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KPhA’s 133rd Annual Meeting
and Trade Show
1
DermatologySeptember 21, 2013
Emily Prohaska, Pharm.D.
KPhA’s 133rd Annual Meeting and Trade Show“Be the Critical Link”
DoubleTree by Hilton HotelOverland Park, Kansas
Disclosures
• Dr. Prohaska has no disclosures to report.
3
Learning Objectives
1. Identify the presentation of common dermatologic conditions based on physical description or appearance.
2. Select safe and effective over-the-counter and/or prescription products to treat common dermatologic conditions.
3. Assess patient-specific information such as age and concurrent disease states to determine if the patient may effectively self-treat or needs to be referred to another healthcare provider.
4. Recognize when patients should initiate, switch, or modify treatment regimens for topical or oral pharmacologic agents.
5. Develop an appropriate treatment plan for a given patient case, including pharmacologic and non-pharmacologic therapy.
4
Getting Started
Skin Structure
6
www.aocd.org/?page=SkinFacts
Types of Skin Lesions
7
http://www.faqs.org/health/Body-by-Design-V1/The-Integumentary-System-Ailments-what-can-go-wrong-with-the-integumentary-system.html
Estimating Body Surface Area
8
http://www.mdcalc.com/parkland-formula-for-burns http://vitualis.wordpress.com/2007/02/26/the-fingertip-unit-of-topical-steroids/
Structured Assessment:
QuEST-SCHOLAR MAC• Provider consultation▫ Quickly and accurately assess the patient▫ Establish that the patient is an appropriate self-care candidate▫ Suggest appropriate self-care strategies▫ Talk with the patient
• Gather information from the patient▫ Symptoms: What are the main and associated/related symptoms?▫ Characteristics: What are the symptoms like?▫ History: What has been done so far? Has this ever happened and what was successful?▫ Onset: When did this particular problem start?▫ Location: Where is the problem?▫ Aggravating factors: What makes it worse?▫ Remitting factors: What makes it better?
▫ Medications: prescription and nonprescription medications, natural products, and trade-name and generic products
▫ Allergies: medication and other types of allergies▫ Conditions: other medical conditions
9
Irritant and Allergic Contact
Dermatitis
Patient Case 1
• John is an 18-year-old male who returned today from a camping trip with his fraternity brothers. He presents to the pharmacy with linear streaks of vesicles on his calves and ankles. He also states that his groin is involved and notes, “Don’t ask.” He believes the rash is due to poison ivy and wants to know if he can purchase something over the counter or if he needs to go to an urgent care clinic. He has exercise-induced asthma and uses albuterol PRN, but does not regularly take any other medications. Which of the following is the best treatment course to recommend for John?A. Self treat; hydrocortisone 1% ointment, aaa TIDB. Refer to provider; methylprednisolone 4 mg dosepak, tud x 6
daysC. Refer to provider; prednisone 10 mg, taper x 21 daysD. Refer to provider; triamcinolone 0.1% cream, aaa BID
11
Overview• Irritant Contact Dermatitis (ICD)▫ Caused by exposure to an irritant
� Chemicals, solvents, detergents
▫ Can occur within minutes—weeks
▫ More likely to occur in persons with a history of atopic dermatitis
• Allergic Contact Dermatitis (ACD)▫ Caused by exposure to an allergen
� Most commonly urushiol
� May also be caused by metals, fragrances, cosmetics
▫ Re-exposure to allergen leads to allergic reaction
12
Symptoms• Inflammation• Erythemous rash or bumps• Formation of vesicles or pustules• Itching• Pain or tenderness• Urushiol-Induced ▫ Itching and erythema progressing to blisters or bullae▫ Crusting occurs after several days
13
ICD vs. ACD
Feature/
CharacteristicACD ICD
LocationExposed areas, often the hands
Usually the hands
Symptoms Primarily pruritusBurning, stinging, pruritis, pain
BordersDistinct lines and borders
Less distinct
Time to symptom development after exposure
Days Minutes to hours
Mechanism of symptom development
Immune reactionDirect damage to exposed tissues
14
Clinical Presentation—ICD
15
Images taken from: http://www.mayoclinic.com/health/dermatitis/DS00543&slide=4http://emedicine.medscape.com/article/1049353-overview
http://www.skinsight.com/images/dx/webAdult/irritantContactDermatitis_34209_med.jpg
Clinical Presentation—ACD
16
Images taken from:: http://www.mayoclinic.com/health/dermatitis/DS00543&slide=2http://www.drreddy.com/ivyrash1.jpg
http://www.consultantlive.com/skin-diseases/content/article/10162/1658680?pageNumber=3http://images.suite101.com/724220_com_allergic_c.jpg
Self-Treatment Exclusions• < 2 years of age
• > 25% involvement of body surface area
• Swelling of eyes, body, or extremities
• Discomfort in genital region due to itching, redness, swelling, or irritation
• Involvement of mucous membranes of mouth, eyes, nose, or anus
17
