Common Skin Conditions

Occasionally antifungal agents such as ketoconazole are given as intermittent "pulse" therapy when being used long-term. What is the purpose of pulse therapy? Answer A Less side effects and less costly B Easier to remember to take the doses as prescribed. C Increased hair growth. D Higher risk of liver damage than with daily administration. E It kills the organism more efficiently.

A

Counseling instructions for the use of a topical antifungal for athlete's foot (tinea pedis) should include all of the following except: Answer A Apply the medicine directly on the rash; do not extend the application beyond the visible rash. B Use for at least 2-4 weeks, even if the rash appears to be healed. C Do not walk barefoot to avoid spreading it. D Wear sandals in public showers to avoid catching it. E All of the above are correct statements.

A Apply the medicine 1-2 inches beyond the rash.

Taclonex is a popular dermatological drug. Taclonex is used for this condition: Answer A Psoriasis B Acne C CA-MRSA D Poison ivy, oak or sumac E Eczema

A Calcipotriene and betamethasone ointment comes as Taclonex and Taclonex scalp suspension. Calcipotriene comes alone as Dovonex. Calcipotriene is a vitamin D analog.

Which of the following prescription agents may be prescribed to a teenager with acne? Answer A Solodyn B Ketoconazole C Lamisil AT D Nizoral E Clearasil

A Ketoconazole is an OTC shampoo used for dandruff (usually if less expensive options have failed). Lamisil AT contains terbenafine, and is for topical fungal infections. Minocycline (Solodyn) is a popular agent for acne. If used long-term it can discolor teeth. Use caution in the sun. Check case for tetracycline allergy.

Which of the following agents is not used first line for scabies (mites), due to neurotoxicity/seizures, and requires a Medication Guide if dispensed? Answer A Lindane B Permethrin C Ovide D Benzyl alcohol lotion E Spinosad

A Lindane is used for scabies, but only if other agents, including permethrin, cannot be used due to the risk of neurotoxicity with this agent. If a patient has a seizure they should call 911 or go to the emergency room.

Which acne products are available over-the-counter? Answer A Salicylic acid, benzoyl peroxide, adapalene B Salicylic acid, benzoyl peroxide, isotretinoin C Salicylic acid, benzoyl peroxide, tazarotene D Salicylic acid, benzoyl peroxide, clindamycin E Salicylic acid, benzoyl peroxide, dapsone gel

A OTC products contain benzoyl peroxide or salicylic acid (and less commonly sulfur or lactic acid) as their active ingredient. They can be useful for mild acne.

A patient approaches the pharmacy counter to ask if she should purchase a steroid cream, ointment or lotion. She wants to treat an itchy rash on her palm. She reports that she sometimes gets topical reactions to things that she touches, which appear similar to the current reaction and it generally dissipates on its own. The skin appears thick and calloused. Which formulation would be most appropriate? Answer A An ointment B A cream C A lotion D To treat the palm, she needs a systemic product. E She should be referred to the physician.

A Ointments are used for thick or dry skin and provide the best moisture barrier. Creams are generally less potent than ointments. Lotions, gels and foams are best for hairy skin.

Choose the correct application instructions/safety information for a topical retinoid: Answer A Limit sun exposure; skin will burn more easily. B Use several times a day in the beginning of treatment to improve tolerance. C Products should be used as "spot" therapy only. D It works best if salicylic acid is used while taking this product; be sure to apply the retinoid first. E These products are available over the counter.

A When using a topical retinoid wash the face with mild soap only, twice daily.

Zoe Brown is a fifteen year old girl who was hiking in the woods near her home in California. She picked up a rash that is itchy and spreading. The pharmacist suspects the rash is from contact with poison oak. The pharmacist should offer the following advice to Ms. Brown: (Select ALL that apply.) Answer A Use a product such as Aveeno or Caladryl that may provide relief. Cold compresses may help. B The skin should be washed with soap and water; it is best to try and remove the toxin. C If the rash worsens she can ask her physician for stronger medicine, such as an oral steroid. D Avoid baths until the rash is healed. E Remove the oil from the skin using 70% propyl alcohol.

ABC Do not touch the rash and then touch the face, especially around the eyes. Ivy Block (bentoquatam) or other barrier blocks may have been helpful if applied prior to the hike. Clothing should cover legs that may come into contact with poison ivy (east coast), sumac or oak.

Megan MacDonald will begin therapy with Retin-A Micro. Which of the following are correct counseling statements? (Select ALL that apply.) Answer A Begin with a reduced frequency of application (every second or third day) and shorter duration of contact (washing off the application after a period of time), to improve tolerance. B A pea-sized amount is sufficient (for facial application); it should be divided into 4 equal parts and smoothed over the entire surface of the face. This medication should not be used as "spot" therapy. C It will take 1-3 months to see the full response. Initially, the acne may actually worsen. D The topical retinoid acne medications such as this one do not cause photosensitivity like the OTC products can; they are safer if going out in the sun. E The topical retinoids are safe to use in pregnancy; the oral form is not.

