Common Skin Conditions

Yup

Potencies of Topical Steroids: The important ones.

Very High Potency

• Clobetasol

• Fluocinonide Cream (0.1%)

High Potency

• Betamethasone Cream (0.05%)

• Fluocinonide Ointment (0.05%)

• Mometasone Ointment (0.1%)

High-Medium Potency

• Fluocinonide Cream (0.05%)

Medium Potency

• Mometasone furoate Lotion

• Triamcinolone

Low Potency

• Hydrocortisone

What is the order of steroid vehicle in strength from highest to lowest (GENERALLY?)

Ointment > Cream > Lotion > Solution > Gel > Spray

What areas of the body would you ONLY use low potency steroids?

Thin skin areas such as face, eyelids, genitals, and skin folds

Approximately how many grams is one finger tip unit of steroids? How much are does it cover?

½ gram, which is enough to cover one adult hand

Which drugs are notable for causing brown discoloration?

• Parkinson’s meds (Levodopa, entacapone)

• Methyldopa

Which drugs are notable for causing brown/yellow discoloration?

• Metronidazole

• Nitrofurantoin

• Riboflavin (B2)

Which drugs are notable for causing orange/yellow discoloration?

Sulfasalazine (DMARD)

Which drugs are notable for causing yellow-green discoloration?

Propofol

Which drugs are notable for causing red-orange discoloration?

• AZO

• Rifampin

• Anthracyclines (like doxorubicin)

Which drugs are notable for causing blue/gray discoloration?

• Mitoxantrone (for MS)

• Methylene blue (DUH)

• Amiodarone

• Chloroquine

Which natural product can be used for cold sore prevention

Lysine, an amino acid

What can topical vitamin D be used for?

Diaper rash and psoriasis

1st line treatments for mild acne? OTC vs RX?

OTC:

• Benzoyl peroxide

• Adapalene (Differin) a topical retinoid

RX:

• Topical antibiotics like Erythromycin, Clindamycin, Minocycline foam

• Topical retinoids like Tretinoin

1st line treatments for moderate acne?

• Same options as mild but can also think about adding PO antibiotics like Minocycline (Minocin, Solodyn)

1st line treatments for severe acne?

• Same as moderate acne but can also think about PO Isotretinoin

Alternative treatments to acne in females? (That are not topicals?)

Spironolactone and Oral Contraceptive pills

Considerations for topical retinoids? Counseling? When to avoid?

• Use at bedtime. Wash face let dry, apply 20 mins later

• If skin is really sensitive to it, can use every other night or a weaker strength

• Pea sized amount

• Can worsen before gets better. May take 4-12 weeks to see response

• AVOID in pregnancy

Considerations for benzoyl peroxide (BPO?)

• Be careful, can bleach clothing, pillows, and hair!

• Sun sensitivity (use at bedtime)

Consideration for topical Dapsone (Aczone)?

• Avoid Dapsones in G6PD deficiency

Considerations for oral Minocycline (Solodyn)?

• Photosensitivity can occur.

• Can discolor teeth if used in those younger than 8 so , only use in those ≥12 years old

What tests are include in iPledge for Isotretinoin?

• Pregnancy

• Lipid

• Liver

How many negative pregnancy tests are required before starting Isotretinoin? How many forms of birth control are required? how much of it can be dispensed at a time?

• 2 pregnancy tests

• 2 forms of BC (CANNOT use progestin only pill)

• 1 month at a time

How long must you wait after stopping isotretinoin to get pregnant?

• 1 month

Which drugs should be avoided while taking isotretinoin?

• Vitamin A supplements

• Tetracyclines

• Progestin-only contraceptives

• SJW

• Steroids

Which deficiencies can contribute to hair loss?

• Zinc

• Vitamin D

• Biotin

• Selenium

Which medications can contribute to hair loss?

• Chemotherapy

• Autoimmune (tacrolimus mostly)

• Lamictal

• Heparin

• VPA

• Spironolactone

Which medical conditions can contribute to hair loss

• Hypothyroid

• Lupus

OTC treatments for alopecia?

• Minoxidil (Rogaine)

RX treatments for Alopecia?

• Finasteride (Propecia)

• Minoxidil PO (mostly see this for HTN)

• Bimatoprost (Latisse) for eyelashes

Finasteride and Bimatroprost both have different formulations for different indications. What are they are what are the different brands you’d use for either?