Non-Pharmacologic Therapies• Wash exposed areas with water and cleanse with mild soap as soon as possible
• Wear protective clothing or gloves to limit exposure
▫ Change often to avoid skin occlusion
• Practice good handwashing technique
• Cool or lukewarm showers to relieve itching
18
Non-Prescription Pharmacologic Therapy• Mild dermatitis▫ Shake lotion containing calamine, menthol, and/or phenol � Apply every 4 hours as needed
▫ Hydrocortisone cream or ointment� Apply 3-4 times daily for up to 7 days
▫ Sodium bicarbonate paste, soaks, compresses� Apply directly to rash for 20-30 minutes as needed
▫ Oral antihistamines� Use at bedtime to relieve itching
19
Non-Prescription Pharmacologic Therapy• Moderate-severe dermatitis
▫ Aluminum acetate solution
� Add 1 tablet or package to 1 pint cool water
� Soak 15-30 minutes tid or apply compresses PRN
▫ Colloidal oatmeal baths
� One packet (30 grams) per tubful
� Soak 15-20 minutes once or twice daily
• Severe dermatitis
▫ Requires referral to provider
20
Urushiol-Specific Non-Prescription
Pharmacologic Treatments• Tecnu® Outdoor Skin Cleanser
▫ Use as soon as possible after exposure
▫ Cleanse for at least 2 minutes
• IvyBlock® (bentoquatam)
▫ FDA-approved organoclay to protect against poison ivy/oak/sumac exposure
▫ Apply at least 15 minutes before exposure, reapply every 4 hours
21
Prescription Pharmacologic Therapy
• Topical corticosteroids▫ High potency agents (eg, clobetasol)
• Oral corticosteroids (ACD)▫ Useful when face or groin is involved and topical agents cannot be used
• Injectable corticosteroids (ACD)▫ For patients who cannot tolerate or comply with other routes
• Systemic antibiotics for secondary infection▫ Target Gram-positive coverage
22
Topical Corticosteroids:
Very/Super High Potency
Drug NameBrand Name(s)®
Vehicle Strength Generic
Betamethasone dipropionate, augmented
Diprolene G, L, O 0.05% Yes
ClobetasolClobex*, Cormax, Olux, Temovate
C, F, G, L, O, Sh, So, Sp
0.05% Yes*
Diflorasonediacetate
Apexicon,Psorcon
O 0.05% Yes
Fluocinonide Vanos C 0.1% No
Flurandrenolide Cordran T 4 mcg/cm2 No
Halobetasol Ultravate C, O 0.05% Yes
23
C=Cream; F=Foam; G=Gel; L=Lotion; O=Ointment; Sh=Shampoo; So=Solution; Sp=Spray; T=Tape*: Preparation not available as a generic product
Topical Corticosteroids:
High Potency
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Drug Name Brand Name(s)® Vehicle Strength(s) Generic
Amcinonide Amcort; Cyclocort C, L, O 0.1% Yes
Betamethasone dipropionate
Diprolene; Diprosone C, L, O 0.05% Yes
Desoximetasone Topicort C, G^, O0.25%, 0.05%^
Yes
Diflorasonediacetate
ApexiCon, Florone C, O 0.05% Yes
Fluocinonide Lidex C, G, O, So 0.05% Yes
Halcinonide Halog C, O 0.1% No
Triamcinolone acetonide
Kenalog; Triderm C, O 0.5% Yes
C=Cream; G=Gel; L=Lotion; O=Ointment; So=Solution^: Vehicle supplied as indicated strength
Topical Corticosteroids:
Medium Potency
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Drug NameBrand Name(s)®
Vehicle Strength(s) Generic
Betamethasone valerate
Luxiq C, F^, L, O0.01%; 0.12%^
No
Clocortolonepivalate
Cloderm C 0.1% No
Desoximetasone Topicort C 0.05% Yes
Fluocinolone Synalar C, O 0.025% Yes
Fluocinonide Lidex C, G, O, So 0.05% Yes
Fluticasone propionate
Cutivate C, O^, L0.005%^; 0.05%
Yes
C=Cream; F=Foam; G=Gel; L=Lotion; O=Ointment; So=Solution^: Vehicle supplied as indicated strength
Topical Corticosteroids:
Medium Potency (cont’d)
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Drug NameBrand Name(s)®
Vehicle Strength(s) Generic
Hydrocortisone butyrate
Locoid C, L, O, So 0.1% Yes
Hydrocortisone valerate
Westcort C, O 0.2% Yes
Mometasone Elocon C, L, O, So 0.1% Yes
Prednicarbate Dermatop C, O 0.1% Yes
Triamcinolone acetonide
Kenalog C, L, O, Sp^0.147%^; 0.025%; 0.1%
Yes
C=Cream; G=Gel; L=Lotion; O=Ointment; So=Solution; Sp=Spray^: Vehicle supplied as indicated strength
Topical Corticosteroids:
Low Potency
27
Drug NameBrand Name(s)®
Vehicle Strength(s) Generic
Alcometasonedipropionate
Aclovate C, O 0.05% Yes
DesonideDesonate, DesOwen, Verdeso*
C, F, G, L, O 0.05% Yes*
Fluocinoloneacetonide
Capex, Derma-Smoothe/FS
C, Oi, Sh, So 0.01% Yes
HydrocortisoneCortaid, Cortizone, U-cort
C, O, L^0.5%, 1%, 2.5%^
Yes
C=Cream; G=Gel; L=Lotion; O=Ointment; Oi=Oil; So=Solution; Sp=Spray*: Preparation not available as a generic product^: Vehicle supplied as indicated strength
Oral Corticosteroid Comparison
DrugEquivalent
DoseDuration of
ActionMineralocorticoid
Activity
Cortisone 25 mg Short ++
Dexamethasone 0.75 mg Long No
Hydrocortisone 20 mg Short ++
Methylprednisolone 4 mg Intermediate No
Prednisolone 5 mgIntermediate(12 – 24 hours)
+
Prednisone 5 mgIntermediate(12 – 24 hours)
+
28
Counseling Points• Treatment involves identifying the causative agent
• Avoid use of topical “caine-type” anesthetics, topical antihistamines, and topical antibiotics
• Urushiol can remain active for long periods of time on inanimate objects or pet fur