ABC It is best to limit sun exposure; the skin will burn more easily. Isotretinoin oral is much, much more dangerous in pregnancy, however even the topical retinoids are not recommended for use in pregnancy. Start with reduced frequency of application to help the patient get used to the medicine. These typically worsen acne initially.

A pharmacist is discussing oral isotretinoin with a prescriber. Which statements are correct? (Select ALL that apply.) Answer A Due to the birth defect risk, this is a REMS drug. It can only be dispensed by a pharmacy registered with the pregnancy risk management iPLEDGE program. B The progestin-only "mini pill" is not adequate as a form of birth control in females using oral isotretinoin. C This medication is Pregnancy Category X; use causes severe birth defects if pregnancy occurs while using this medication. D Patients should be instructed that they will have dry skin; use a lip moisturizer and carry a water bottle to keep well-hydrated. E The patient cannot get pregnant while taking this medication and for six months afterwards.

ABCD Patients cannot become pregnant one month before taking this medication, while taking this medication and for one month afterwards.

Which of the following brand-generic matches are correct? (Select ALL that apply.) Answer A Terbinafine-Lamisil AT B Butenafine-Lotrimin Ultra C Tolnaftate-Tinactin D Clotrimazole-Lotrimin E Undecylenic acid-Desenex

ABCDE The same brand name can mean different active ingredients; be careful when making recommendations that the patient gets the product intended.

Which of the following statements concerning sun exposure and sunscreens are correct? (Select ALL that apply.) Answer A It is advisable to stay out of the sun when it is strongest: between 10AM-4PM. Sun-protective clothing is also helpful. B Agents that block UVA include avobenzone and ecamsule (and others); the American Academy of Dermatology states that a sunscreen with a recommended UVA-blocking agent should be chosen. C On a cloudy, overcast day there is little risk of burning. D "Broad-spectrum" sunscreens protect against both UVA and UVB. E A sunscreen of an SPF of 50 or higher should be chosen for infants

ABD Some dermatologists recommend SPF of 15 and some recommend an SPF of 30; higher ratings than this are not useful. Infants should stay out of the sun.

A father is picking up a prescription of Elidel for his child. Counseling statements should include the following: (Select ALL that apply.) Answer A Use the smallest amount needed to control symptoms. Continue as long as signs and symptoms persist; discontinue if resolution occurs. B Wash hands after application. Keep the skin well hydrated by using a good moisturizer. C This medication cannot be used in children who are not at least 36 months of age; use is contraindicated in infants. D Limit sun and ultraviolet ray exposure if using this medication. E This drug may add to the child's chance of getting lymphoma or other cancers.

ABDE This medication cannot be used in children who are not at least two years of age (boxed warning).

Which of the following statements concerning sunscreens are correct? (Select ALL that apply.) Answer A If a patient would normally burn in 10 minutes, if they used a sunscreen with an SPF of 5 they would burn in 50 minutes (5 * 10 = 50). B If a person is avoiding the sun they may require vitamin E supplementation; this fat-soluble vitamin is produced through sun exposure on the skin, and can be consumed in dietary sources. C All sunscreens should be reapplied at least every two hours and after going in the water; no sunscreens are truly "waterproof." D UVA and UVB exposure increases the risk of skin cancer. E Water-resistant means the sunscreen is resistant for somewhere between 40-80 minutes.

ACDE If a person is avoiding the sun they will likely require vitamin D supplementation.

A 29 year-old male patient uses the local gym daily. He was not careful to use sandals in the shower and his feet are itchy, particularly between the toes. Choose appropriate OTC medications that will eradicate the infection and are recommended for this purpose: (Select ALL that apply.) Answer A Lamisil AT B Hydrocortisone 1% cream C Diphenhydramine oral tablet D Clotrimazole 7-day treatment E Lotrimin AF

AE Lotrimin AF contains clotrimazole, and Lotrimin Ultra contains butenafine; if the name has Lotrimin, it is an antifungal for somewhere on the skin, and these come in creams and sprays.

Which OTC acne product is considered the first-line recommendation due to higher efficacy for acne than the others? Answer A Salicylic acid B Benzoyl peroxide C Sulfur D Resorcinol E Lactic acid

B Benzoyl peroxide is useful in a cream or as "spot" treatments. If OTC products are not sufficient, the usual next step is a topical retinoid.

A patient asks the pharmacist if Duac topical gel is a useful product for acne. Choose the correct statement concerning Duac: Answer A Duac contains erythromycin and benzoyl peroxide. B Duac can be stored at room temperature for up to two months. C Duac cannot bleach clothing. D Prior to dispensing, store in the freezer. E Duac contains isotretinoin.

