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106 Cards in this Set
- Front
- Back
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What is the most common type of psoriasis?
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Chronic plaque psoriasis
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What is the defining characteristics of chronic plaque psoriasis?
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-Erythematous papules
-Evolves into plaque that range in color (red, brown and purple lesions) -Demarcated margins accompanied by silver white scales |
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What are the treatment plans for chronic plaque psoriasis?
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Topical steroids (mild conditions)
Emollients Salicylic acid Calcipotriol Tazarotene Coal Tar Tacrolimus Systemic Agents: Methotrexate, Acitretin, Sulfasalazine, Cyclosporine, Mycophenolate, Biologics |
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List the Very High Potency steroids. What group are they?
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Super Potent - Group I
-Augmented betamethasone dipropionate (Diprolene) -Clobetasol propionate (Temovate) -Diflorasone diacetate (Psorcon) -Halobetasol propionate (Ultravate) |
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List the High Potency steroids. What group are they?
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Potent - Group II
-Betamethasone dipropionate 0.05% -Fluocinonide 0.05% |
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List the medium and low potency steroids. What group are they?
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Medium - Group III & IV
-Triamcinolone 0.1% Low - Group V - VII -Hydrocortisone 0.5% and 1% |
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What are the therapeutic roles for biologic agents?
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-Used for moderate - severe psoriasis or psoriatic arthritis
-Target T cells or TNF-alpha antagonist |
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What is the epidemiology of psoriasis?
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-Hyperproliferation of epidermal cells
-Genetically linked -Life long disease with "flare ups" -Onset generally in 20's; most cases occur between 20-60 |
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Should you avoid irritating topical agents (i.e. calcipotriol, tazarotene, coal tar and anthralin) for non-inflammed or inflammed psoriasis?
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Inflammed
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What are common affected areas of chronic plaque psoriasis?
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Palms, digits, elbows, knees, nails, scalp
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Mild psoriasis
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3% BSA
-Isolated patches on knees, elbows, scalp, hands or feet -Topical therapy |
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Moderate psoriasis
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3-10% BSA
-Plaque on knees, legs, torso and scalp -Topical, phototherapy, systemic therapy and biologics |
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Severe psoriasis
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>10% BSA
-Extensive palques or pustules -Combo therapy: biologics, systemics and/or topicals |
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What is PASI?
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-Psoriasis Area and Severity Index
-75% improvement = effective -Assess BSA, erythema, induration and scaling |
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Which group of topical steroids is reserved for face and genitals?
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Low potency - Group V - VII
Hydrocortisone |
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What dosage route is used for hairy parts of the body?
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Solutions
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What is the finger rule?
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One finger tip is ~ 500 mg
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Which do you apply first, steroids or emollient for psoriasis?
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Steroids first then emollient within first 5 minutes out of shower to trap in moisture
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Which psoriasis treatment is a synthetic vitamin D analog?
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Calcipotriol (Dovonex)
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Taclonex is made up of what?
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Combination of Calcipotriene 0.005% and betamethasone 0.064%
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Tazarotene (Tazorac) is a ______ derivative? What pregnancy category is it?
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Retinoid
X |
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How should you dose methotrexate for chronic plaque?
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Cyclic dosing to decrease N/V or one time dose one day a week
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What are absolute contraindications to methotrexate?
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Pregnancy, nursing mothers, alcoholism, chronic liver disease, leukopenia, thrombocytopenia or significant anemia
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What is the dosing of cyclosporine (CSA)?
What conditions should you monitor with this drug? |
-Two divided doses
-Hypertension & Nephrotoxicity |
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What is the most commonly prescribed, most effective and least effective treatment for chronic plaque psoriasis?
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Methotrexate, Cyclosporine and Acitretin (respectively)
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What are the precautions for Acitretin (Soriatane) use in chronic plaque psoriasis?
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-Pregnancy category X
-Lipid disorders -Hepatotoxicity -Hyperostosis, Opthalmologic effects |
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Alefacept
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-Biologics
-Mod - severe psoriasis -Non-continuous dosing with drug holidays -Decrease CD4 count -- do not use in HIV patients -No rebound or flare up when d/c -Some transient reaction at site of injection |
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Etanercept
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-Biologics
-Mod-Severe psoriasis -Pregnancy category B -Contraindication - Sepsis |
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Infliximab
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-Biologic
-Severe psoriasis -Pregnancy category B -Generally given in a hospital/office setting.. continuous dosing |
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What are the triggers for rosacea?
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Foods, beverages, drugs, topical agents, temp extremes, emotion, exercise
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What are the primary and secondary clinical features of rosacea?
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-Primary: Flushing (transient edema), Non-transient erythema, papules and pustules, telangiectasia
-Secondary: Burning or stinging, plaque, dry appearance, ocular manifestations, phymatous changes |
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What topical drugs are used for treatment of rosacea?