• Resolution of CD will occur in one to three weeks with or without treatment
29
Atopic Dermatitis
Overview• Part of the atopic triad
• Chronic, relapsing skin disorder
▫ Most commonly develops before age 5
▫ Stratum corneum contains less moisture than normal skin
• Caused by genetic and environmental factors
▫ Irritants, allergens, climate
• Can affect any area of the body
31
Symptoms
• Papules and vesicles
• Intense itching
• Redness and chapping of the skin
• Crusting and scaling may also occur
32
Clinical Presentation
33
Images taken from: http://www.mayoclinic.com/health/medical/IM02939, http://www.webmd.com/skin-problems-and-treatments/slideshow-common-adult-skin-problems, http://www.nlm.nih.gov/medlineplus/ency/imagepages/2407.htm, http://www.skinsight.com/images/dx/webAdult/atopicDermatitisEczema_8506_lg.jpg,
http://www.nlm.nih.gov/medlineplus/ency/imagepages/2390.htm, http://www.mayoclinic.com/health/medical/IM02942
Self-Treatment Exclusions
• Involvement of large body surface areas
• < 2 years of age
• Secondary skin infection
• Severe condition with intense itching
34
Non-Pharmacologic Therapy
• Identify triggers• Limit exposure to exacerbating factors• Avoid occlusive clothing and irritating fabrics• Keep nails trimmed short and clean• Bathe or shower every other day in lukewarm water• Apply cool water compresses for oozing or weeping lesions
35
Non-Prescription Therapies
• Bath products▫ Bath oils▫ Oatmeal products▫ Cleansers
• Emollients and Moisturizers▫ Lotions, creams, ointments
• Humectants▫ Glycerin, polyethylene glycol
• Keratolytics▫ Urea, alpha-hydroxy acids, allantoin
36
Non-Prescription Therapies• Astringents
▫ Aluminum acetate
� Dilute before use
� Soak 2-4 times daily for 15-30 minutes
� Apply wet compresses as needed
▫ Witch hazel
• Topical corticosteroid
▫ Hydrocortisone
� Apply 3-4 times daily for up to 7 days
37
Non-Prescription Therapies• Antipruritics
▫ Topical anesthetics
� Pramoxine, Lidocaine, Benzocaine
� Apply 3-4 times daily
▫ Topical antihistamines
� Diphenhydramine
� Apply 3-4 times daily
▫ Counterirritants
� Camphor and menthol
� Avoid in pediatric patients
38
Prescription Therapy
• Topical corticosteroids▫ Daily application as beneficial as multiple daily applications▫ Mild dermatitis: low potency▫ Moderate – severe dermatitis: medium potency
• Topical calcineurin inhibitors▫ Tacrolimus (Protopic®) cream BID
� 0.03% for ages 2 to 15� 0.1% for patients > 15 years old
▫ Pimecrolimus (Elidel®) 1% cream BID• Oral corticosteroids▫ Adults and adolescents: taper x 7 days for acute exacerbations
• Cyclosporine 3 to 5 mg/kg/day▫ Very severe cases only
• Oral or topical antibiotics for secondary infections
39
Counseling Points• Relief can occur in 1-2 days when treated appropriately
• There is no cure
• Exacerbations are likely
• Avoid use of potent corticosteroids in skin folds and on the face; consider topical calcineurininhibitors in these cases
• Consider chronic topical corticosteroids for those with frequent exacerbations
40
Urticaria
Patient Case 2
• Jessica is a 27 year-old female who developed hives after receiving iodine contrast dye prior to an MRI last week. She was treated with steroids and anitihistamines at the hospital, but presents to your pharmacy today concerned that the lesions have improved but not completely gone away and are still very itchy. Her current medications include topiramate 25 mg qday for migraine prevention and sumatriptan 100 mg as needed for acute migraines. She asks for your advice as to what she should do. Which of the following is the best recommendation for Jessica?A. Self treat; loratadine 10 mg qdayB. Self treat; loratadine 40 mg qdayC. Self treat; loratadine 10 mg qday + famotidine 10 mg BIDD. Refer to provider; prednisone 50 mg qday x 3 days
42
Overview
• Also known as hives
• Many causes, including allergy, cold, heat, or medication
• Can be acute or chronic
43
Symptoms
• Well defined wheals or plaques
• May be paler in center
• Can be swollen/raised or flat
• Highly pruritic
▫ Worsening at night
44
Clinical Presentation
45
Images taken from:: http://www.webmd.com/skin-problems-and-treatments/picture-of-hives-urticariahttp://www.mayoclinic.com/health/medical/IM01519
https://ufhealth.org/hives
Self-treatment Exclusions
• Signs of angioedema
▫ Swelling of lips, throat, tongue
46
Non-Pharmacologic Therapy• Identification and removal of trigger exposure
Pharmacologic Therapy:
Non-Sedating Antihistamines
47
Drug NameBrand Name®
Vehicle Strength Generic Typical Dose OTC
Certirazine ZyrtecCh, Li^, T
5mg10mg1mg/mL^5mg/mL^
YesUp to 40mg qday
Yes
Fexofenadine Allegra Li*^, T60mg 180mg30mg/mL^
Yes*Up to 720mg qday
Yes
Loratadine ClaritinCh, Li^, T
5mg10mg5mg/mL^
YesUp to 40 mg qday
Yes
Ch=Chewable; Li=Liquid; T=Tablet^: Vehicle supplied as indicated strength*: Preparation not available as a generic product
Pharmacologic Therapy:
Sedating Antihistamines
48
