Conflict of Interest Disclosures Learning Objectives Acne Acne Patient Case 1

30 Pages·2012·1.04 MB·English

Updates in Therapeutics® 2012:
Ambulatory Care Pharmacy Preparatory Review and Recertification Course
Conflict of Interest Disclosures
None
Uppdates in Therappeutics® 2012:
Ambulatory Care Pharmacy Preparatory Review and Recertification Course
Dermatology & HEENT
Daniel S. Longyhore, Pharm.D., BCACP
Wilkes University School of Pharmacy
Learning Objectives Acne
 Determine when patients with acne should add oral  Types of Acneform Presentation
therapy to their topical therapeutic agents using a  Acne conglobata –Inflammatory cysts
treatment algorithm.
 Effectively educate a patient on an infestation and the  Acne mechanica –Lesions in areas of friction
ppurppose,, ppropper use,, and ppotential adverse reactions of  Acne rosacea –Eryythema & telanggiectasias
the first-line treatment options for scabies and/or lice.
 Comedogenic acne –comedones (no inflammation)
 Recommend single or multiple topical agents for
treating plaque psoriasis given the patient’s disease  Common acne –Pustules & comedones
presentation, severity, and (if applicable) previously  Cystic acne –Cysts with infection (poss. scarring)
used therapies.
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Acne Patient Case 1
 Medication-Induced D.M. is a 17-year-old adolescent boy with
 Anabolic steroids  Lithium inflammatory nodular acne on his face, shoulders,
and back that becomes increasingly irritated during
 Azathioprine  Phenytoin football season secondary to friction from his
 CCoorrttiiccoosstteerrooiiddss  PPrrooggeessttiinnss hheellmmeett ssttrraapp aanndd sshhoouullddeerr ppaaddss.. HHiiss ccuurrrreenntt aaccnnee
medications include an oral antibiotic, topical
 Cyclosporine  Tetracycline retinoid, and benzoyl peroxide…
 Isoniazid  Vitamin B1, B6, B12
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Acne Acne
 Severity Classification  Goals of therapy
 Controlling acne lesions
Classification Criteria
 Preventing scarring
less than 20 comedones, less than 15 inflammatory
Mild
lesions, or less than 30 lesions (total)  Minimizingg morbidityy ((siggnificant infections))
20–100 comedones, 15–50 inflammatory lesions,
Moderate
or a total lesion count of 30–125
Greater than 5 cysts, greater than 100 comedones,  Reasonable treatment goals should be set and
Severe greater than 50 inflammatory lesions, or greater discussed with the patient prior to starting therapy
than 125 lesions (total)
Page 2-5
Acne Acne
 Non-pharmacologic interventions Treatment Recommendations
 Avoid popping pimples
 Wash face with a non-comedogenic soap
 Sunlight exposure
 DDiieettaarryy mmooddiiffiiccaattiioonnss hhaavvee nnoott pprroovveedd eeffffeeccttiivvee ttoo
reduce acne
 Chocolate
 Fatty foods
 Caution regarding photosensitivity with all agents (at least
SPF 15)
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Patient Case 1 Acne
…He is beginning to develop scarring because of this  Topical Retinoids
irritation and would like something new. Which one  Reduces the presence of mild-to-moderate acne
of the following is the best alternative regimen for  Recommended as first-line treatment for most
the patient to try? types/severities of acne
A. Oral isotretinoin.  MMaayy ttaakkee uupp ttoo 33 mmoonntthhss ttoo sseeee aa cclliinniiccaallllyy ssiiggnniiffiiccaanntt
difference
B. Topical retinoid plus azelaicacid.  Safety Concerns & Adverse Reactions
 Photosensitivity
C. Oral antiandrogen(drospirenone).  Skin irritation
 Pregnancy Category X
D. Topical retinoid plus topical antibiotic.
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Answer 2-47
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Acne Acne
 Topical Antimicrobials  Benzoyl Peroxide
 May be used in all classifications/severities of acne as  Introduce as add-on therapy for moderate-to-severe acne
add-on therapy to the primary or alternative regimens  Should be used in combination with topical and/or oral
 Typically used in addition to a topical retinoin or as a antibiotics because it decreases the chance of
ccoommbbiinnaattiioonn pprroodduucctt wwiitthh bbeennzzooyyll ppeerrooxxiiddee antimicrobial resistance
 Additive to adverse effects of topical acne medications:  Comparable efficacy to oral antibiotics, but without
developing bacterial resistance.
