Dermatological therapies EXAM 1

Topical Antibacterial Agents (class overview)

MOA: Kill bacteria or prevent growth/multiplication | Indication: Superficial skin infections (folliculitis, impetigo) | AE: Itching, burning, allergic contact dermatitis

Bacitracin and Gramicidin

MOA: Peptide antibiotics active against gram-positive organisms | Indication: Prevent infection after a burn; superficial skin infections; often combined with polymyxin/neomycin | Available: Bacitracin OTC ointment; Gramicidin Rx

Mupirocin (Bactroban)

MOA: AB that Inhibits bacterial protein synthesis of gram-positive organisms | Indication: Superficial skin infections; effective against MRSA | Available: Rx cream/ointment

Retapamulin (Altabax)

Topical AB: MOA: AB that is a protein synthesis inhibitor active against gram-positive organisms | Indication: Superficial skin infections | Available: Rx ointment only

Polymyxin B Sulfate (Polysporin)

MOA: Cyclic hydrophobic peptide that disrupts gram-negative cell membranes | Indication: Superficial skin infections | Available: OTC ointment | Note: 'Double AB'=polymyxin+bacitracin; 'Triple AB'=neomycin+bacitracin+polymyxin

Neomycin and Gentamicin

MOA: Aminoglycosides that interfere with bacterial protein synthesis (gram-negative, Neomycin also some gram-positive) | Indication: Superficial skin infections | AE: Neomycin is a common topical sensitizer | Available: Rx cream/ointment

Topical Antifungal Agents (class overview)

MOA: Varies by class | Indication: Dermatophytosis (tinea), Malassezia, cutaneous/mucosal candidiasis, onychomycosis | AE: Local irritation, burning, erythema, itching, possible contact dermatitis

Topical Azole Derivatives (Clotrimazole, Econazole, Ketoconazole, Miconazole, Oxiconazole, Sertaconazole, Sulconazole)

MOA: Inhibits ergosterol synthesis, disrupts fungal cell membrane | Indication: Tinea infections and candidiasis | AE: local irritation

Ciclopirox Olamine (Loprox)

MOA: Chelates metal ions needed for fungal enzymes | Indication: Mostly onychomycosis | AE: Small potential for allergic contact dermatitis | Available: Cream, lotion, nail lacquer, shampoo

Tavaborole (Kerydin)

MOA: First oxaborole antifungal; inhibits fungal protein synthesis | Indication: Toenail onychomycosis (daily x48 weeks, cure rate only 6.5-9.1%) | Available: Solution

Allylamines: Naftifine and Terbinafine (Lamisil)

MOA: Selective inhibition of squalene epoxidase, blocks ergosterol biosynthesis | Indication: Tinea infections | AE: Local irritation, avoid mucous membranes | Available: Cream, gel, solution

Butenafine (Lotrimin Ultra)

MOA: Selective inhibition of squalene epoxidase, disrupts cell wall membrane | Indication: Superficial dermatophytosis | AE: minimal | Available: OTC cream

Tolnaftate (Tinactin)

MOA: Distorts hyphae, stunts mycelial growth of dermatophytes; P. orbiculare (NOT active against Candida) | Indication: Tinea pedis, cruris, corporis | AE: rare irritation or allergic contact dermatitis | Available: OTC cream, solution, powder

Nystatin and Amphotericin B

MOA: Bind ergosterol, disrupt fungal cell membrane | Nystatin Indication: Cutaneous/oral candida (toxic if given parenterally); oral suspension, cream, troches, vaginal tab | Amphotericin B: Drug of choice for systemic mycoses but HIGHLY nephrotoxic with infusion reactions; water-soluble solution NOT for oral/IM use

Oral Azole Derivatives (Fluconazole, Itraconazole, Posaconazole)

MOA: Inhibits ergosterol biosynthesis, disrupts fungal membrane | Indication: Candida and dermatophyte infections | AE: Nausea, headache, rash; Itraconazole: cardiac suppression, liver impairment, peripheral neuropathy