Drug NameBrand Name®
Vehicle Strength GenericTypical Dose
OTC
ChlorpeniramineChlor-Trimeton
Li^, T, X^
4mg, 12mg^2mg/5mL^
Yes4mgQID
Yes
Clemastine Tavist Li^, T1.34mg,2.68mg0.67mg/5mL^
Yes1.34mgQID
Yes
Diphenhydramine BenadrylCh*, Li, T
12.5mg, 25mg12.5mg/5mL
Yes25mg QID
Yes*
Hydroxyzine Atarax Li^, T10mg, 25mg, 50mg, 100mg, 10mg/5mL^
Yes25mgQID
No
Ch=Chewable; Li=Liquid; T=Tablet ; X=Extended release^: Vehicle supplied as indicated strength*: Preparation not available as a generic product
Pharmacologic Therapy:
H2 Antagonists
49
Drug NameBrand Name®
Vehicle Strength GenericTypical Dose
OTC
Famotidine PepcidT, Ch*, Li^
10mg, 20mg, 10mg/mL^
Yes10mg BID
Yes*
Nizatadine Axid Li, Cp, T150 mg, 300 mg15 mg/mL~
Yes150 mg BID
Yes~
Ranitidine Zantac T75mg, 150mg, 300mg~
Yes150mg BID
Yes~
Ch=Chewable; Cp=Capsule; Li=Liquid; T=Tablet^: Vehicle supplied as indicated strength*: Preparation not available as a generic product~: Strength not available OTC
Pharmacologic Therapy - Refractory
• Add-on therapy options – chronic urticaria or failed initial therapy
▫ H2 antagonists
� Add-on to H1 antagonists therapy
▫ Corticosteroid burst
� Prednisone 50mg x 3d
� Follow burst therapy with H1 antagonists
50
Counseling Points
• Most cases will resolve spontaneously
• Initial selection of product should depend on patient schedule and ability to dose medication
51
Sunburn
Overview
• Acute inflammatory response to UV radiation
▫ Transient, self-limiting
• Classified as first degree and second degree
• Ranges in severity from mild erythema to severe blistering
• Can be worsened by photosensitizing drugs
53
Common Photosensitizing Medications
▫ Diuretics (especially thiazide-type)
� Chlorthalidone, furosemide, HCTZ
▫ Sulfonamides
� Sulfadiazine, sulfamethoxazole, sulfasalazine
▫ Sulfonylureas
� Glimepiride, glipizide
▫ Tetracyclines
� Doxycycline, minocycline, tetracycline
54
Symptoms
• Erythema of exposed skin
▫ Occurs 3-5 hours after exposure
▫ Begins healing after 12-24 hours
• Blistering of exposed skin
• Increased sensitivity of skin to mechanical pressure
• Severe sunburn can lead to fever, chills, nausea/ vomiting, and shock
55
Clinical Presentation
56
Images taken from: http://www.medicinenet.com/image-collection/acute_sunburn_picture/picture.htmhttp://www.uptodate.com/contents/image?imageKey=DERM%2F73224~DERM%2F59991~DERM%2F52112~DE
RM%2F88081&topicKey=DERM%2F6624&rank=1~68&source=see_link&search=sunburn&utdPopup=true
Self-treatment Exclusions
• < 6 months of age
• Severe systemic symptoms
▫ Nausea
▫ Fever
▫ Headache
▫ Extreme pain
57
Non-Pharmacologic Therapy
• PREVENTION is key!• Cover exposed skin• Sunscreen, sunscreen, sunscreen▫ FDA updated labeling regulations December 2012� Broad spectrum and SPF>15 = Protection against UVA and UVB rays, may protect against skin cancer and early skin aging
� Water resistance = length of time you get full SPF benefits during exposure to water or sweat (40 or 80 minutes)
▫ Reapply sunscreen q2h
58
Non-Pharmacologic Therapy
• No therapies shown to decrease healing time
• Cold compresses
• Aloe-vera based gels
• Emollients
• Cover ruptured blisters with bandages
59
Pharmacologic Therapy
• Ibuprofen 400-800mg q4-6h
• Topical antimicrobials
▫ Mupirocin 2%
▫ Silver sulfadiazine
60
Counseling Points
• Photosensitizing medications
• New sunscreen labeling
61
Acne
Patient Case 3
• Amy is a 16-year-old female presenting to the pharmacy today with her mother. They are concerned because Amy’s acne has gotten progressively worse over the summer. Amy is especially worried about how she will look in her upcoming pictures at the homecoming dance next month. She has been using OTC salicylic acid 2% twice daily with minimal improvement. You can see a mixture of comedones and pustules on her face, and you estimate that there are about 50 total lesions present. Amy is otherwise healthy and takes only a daily multivitamin. Which of the following would be the best recommendation for Amy?A. Self treat; add benzoyl peroxide 5% aaa BIDB. Refer to provider; tretinoin 0.025% aaa qHSC. Refer to provider; spironolactone 50 mg qday + tretinoin 0.025% aaa
qHSD. Refer to provider; doxycycline 100 mg BID + tretinoin 0.025% aaa
qHS + benzoyl peroxide 5% aaa BID
63
Overview
• Most common in adolescents but may persist in up to 40% of adults• Multifactorial underlying pathophysiology▫ Follicular hyperproliferation and abnormal desquamation▫ Androgenic hormonal triggers▫ Increased sebum production▫ Propionibacterium acnes (P. acnes) proliferation▫ Inflammation
• Exacerbated by cosmetics, environment, local irritation, medications, stress
64
Medication-Related Causes
• P.I.M.P.L.E.S.
▫ Phenytoin
▫ Isoniazid
▫ Moisturizers
▫ Phenobarbital
▫ Lithium
▫ Ethionamide
▫ Steroids
• Also azathioprine, cyclophosphamide, rifampin
65
Precursor Acne Lesions
66
Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: the American
Pharmacists Association; 2009.