 Dry skin
 Higher concentrations (10%) are only minimally more
 Erythema effective with worse adverse reactions
 Itching
 Scaling/Peeling
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Acne Acne
 Azelaic Acid  Other Topical Agents
 Not recommended as a first line agent to treat acne  Dapsone
 Considered an alternative choice as monotherapy or an  Ssatiflel tuyn odfe trogpoiicnagl sdtaupdsioesn eth uaste evaluate the long-term efficacy and
add-on for patients with mild-to-moderate acne
 Questionable decrease in hemoglobin with use
 Same treatment response is seen with once-daily and
twice-daily application  Salicylic Acid
 Efficacy is comparable to that of benzoyl peroxide (improved
when used in combination with other agents)
 Unlikely to cause salicylate toxicity unless used on a large area of
the skin for an extended period of time
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Acne Acne
 Oral Contraceptives  Oral Antimicrobial
 Later generation progestins have less androgenic activity  Introduced in patients with moderate-to-severe acne
 Third generation: desogestrel, nogestimate  AAD recommends that treatment with oral
 Fourth generation: drospirenone antimicrobials be for limited intervals
 Beneficial for female patients using oral isotretinoin as an  MMiinocyclliine appears mostt effffiicaciious orall
antomicrobial therapy
oral contraceptive and anticomedogenic drug
 Save erythromycin for patients who are
 Increases risk for venous thromboembolism, breast & recommended against using tetracyclines
cervical cancer, and cerebrovascular disease  Be cautious of bone-related adverse events in children
younger than 8 and fetal/infant toxicity
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Acne Acne
 Oral Isotretinoin  Oral Isotretinoin
 Reserved for patients with severe nodular (+conglobate)  Caution against arthralgias, myalgias, and excessive skin
acne or mucus membrane drying
 Treatment resistant acne
 Acne that results in physical or psychological scarring  Multiple safety concerns
 Highly teratogenic (iPledge Program)
 Treatment duration is typically 15 to 20 weeks  Suicidal ideations
 Discontinue sooner if >70% reduction in lesions  Pancreatitis
 Pseudotumor cerebrii
 Requires monthly monitoring for neurologic,
ophthalmologic, gastrointestinal, and metabolic changes
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Acne Acne
 iPledge Program Treatment Recommendations
 Creates a single resource to create a “verifiable link
between the negative pregnancy test and the dispensing
of the isotretinoin…”
 Reqquires monthlyy pprovider documentation that a ppatient
has been counseled on the risks of isotretinoin therapy
 Before starting therapy, iPledge requires two consecutive
blood or urine tests to be negative for pregnancy.
 Patients commit to using two forms of contraception 1
month before, throughout, and 1 month after therapy
 Documented online monthly
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Patient Case 1 Infestations: Scabies
…He is beginning to develop scarring because of this  Irritating, allergic reaction to a mite (Sarcoptes scabiei)
irritation and would like something new. Which one that burrows under the skin
of the following is the best alternative regimen for  Transferred with person-to-person contact
the patient to try?
