Ch. 39 Common Skin Conditions

Stabinsky

select drugs that can discolor skin and secretions

brown --> entacapone, levodopa, methyldopa

brown/yellow --> nitrofurantoin

black/green --> iron

orange/yellow --> salfasalazine

yellow/green --> propofol

red/orange --> phenazopyridine, rifampin

red --> anthracyclines

blue --> methylene blue, mitoxantrone

blue/gray --> amiodarone

natural products

aloe --> soothing

tea tree oil is useful for a variety of skin conditions, including acne

topical lysine is used for cold sore (herpes simplex labialis) prevention and treatment

biotin is used for hair loss and brittle nails

topical vitamin D is used for diaper rash and psoriasis

acne vulgaris

androgen (male sex hormone) is the primary determinant of acne

the presence of cutibacterium acnes and sebum in oil (sebaceous) glands also contribute

acne can be treated with OTC benzoyl peroxide and salicylic acid, retinoids, topical or systemic (oral) antibiotics and systemic isotretinoin

retinoids --> vitamin A derivatives that work by reducing cohesion of epithelial cells ---> should be applied nightly using a pea sized amount, takes 4-12 weeks to work and acne may worsen initially

the oral retinoid isotretinoin has many safety considerations and is approved for severe, recalcitrant nodular acne only --> pregnancy (teratogenic), lipid, and LFTs are required

COCs, azelaic acid, and clascoterone can also be useful

acne treatment summary

mild -->

first line: BPO or retinoid or combo

alternative: add topical retinoid or BPO, switch to another retinoid, or topical dapsone

moderate -->

first line: topical combo or PO antibiotic + BPO + topical retinoid (+/- topical antibiotic)

alternative: other combo, switch PO antibiotic, add combined OCP or spirinolactone (females) or PO isotretinoin

severe -->

first line: combo topical + PO antibiotic OR PO isotretinoin

alternative: switch PO antibiotic, add COC or spirinolactone (females) or PO isotretinoin (if not previously tried)

topical combo examples

BPO + topical antibiotics

BPO + retinoid

BPO + retinoid + topical antibiotic

topical retinoids

tretinoin (atralin, renova, retin-A, retin-A micro, altreno)

adapalene (differin)

tazarotene

trifarotene

topical retinoid notes

topical retinoids should be avoided in pregnancy

retin-A micro and avita --> slower release, less skin irritation

tazardotene --> CI in pregnancy

topical retinoid safety/counseling

limit sun exposure

apply daily, at bedtime, about 20 minutes after washing face

if irritation occurs, use lower strength or decrease frequency to every other night

a pea-sized amount should be used

takes 4-12 weeks

acne may worsen initially

other topical products

benzoyl peroxide (BPO) --> can bleach clothing

salicylic acid

azelaic acid

dapsone gel --> avoid in G6PD deficiency

clascoterone cream -- HPA axis suppression may occur

oral retinoid

isotretinoin (absorica, amnesteem) --> capsules

isotretinoin notes

only approved for severe, nodular acne

patients who can get pregnant must sign informed consent form about birth defects and must have 2 negative pregnancy tests prior to starting

do not get pregnant for 1 month before, while taking, or for 1 month after the drug is stopped

do not use with vitamin A supplements, tetracyclines, progestin-only contraceptives, or st. john's wort

isotretinoin BBW

birth defects have been documented

can only be dispensed by a pharamcy registered with REMS (ipledge)

1 month Rx at a time

isotretinoin warnings

dry skin

chapped lips

dry eyes/eye irritation

counseling --> 2 forms of BC are required (cannot use progestin only)

oral antibiotics for acne

minocycline (minocin, solodyn)

only approved for 12yo or older

can cause photosensitivity, fetal harm, and discoloration of teeth if used when teeth are forming (up to 8yo)

cold sores

cold sores (herpes simplex labialis) is caused by HSV-1

virus spreads mostly with active lesions; kissing or sharing drinks

sore eruption is preceded by prodromal symptoms

the natural product lysine is used for cold sore prevention and treatment

cold sore drug treatment

OTC --> docosanol (abreva) --> apply 5x daily at first sign of outbreak

Rx --> acyclovir topical cream/ointment (zovirax) --> apply 5x daily for 4 days

dandruff

causes white, itchy flakes of dead skin cells in the hair

dandruff treatment

OTC -->

ketoconazole 1% shampoo (nizoral A-D)

selenium sulfide (selsun)

pyrithione zinc (head and shoulders)

coal tar shampoo (T/gel)