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Metronidazole (Metrogel)
Azelaic acid (Azelex) Sodium sulfacetamide Clindamycin 1% Erythromycin 2% |
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What oral antibiotics are used for treatment of rosacea?
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Doxycycline
Minocycline Tetracycline Erythromycin Metronidazole |
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When should you use isotretinoin for the treatment of rosacea?
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Refractory or Severe cases
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What is the epidemiology of rosacea?
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-Fair-skinned
-Women > Men -Onset between 30-60 y.o. -Chronic and will last for years |
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What is telangiectasia?
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"Whiskey nose", spider like veins that appear on nose (rosacea)
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In the treatment of rosacea, metronidazole topical has comparable efficacy to oral _______?
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Tetracycline
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Which causes more irriation, Metronidazole or Azelaic acid?
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Azelaic acid
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True/False. Azelaic acid can be used for pregnancy?
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True
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Treatment selection for rosacea.
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-Initial oral antibiotics: 6-12 wks
-Mod-severe: oral + topical -Oral: papules + pustules -Topical: erythema + telangiectasia |
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What derm condition is rhinophyma seen in?
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Rosacea
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What are the differences between mild, moderate and severe acne?
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-Mild: <10 comedones, small number/size of papules and pustules
-Moderate: 10-40 lesions, mainly face -Moderately severe: 40-100 lesions or comedones, widespread of face, chest and back -Severe:Nodulocystic, large & painful nodular, pustular lesions |
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What is the IPledge program?
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Created to minimize risk of teratogenicity with usage of isotretinoin (Accutane)
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Treatment for mild acne?
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Topical tretinoin, tazarotene, adapalene, BPO or azelaic acid
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Treatment for moderate acne?
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Topical tretinoin, tazarotene or adapalene + Topical antibiotics
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Treatment for moderately severe acne?
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Oral antibiotics +/- Topical retinoids
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Treatment for severe acne?
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Isotretinoin (or 3 mo trial of topical retinoids + oral antibiotics)
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Benzoyl Peroxide for acne
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2.5 - 10% cream, gel, wash, soaps
-Side effects: irritation -Counsel: it can get worse before it gets better |
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Tretinoin for acne
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-Start with 0.025% cr and work up to 0.1% cream or gel
-Combo with BPO, topical and oral antibiotics -Side effects: irritation (esp gel which is more drying) -Counsel: it can get worse before it gets better, Preg Category C |
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Tazarotene (Tazorac) for acne
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0.05% and 1% cr or 0.1% gel
-Most irritating retinoid -Side effects: burning, dry skin, peeling, redness -Counsel: apply QHS, Preg Category X |
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Adapalene (Differen) for acne
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0.1% cr, solution and gel
-Best tolerated but least effective retinoid -Counsel: Apply QAM or QD |
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True/False. You can use oral and topical antibiotics at the same time.
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False
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Azelaic acid (Azelex) for acne
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-Best as an adjunct therapy
-Doesn't cause photosensitivity or significant irritation |
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Oral antibiotics for acne
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Tetracycline 250-500 mg BID
Doxycycline 50 -100 mg QD - BID Minocycline 50-100 mg QD- BID Bactrim DS BID Erythromycin 250-500 mg BID-QID |
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Dose for isotretinoin (Accutane) for acne
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0.5 mg to 1 mg/kg/day
-Cumulative dose: 120-150 mg/kg -Duration: 6 months -Availability: 10, 20 and 40 mg capsules |
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Side effects for isotretinoin (Accutane) for acne
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Dryness, photosensitivity, hair, nails, mucous membrane, liver, bone abnormalities, increase chol and TG, depression linked to suicide
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Describe the iPledge process
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-Registration: Prescriber, patient, pharmacy
-ID number and card, 2 forms of contraception, pregnancy test each month -Pharmacies: obtain authorization and RMA number, Max 30 day supply, filled w/i 7 days and picked up w/i 7 days -New Rx each month |
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What are the clinical features of atopic dermatitis?
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aka eczema
-Onset generally childhood -Can be lifelong and progress into adulthood -Hereditary component -Elevated eosinophils and IgE levels -Presentation: Itch-scratch cycle, erythematous skin/papules and vesicles, lichenification, excoriations and exudates |
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What are the clinical presentation of infant atopic dermatitis?
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-Birth to 2 y.o.
-Cheeks, chin, lips, scalp -Inflammed skin (cheek), oozing, crusting and scaling (lip) -Rash remains localized and chronic -Excoriation, lichenification and papules not common but possible |
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What are the clinical presentation of childhood atopic dermatitis?
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-2-12 y.o.
-Inflammation of flexural areas -Starts as a papule then quickly into plaque that becomes lichenified -Exudative lesions not common as infant stage |
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What are the clinical presentation of adult atopic dermatitis?
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-12 - adult
-Lesion pattern includes localized inflammation followed by lichenification |
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Group I or II is used to treat what symptoms of atopic dermatitis?