• Finasteride is used for BPH and Alopecia

  • Proscar = BPH

  • Propecia =Alopecia

• Bimatoprost is used for eyelash growth and glaucoma

  • Latisee= eyelashes

  • Lumigan = glaucoma

How to apply Latisse

• Apply at night to skin at based of upper lashes, do not apply to lower lid

• Single use applicators, can cause infection is reused

What is the medical term for thinning eyelashes

Hypotrichosis

OTC treatment for herpes?

• Lysine for prevention

• Docosonal (Abreva) a topical

Topical RX treatment for Herpes?

Best to do PO antivirals honestly but…

• Acyclovir cream (Zovirax) apply 5x daily for 4 days

• Acyclovir buccal tablets (Sitavig): Apply single dose to upper gum region

• Penciclovir topical (Denavir): Apply Q2H while awake for 4 days

OTC treatment for dandruff?

• Selenium Sulfide (Selsun)

• Pyrithione Zinc (Head & Shoulders)

• Coal Tar (T/Gel)

• Ketoconazole Shampoo 1% (Nizoral A-D) (A-D stands for Anti Dandruff)

How often should OTC Ketoconazole (Nizoral A-D) be applied and for how long?

Up to twice weekly for 8 weeks. If not controlled after that, seek medical advice

Rx treatment for dandruff?

• Ketoconazole shampoo 2% (Nizoral)

OTC options for Diaper Rash?

• Plain Petrolatum

• Petrolatum + Zinc Oxide (Desitin, Buttpaste)

• LOW DOSE hydrocortisone (to minimize discomfort)

Desitin = a DESSICANT, helpful for pulling moisture out of skin!

RX options for diaper rash?

• Clotrimazole, miconazole

• Vusion = Miconazole + zinc oxide +petrolatum

What options can you consider in severe eczema?

Can consider Topical PDE-4 inhibiotrs

• Crisaborole (Eucrisa)

Can consider topical immunomodulators

• Tacrolimus ointment (Protopic)

• Pimecrolmius ointment (Elidel)

Can consider SC/PO immune modulators

• Monoclonal ABs

• JAK inhibitors (the “inibs” like Upcatinib/Rinvoq)

In what special population topical calcineurin inhibitors cannot be used? What’s the risk?

• Avoid/don’t use these in kids, can increase risk of lymphoma and skin cancer

What are the BBWs for JAK inhibitors?

BBW for serious infections, malignancy, thrombosis

Rx for hyperhidrosis

Glycopyrronium (Qbrexa) an anticholinergic

Which conditions would you avoid using anticholinergics b/c they can worsen the condition?

• Glaucoma

• Ulcerative colitis

• Myasthenia gravis

Which fungal infection requires a 20% KOH smear to diagnose?

• Fungal infections of nails

Common names for these infections:

• Tinea pedis?

• Tinea cruris?

• Tinea corporis?

• Tinea capitis?

• Athlete’s Foot: Tinea pedis

• Jock Itch: Tinea Cruris

• Ring Worm: Tinea Corporis

• Ring worm on scalp: Tinea capitis

What does ringworm look like?

Circular red flat sore with raised edges, while middle is not raised

Which is the antifungal ingredient in the following brands:

• Lamisil AT

• Lotrimin Ultra

• Lotrimin AF (cream vs spray)

• Tinactin

• Toeliva

• Lotrisone (2 ingredients)

• Extina

Terbinafine (Lamisil AT)

Butenafine (Lotrimin Ultra)

Clotrimazole (Lotrimin AF cream)

Miconazole (Lotrimin AF spray)

Tolnaftate (Tinactin)

Undecylenic acid (Toeliva)

Betamethasone/Clotrimazole (Lotrisone)

Ketoconazole (Extina)

Counseling points for antifungals?

Apply meds 1-2 inches BEYOND the rash

Use for at LEAST 2-4 weeks even if it appears healed

Reduce moisture in affected areas when possible

Which formulation is best for onychomycosis? Which antifungals are best? What is pulse therapy? How long does it take to work?

• PO antifungals, need systemic effect

• Itraconazole (Sporanox) and Terbinafine (Lamisil)

• Pulse = intermittent therapy to reduce costs and toxicity, but may equal less efficacy

• Can take up to a YEAR for nail bed appearance to improve

Considerations for Itraconazole?