Noninflammatory Acne Lesions
67
Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: the American
Pharmacists Association; 2009.
Inflammatory Acne Lesions
68
Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: the American
Pharmacists Association; 2009.
Symptoms and Classification
• Mild
▫ < 20 comedones; < 15 inflammatory lesions; < 30 total lesions
• Moderate
▫ 20 – 100 comedones; 15 – 50 inflammatory lesions; 30 – 125 total lesions
• Severe
▫ > 5 cysts; > 100 comedones; > 50 inflammatory lesions; > 125 total lesions
69
Clinical Presentation
70
Images taken from: http://www.webmd.com/skin-problems-and-treatments/acne/ss/slideshow-acne-dictionary
Self-Treatment Exclusions
• Moderate-severe acne
• Possible rosacea
71
Non-Pharmacologic Therapy
• Identify and avoid exacerbating factors
• Avoid touching face
• Washing face with mild soaps or cleansers BID
• UV exposure
• Hydration
72
Treatment Algorithm for Acne
Mild
• First line: TR + TA• Alternatives: TR + TA; TR or AA or SA• Maintenance: TR
Moderate
• First line: OA + TR + BPO• Alternatives: OI (nodular); OA + TR + BPO/AA• Maintenance: TR + BPO
Severe
• OI• High-dose OA + TR + BPO – or – High-dose OAAn + TR + TA• Maintenance: TR + BPO
73
AA=azelaic acid; BPO=benzoyl peroxide; OA=oral antibiotic; OAAn=oral antiandrogenic; OI=oral isotretinoin; SA=salicylic acid; TA=topical antimicrobial; TR=topical retinoid
Pharmacologic Therapy: Retinoids
74
Drug Name
Brand Name(s)®
Vehicle Strength(s) GenericTypical Dose
Adapelene Differin C, G^, L 0.1%, 0.3%^* Yes* qHS
Isotretinoin
Absorica, Amnesteem,Claravis, Myorisan, Zenatane
Cap10, 20, 30, 40 mg
No
0.5 – 1 mg/kg/dayin 1 to 2 divided doses
Tazarotene Tazorac C, G 0.05%, 1% No qHS
Tretinoin
Atralin, Renova,Retin-A, Tretin-X
C, G
0.01%, 0.025%, 0.0375%, 0.04%, 0.05%, 0.1%
Yes qHS
C=Cream; Cp=Capsule; G=Gel; L=Lotion^: Vehicle supplied as indicated strength*: Preparation not available as a generic product
Pharmacologic Therapy:
Topical Antimicrobials
75
Drug NameBrand Name(s)®
Vehicle Strength(s) GenericTypical Dose
Benzoyl Peroxide
Oscion, PanOxyl
C, G, L, Pl
2.5%, 5%,10%
Yes BID
ClindamycinCleocin, ClindaGel
F, G, L, Pl, So
1% Yes qday – BID
Dapsone Aczone G 5% No BID
ErythromycinAkne-Mycin, Ery
G, Pl, So 2% Yes BID
SulfacetamideKlaron, Ovace
L, Su, W 10% Yes BID
C=Cream; G=Gel; L=Lotion; Pl=Pledget; So=Solution; Su=Suspension; W=Wash
Phamacologic Therapy: Oral Antibiotics
76
Drug NameBrand Name(s)®
Vehicle Strength(s) GenericTypical Dose
DoxycyclineDoryx,Monodox*, Vibramycin
Cp, T; TX
50, 75, 100, 150, 200 mg
Yes* qday – BID
Erythromycin Ery-tabs T 500 mg Yes BID
MinocyclineMinocin, Solodyn
Cp, T, TX^
Cp: 50, 75, 100 mgT: 45^, 50, 55*^, 65*^, 80*^, 90^, 100, 105*^, 115*^, 135 mg^
Yes qday – BID
SMZ-TMP Bactrim DS T 800/160 mg Yes qday – BID
Cp=Capsule; T=Tablet; TX=Extended-release tablet*: Preparation not available as a generic product^: Vehicle supplied as indicated strength
Phamacologic Therapy: Misc.