Rx -->

ketoconazole 2% shampoo (nizoral)

alopecia

hair loss

what can cause alopecia

hypothyroidism

chemo due to its effects on rapidly dividing cells

valproate, lamotrigine, tacrolimus

biotin, zinc, selenium, and vitamin D deficiency

alopecia treatment

finasteride (propecia)

baricitinib (olumiant)

minoxidil topical (rogaine)

bimatoprost (latisse)

finasteride

tablet

1mg daily; can take for 3 or more months to see effect

do not dispense to patients taking finasteride (proscar) for BPH

CI --> pregnancy

warnings --> hazardous drug for females of childbearing potential

baricitinib

BBW --> infections, malignancy, thrombosis

bimatoprost

for thinning eyelashes (hypotrichosis)

do not use with prostaglandin analogs used for glaucoma (IOP may increase)

apply nightly, to the skin at the base of the upper eyelashes

eczema

atopic dermatitis

appears as itchy, red, dry skin rashes that may turn into crusty, scaly sores

hydration and moisturizers may reduce severity or OTC antihistamines may reduce itching

treatment includes topical steroids (occasional oral courses if needed) or calcineurin inhibitors

eczema treatment

*** all --> wash hands after application

OTC -->

aquaphor

eucerin

Rx -->

topical steroids

topical calcineurin inhibitors (protopic, elidel) --> do not use in children <2yo; associated with lymphoma and skin cancer

others -->

topical PDE-4 inhibitor (crisaborole)

monoclonal antibodies (dupilumab, tralokinumab)

JAKi (abrocitinib, upadacitinib, ruxolitinib) --> BBW for infection, malignancy, and thrombosis

hyperhydrosis

excessive sweating

treat with glycopyrronium topical or antiperspirants

fungal infections of the skin

athlete's foot (tinea pedis)

jock itch (tinea cruris)

ringworm (tinea corporis)

cutaneous candida infections

athlete's foot (tinea pedis)

fungal infection of the foot

causes itching, peeling, redness, mild burning

common among those using public pools, showers, and locker rooms

jock itch (tinea cruris)

affects the genitals, inner thighs, and butt

rash is red, itchy, and can be ring shaped

ringworm

not a worm, but a fungal skin infection

circular, red, flat sores

occasionally, the ring-like presentation is absent - just itchy, red skin

the outer part is raised while the skin in the middle appears normal

tinea capitis is ringworm on the scalp

cutaneous candida infections

topical candida infections cause red, itchy rashes, commonly in the groin, armpits, or anywhere the skin folds

fungal treatments for the skin

OTC -->

terbinafine (lamisil AT)

butenafine (lotrimin ultra)

clotrimazole (lotrimin AF)

miconazole (lotrimin AF)

tolnaftate (tinactin)

undecylenic acid (toelieva)

Rx -->

betamethasone/clotrimazole (lotrisone)

ketoconazole (extina)

luliconazole (luzu)

fungal treatment for the skin safety/counseling

if infection is on the foot, do not walk barefoot (to avoid spreading it)

apply medication 1-2 inches beyond the rash

use for at least 2-4 weeks, even if it appears healed

reduce moisture to effected area

fungal infections of the toenail and fingernail

onychomycosis

topical drugs are not potent enough to cure

itraconazole and terbinafine are indicated

pulse therapy (intermittent) can be used to reduce costs and possibly toxicity but may not be as effective

a 20% potassium hydroxide (KOH) smear is essential for diagnosis

onychomycosis treatment

terbinafine (lamisil AT) --> can cause hepatotoxicity

itraconaozole (sporonox) --> avoid use in HF

ciclopirox (loprox)

tavaborole (kerydin)

efinaconazole (jublia)

vaginal fungal infections

pregnant patients should consult their physician --> longer treatment courses are required (7-10 days)

primary symptom is itching

a pH >4.5 is consistent with bacterial vaginosis or trichomoniasis infection --> OTC test kits are available to test vaginal pH

if there are more than 4 infections in a year, or if symptoms recur within 2 months, refer to physician

lactobacillus or yogurt with active cultures is thought to reduce infection recurrence

vaginal fungal infection treatmnet

mild-moderate, infrequent infection --> 1,3, or 7 day treatment with vaginal cream, ointment, or vaginal suppository/tab

OTC topical --> clotrimazole, miconazole (monistat)