Terbinafine (oral, Lamisil)

MOA: Selective inhibition of squalene epoxidase, which blocks biosynthesis of ergosterol | Indication: Onychomycosis (250mg daily; 6wks fingernails, 12wks toenails) | AE: Headache, hepatic dysfunction

Griseofulvin

MOA: Disrupts the mitotic spindle, inhibits fungal mitosis | Indication: Tinea capitis x1 month; nails 6-12 months | AE: Headache, nausea, skin reactions, hepatic impairment

Acyclovir, Valacyclovir, Penciclovir, Famciclovir

MOA: Inhibits viral DNA polymerase, causes chain termination | Indication: Recurrent HSV-1/HSV-2, herpes zoster | AE: Pruritus, mild stinging | Available: Cream

Imiquimod (Aldara)

MOA: Induces cytokine production, intensifies immune response to HPV | Indication: Genital warts | AE: Local inflammation, pruritus, erythema | Available: Cream (Aldara)

Tacrolimus (Protopic) and Pimecrolimus (Elidel)

MOA: Attenuates local immune response by decreasing release of inflammatory mediators | Indication: Atopic dermatitis | AE: Erythema, pruritus, burning | Available: Tacrolimus-ointment; Pimecrolimus-cream

Permethrin

MOA: Kills mite/lice by disrupting nerve traffic, causing paralysis | Indication: Pediculosis and scabies | AE: Burning, stinging, pruritus | Available: Cream, cream rinse (Nix, OTC)

Spinosad

Ectoparasitic: MOA: Neurotoxic to lice, leads to paralysis and death | Indication: Pediculosis capitis | AE: Local irritation | Note: Only 1 application needed

Ivermectin (ectoparasiticide)

MOA: Disrupts nerve and muscle function of the parasite | Indication: Pediculosis and scabies | AE: Headache, abdominal pain | Available: Topical and oral

Lindane

MOA: Attacks nervous system, causes convulsions/death in the mite | Indication: 2nd-line for pediculosis and scabies | AE: Can cause convulsions (neurotoxic) | Available: Shampoo or lotion

Crotamiton (Eurax)

MOA: Disrupts metabolic processes of scabies | Indication: Scabies | AE: Allergic contact dermatitis, primary irritation | Available: Cream or lotion

Malathion (Ovide)

MOA: Organophosphate cholinesterase inhibitor | Indication: Pediculosis capitis | AE: Scalp irritation | Available: Lotion

Benzyl Alcohol (Ulesfia)

MOA: Blocks breathing of the lice | Indication: Pediculosis capitis | AE: Eye irritation, allergic contact dermatitis possible | Available: Lotion

Hydroquinone, Monobenzone, and Mequinol

MOA: Inhibits tyrosinase, interferes with melanin biosynthesis | Indication: Hydroquinone/Mequinol=temporary lightening (melasma, lentigos); Monobenzone=permanent depigmentation (vitiligo) | AE: Local irritation, allergic contact dermatitis, long-term use possibly carcinogenic | Available: Combination preparation (hydroquinone, fluocinolone acetonide and retinoic acid-Tri Luma)

Trioxsalen and Methoxsalen

MOA: Psoralens that stimulate melanocytes to repigment depigmented macules of vitiligo; must be photoactivated by long-wavelength UVA | Indication: Vitiligo | AE: Cataracts and skin cancer possible with long-term use | Available: Oral tablets

UVA Radiation

penetrates deep into the dermis, leads to drug reactions and aging, can lead to skin cancer

UVB radiation

penetrates only into the epidermis, can lead to skin cancer

Organic (Chemical) Sunscreen

MOA: Absorbs UV radiation | Most sunscreens are organic; most absorb UVB only, some absorb UVA too | Need both UVA+UVB coverage for full-spectrum protection

