Anti-Fungals, Anti-Virals, Steroids

treatment- antifungals

-topical: maximize systemic absorption, minimize systemic side effects, takes ~20 minutes for the medications to be absorbed through mucosa → no eating or drinking

-systemic: provides systemic therapy

-for oral infections, antifungals should be given for 2-3 weeks minimally

antifungals- topicals and systemics

-topicals: nystatin (mycostatin oral suspension), clotrimazole (mycelex oral troches)

-systemics: fluconazole (Diflucan tablets)

nystatin

-generic name: nystatin

-trade name: mycostatin oral suspension

-nystatin oral suspension 100,000u/mL

-dispense 8oz (240mL)

-1 teaspoon (5mL), qid after meals and h.s. as a 2 minute rinse and expectorate, for 2 wks

nystatin adverse reaction

-nausea

-diarrhea

-vomiting with large dose

-no known drug interactions

nystatin advantages

-very safe and effective (has been available for more than 40 years)

-dentures can be soaked in the solution overnight (in case of denture stomatitis)

-poorly absorbed- no reason to swallow → minimal systemic side effect

nystatin disadvantages

-least effective

-patient compliance may be compromised- requires pts to carry a bottle and teaspoon

-high sucrose content with risk of caries (especially in xertostomia-induced candidiasis)

azole antifungals

-include mycelex, diflucan, and more

-efficacy improves from mycelex to diflucan

-all have potential harmful liver effects

-diflucan are involved with the cytochrome p450 system

Mycolog II

-generic name: nystatin + triamcinolone 0.01% ointment/cream

-trade name: Mycolog II

-Mycolog II, dispense 15g tube, apply tid until healing occurs

Mycolog II ointment

-for angular cheilitis

-antifungal with steroids

-no antibacterial property

Mycelex Troches

-generic name: clotrimazole

-trade name: mycelex oral troches (lozenge)

-Mycelex oral troches 10mg, dispense 60, slowly dissolve 4 per day (one after each meal and one at bedtime), for 2 weeks

mycelex troches adverse reactions

-mild elevations of liver enzymes in 15% of patients- periodic liver function test in patients with hepatic impairment

-n/v

-no known drug interactions

mycelex troches advantages and disadvantages

-advantages: very safe with minimal systemic absorption and few side effects, more effective than nystatin

-disadvantages: patient compliance- must dissolve 4 per day in mouth

clotrimazole cream

-generic name: clotrimazole topical cream

-trade name: lotrimin

-clotrimazole 1% cream, dispense 1 small tube, apply a thin amount to affected area bid, for 10 days

clotrimazole cream use

-for angular cheilits

-antifungal

-clotrimazole also has antibacterial properties

lotrisone cream

-generic name: clotrimazole + betamethasone

-trade name: lotrisone cream

-lotrisone cream, dispense 15g tube, apply a thin amount to affected area bid, for 10 days

lotrisone cream uses

-for angular cheilitis

-antifungal with steroids

fluconazole

-generic name: fluconazole

-trade name: diflucan tablets

-diflucan tablets 100mg, dispense 15 tabs, 2 tablets on day 1 and then 1 tablet daily for 2 weeks

fluconazole adverse reaction and drug interactions

-adverse reaction: rare cases of hepatotoxicity, ranging from mild transient elevation of liver enzymes to hepatic failure, headache, n/v, abdominal pain, diarrhea

-drug interactions: potentiates the effects of phenytoin (Dilantin, antiseizure med), warfarin compounds (anticoagulants), sulfonylureas (oral hypoglycemic agents)

fluconazole advantages and disadvantages

-advantages: more effective than nystatin or mycelex, well-absorbed systemically, relatively long half-life- once daily dosing (ready patient compliance), liver toxicity is rare at the doses used to treat oral candidiasis

-disadvantages: may develop resistance to the drug: not appropriate for long-term preventive therapy, drug interactions

primary herpetic gingivostomatitis

-best treated symptomatically

-topical spray: 0.5 or 1.0% dyclonine hydrochloride, temporarily decrease the mucosal discomfort

-tetracycline lollipops: rapid numbing of the affected mucosa

-NSAIDs to alleviate the discomfort

-*avoid viscous lidocaine (lidocaine-induced seizures) and topical benzocaine (association with methemoglobinemia) in ped patients