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Acute flare-ups or lichenified skin
Use for 3 wks or until skin clears |
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What group of steroid do you use for red, scaling skin or maintenance therapy of atopic dermatitis?
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Group V
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What group of steroid do you use for children with atopic dermatitis?
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Group V (can also be used in face and genitals)
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Calcineurin inhibitors (Tacrolimus, Pimecrolimus):
Indication? Length of therapy? |
-Indication: inflammation and pruritus for acute flare-ups and maintenance
-Length of therapy: short term or non-continuous chronic therapy |
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Calcineurin inhibitors:
Side effects? Warnings? |
-Side effects: erythema, pruritus, burning at site of application and skin infections
-Warnings: Avoid excess sun, resolve infection before use, long term should be limited to 6 wks, avoid occlusive dressings -Black box warning: long term use has not been established and rare cases of skin malignancy can occur |
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When and which antihistamine and antibiotics should be used in atopic dermatitis?
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-Antihistamine: controls pruritus and helps for sleep
Hydroxyzine, Diphenhydramine, Doxepin (TCA) -Antibiotic: prevent infection Cephalaxin, Dicloxacillin, Bactroban (topical) |
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Which UV light penetrates the deepest?
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UVA
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Which UV light is responsible for synthesis of Vitamin D?
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UVB
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Which UV light is blocked by the ozone layer?
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UVC
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Psoralens + UV light therapy (PUVA) is also called?
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Methoxsalen or Trioxsalen
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What rxns does PUVA undergo?
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-O2 indepedent: direct covalent bond to nucleic acids
-O2 dependent: ROS produced causing apoptosis |
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Carcinogens are known to be in what type of treatment?
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Coal tar
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What color characteristic does anthralin show on skin and clothes?
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Violet-brown staining
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What are the effects and duration of anthralin use?
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Effect: inhibition of cell growth
Use for 20 mins then wash off |
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What is the MOA of azelaic acid?
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inhibits DNA synthesis
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What type of treatment dissolves the intercellular cement between tissues?
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Salicylic acid
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Methhemoglobinemia is an adverse effect of what type of treatment?
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Resorcinol --- systemic absorption
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What is the general effect of retinoids?
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increase epidermal thickness; makes stratum corneum look more normal and expand s. granulosum
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What are some adverse effects of retinoids?
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Teratogenesis, spontaneous abortion, pregnancy category X
Do not donate blood - risk for donor |
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Vitamin D is thought to do what in the immune system in regards to T cells?
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Immune deviation shift fom Th1 to Th2 response
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Cyclosporin MOA
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inhibits calcineurin
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Mycophenolate mofetil (Cellcept) is used for what?
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-Organ rejections
-Good specificity in immune system -"steroid-sparing" |
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Azathioprine (Imuran) MOA
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False nucleotides used for nucleic acid synthesis but fails to function correctly
"Steroid-sparing" |
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True/False. Methotrexate is a Pregnancy category C?
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False. Category X!
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Alefacept (Amevive) MOA
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1. Blockage of activation of T cells (LFA-3 segment)
2. Induction of apoptosis of memory effector T cells (IgG segment) |
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Psoriasis is an ______ disorder.
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Autoimmune
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What is the cause of psoriasis?
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-Over activity of memory T cells
-Dysregulation of feedback mechanisms -Triggered by stress and other environmental factors |
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What are Langerhan cells role in psoriasis?
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Immature dendritic cell that picks up what it "thinks" is an antigen and educates other cells --> clonal expansion
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What shape is guttate psoriasis?
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Tear drop shaped
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What drugs exacerbate psoriasis?
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Lithium
Beta-blockers Antimalarial Systemic steroids |
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Keratoderma blennorrhagicum (Reiter's syndrome) follows what kind of infection?
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Yersinia
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Explosive, rapidly developing pustular psoriasis is an initial indication of what?
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HIV
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What is "atopy"?
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Describe patients with a family history of one or more of hay fever, asthma, dry skin or eczema; aspirin allergy is common
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What will >50% BSA of atopic dermatitis in children do?
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Retard growth
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What bacteria is responsible for acne?
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Propionibacterium acnes
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Can tetracycline be given as a treatment option for infant's acne?
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No
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What are the 2 nuclear receptors for cortisol?
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-Glucocorticoid (GR)
-Mineralocorticoid (MR) |
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Type 2 enzyme is seen in what organ?
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Kidney
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True/False. Cortisone binds to GR and MR.
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False -- only CORTISOL
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What do steroids do to the immune system?
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Decreases
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How do you determine potency of a steroid?
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Forearm blanching test and clinical experience
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True/False. Occlusive dressing is not recommended for Group I steroids.
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True, except diflorasone
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Is percent strength a reliable guide of potency?
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No
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What is the "rule of hand"?
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Skin area equal to one side of the hand requires about 0.25 g of ointment for coverage
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True/False. High absorption occurs in inflamed skin.
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True -- occlusions such as diapers can increase potency 10-100x
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