Chapter 39. Common Skin Conditions

Select Drugs that Can Discolor Skin and Secretions

Brown

• Methyldopa

• Levodopa

• Entacapone

Orange/Yellow

• Sulfasalazine

Red

• Anthracyclines

Brown/Yellow

• Nitrofurantoin

Red-Orange

• Phenazopyridine

• Rifampin

Blue

• Methylene blue

• Mitoxantrone

Blue/Gray

• Amiodarone

Green

• Propofol

Black/Green

• Iron (black stool)

Natural product for sunburn and psoriasis?

Aloe

• Provides soothing effect when used as gel or lotion

What is a natural product used for acne?

Tea tree oil

• Also helpful for onychomycosis (will not eradicate infx in most)

What natural product is used for cold sore (herpes simplex labialis) prevention and treatment? Route?

Oral or topical lysine

What vitamin is used for hair loss and brittle nails?

Biotin

Which topical vitamin is used for diaper rash and psoriasis?

Vitamin D topical

What hormone is the primary determinant of acne?

Androgen (MALE SEX HORMONE)

• Cutibacterium acnes and sebum in oil (sebaceous) glands can also contribute

• Remember: whiteheads (closed comedones), blackheads (open comedones), papules, pustules nodules (Cysts)

  • severity determined by mild (few pimples), moderate (inflam papules), or severe (nodules)

What is acne primarily treated with?

• OTC benzoyl peroxide and salicylic acid

• Retinoids

• Systemic isotretinoin

• Systemic / topical ABX

Retinoids MOA

Vitamin A derivatives

MOA: Reduce the cohesion of follicular epithelial cells, increasing turnover and unblocking pores to prevent acne and for wrinkles

Counseling for retinoids and CI?

• Apply a pea-sized amount nightly

• Takes 4-12 weeks to work

• Acne may worsen initially

CI: Teratogenic - avoid in pregnancy or breastfeeding

What is oral isotretinoin FDA-approved for?

Severe, racalcitrant nodular acne only

• Many safety considerations

What tests are required for the isotretinoin REMS program? (ipledge)

• Pregnancy, liver function, and lipid

What medication is a topical dicarboxylic acid available OTC and Rx as a cream, foam or gel for acne and rosacea?

Azelaic acid

• Class: topical dicarboxylic acid

Other OTCs Acne Tx

Salicylic acid (Clearasil)

Azelaic acid lower strengths (Paula’s choice, The Ordinary)

Azelaic acid cream, gel, foam (Azelex, Finacea)

Females may use this product to find benefits with acne

Oral Contraceptives

• Esp if acne occurs around menstrual cycle or if irregular menstruation/sx of excess androgen

  • Also another agent: Spironolactone (Aldosterone receptor antagonist w/ anti-androgenic effect)

Which medication is a topical androgen receptor inhibitor and can be used as an alternative for the treatment of mild acne?

Clascoterone

• causes HPA axis suppression (more likely with use over large surface area, prolonged use, and occlusive dressing)

• In patients age 12 and older ONLY

Acne Treatments Based on Severity

Mild

• Topicals (BPO or retinoid) or in combination +/- abx

- always includes BPO in combo

• Alternative: Add topical retinoid or BPO; switch to topical dapsone or a different retinoid

Moderate

• Combination of topicals OR

• PO abx + BPO + topical retinoid (+/- topical abx)

• Alternative: use other combo; switch PO abx, add combined OCP or spironolactone (females), isotretinoin

Severe

• topical combo + PO abx

• PO isotretinoin

• Alternative: switch PO abx, add combined OCP or spirnolactone (females), PO isotretinoin (if not tried previously)

Counseling for BPO (Benzyl Peroxide)

Can bleach clothing and hair + photosensitivity

Topical Tretinoin brand names

• Atralin

• Renova

• Retin-A

• Retin-A micro

• Altreno

Topical Retinoid counseling + Warning

Counseling:

• Apply pea-sized amount daily, usually at bedtime, about 20 minutes after washing face

