Chapter 105: Drugs for the Skin

Psoriasis

common chronic inflammatory disorder that follows an erratic course; initial episode usually develops in childhood and subsequent attacks may occur spontaneously due to triggers

Big adverse effect of sunscreens

contact dermatitis

Physical measures to treat venereal warts

cryotherapy, electrodessication, laser surgery, and conventional surgery

Sulfer (keratolytic) uses

dandruff, acne, psoriasis, and seborrheic dermatitis

Retinoids for acne MOA

derivative of vitamin A that is used to unplug existing blackheads and prevent development of new ones (can be used alone or in combination)

Which HPV causes venereal warts

6 and 11

Which HPV viruses cause common warts?

1, 2, and 3

Why does acne occur during puberty?

there is an increase in hormones and androgens

How is impetigo treated?

with antibiotics

Treatment for psoriasis

topical drugs, systemic drugs, phototherapy (most suppress activity of inflammatory cells)

Retinoids for acne

tretinoin adn adapalene

Topical minoxidil

used for hair growth (Rogaine)

Salicylic acid (keratolytic) uses

used for warts and corns

Isoretinoin (Accutane)

used to treat severe nodulocystic acne vulgaris

Safe sun exposure

using sunscreen, wearing protective clothing, and being mindful of the time of day you're going outside

Which instruction should the nurse give a patient who is prescribed a topical glucocorticoid for a dermatologic disorder? (Select all that apply.) A. "You may note some local irritation when using this product." B. "Avoid using any tight-fitting bandages or dressings after applying." C. "Apply in a thin film and gently rub into the affected area." D. "Topical glucocorticoids pose a risk of local infection." E. "Topical glucocorticoids can lead to thickening of the skin at the application site."

A, B, C, and D Rationale: It is most important that a patient understand the proper application of a topical glucocorticoid, because they vary in intensity and duration. Topical glucocorticoids can lead to local irritation and an increased risk for local infection. The medication should be applied in a thin layer to the affected area and rubbed into the skin. The medication should not be covered with a dressing or bandage, because this increases the intensity. Use of topical agents can lead to atrophy (thinning) of the epidermis and dermis.

A nurse teaches a patient who has multiple areas of actinic keratoses on the face and scalp about the use of which medication? A. Fluorouracil [Efudex] B. Podophyllin [Podocon-25] C. Tacrolimus [Protopic] D. None of the above

A. Rationale: Actinic keratoses are rough, scaly skin papules caused by long-term exposure to sunlight. The lesions are treated topically with fluorouracil, a cytotoxic agent. Podophyllin is used to treat perianal and venereal warts. Tacrolimus is a topical immunosuppressant used for moderate to severe atopic dermatitis (eczema).

A nurse is planning care for an 18-year-old woman who has acne and is scheduled to start taking isotretinoin. The nurse should establish which outcomes on the plan of care? (Select all that apply.) A. Use of two effective forms of birth control B. Registration with the iPLEDGE program C. Negative pregnancy test result before refills D. Reports of depressed mood, suicidal thoughts E. No elevation in blood triglyceride levels

All of them Rationale: Isotretinoin has demonstrated teratogenic effects and must not be used during pregnancy. All female patients must use two effective forms of birth control and have one negative pregnancy test result before monthly refills. iPLEDGE is a risk-management program used by the prescriber, pharmacist, and patient to ensure that the patient will not become pregnant while taking isotretinoin. Triglyceride levels should be measured periodically, because they may become elevated with the treatment. Depression and suicide are rare effects without direct causal links to isotretinoin, but patients should still be taught to report any signs of depression to a clinician.

Which statement by a patient being started on tretinoin [Retin-A] for acne treatment indicates a need for further teaching? A. "I'll avoid using abrasive soaps on the areas where I'm applying the Retin-A." B. "I'll apply the Retin-A after washing my face and while it is still slightly damp." C. "I'll need to apply sunscreen with a sun protection factor of 15 or higher to my face and wear a hat." D. "I'll apply the cream daily at bedtime."

B. Rationale: Before applying Retin-A, the patient should wash the skin, towel it dry, and then allow it to dry fully for 15 to 20 minutes. Abrasive soaps can intensify blistering, peeling, crusting, burning, and edema and should be avoided. Treated skin has an increased susceptibility to sunburn and should be protected with sunscreen (SPF 15 or higher) and protective clothing. Retin-A typically is applied daily at bedtime.