 Dense living communities
A. Oral isotretinoin.  HHospiittalls, nursiing hhomes, schhoolls
 Types of Scabies:
B. Topical retinoid plus azelaicacid.
 Common Scabies
C. Oral antiandrogen(drospirenone).  Norwegian (crusted) scabies
 Nodular scabies
D. Topical retinoid plus topical antibiotic.
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Answer 2-45
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Infestations: Scabies Infestations: Scabies
 Symptoms Abdomen
 May take 3–6 weeks after initial infestation to present Areola and nipples
with common symptoms Axillary folds
Elbows
 Symptoms may be: FFiinger webbs
 Worse during evening hours and while sleeping Flexor of wrists
 Worsen for 1–2 days after starting treatment Lower buttocks
 Persist for up to 1 week after resolving infestation Penis
Under breasts
Image from the U.S. Center for Disease Control & Prevention
http://dpd.cdc.gov/dpdx/html/Scabies.htm
Page 2-16 Page 2-17
Patient Case 3 Patient Case 3
 P.F. is a 26-year-old mother of two children (6 and …Which one of the following factors is the most
8 years old), who have contracted scabies after likely cause of the treatment failure?
spending the night at a neighborhood friend’s A. Increasing resistance patterns for scabies in the United
house. They developed symptoms about 2 weeks States.
aafftteerr eexxppoossuurree,, aanndd tthhee ffaammiillyy’ss pprriimmaarryy ccaarree BB. TThhee pprreessccrriibbeerr oorrddeerriinngg aann iinnaapppprroopprriiaattee ddoossee ooff
provider gave them a prescription for permethrin permethrinfor the children (pediculosisdose).
5%. Unfortunately, permethrin did not eradicate the
C. Not applying permethrinto areas such as the soles of
infestation, and the symptoms recurred 1 month feet or unexposed areas.
later…
D. Not evaluating infested/symptomatic areas and
removing nits (eggs).
Page 2-17 Page 2-17
Answer 2-45
Infestations: Scabies Infestations: Scabies
 Non-pharmacologic Interventions  Non-pharmacologic Interventions
 Evaluation of all close contacts within the past 30 days  In hospital or nursing home situations:
for symptoms of infestation  Isolate infested patients (may require prolonged isolation to
 Identify all items in contact with the infested person for ensure eradication).
the ppast 72 hours.  Provide education and therapy for family, staff, and residents in
contact wiithh person.
 Decontaminate all bedding, clothing, and toys using machine
washer (at least 140°F water) and heated dryer.  May require treatment of the entire at-risk population
 Isolate items that cannot be put in a machine washer using an
insecticide powder and sealed plastic bag for 48–72 hours.
 Remove infested children from school until infestation is
adequately treated.
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Infestations: Scabies Infestations: Scabies
 Treatment Recommendations  Permethrin 5%
 Most effective agent and first-line recommendation from
the American Academy of Pediatrics
 The 5% cream is to treat scabies and the 1% cream is to
treat head lice
 Patients should apply all over their body (below the head)
and leave on for 8 to 14 hours
 May cause skin irritation, erythema, or numbness
 May worsen symptoms or cause an asthma exacerbation
Page 2-18 Page 2-18
Infestations: Scabies Infestations: Scabies
 Ivermectin  Lindane
 Appears to be less effective than permethrin, but still an  Third-line option for patients who have failed treatment
option for first-line to eradicate scabies (or cannot tolerate) permethrinand ivermectin
 Not FDA approved for treatment, but endorsed by the  Warnings:
CDC as a treatment opption  Increased risk of seizures and death with reppeated or pprolongged
 Oral option for patients who cannot use permethrin exposure
 Serious adverse events:  Precautions:
 Symptomatic postural hypotension  Do not leave on skin for greater than 12 hours
 Associated with an increased 6-month mortality when used in  Avoid any skin-to-mouth contact during application
long-term care residents  Do not retreat if the infestation is not completely eradicated
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Infestations: Scabies Patient Case 3
 Treatment Recommendations …Which one of the following factors is the most
likely cause of the treatment failure?
A. Increasing resistance patterns for scabies in the United
States.
BB. TThhee pprreessccrriibbeerr oorrddeerriinngg aann iinnaapppprroopprriiaattee ddoossee ooff
permethrinfor the children (pediculosisdose).
C. Not applying permethrinto areas such as the soles of
feet or unexposed areas.