• Limit sun exposure (photosensitivity)

• If irritation occurs, use lower strength or decrease frequency to QOD

• Takes 4-12 weeks to see improvement; may worsen initially

Warning: AVOID TOPICAL RETINOIDS IN PREGNANCY

Retin-A Micro and Avita generic and unqiue counseling note

Both are slower release, with less skin irritation

• Retin-A Micro (Microsphere gel)

• Avita (Polymerized cream/gel)

GENERIC = TRETINOIN

Adapalene brand name

Differin (OTC) as gel 0.1%

When should Dapsone gel be avoided?

G6PD deficiency

Isotretinoin brand names and form

Absorica, Amnesteem

RX form only as (capsules)

Requirements for Isotretinoin (absorica, amnesteem)

• FDA Approved for severe, nodular acne only

• sign informed consent for pt who can get pregnant about birth defects; 2 negative pregnancy tests prior to starting

• Do not get pregnant for 1 month before or for 1 month after the drug is stopped

• Do not use with vitamin A supplements, tetracyclines, progestin-only contraceptives, St. johns wort, or steroids

Boxed Warnings for Isotretinoin

• Birth defects have been documented

• Can only be dispensed by a pharmacy registered with REMS (iPLEDGE)

• 1 month Rx at a time

Warnings for isotretinoin

• dry skin

• chapped lips

• dry eyes/eye irritation

Counseling for Isotretinoin

2 forms of birth control are required during tx (cannot use progestin-only pill)

• Must have monthly pregnancy test

Minocycline brand names

Minocin (Injection, PO), Solodyn (PO)

• Can cause photosensitivity, Fetal harm, and discoloration in teeth

  • XR form used in patients ≥12 years

Doxycycline Brand Name

Vibramycin

• Can cause photosensitivity, Fetal harm, and discoloration in teeth

What natural product is used for cold sore prevention and treatment? What are they caused by?

Lysine (both prevention and treatment)

• Cold sores caused by herpes simplex labialis (HSV-1)

• Spreads mostly with active lesions, kissing, sharing drinks

  • Sore eruption preceded by prodromal symptoms (tingling, itch, soreness) → optimal time to start topical tx

Docosanol (OTC) brand name and indication

Abreva

• Apply 5x daily at sign of first outbreak

• For Cold Sores!

Rx Acyclovir topical cream/ointment brand and indication

Zovirax cream

• Apply 5x daily for 4 days

• For Cold Sores!

Dandruff Treatments

Dandruff = mild form of seborrheic dermatitis that involves scalp, causing WHITE, ITCHY FLAKES of DEAD SKIN CELLS in HAIR

OTC

• Ketoconazole 1% shampoo (Nizoral A-D)

• Selenium sulfide (Selsun)

• Pyrithione zinc (Head & Shoulders)

• Coal tar shampoos (T/Gel)

Rx

• Ketoconazole 2% shampoo (Nizoral)

• Niozoral: apply twice weekly up to 8 weeks

What is a medical condition that can cause hair loss (alopecia)?

Hypothyroidism

• FYI - Most common cause of hair loss is hereditary male-pattern baldness

Other than chemotherapy that causes cytotoxic effects on rapidly dividing cells (i.e. hair cells), what drugs can cause alopecia?

• Valproate

• Lamotrigine

• Tacrolimus

• Naturals: biotin, zinc, selenium, and vitamin D deficiencies

• All of these + chemotherapeutics (targets rapidly dividing cells)

Finasteride brand name, formulation, and MOA

Brand: Propecia

Formulation - RX: Tablet

Proscar is a 5-alpha reductase type 2 inhibitor for BPH

• dec. dihydrotestosterone (hormone involved in male-pattern baldness)

• NOTE: Do not use Propecia (1mg) in patients taking Proscar (5mg) for both

Warnings + CI of Finasteride

Brand = Propecia (1mg) (FOR HAIR LOSS) / Proscar (for BPH) = 5mg

Warnings: hazardous drug for females of childbearing potential

CI: Pregnancy

Dosing for Propecia (finasteride)

1 mg daily

• Can take ≥3 months to begin to see effect

• Reminder: Proscar (Finasteride) is 5 mg and for BPH (not hair loss)

Boxed Warning for Baricitinib for Alopecia

Serious infections (herpes zoster), malignancy, thrombosis

Minoxidil Topical brand

Rogaine (Topical)

• Tablets are indicated for hypertension (rarely used)

Which drug is used for thinning eyelashes (hypotrichosis) and should not be used with?