Inorganic (Physical) Sunscreen

MOA: Scatters/reflects UV radiation | Only two agents: Titanium dioxide and Zinc oxide

Sun Protective Factor (SPF)

Index of protection against UVB ONLY | Relationship between SPF and sunburn protection is NOT linear (SPF30 is not double SPF15) | As SPF increases, marginal protection gets smaller | Look for 'broad spectrum' label for UVA+UVB | Water-resistant (not waterproof) with a stated duration

Clindamycin, Erythromycin, Minocycline (topical, for Acne)

MOA: Antibacterial and anti-inflammatory properties, interferes with bacterial growth | Indication: Mild acne | AE: Local irritation, burning, erythema | Available: Cream, gel, lotion, solution

Metronidazole (topical)

Class: Nitroimidazole | MOA: Antibacterial, believed to be anti-inflammatory | Indication: Papulopustular rosacea | AE: Local irritation, burning, erythema | Available: Cream, gel

Sodium Sulfacetamide

Class: Sulfa antibiotic | MOA: Interferes with bacterial growth | Indication: Inflammatory acne | AE: Contact dermatitis, erythema | Available: Cleanser, cream, foam, gel, lotion, pads, suspension, wash

Dapsone (for Acne)

Class: Sulfone | MOA: Modest anti-inflammatory effect | Indication: Inflammatory acne | AE: Transient oiliness, dryness, erythema

Systemic Tetracyclines

MOA: Inhibits bacterial protein synthesis | Indication: Moderate to severe acne | AE: GI upset (nausea, vomiting, diarrhea), photosensitivity

Systemic Sulfa Drugs

MOA: Block bacterial folate synthesis | Indication: Moderate to severe acne | AE: Hypersensitivity reactions incl. Stevens-Johnson syndrome, photosensitivity

Topical Retinoic Acid Derivatives (for Acne)

MOA: Vitamin A derivative, normalizes keratinocyte growth to prevent clogged pores | Indication: Moderate to severe acne | AE: Erythema, desquamation, burning | Available: OTC/Rx creams, gels, lotions, serums

Isotretinoin (Accutane)

MOA: vitamin A derivative, normalizes keratinocyte growth to prevent clogged pores. Synthetic retinoid; inhibits sebaceous gland size/function, inhibits P. acnes, keratolytic, anti-inflammatory | Indication: Severe cystic/scarring or recalcitrant acne (last resort) | AE: Dryness, sun sensitivity, epistaxis, vision changes, cheilitis, depression, myalgia, high cholesterol, hepatitis, pseudotumor cerebri | Contraindication: Pregnancy (highly teratogenic) - requires iPLEDGE

Benzoyl Peroxide (for Acne)

MOA: Oxidizes C. acnes (antibiotic AND keratolytic) | Indication: Mild to severe acne | AE: Dry skin, irritation | Available: OTC washes, foams, creams, gels

Azelaic Acid

MOA: Inhibits protein synthesis of C. acnes (keratolytic) | Indication: Mild to severe acne AND rosacea | AE: Stinging, burning, pruritus, hypopigmentation | Available: OTC creams, gels, foams, serums

Aldactone (Spironolactone) for Acne

MOA: Aldosterone antagonist, decreases androgen-mediated sebum production | Indication: Moderate to severe acne in AFAB patients | AE: Menstrual irregularities, breast tenderness | Available: Pill

Oral Contraceptives (for Acne)

MOA: Estrogen+progestin combo reduces androgen and sebum production | Indication: Moderate to severe acne in AFAB patients | AE: Irregular bleeding, thromboembolism, headaches, breast tenderness| Available: pill, transdermal patch, vaginal ring

Ivermectin (Soolantra) for Rosacea

MOA: Antiparasitic; MOA for rosacea unknown, possibly lethal effect on Demodex (skin mite) | Indication: Papulopustular rosacea, inflammatory lesions | AE: Burning, skin irritation | Available: Cream