D. Not evaluating infested/symptomatic areas and
removing nits (eggs).
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Answer 2-45
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Infestations: Lice Infestations: Lice
 Classification  Non-pharmacologic
 Pediculuscapitis: head lice  Nit removal using a fine-tooth comb
 Pediculuscorporis: body lice  Comb starting from the scalp to the end of the hair
 Phthiruspubis: pubic lice follicle and repeat every 2-3 days until no eggs are found
 SSymppttoms && CClliiniicall FFiinddiings  MMaacchhiinnee wwaasshh lliinneennss aanndd sseeaall uunnwwaasshhaabblleeiitteemmss iinn aa
plastic bag for 14 day
 Rash
 Malaise
 Headache  AAP does not recommend removing students from
school
 Nits (eggs) at the base of hair follicles
Page 2-19 Page 2-20
Infestations: Lice Infestations: Lice
 Treatment Recommendations  Pyrethrins
 Permethrin1% cream is preferred by American Academy
of Pediatrics for treating lice
 Pyrethrins0.33% & PiperonylButoxide3-4% may be
considered as a first-line alternative
 Apply to (washed and dried) hair and rinse after 10
minutes
 May be used as prophylaxis in household contacts and
situations with >20% populations involvement
Page 2-20 Page 2-21
Infestations: Lice Infestations: Lice
 Malathion  Spinosad
 Treatment option for patients older than 24 months who  Approved for use in the United States in January 2011
have failed permethrinor when permethrinresistance is  Not included in the AAP 2010 treatment recommendations
suspected
 Malathionresistance is repported in the United Kindggom,,  LLiimmiitteedd nnuummbbeerr ooff cclliinniiccaall ttrriiaallss ccoommppaarriinngg ssppiinnoossaaddttoo
but U.S. formulation does not have same reports permethrin, but initial data shows spinosadto be superior
(regional data excluded)
 High isopropyl alcohol content poses issues:  Avoid use in infants less than 6 months old secondary to
 Flammable risk of gasping syndrome (benzyl alcohol)
 Skin and scalp irritation
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Infestations: Lice Infestations: Lice
 Ivermectin  Suffocation-Based Pediculocides
 Apply petrolatum shampoo to scalp, dry with a hair
dryer, leave on overnight, and wash out in the morning
 Sulfamethoxazole/Trimethoprim
 Used in addition to permethrim1% for treatment-  Requires manual removal of all lice and nits with a fine-
resiistant iinffestatiions whhere niits andd lliice are ffoundd 22 tooth comb
weeks after initial therapy
 Less expensive alternative than ivermectinfor treatment-  Must thoroughly wash hair for 7 to 10 days to remove
resistant infestations the petrolatum residue
Page 2-22 Page 2-22
Infestations: Lice Patient Case 7
 Treatment Recommendations J.W. presents to his primary care provider’s office for his
annual physical examination. He is a 25-year-old man
with past medical history significant for bipolar disease
with rapid cycling. His medications include quetiapine,
valproicacid, sertraline, and lithium. Today, he presents
with new itchy and painful skin lesions on his knees. He
was involved in a car accident about 12 months ago,
which resulted in several contusions on his upper legs
from impact with the dashboard. Since then, lesions
have developed, and he asks his primary care providers
to identify them.
Page 2-20 Page 2-30
Patient Case 7 Psoriasis
The patient is given a diagnosis of psoriasis, and the  Types of Psoriasis
provider thinks that the patient’s mental health agents  Plaque psoriasis is most common (80% of cases)
may be contributing to the development of these
 Pustularpsoriasis, Guttatepsoriasis, and Erythrodermic
lesions. Which one of the following agents is most psoriasis
likely causing the psoriatic lesions?