77
Drug NameBrand Name(s)®
Vehicle Strength(s) GenericTypical Dose
Azelaic acidAzelex, Finacea
C, G 15%, 20% No BID
Combination oral contraceptives
Various T Various Yes qday
Salicylic Acid OTC
Neutrogena, Stridex, others
C, F, G, Pl
2% Yes qday – BID
Spironolactone Aldactone T25, 50, 100 mg
Yes25 to 200 mg in 1 to 2 divided doses
C=Cream; F=Foam; G=Gel; Pl=Pledget; T=Tablet
Pharmacologic Therapy:
Combination Products
78
Drug NameBrand Name(s)®
Vehicle Strength GenericTypical Dose
BPO –Adapalene
Epiduo G 2.5% - 1% No qHS
BPO –Clindamycin
Benzaclin G 5% - 1% Yes BID
BPO –Clindamycin
Acanya*, Duac
G 2.5% - 1.2% Yes* qday
BPO –Erythromycin
Benzamycin G 5% - 3% Yes BID
Clindamycin-Tretinoin
Veltin;Ziana
G1.2% -0.025%
No qHS
BPO=Benzoyl Peroxide; G=Gel*: Preparation not available as a generic product
Counseling Points
• Product selection• Realistic expectations: treatments may take up to 12 weeks to improve symptoms• Adverse reactions▫ Photosensitivity: BPO, dapsone, retinoids, tetracyclines▫ Bleaching with BPO▫ Skin hypopigmentation with azelaic acid
• Tazotarotene and isotretinoin are pregnancy category X• Avoid tetracyclines in children < 9 years old
79
Insect Bites
Overview
• Reactions caused by bites from many species of insects
• Rarely dangerous, but highly irritating to the patient
81
Symptoms
• Mosquito Bites• Chigger Bites▫ Hardened, red papule▫ Intense itching▫ Generally found near collars, waistbands, sleeves
• Spider Bites – Brown Recluse▫ Spreading, ulcerated wound
• Scabies▫ Many small bites between fingers, around genitalia, and in skin folds▫ Itching worse during evening hours
82
Clinical Presentation
83
Scabies
Chigger bites
Mosquito bites
Brown recluse spider bite
Images taken from:: http://indianapublicmedia.org/amomentofscience/the-itchy-truth/ http://www.webmd.com/allergies/ss/slideshow-bad-bugs
http://www.webmd.com/skin-problems-and-treatments/ss/slideshow-scabies-overviewhttp://www.myhousecallmd.com/arachnophobia-the-truth-behind-spider-bites/
Self-Treatment Exclusions
• <2 years of age
• Hypersensitivity to bites or swelling away from the bite area
• Fever, joint pain, or lymph node enlargement
• Signs of secondary infection of bite area
• Symptoms persisting >7 days
• Signs of necrosis
84
Non-pharmacologic Therapy
• Insect avoidance▫ Cover skin with clothing
• Insect repellents▫ DEET most effective� Products containing 7%-100% DEET available� Use <30% DEET for children
▫ Picaridin▫ Citronella, lemon eucalyptus oil, soybean oil also effective
• Cold packs on bite area to reduce swelling
85
Pharmacologic Therapy
• Hydrocortisone
• Topical diphenhydramine
▫ May cause contact dermatitis
• Local anesthetics
▫ May cause contact dermatitis
▫ Caution in patients with known or suspected hypersensitivity to benzocaine
• All products: Apply to bite area TID or QID
• Can be used for up to 7 days
86
Pharmacologic Therapy - Scabies
• Can be cured with eradication
• Permethrin 5% (Elimite)
▫ Apply to entire body 1 time
▫ Leave on skin 8-14 hours then wash off
▫ May repeat in 1 week
• Ivermectin (Stromectol)
▫ Less effective than permethrin
▫ Single oral dose, repeated in 14 days
• Do not use hydrocortisone – may worsen scabies
87
Counseling Points
• Insect bites
▫ Avoidance and repellant is the best solution
▫ Bites should resolve in 3-4 days
• Scabies
▫ Complete coverage with premethrin can help achieve eradication
� Counsel patient to cover head to toe, including palms, soles of feet, under finger and toe nails, and around scalp line
88
Pediculosis
Patient Case 4
• Christina is a 35-year-old female who presents to the pharmacy today asking for advice regarding her son, Eric. Eric is 8 and recently started back to school. He was treated 2 days ago with OTC permethrin 1% for head lice but Christina notes that she can still see “those things in his hair.” Eric is otherwise healthy and takes no medications. Christina is worried about the cost of a physician visit because she is a single mom on a limited income. Which of the following would be the best treatment to recommend for Eric?A. Self treat; nit comb, no additional medication treatmentB. Self treat; repeat permethrin 1% and comb for nitsC. Refer to provider; spinosad 0.9% x 1 applicationD. Refer to provider; SMZ-TMP 800-160 mg BID x 10 days
90
Overview
• Pediculosis capitis
▫ Head lice
• Pediculosis corporis
▫ Body lice
• Both species bite to feed on blood
• Spread by direct contact
• Potentially spread by sharing objects such as hairbrushes, hats, clothing, and towels
91
Symptoms
• Head lice
▫ Many asymptomatic
� Common in children
▫ Itching of scalp, neck, and ears
• Body lice
▫ Itchy, hyperpigmented lesions clustered in areas where clothing seams contact the skin
• Enlarged lymph nodes
• Lice and egg sacs visible in hair or on clothing
92
Clinical Presentation
93
Images taken from:: http://www.healthhype.com/itchy-scalp-causes-and-treatment.htmlhttp://www.skinsight.com/infant/pediculosisCapitisHeadLice.htm
http://www.uptodate.com/contents/images/DERM/86442/Pediculosis_corpor_hyperpig.jpg?title=Pediculosis+corporis+hyperpigmentation
Self-treatment Exclusions
• <2 years of age
• Infestations involving the eyelids or eyebrows
• Pregnancy or breast-feeding
• Allergy to chrysanthemums
94
Non-pharmacologic Therapy
• Lice (nit) combs in treatment of head lice▫ Use every 2-3 days▫ Carefully comb clean hair that has detangled with hair conditioner or olive oil
• Wash all clothing, bedding, and hair brushes in soap and hot water• Vacuum furniture, carpets, and rugs• Put pillows, rugs, and stuffed animals in clothes dryer on hot setting or in an airtight bag for 2 weeks• Avoid close contact with infected individuals to prevent spread of infestation
95
Pharmacologic Therapy: Pediculicides
96