-instruct the pt to restrict contact with active lesion- autoinoculation of the eyes and repeated reinfection from recurrences can result in permanent damage and blindness

primary herpetic gingivostomatitis- if diagnosed during the first 3 symptomatic days

-acyclovir suspension 200mg/5mL, rinse-and-swallow, 5x daily for 5 days (children: 15mg/kg up to the adult dose of 200mg)

-suspension: maximizes the local exposure and by swallowing- increases bioavailability

-associated eating and drinking difficulties, pain, healing time, duration of fever, viral shedding are shortened dramatically

recurrent herpes labialis

-penciclovir cream 1%: apply thin film every 2 hours during the day for 4 days, available in a base that allows increased absorption through the skin of the lips (better absorption than acyclovir ointment), reduction in healing time and pain, best result when initiated during the prodrome

-OTC formulations: 10% n-docosanol cream, acyclovir cream 5%, not as effective as penciclovir

to suppress or minimize recurrences

-valacyclovir 500mg

-take 2g when prodromal symptoms are recognized, and 2g 12 hours later

-if recurrences associated with dental procedures- take 2g twice on the day of the procedure and 1g twice the next day

-acyclovir 400mg- 5x daily for 5 days

for prophylactic short-term use

-if individuals have known trigger that extends over a period of time:

-acyclovir 400mg, twice daily

-valacyclovir 1g, daily

-famciclovir 250mg twice daily

-*reduce the prevalence and severity of trigger associated recurrence

long-term suppression of recurrences with an antiviral medication is reserved for

-those with more than 6 recurrences per year

-those suffering from HSV-triggered erythema multiforme

-immunocompromised

recurrent intraoral herpes infection

-not very painful- most patients do not require treatment

-chlorhexidine- seems to exert antiviral effect

-acyclovir function synergistically with chlorhexidine

corticosteroids

-topical: spray-on steroids (Q-var), liquid steroids (dexamethasone), creams and gels (lidex, temovate)

-systemic corticosteroids: dexamethasone elixir, prednisone

Q-Var (beclomethasone dipropionate) aerosol spray 40 or 80

-for lesions in hard-to-reach areas (ie, tonsilar pilar)

-Q-Var spray 40 or 80, dispense one canister, 2 puffs qid, after meals and h.s.

dexamethasone elixir 0.5/5mL

-for diffuse/multifocal lesions (cover large surface area)

-mildest of all topical steroids

-dexamethasone elixir 0.5/5mL, dispense 240mL, 1tsp, qid, after meals and h.s. as a 2 minute rinse and expectorate (rinse-and-spit)

lidex cream 0.05% (fluocinonide)

-for localized lesions: moderate strength topical steroid, remember to use cream not gel, creams adhere better to moist surfaces

-lidex gel 0.05%, dispense one small tube, 1-2 thin applications per day, after meals

temovate cream 0.05% (clobetasol propionate)

-for localized lesions: strongest topical steroid

-temovate cream 0.05%, dispense one small tube, 1-2 thin applications per day, after meals

topical corticosteroids

-minimal systemic absorption- minimal to no adverse events

-long-term use of topical steroids can result in oral candidiasis → instruct the pt to not use them more than 2 weeks at a time, monitor for candidiasis (red/white lesions, burning sensation)

prednisone tablets

-for most of vesiculoulcerative lesions, including major aphthae

-most potent

-prednisone 5mg, dispense 80

-directions: take 10 the first day (50mg), 6 for the next 7 days (30mg), 3 for 7 days (15mg), 1 for 7 days (5mg)

-take all tablets together in the morning with food

-patients should be tapered off

prednisone tablets for minor and herpetiforme aphthae

-predinose 5mg

-dispense 20

-directions: 4 per day for 2 days (20mg), 3 per day for 2 days (15mg), 2 per day for 2 days (10mg), 1 per day for 2 days (5mg)

prednisone tablets- side effects associated with long-term use

-DM

-adrenal suppression

-weight gain

-osteoporosis

-peptic ulcers

-severe mood swings

-increased susceptibility to a wide range of infections- including candidiasis (more steroid ~ increased risk of candidiasis)