Latisse (Bimatoprost) [also for thinning eyelashes [hypotrichosis]]

• Do not use with other prostaglandin analogs d/t risk for increased IOP

Lumigan is for glaucoma

Counseling for administration of Latisse (bimatoprost)

Apply nightly with applicator brush to the skin at the base of the upper eyelashes only (not lower lid)

Eczema appearance/symptoms

• Itchy, red, dry skin rashes that may turn into crusty, scaly sores

• common in young children and infants, appears at any age

Treatment for Eczema (atopic dermatitis)

• Hydration and moisturizers (reduce severity)

• RX or OTC antihistamines (reduce itching)

• Topical steroids (occasional oral courses if needed) or Topical calcineurin inhibitors

Counseling for topical calcineurin inhibitors?

• do not use in children <2 yrs

• associated with lymphoma and skin cancer

• Topical Options: Tacrolimus, Pimecrolimus

All topical products for eczema counseling

wash hands after application

Janus Kinase inhibitor counseling for eczema

Boxed warning includes serious infections (herpes zoster) and higher rates of malignancy, thrombosis

What is a topical medication for hyperhidrosis (excessive sweating)?

Glycopyrronium topical (Qbrexza) and Fopironium

• MOA: Topical anticholinergics

Drug Classes used to treat Atopic Dermatitis (Eczema)

• OTC moisturizers (Aquaphor, Eucerin)

• Topical Steroids

• Topical calcineurin inhibitors

• Topical PDE-4 inhibitors

• MAbs (interleukin receptor antagonists)

• Janus Kinase inhibitors

Fungal skin infections

• Tinea Pedis (athletes foot)

• Sx: itching, peeling, redness, mild burning likely from public pools, showers, and locker rooms

• Tx: topical antifungals

• Tinea cruris (jock itch)

• Sx: affects genitals, inner thighs, and buttocks; rash is red, itchy, can be ring-shaped

• Tx: topical antifungals

• Tinea corporis (ringworm)

• Not a worm; fungal infx

• Sx: circular, red, flat sores (Occasionally, ring isnt present; just red itchy skin) → outer part of sore raised while middle of skin appears normal

• Tx: topical antifungals

• Tinea capitis (ringworm on scalp)

Cutaneous Candida Infections

• Cause red itchy rashes

• Commonly in the groin, armpits, or anywhere with skin folds

OTC drug treatments for Fungal infections (skin)

• Terbinafine (Lamisil AT)

• Butenafine (Lotrimin Ultra)

• Clotrimazole (Lotrimin AF)

• Miconazole (Lotrimin AF)

• Tolnaftate (Tinactin)

• Undeclyenic acid

RX treaments for Fungal Infections for the skin

• Betamethasone/Clotrimazole (Lotrisone)

• Ketoconazole

Counseling for Fungal Skin Treatments

• Infection on foot = do not walk barefoot to avoid spreading it

• Apply medication 1-2 inches beyond rash

• Use for 2-4 weeks, even if it appears healed

• Reduce moisture to infected area

Treatment for Onychomycosis

Onychomyocsis = fungal infection of nail by tinea unguium

• Topical treatments are not potent enough to cure most infections (only for mild cases and who can’t tolerate systemic)

• Systemic Itraconazole or Terbinafine is indicated to treat fungal nail infx

  • Fluconazole and Posaconazole off-label

  • Terbinafine: 250 mg PO daily for 6 weeks (finger) vs 12 weeks (toenail)

• Takes sometimes up to a year to work (Toenails take longer than fingernails)

Pulse therapy for onychomycosis

• Intermittent

• Can reduce costs and possibly toxicity, but may not be as effective

What is essential for diagnosis of onychomycosis?