Which laboratory value does not require monitoring for a patient receiving treatment with methotrexate [Rheumatrex] for psoriasis? A. White blood cell (WBC) count B. Thyroid-stimulating hormone (TSH) levels C. Platelet count and hemoglobin/hematocrit level D. Alanine and aspartate aminotransferase (ALT and AST) levels

B. Rationale: TSH levels do not require monitoring. However, because of the potential for adverse effects, such as anemia (hemoglobin and hematocrit), leukopenia (WBC count), thrombocytopenia (platelet count), and liver impairment (ALT and AST), these laboratory tests should be monitored.

A 22-year-old female pt is prescribed isoretinoin (Accutane) for severe acne vulgaris. What statement will the nurse include in the pt teaching? A. vitamin A supplements can be used with this medication B. pregnancy must be avoided while taking this medication C. oral contraceptives must not be used with this medication D. the most common adverse effect of this medication is depression

B. Rationale: This drug is teratogenic and must not be used during pregnancy. Vitamin A supplements should be avoided, and oral contraceptives can be used with this drug, and depression can occur although it is rare.

Which topical antimicrobial does not promote resistance in Propionibacterium acnes when used to treat acne? A. Clindamycin [Cleocin] B. Erythromycin [Eryderm] C. Benzoyl peroxide D. Minocycline

C. Rationale: Benzoyl peroxide does not promote resistance in P. acnes.Monotherapy with either clindamycin or erythromycin quickly leads to resistance in P. acnes; therefore, to protect against the development of resistance, these drugs should be combined with benzoyl peroxide (eg, clindamycin/benzoyl peroxide, or erythromycin/benzoyl peroxide). Minocycline is an oral, not a topical, antimicrobial.

Melanin provides protection against ultraviolet radiation through which layer of the skin? A. Dermis B. Subcutaneous tissue C. Basal layer of the epidermis D. Cornified layer of the epidermis

C. Rationale: Melanin is produced by the melanocytes, which are located in the basal layer of the epidermis, the outermost layer of the skin. The dermis underlies the epidermis and is mostly connective with collagen tissue. The subcutaneous tissue provides a layer of insulation and is mostly fat. The cornified layer of the epidermis has a high keratin content and is continuously shed.

A pt has used a topical glucocorticoid preparation daily for several years. It is most important for the nurse to assess the pt for which adverse effect of long-term topical glucocorticoid therapy? A. shedding of dry scales B. open and closed comedones C. atrophy of dermal and epidermal layers D. cancerous lesions

C. Rationale: Prolonged use of topical glucocorticoids may result in atrophy of the dermis and epidermis, with thinning of the skin, striae, and purpura.

A patient is scheduled to start using tretinoin [Retin-A] topically for acne. The nurse instructs the patient also to begin using which product? A. Folic acid B. Stool softener C. Sunscreen D. Vitamin D

C. sunscreen Rationale: Tretinoin, a derivative of vitamin A, is a cornerstone topical treatment of acne. However, it increases susceptibility to sunburn, and patients should be taught to apply sunscreen products and wear protective clothing. It is not necessary to use a stool softener or take vitamin D or folic acid when using topical tretinoin.

Which statement should the nurse include when teaching a pt about sunscreens? A. the relationship between SPF and protection against sunburn is linear B. PABA-containing products are safe for people allergic to thiazides C. sunscreens can claim to be waterproof or sweatproof D. the intensity of UVB radiation is greatest between the hours of 10 am and 4 pm

D. Rationale: The relationship between SPF and protection against sunburn is NOT linear. PABA containing products should be avoided by those who have allergies to benzocaine, sulfonamides, or thiazides. Sunscreens can no longer claim to be sweat proof or water proof, they can claim to be sweat or water RESISTANT.

A nurse teaches a patient who is applying salicylic acid for acne to report which finding as a manifestation of systemic toxicity? A. Nausea and vomiting B. Diarrhea C. Hypoglycemia D. Tinnitus

D. tinnitus Rationale: Salicylic acid is readily absorbed through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, hyperpnea, and psychologic disturbances. Nausea and vomiting, diarrhea, and hypoglycemia are not associated adverse effects of salicylic acid.

Treatment of unwanted facial hair

Eflornithine (Vaniqa)

Drugs for Atopic Dermatitis (Eczema)

Glucocorticoids Topical immunosuppressants (May cause skin cancer or lymphoma) Tacrolimus Pimecrolimus

Tanning and sunburn are caused primarily by which UV type?