Brimonidine (Mirvaso) for Rosacea

MOA: Adrenoceptor agonist, causes vasoconstriction | Indication: Rosacea - telangiectasia, erythema | AE: Burning, flushing, localized warm feeling | Available: Cream

Acitretin (Oral Retinoid)

MOA: Normalizes keratinocyte differentiation, reduces hyperproliferation/inflammation | Indication: Plaque psoriasis | AE: Cheilitis, pruritus, peeling skin | Contraindication: Pregnancy - very long half-life, no pregnancy for 3 years after last dose; monitor lipids/LFTs

Methotrexate

MOA: Cytotoxic agent, sensitivity to high-growth-fraction cells | Indication: Severe psoriasis, rheumatoid arthritis | AE: Nausea, diarrhea, mucosal ulcers, leukopenia, liver damage | Monitor: LFTs | Available: pill

Tazarotene (Tazorac)

MOA: Vitamin A derivative, binds retinoic acid receptors to normalize skin cell differentiation | Indication: Psoriasis | AE: Burning/stinging; teratogenic if applied to >20% of body | Available: Cream and gel

Vitamin D Analog: Calcipotriene and Calcitriol

MOA: Inhibits keratinocyte proliferation, enhances differentiation, inhibits inflammation | Indication: Topical treatment for psoriasis | AE: Hypercalcemia, dry skin, burning | Available: Cream, ointment, solution, foam

Biologic Agents for Psoriasis

MOA: TNF-alpha inhibitors, Cytokine inhibitors (Anti-IL-12/23), Anti-IL-17A | Indication: Moderate-severe psoriasis | AE: Immunosuppression/infection risk (less liver/kidney/marrow toxicity than other systemics) | Given SubQ or IV

TNF-alpha inhibitors

Adalimumab, Etanercept, Infliximab

Cytokine inhibitors (Anti-IL-12/23)

Ustekinumab, Guselkumab, Risankizumab

Anti-IL-17A

Ixekizumab, Secukinumab, Brodalumab

Apremilast (Otezla)

MOA: Oral PDE4 inhibitor, reduces inflammatory mediators | Indication: Moderate to severe plaque psoriasis | AE: GI complaints, headaches, weight loss | Available: Pill

Cyclosporine

MOA: Immunosuppressant, inhibits B-cell and T-cell proliferation | Indication: Severe, recalcitrant plaque psoriasis after failing 1 systemic therapy | AE: Renal damage | Available: Pill

Topical Corticosteroids

MOA: Bind intracellular corticosteroid receptors; anti-inflammatory, antiproliferative, immunosuppressive, vasoconstrictive | Indication: Contact/allergic dermatitis, psoriasis, lichen planus, inflammatory dermatoses | AE: Skin atrophy, striae, acneiform eruptions, hypopigmentation, increased intraocular pressure, rare systemic effects (more common in children). Consider severity of condition, extent of involvement, area of body and duration of treatment.

Topical Corticosteroid Vehicles

Ointment: most effective/penetrating, avoid on thin skin (axilla, groin, face) | Cream: patient-preferred, more drying | Gel: good for hairy/drying areas, dries quickly | Lotion: good for hairy areas needing lubrication | Shampoo: scalp | Foam: easy scalp application, alcohol base may burn

Topical Corticosteroid Potency Ranking

Low potency (hydrocortisone base or acetate 0.25% to 2.5%) -> Intermediate potency (triacinolone acetonide 0.1% to 0.2%) -> High potency (betamethasone dipropionate augmented 0.05%) -> Very High potency (clobetasol propionate 0.05%) | Choose based on severity, body area, and duration of treatment

Crisaborole (Eucrisa)

MOA: Nonsteroidal topical anti-inflammatory PDE4 inhibitor | Indication: Mild to moderate atopic dermatitis | AE: Burning and stinging | Available: Ointment