BBW to avoid in Heart failure.

Can cause QT prolongation.

Can be hepatoxic.

Also requires acidic gut for absorption so DO NOT USE with strong antacids

When is it not appropriate to self-treat a vaginal yeast infection?

• If never had one before and haven’t been diagnosed at least once

• Pregnancy, diabetes, HIV, steroid use

• More than 4 infections in one year or symptoms recur within two months

Which OTC test can be used to diagnose a yeast infection.

pH > 4.5, which can be detected with a OTC test kits (Trichomoniasis also presents with this)

OTC treatments for yeast infections? Durations of treatment?

Possible to get 1, 3 or 7 day durations

• Miconazole (Monistat)

• Clotrimazole (Gyne-Lotrimin)

• Yogurt with active cultures may or may not be effective

RX treatment for vaginal yeast infections? What about for recurrent infections?

PO drugs

• Butoconazole (Gynazole -1)

• Fluconazole (Diflucan)

• Oteseconazole (Vivjoa)

What’s the vaccine to prevent HPV? If symptomatic, what RX to treat with?

• Gardasil

• Imiquimod Cream (Aldara, Zyclara)

What are the treatments of hemorrhoids and how do they work? (Which ones shrink hemorrhoids? Which helps with inflammation? Which helps with itching?)

Phenylephrine (Preparation H): Shrinks hemorrhoids and reduces burning/itching. Clean skin first then apply up to 5x daily!

Hydrocortisone (Anusol-HC): Comes in suppositories, reduces itching and inflammation

Witch Hazel (TUCKS): Mild astringent to help with itching

OTC treatment for lice?

Permethrin (Nix)

Prethin/Piperonyl butoxide (Rid)

Ivermectin (Sklice)

Counseling points for treating lice? (Washing hair? how often to use nit comb? Retreatment? How long to leave product on?)

• DO NOT USE CONDITIONER before using lice medicine. Also don’t wash hair for 1-2 days after treatment

• Use nit comb to remove lice every 2-3 days. Retreat on days 7-10 to kill any survivors.

  • Ivermectin doesn’t need retretament its one and done

• Leave product on for at least 10 mins then wash off. (Unless it’s Ovide, which is left on for 12 hours!)

RX treatment for lice?

Malathion lotion (Ovide) can be used in those 6 or older

Special consideration for Malathion lotion? (lice treatment)

FLAMMABLE, also AndroGel is flammable too

Rx treatment for scabies?

• Permethrin (Elimite)

• PO ivermectin (Stromectol)

Lice vs Scabies (Who is primarily affected? Where do the critters attach? What are the critters?)

• Lice =mostly kids, scabies = mostly adults

• Lice attach to hair shaft, scabies burrow under skin

• Lice are insects, scabies = mites

What are the different degrees of burns? Which ones require medical attention

1st = red, painful, minor swelling

2nd = thicker, produces blisters, very painful (go to provider)

3rd = damage to all skin layers, appears white or charred (go to provider, DUH)

Brand name for silver sulfadiazine? What is it used for/why does it help

• Silvadene, SSD

• Topical to reduce infection risk and promote healing in burns

What is the name of the RX used for enzymatic debridement

Santyl = collagenase ointment

OTC for pinworms?

Pyrantel pamoate (Reese’s Pinworm Medicine)

RX for systemic worm infections? Why are they avoided when possible?

The Benzimidazoles (DAZOLES)

• Albendazole

• Mebendazole

• They are anthelmintics. these can mess you up bad and often need to be given with steroids and antiseizure meds

What is the name of the substance that makes us itchy from poison ivy/oak/sumac?

Urushiol

Treatments for poison ivy/oak/sumac?

Aluminum acetate is an astringent (drying agent)

Calamine = most common

Aveeno has colloidal oatmeal

UVA vs UVB?

UVA = Aging

UVB= Burning

TTB equation?

TTB (with sunscreen) = SPF x TTB (without sunscreen)

Physical vs Chemical sunscreens?

Physical = Zinc oxide and titanium oxide, like that stuff lifeguards wear on their nose

Chemical = normal sun screen (oxybenzone, abenzone, etc.)