UV-B

Organic sunscreens (chemical)

absorb UV radiation and displace it as head (15 of the approved sunscreens are organic)

Symptoms of psoriasis result from

accelerated maturation of epidermal cells or excessive activity of inflammatory cells

What is the most common dermatologic condition?

acne

Half of all of the skin cancers in the US start as...

actinic keratoses (AKS)

Adverse effects of topical glucocorticoids

stretch marks, purport, hypertrichosis (more hair growth), thinning of the skin, and possible systemic toxicity

Oral antibiotics for acne

tetracyclines, isoretinoin, and hormonal agents

2 interlukin antagonists for psoriasis

adalimumab and ustekinunab

What should someone taking methotrexate avoid?

alcohol because it can potentiate liver toxicity

Emla cream

anesthetic ointment that can be used with children before an infection to help anesthetize the skin (can also be an injection)

Benzoyl Peroxide

antibiotic and keratolytic that suppresses bacteria production and reduces inflammation

Administration of topical glucocorticoids

apply a thin film and rub into the skin and do not use an occlusive dressing (let the skin breathe)

Topical local anesthetics that can be used to relieve pain and itching associated with skin disorders

benzocaine, lidocaine, and pramoxine

What is the first line drug for mild to moderate acne?

benzoyl peroxide

Spironolcatone for acne

blocks aldosterone receptors and sex hormones because they can cause more acne

Adverse effects of methotrexate

blood dycrasias, severe damage to the liver, GI, nausea, vomiting, and bone marrow suppression

Acne is more common and severe in...

boys

Two forms of impetigo

bullous (caused by S. aureus) and nonbullous (most common, caused by staph or strep)

Impetigo is usually seen in...

children aged 2-5

Rosacea

chronic inflammatory disorder of the facial skin which causes redness, primarily in the areas of blushing/flushing (can lead to spider like vessel dilation in the face and cause a bulbous nose)

Nondrug therapy for acne

cleansing the face

Topical antibiotic for acne

clindamycin

What does a sunscreen label have to have?

the amount of UV protection and SPF and it also has to be water or sweat resistant

Uses of topical glucocorticoids

to relieve inflammation and itching and dry out the skin

UV-B

doesn't penetrate the dermis but can cause damage to DNA and skin cancer

What is the oral antibiotic of choice for acne?

doxycycline (or tetracylines or erythromycin if they cannot take doxycycline)

2 tumor necrosis factor antagonists for psoriasis

enteracept and infliximab

Rosacea is more common in...

fair skinned individuals

Drugs for actinic keratoses

fluorouracil, diclofenac sodium, imquimod, and amnivulinic acid and blue light

Most common topical drug used for psoriasis

glucocorticoids

Topical drugs for venereal warts that can be applied at home

imiquimod, podofilox, and kunecatechins

Sunscreens

impede UV penetration into the skin; can protect against sunburn and can reduce the risk of skin cancers

What is the most common bacterial infection of the skin and which microbe causes it?

impetigo caused by staphylococcus aureus

Sun Protection Factor (SPF)

index or protection against UVB radiation and doesn't address UVA

Why is acne treatment prolonged?

it is a chronic condition that needs to be treated because it can cause scarring and we want to decrease the duration of it

Why does someone who takes isoretinoin (Accuetane) need to receive a pregnancy test the month before and after taking it as well as register with ipledge to use 2 forms of birth control while taking it?

it is a teratogenic drug and can cause fetal harm and death if taken while the pt is pregnant

Systemic drugs for psoriasis

methotrexate (Cytotoxic), glucocorticoids for inflammation, and cyclosporine for immunosuppression

Systemic toxicity with topical glucocorticoids

more likely with higher doses for a prolonged amount of time; results in growth retardation in children and adrenal suppression

Where do actinic keratoses usually develop?

on the face, scalp, forearm, and hands

UV-A

penetrates deep into the dermis; can cause DNA damage and skin cancer (penetrates deeper than UVB)

Topical drugs for venereal warts that must be applied by a provider

podophyllin, bicoloroacetic acid (BCA) and trichloroacetic acid (TCA)

Clindamycin with benzoyl peroxide for acne

prevents bacterial resistance to the peroxide

Keratolytic agents

promote shedding of horny later of the skin

What is the microbe that intensifies acne?

propoinibacterium acne; it converts sebum into an irritating fatty acid

Actinic keratosis

rough, scaly, red or brown papule caused by chronic exposure to sunlight

Drug used to treat common warts

salicylic acid to help erode and burn off the wart after a period of time

Inorganic sunscreens (physical)

scatter UV radiation