claim is OK, but only for 40-80 min