20% potassium hydroxide (KOH) smear

Itraconazole should be avoided in which patient population? (boxed warning)

Heart Failure

Systemic antifungals carries a risk of what side effect?

Hepatotoxicity (Monitor LFTs)

• QT-Prolonging

• CYP3A4 Substrates and Inhibitors

Sx of infx and How long to treat vaginal fungal infections in pregnant patients?

More common in pregnancy

• Longer treatment courses - 7 to 10 days

• Sx: Itching with possible soreness/pain during urination and sex and/or cottage cheese like discharge (White thick clump)

A pH ______ is consistent with bacterial vaginosis or trichomoniasis infection.

pH > 4.5

• (OTC test kits are available)

When should a patient refer to a physician for vaginal fungal infections?

More than four infections in a year or if symptoms recur within 2 months

• Rule out causative underlying conditions

What natural products are thought to reduce vaginal fungal infection occurrence?

lactobacillus or yogurt with active cultures (mixed evidence of working)

How can a woman self treat a mild-moderate infrequent vaginal fungal infection?

1, 3, or 7 day treatment with vaginal cream, ointment, suppository, or tab

Drugs to Treat vaginal fungal infections

OTC, topical

• Clotrimazole

• Miconazole (Monistat 3)

RX, topical

• Butoconazole (Gynazole-1)

RX, oral

• Fluconazole (diflucan) 150 mg PO x 1

• Complicated infx, pregnant: 7-10 days treatment or refer to healthcare provider

Recurrent Vulvovaginal Candidasis

• Oteseconazole (Vivjoa) for prevention of inx in females (not of reproductive potential)

Which skin protectants are good for diaper rash prevention?

• Petrolatum ointment (contains Vitamin A and D)

• Petrolatum with zinc oxide (dessicant) → dries the skin

If yeast is thought to be involved in a diaper rash, which medication should be used?

Nystatin for stubborn rashes if yeast involved (or clotrimazole, miconazole)

Petrolatum/zinc oxide brand name

Desitin

Treatments for Hemorrhoids

Sx: Pruritus, burning, rectal bleeding with bright red blood

• Increasing fiber intake to reduce straining (psyllium to absorb water in the intestine and promote peristalsis)

• Phenylephrine (Preparation H) - a vasoconstrictor that shrink hemorrhoids; reduces burning/itching

• Hydrocortisone (Anusol-HC, Prepartion H) - reduce itch/inflammation

• Witch Hazel (Tucks Medicated Cooling Pads) - mild astringent to help mild itch

What drug is used for pinworm infection (Vermicularis) that presents as anal itching in children?

Pyrantel Pamoate

• Commonly occurs in children and presents as anal itching

How to identify pinworm infection?

"tape test"

• Tape around anus in morning prior to voiding/defecating

• Tape is then brought to healthcare provider to examine under microscope

• It can take up to 3 tape tests to identify eggs

• Reinfection + resistance common; must treat entire household

Melbendazole and Albendazole, Rx options for pinworm tx, have what side effects and indicated for?

Indication: more severe/systemic worm infections

Side effects:

• headache, nausea

• Hepatotoxicity

What medications may be given with antihelminthics d/t toxicity?

Steroids and ASMs (for CNS infections)

• antihelminthics = Albendazole, Mebendazole

How should Albendazole be taken?

With a high-fat meal (inc. absorption)

Permethrin for scabies vs lice

Scabies = Permethrin cream 5%

Lice = Permethrin lotion 1% (Nix) (OTC) avaialble)

What is an alternative to permethrin for head lice?