Rx, topical --> butoconazole (gynazole-1), terconazole

Rx, oral --> fluconazole (diflucan) 150mg PO x1

complicated infections, pregnancy: 7-10 days treatment, or refer to HCP

diaper rash

use a skin protectant --> petrolatum ointment or use petrolatum + zinc oxide (a desiccant to dry the skin) (desitin)

treatment --> nystatin if yeast is thought to be involved

hemorrhoids

increasing fiber intake can help reduce straining --> use psyllium

OTC treatment --> phenylephrine topical (preparation H) is a vasoconstrictor that shrinks the hemorrhoid and reduces burning and itching

hydrocortisone (anusol-HC, preparation H)

witchhazel (tucks medicated cooling pads)

pinworm (vermicularis)

most commonly occurs in children and presents as anal itching

the tape test is used to identify eggs --> stick a piece of tape around the anus in the morning

it can take up to 3 tape tests to identify

pinworm treatment

OTC -->

pyrantel pamoate (reese's pinworm medicine)

Rx -->

albendazole

mebedazole (emverm)

pinworm treatment safety/counseling

mebendazole and albendazole can cause HA, nausea, and are hepatotoxic

treatments for systemic worm infections are toxic --> in some cases, steroids and antiseizure meds will be given in addition to an anthelmintic

lice and scabies

permethrin cream 5% is used to treat scabies while permethrin lotion 1% (nix) is used to treat lice

topical ivermectin (sklice) is used to treat head lice

lice --> pediculus humanus capitis

topical OTC drugs are generally first line, such as pyrethrins and permethrin

malathion lotion 0.5% (ovide) can cause skin irritation and is flammable

lindane is no longer available due to neurotoxicity

after treatment, use a knit comb to remove nits and lice every 2-3 days

most products, except sklice, require re-treatment

lice and scabies drug option

LICE

OTC -->

permethrin 1% lotion (nix)

pyrethrin/piperonyl butoxide (RID)

ivermectin lotion (sklice)

Rx -->

spinosad (natroba)

SCABIES

Rx -->

permethrin 5% cream

ivermectin oral (stromectol)

lice and scabies safety/counseling

drug of choice for lice --> OTC topical treatment such as permethrin or pyrethrin/piperonyl butoxide --> repeat treatment on day 9

malathion is flammable

minor wounds

cuts, lacerations, abrasions

bites

burns

** chronic wounds require debridement (many ways, but most common is enzymatic debridement --> done with the application of collagenase ointment)

burns

characterized as first, second, or third degree

in diabetes, a mild foot burn can lead to amputation

ointments (aquaphor) should be applied to minor burns to protect the skin, retain moisture, and reduce scarring risk

silver sulfadiazine (silvadene; SSD) can be used topically to reduce infection risk and promote healing

treatment of minor wounds

OTC -->

polymyxin/bacitracin/neomycin (neosporin) --> use polysporin if there is a neomycin allergy

Rx -->

mupirocin --> antibiotic that has very good staph and strep coverage

bacitracin/neomycin/polymyxin B/hydrocortisone (cortisporin)

collagenase (santyl)

poison ivy, oak, and sumac

all are allergic reactions that result from touching the sap of these plants, which contain the toxin urushiol

treatment of poison ivy, oak, and sumac

ALL OTC

aluminum acetate solution --> astringent

colloidal oatmeal (aveeno)

calamine lotion/pramoxine (caladryl)

zanfel

** topical or oral steroids will help (oral needed in severe rash)

inflammation and rash

primary treatment is topical steroids --> fingertip unit is used to estimate amount

two strengths of hydrocortisone are available OTC (0.5% and 1%); all others are Rx

the steroid vehicle influences the strength of the med --> usual potency, from highest to lowest --> ointment > cream > lotions > solutions > gels > sprays

hydroxyzine (vistaril) can be used for general hives --> causes sedation and dry mouth

very high potency topical steroids

clobetasol propionate 0.05% lotion/shampoo/spray (clobex), cream/ointment (temovate), foam (olux), gel

fluocinonide 0.1% cream (vanos)

high potency topical steroids

betamethasone dipropionate 0.05% cream (diprolene AF)

fluocinonide 0.05% ointment

mometasone furoate 0.1% ointment

high-medium potency topical steroids

fluocinonide 0.05% cream

medium potency topical steroids

mometasone furoate 0.1% lotion

triamcinolone acetonide 0.1% cream (triderm), 0.147mg/g spray (kenalog)

lowest potency topical steroid

hydrocortisone cream 0.5%, 1% (cortizone-10)

sunscreen and sun protectant

a broad spectrum sunscreen protects against both UVA and UVB

SPF stands for sun protection factor

sunscreen should be applied liberally at least every 2 hours and reapplied after swimming

keep babies <6 months old out of the sun

sunscreen labeling is no longer permitted to use "waterproof" or "sweatproof"

a sunscreen can claim to be "water-resistant" but only for 40-80 minutes

zinc oxide and titanium dioxide are physical sunscreens

TTB

TTB (w/ sunscreen) = SPF x TTB (w/o sunscreen)