 RRiisskk FFaaccttoorrss
A. Quetiapine.
 Genetics
B. Valproate.
 Skin trauma
C. Sertraline.
 Smoking
D. Lithium.  Medications –(N)SAIDs, (A)CE inhibitors, (I)nderal,
(L)ithium, (S)alicylates
Page 2-30 Page 2-30
Answer 2-45
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Patient Case 7 Psoriasis
The patient is given a diagnosis of psoriasis, and the  Clinical Presentation
provider thinks that the patient’s mental health agents  Skin lesions that are itching and/or painful
may be contributing to the development of these
 Silvery scales, symmetric, red lesions:
lesions. Which one of the following agents is most
 Arms & legs
likely causing the psoriatic lesions?
 Buttocks
A. Quetiapine.  Genitals
B. Valproate.  Palms & Soles
C. Sertraline.  Scalp
 Trunk
D. Lithium.
 PASI –Psoriasis Area and Severity Index
Page 2-30 Page 2-31
Answer 2-45
Psoriasis Psoriasis
 Severity Classification  Non-Pharmacologic Interventions
 Moisturizers
Classification Criteria  Ultraviolet radiation (UVA or UVB) for psoriasis that
does not respond to topical treatments
Mild Less than 3% of the body
Moderate 3 to 10% of the body  Smoking cessation
Severe Greater than 10% of the body  Saline spa water therapy (limited efficacy)
Page 2-31 Page 2-31
Psoriasis
 General rules for pharmacotherapy
 Topical agents are first choice for mild-to-moderate
disease
 Systemic therapy may be necessary for severe and/or
extensive disease or those who do not resppond to toppical
therapy
 Medication vehicle may affect efficacy and potency
 Ointments increase medication delivery & absorption
 Foams, shampoos, gels, and sprays may be best for hairy areas
 Creams are ideal for daytime application
 Ointments are ideal for night because of cosmetic shine
Page 2-33
Page 2-32
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Psoriasis Psoriasis
 Topical Corticosteroids  Vitamin D analogs
 First-line treatment option for patients with mild-to-  Recommend use in combination with topical
moderate disease corticosteroids
 Equivalent efficacy to Vitamin D analogs, but with fewer  Area of application should not exceed 30% of the
adverse events ppatient’s bodyy surface area
 As therapy continues, gradually decrease steroid dose and  Risk of hypercalcemiawith use of greater than 100 grams
potency to identify the least efficacious dose per week
 Be aware of skin atrophy and/or dermatologic infections  Counsel patients about photosensitivity and an increased
with long-term use risk of UV-induced skin tumors
Page 2-34 Page 2-34
Psoriasis Psoriasis
 Topical Retinoids  Additional Topical Treatments
 Used in combination with topical corticosteroids in all  Salicylic Acid
severity of disease  Anthralin
 Dermatologic irritation of topical retinoidsmay be  Coal Tar
attenuated with the use of toppical corticosteroids
 TTaaccrroolliimmuussaanndd//oorr ppiimmeeccrroolliimmuuss
 Photosensitivity and increased sensitivity to  Moisturizers
environmental factors (heat, cold, wind, etc)
 Pregnancy category X
Page 2-34 Page 2-35
Patient Case (Self-Assessment) Patient Case (Self-Assessment)
D.T. is a 46-year-old woman with severe and sometimes Which one of the following is the first choice to help
debilitating psoriasis with arthritis symptoms. She has been lessen D.T.’s symptoms?
dealing with painful psoriatic arthritis complications in her
hands, wrists, hips, and knees for the past 6 months and has
only limited relief from nonsteroidalanti-inflammatory
A. Methotrexate20 mgg once weekly.
ddrruuggss ((NNSSAAIIDDss)) aanndd oorraall ccoorrttiiccoosstteerrooiiddss. SShhee uunnddeerrwweenntt aa
hysterectomy with bilateral salpingo-oophorectomy4 years
B. Cyclosporine (equaling 1.25 mg/kg) twice daily.
ago and has poorly controlled hypertension despite being
treated with fosinopril, hydrochlorothiazide, and C. Acitretin50 mg once daily.
amlodipine. She is employed and has medical and
prescription insurance. D. Etanercept50 mg twice weekly.
Page 2-3 Page 2-3
Answer 2-47
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