Tar Compounds

MOA: Suppress DNA synthesis, mitotic activity, cell proliferation | Indication: Psoriasis, dermatitis, lichen simplex chronicus | AE: Irritation, unpleasant odor, staining | Available: OTC (Neutrogena T/Derm, Duplex T)

Salicylic Acid (keratolytic)

MOA: Promotes desquamation of keratotic debris | Indication: Acne, seborrheic dermatitis, psoriasis, keratosis pilaris, wart removal | AE: Irritation, burning, stinging | Contraindication: Salicylate allergy

Propylene Glycol

MOA: Solvent/humectant; increases hydration of outer skin layers by drawing water from inner layers | Indication: Ichthyosis, psoriasis, keratosis pilaris, lichen planus | Available: OTC liquid

Urea

MOA: Emollient and keratolytic effects; softens hyperkeratotic areas, increases water content of stratum corneum | Indication: Ichthyosis, hyperkeratosis (palms/soles), xerosis, keratosis pilaris

Podophyllum Resin and Podofilox

MOA: Cytotoxic agent | Indication: Condyloma acuminatum | AE: Can cause severe irritation | Note: Use 3x/week, max 4 weeks; wash off 3-4 hrs after first application

Sinecatechins (Veregen)

MOA: Made from green tea leaves, mechanism unknown | Indication: Condyloma acuminatum (>18 years old) | Note: Can use 3x/day up to 16 weeks

Fluorouracil (5-FU)

MOA: Interferes with DNA synthesis | Indication: Multiple actinic/solar keratoses, superficial BCC (last resort) | AE: Erythema, scabbing, crusting, erosion, then re-epithelialization over 3-4 weeks

Ingenol Mebutate

MOA: Unknown | Indication: Topical treatment of actinic keratosis | AE: Erythema, flaking, scaling | Available: Gel

NSAIDs - Diclofenac (topical)

MOA: Unknown | Indication: Topical treatment of actinic keratosis | AE: Redness, itching, peeling skin | Available: Gel

Aminolevulinic Acid

MOA: Photosensitizing agent | Indication: Used with photodynamic therapy to treat actinic keratosis | AE: Tingling, stinging | Available: Special applicator, provider-applied

Doxepin (Zonalon)

MOA: Topical antihistamine cream | Indication: Used with other topicals for atopic dermatitis/pruritic conditions | Contraindication: Cannot use with MAOIs, narrow-angle glaucoma, or urinary retention

Pramoxine

MOA: Topical anesthetic, temporary relief from itching | Indication: Pruritus | Available: Cream, foam, lotion, solution | Note: Often combined with hydrocortisone

Anti-Seborrhea Agents - Mild Dermatitis/Dandruff

Treatment: Antifungal shampoo (OTC) 2-3x/week - Ketoconazole, ciclopirox, zinc pyrithione, selenium sulfide

Anti-Seborrhea Agents - Moderate to Severe

Treatment: Antifungal shampoo WITH topical steroids

Anti-Seborrhea Agents - Severe/Refractory or Non-Scalp

Oral antifungals

Anti-Seborrhea Agents - Non-Scalp seborrheic dermatitis

Face: low-potency topical corticosteroids +/- topical antifungal | Trunk: topical antifungal +/- topical corticosteroid

Minoxidil (Rogaine)

Trichogenic: MOA: Not well understood, promotes hair growth | Indication: Vertex balding | AE: Erythema and pruritus | Note: Stopping this med leads to loss of gained hair (not permanent)

Finasteride (Propecia)

MOA: 5-alpha-reductase inhibitor for androgenetic alopecia; prevents hair loss, promotes growth | Indication: Alopecia in men | AE: Decreased libido

Bimatoprost (Latisse)

MOA: Prostaglandin analog, treats hypotrichosis of eyelashes | Indication: Eyelash hypotrichosis, applied nightly to upper eyelid margin | AE: Irritation, skin pigmentation, conjunctival hyperemia