G=Gel; Li=Liquid; L=Lotion; M=Mousse; Sh=Shampoo; ^: Vehicle supplied as indicated strength
Drug Name
Brand Name®
Vehicle Strength GenericTypical Dose
OTC
Citric acid, cytanyl 5, isopropanol
Lycelle G -- No 1x No
Ivermectin Sklice L 0.5% No 1x No
Permethrin Nix L 1% Yes 1x Yes
Pyrethrins/ piperonylbutoxide
RID, Tisit, Pronto
Sh, L, G, M^
0.3%/3%,0.3%/4%^
No 1x Yes
Spinosad Natroba Li 0.9% Yes 1x No
Pharmacologic Therapy –
Head Lice, Misc.• Petrolatum shampoo
▫ Apply to scalp and dry with hair dryer, leave overnight, rinse in morning
▫ Requires manual removal of lice and nits
• Trimethoprim/sulfamethoxazole
▫ Use after initial treatment failure
▫ Use in combination with permethrin rinse
▫ Dosage: 800/160 mg BID x 10d
97
Counseling Points
• Lice diagnosis can be embarrassing for patients
• Students do not need to be removed from school
• Question patient regarding mum and ragweed allergies
• Help patients select an OTC head lice product based on amount of time product is required to be on hair
• Remind patient to retreat if live lice can still be found 7-14 days after initial treatment
98
Fungal Skin Infections
Patient Case 5
• George is a 19 year old male who recently started practicing on the wrestling team at his community college. Over the past 3 days, he has noticed a well-defined, bright red rash on both his inner thighs. He states that the rash itches significantly throughout the day but has not spread to his genitals. He has no other medical conditions and takes only loratadine as needed for allergies. Which of the following would be the most appropriate treatment option for George?A. Self treat; clotrimazole cream, aaa BID x 4 weeksB. Self treat; miconazole powder, aaa BID x 4 weeks C. Self treat; tolnaftate spray, aaa BID x 4 weeksD. Refer to provider; terbinafine 250 mg qday x 12 weeks
100
Overview• Often called ringworm
• Tinea = dermatophyte infection
▫ Named according to affected body area
� Capitis, cruris, corporis, pedis, unguium
• Children more susceptible than adults
• Associated factors: immunosuppression, poor circulation, poor nutrition and/or hygiene, skin occlusion, humid climate, contact with foreign animals
101
Symptoms
• Itching• Tinea cruris▫ Bilateral red, raised scaly patches with well-defined borders
• Tinea corporis and capitis▫ Ring-shaped lesion(s) with clear centers and scaly borders
• Tinea pedis▫ Cracked, flaking skin between the toes▫ Blisters, oozing, or crusting may be present• Tinea unguium▫ Thickened, discolored, and/or dull nails
102
Clinical Presentation
103
Images taken from: http://www.mayoclinic.com/health/medical/IM00983, http://www.mayoclinic.com/health/medical/IM03573, http://www.wrongdiagnosis.com/phil/html/fungal-nail-infections/579.html,http://www.mayoclinic.com/health/medical/IM02353, http://www.webmd.com/skin-problems-and-treatments/slideshow-ringworm,
http://www.skinsight.com/images/dx/webAdult/tineaCruris_5039_med.jpg
Self-Treatment Exclusions
• Involvement of nails, scalp, face, mucous membranes, or genitalia• Diabetes, systemic infection, asthma, immune deficiency• Fever• Secondary bacterial infection• Excessive and/or continuous exudation• Unsuccessful initial treatment or worsening of condition
104
Non-Pharmacologic Therapies
• Cleanse skin daily with soap and water• Keep skin clean and dry• Avoid contact with infected persons• Use separate towel or dry affected skin area last• Wear protective footwear in community areas• Tinea cruris: avoid sexual contact• Tinea pedis: allow shoes to dry thoroughly
105
Pharmacologic Therapy:
Azole Antifungals
106
Drug NameBrand Name®
Vehicle Strength GenericTypical Dose
OTC
Clotrimazole Lotrimin C, L, O 1% Yes BID Yes
Econazole Spectazole C 1% Yes qday No
Ketoconazole Nizoral C 2% Yes qday Yes
Miconazole Monistat C 2% Yes BID Yes
Oxiconazole Oxistat C, L 1% Noqday orBID
No
C=Cream; L=Lotion; O=Ointment
Pharmacologic Therapy:
Amines & Miscellaneous
107
Drug Name
Brand Name(s)®
Vehicle Strength(s) GenericTypical Dose
OTC
ButenafineMentax, Lotrimin@
C 1% Noqday or BID
Yes@
CiclopiroxLoprox, Penlac
C, G, La%, Su^
0.77%^, 1% Yesqday% or BID
No
Naftifine Naftin C^, G% 1%, 2%^ Noqday% or BID
Yes
Terbinafine LamisilC@, G@, Sp@, T^
1%, 250 mg^ Yesqday or BID
Yes@
Tolnaftate TinactinC, G, P, So, Sp
1% Yes BID Yes
C=Cream; G=Gel; La=Laquer; So=Solution; Sp=Spray; T=Tablet@: Specified product available OTC%: Dosing for specified vehicle^: Vehicle supplied as indicated strength
Product Selection
• Creams, solutions
▫ Most efficient and effective
• Sprays, powders
▫ Adjunct therapy
▫ Prophylaxis
• Active ingredient(s)
▫ Check product labeling
108
Counseling Points• Check product labeling for age-specific dosing; some only for use in patients > 12 years
• OTC products must be used for 2-4 weeks to ensure complete eradication
• Wash hands after product application
• Symptomatic relief will not occur quickly
109
Summary
• Drying effects needed
▫ Solutions, gels, astringents
• Lubricating effects needed
▫ Creams, lotions, ointments
• Many common skin disorders can be effectively and appropriately self-treated
• Pharmacists can play a key role in appropriate product selection
110
Patient Case 1
• John is an 18-year-old male who returned today from a camping trip with his fraternity brothers. He presents to the pharmacy with linear streaks of vesicles on his calves and ankles. He also states that his groin is involved and notes, “Don’t ask.” He believes the rash is due to poison ivy and wants to know if he can purchase something over the counter or if he needs to go to an urgent care clinic. He has exercise-induced asthma and uses albuterol PRN, but does not regularly take any other medications. Which of the following is the best treatment course to recommend for John?A. Self treat; hydrocortisone 1% ointment, aaa TIDB. Refer to provider; methylprednisolone 4 mg dosepak, tud x 6