• Topical ivermectin (Sklice) for head lice

• Malathion lotion 0.5% (causes skin irritation, AND is flammable)

• Organophosphate Malathion only for 6 and up

• Lindane shampoo no longer available d/t neurotoxicity

Lice latin name

Pediculus humanus capitis

• Occurs commonly in elementary school-age children

Which drugs are first-line for lice?

Topical OTCs, such as pyrethrins/piperonyl butoxide and permethrin

How often should a nit comb be used to remove nits and lice after treatment? How long to do re-treatment?

every 2-3 days for nit comb

After days 7-10 for retreatment

Most products except which one require re-treatment? When does re-treatment occur?

Sklice

• Re-treatment should occur on days 7-10

• Drugs of choice for Lice is OTC topical tx such as permethrin or pyrethrin/piperonyl butoxide

Pyrethrin/Piperonyl butoxide brand

RID

(for age ≥ 2 years)

Permethrin 1% Lotion Brand

Nix

(for ages ≥ 2 months)

What is the most common form of wound debridement?

Enzymatic debridement with application of Collagenase ointment (Santyl)

When would a mild foot burn require medical attention?

in diabetes, where it could lead to amputation

Burns can be categorized as

First degree: red/painful, minor swelling

Second degree: thicker, blisters, very painful

Third degree: damage to all layers of skin, appears white or charred

• Goes down the # = worst the damage

What OTC product should be applied to minor burns to protect skin, retain moisture, and reduce scarring risk? What degree of burns is this okay in?

Aquaphor, ointments (apply ointments to minor burns to protect skin, retain moisture, reduce scarring)

• Burn is FIRST or SECOND degree OTC okay! (if the area is less than 2” in diameter or sensitive area)

What can be used topically to reduce infection risk and promote healing after a burn?

Silver sulfadiazine (silvadene; SSD)

• Reduce infx risk and promote healing

• Do not use on broken skin (systemic toxicity)

Polymyxin/bacitracin/neomycin Brand name

Neosporin Original

• if neosporin allergy = Use polysporin (Bacitracin/Polymixin) or Bacitracin alone

• - for minor wounds

Rx abx cream for minor wounds that has very good staph and strep coverage

Mupirocin

• THIS IS RX form

• Covers staph and strep

• for minor wounds

Bacitracin/Neomycin/Polymyxin B/Hydrocortisone brand name

Cortisporin

• remember it has (4 components)

• for minor wounds

What toxin do poison ivy, oak, or sumac cause an allergic reaction from touching the sap?

Urushiol

• This is an allergic reaction

• Touching sap of plants

What is an astringent (drying agent) for poison ivy/oak/sumac?

Aluminum acetate

• ± Topical or oral steroids will help

• Oral used in severe rash

What strength of hydrocortisone is available OTC?

0.5% and 1% - all other topical steroids are Rx only

A steroid's vehicle influences its strength of medication. Usual potency from highest to lowest is....

ointment > creams > lotions > solutions > gels > sprays

What is used to estimate amount of topical steroid?

fingertip unit - fingertip to first joint (enough to cover one adult hand about ½ g)

Hydroxyzine brand name

Vistaril

• Used for general urticaria (hives) w/ severe itching

• Anticholinergics - Sedation and dry mouth are side effects

Potencies of topical steroids

Very High Potency

• Clobetasol propionate 0.05% lotion/shampoo/spray (Clobex), cream/ointment (Temovate), Foam (Olux)

• Fluocinonide 0.1% cream (Vanos)

High Potency

• Betamethasone dipropionate 0.05% cream

• Fluocinonide 0.05% ointment

• Mometasone furoate 0.1% ointment

High-Medium Potency

• Fluocinonide 0.05% cream

Medium Potency

• Mometasone Furoate 0.1% lotion

• Triamcinolone acetonide 0.1% cream, spray (Kenalog)

Lowest Potency

• Hydrocortisone Cream, 1% (Cortizone-10)

What kind of sunscreen should be used for skin protection?

"broad spectrum" Covers both UVA and UVB

What does SPF stand for?

sun protection factor

• SPF of at least 30