daysC. Refer to provider; prednisone 10 mg, taper x 21 daysD. Refer to provider; triamcinolone 0.1% cream, aaa BID
111
Patient Case 2
• Jessica is a 27 year-old female who developed hives after receiving iodine contrast dye prior to an MRI last week. She was treated with steroids and anitihistamines at the hospital, but presents to your pharmacy today concerned that the lesions have improved but not completely gone away and are still very itchy. Her current medications include topiramate 25 mg qday for migraine prevention and sumatriptan 100 mg as needed for acute migraines. She asks for your advice as to what she should do. Which of the following is the best recommendation for Jessica?A. Self treat; loratadine 10 mg qdayB. Self treat; loratadine 40 mg qdayC. Self treat; loratadine 10 mg qday + famotidine 10 mg BIDD. Refer to provider; prednisone 50 mg qday x 3 days
112
Patient Case 3
• Amy is a 16-year-old female presenting to the pharmacy today with her mother. They are concerned because Amy’s acne has gotten progressively worse over the summer. Amy is especially worried about how she will look in her upcoming pictures at the homecoming dance next month. She has been using OTC salicylic acid 2% twice daily with minimal improvement. You can see a mixture of comedones and pustules on her face, and you estimate that there are about 50 total lesions present. Amy is otherwise healthy and takes only a daily multivitamin. Which of the following would be the best recommendation for Amy?A. Self treat; add benzoyl peroxide 5% aaa BIDB. Refer to provider; tretinoin 0.025% aaa qHSC. Refer to provider; spironolactone 50 mg qday + tretinoin 0.025% aaa
qHSD. Refer to provider; doxycycline 100 mg BID + tretinoin 0.025% aaa
qHS + benzoyl peroxide 5% aaa BID
113
Patient Case 4
• Christina is a 35-year-old female who presents to the pharmacy today asking for advice regarding her son, Eric. Eric is 8 and recently started back to school. He was treated 2 days ago with OTC permethrin 1% for head lice but Christina notes that she can still see “those things in his hair.” Eric is otherwise healthy and takes no medications. Christina is worried about the cost of a physician visit because she is a single mom on a limited income. Which of the following would be the best treatment to recommend for Eric?A. Self treat; nit comb, no additional medication treatmentB. Self treat; repeat permethrin 1% and comb for nitsC. Refer to provider; spinosad 0.9% x 1 applicationD. Refer to provider; SMZ-TMP 800-160 mg BID x 10 days
114
Patient Case 5
• George is a 19 year old male who recently started practicing on the wrestling team at his community college. Over the past 3 days, he has noticed a well-defined, bright red rash on both his inner thighs. He states that the rash itches significantly throughout the day but has not spread to his genitals. He has no other medical conditions and takes only loratadine as needed for allergies. Which of the following would be the most appropriate treatment option for George?A. Self treat; clotrimazole cream, aaa BID x 4 weeksB. Self treat; miconazole powder, aaa BID x 4 weeks C. Self treat; tolnaftate spray, aaa BID x 4 weeksD. Refer to provider; terbinafine 250 mg qday x 12 weeks
115
Acknowledgements
• Amanda Applegate, Pharm.D.
116
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2. Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; 2013.3. Longyhore DS. Dermatology and HEENT. ACCP Updates in Therapeutics 2013: The Ambulatory Care pharmacy Preparatory Review and Recertification Course. ACCP: 2013. 1-253-302.
4. Mayoclinic.com. Dermatitis. http://www.mayoclinic.com/health/dermatitis/DS00543&slide=4. Updated 24 April 2010.
5. Hogan D. Contact dermatitis, irritant. http://emedicine.medscape.com/article/1049353-overview. Updated 16 October 2009.
6. Hogan D. Contact dermatitis, allergic. http://emedicine.medscape.com/article/1049216-overview. Updated 3 June 2010.
7. Usatine R & Riojas M. Diagnosis and management of contact dermatitis. American family Physician. 2010; 82(3): 249-55.
8. Mayoclinic.com. Atopic dermatitis (eczema). http://www.mayoclinic.com/health/eczema/DS00986. Updated 22 August 2009.
9. NIAMS. Atopic dermatitis. http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis/default.asp. Updated May 2009.
10. Weston WL & Howe W. Treatment of atopic dermatitis (eczema). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
11. PL Detail-Document, Comparison of Topical Corticosteroids. Pharmacist’s Letter/Prescriber’s Letter. September 2012
12. Using oral corticosteroids: a toolbox. Pharmacist's Letter/Prescriber's Letter 2010;26(5):260507.13. Bingham CO. New onset urticaria. In UpToDate, Sani S; Callen J (ed), UpToDate, Waltham, MA 2013. 14. FDA.gov. FDA sheds light on sunscreens. http://www.fda.gov/forconsumers/consumerupdates/ucm258416.htm . Updated 20 August 2013.
15. Young AR; Tewari A. Sunburn. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA 2013. 16. Graber E. Treatment of acne vulgaris. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.17. PL Detail-Document, Pharmacotherapy of Acne. Pharmacist’s Letter/Prescriber’s Letter. August 2013.18. Goldstein AO & Goldstein BG. Pediculosis capitis. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA 2013. 19. Goldstein AO & Goldstein BG. Pediculosis corporis. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA 2013. 20. Goldstein AO & Goldstein BG. Dermatophyte (tinea) infections. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
21. Topical treatment of superficial fungal infections. Pharmacist's Letter/Prescriber's Letter 2009;(8):250806.
Questions?Emily Prohaska, Pharm.D.emily.prohaska@ballsfoods.com
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