B Duac contains clindamycin and benzoyl peroxide. It can bleach clothing because it contains benzoyl peroxide. Prior to dispensing, store in the refrigerator and do not freeze. It can be stored at room temperature, for up to 60 days.

A patient has suspected onychomycosis and the physician is considering systemic terbinafine therapy. Choose the correct statement: Answer A Potassium hydroxide smears are rarely required for this condition; it is generally sufficient to use a visual inspection. B If starting terbinafine, monitor for hepatotoxicity. C Eight weeks are required for treatment of toenail onychomycosis. D Four weeks is a usual treatment duration for treatment of fingernail onychomycosis. E The brand name for terbinafine is Sporanox.

B If using systemic therapy for nail infection, always test with KOH smear first (a messy looking toe nail may not necessarily be due to a fungal infection and these are toxic drugs). Monitor for liver toxicity by instructing patients to report unusual fatigue, anorexia, nausea and/or vomiting, jaundice, dark urine or pale stools. Patients must complete 6 weeks of treatment for fingernail infections and 12 weeks of treatment for toenail infections.

What are the ingredients in the OTC "Triple Antibiotic" products? Answer A Polymyxin, bacitracin, amikacin B Polymyxin, bacitracin, neomycin C Polymyxin, bacitracin, gentamicin D Polymyxin, bacitracin, colistin E Polymyxin, bacitracin, mupirocin

B The triple antibiotic ointment (Neosporin, store brands) contains polymyxin, bacitracin and neomycin. It is used to prevent infections from minor cuts, scrapes or burns. Bacitracin comes as a stand-alone OTC product that is used for the same purpose.

Rank the following topical steroids in order from highest to lowest potency. (Left-click the mouse to highlight, drag, and order the answer options; ALL options must be used.) Answer A Fluocinonide 0.05% B Halobetasol 0.05% C Mometasone (cream) 0.1% D Hydrocortisone 1%

B,A,C,D Highest potency = halobetasol 0.05%. Lowest potency = hydrocortisone 1% (which is available OTC).

Which of the following steroid topical formulations are available over-the-counter? (Select ALL that apply.) Answer A Hydrocortisone 2.5% B Hydrocortisone 0.5% C Hydrocortisone 1% D Betamethasone 0.25% E Betamethasone 0.5%

BC OTC steroids are low potency: hydrocortisone 0.5% (infants, sensitive skin, groin area) and 1% for mild conditions. Hydrocortisone 2.5% is Rx.

Which medications cannot be used if a patient is taking oral isotretinoin? (Select ALL that apply.) Answer A Vitamin D supplements B Vitamin A supplements C Tetracyclines D Steroids E St John's wort

BCDE

Which of the following statements concerning athlete's foot are correct? (Select ALL that apply.) Answer A It is also called tinea cruris. B It is usually treatable with topical OTC agents. C Symptoms include itching, peeling and redness. D Pharmacists should not recommend OTC treatment without first obtaining a potassium hydroxide smear. E Patients should be careful to wear sandals or other foot coverings in public showers and locker rooms in order to avoid infection (and avoid spreading it).

BCE Athlete's foot is tinea pedis. Jock itch is tinea cruris. Skin fungal infections (unlike nailbed fungal infections) are primarily treated by symptoms, unless the patient has a condition such as an immune-compromised state.

Choose the correct statements concerning benzoyl peroxide-antibiotic combination products (Benzamycin, BenzaClin): (Select ALL that apply.) Answer A Benzamycin is an oral formulation indicated for mild acne. B Benzamycin is stored by the patient in the refrigerator. BenzaClin is stored at room temperature. C Benzamycin is mixed with 70% ethyl alcohol and shaken prior to dispensing. D Benzamycin contains benzoyl peroxide and clarithromycin. E Benzamycin contains benzoyl peroxide and erythromycin.

BCE BenzaClin contains benzoyl peroxide and clindamycin. Instruct the patient that if the acne does not respond to OTC treatments, or if they are too drying, they should get a prescription for a stronger agent.

Which of the following medications are first-line treatments for lice? (Select ALL that apply.) Answer A Lindane B Nix C RID D Imiquimod E Permethrin

BCE Lindane (Kwell) is no longer recommended as a first line option due to risk of neurotoxicity/seizures.

If systemic ketoconazole is used to treat onychomycosis, which of the following medications must be stopped during the ketoconazole therapy? Answer A Amlodipine B Carvedilol C Rabeprazole D Multivitamin/mineral supplement E Digoxin

C Ketoconazole and itraconazole are used for onychomycosis. These agents require an acidic medium for adequate absorption. No acid-suppressive agents of any type concurrently.

A patient asks the pharmacist what to do about a circular patch on her forearm that has raised, red edges. The inner part of the circle is clear. The circle edges have small bumps that look like blisters. The patch is ¾" in diameter. Which product should the pharmacist recommend? Answer A Hydrocortisone 0.5% cream B Hydrocortisone 1% cream C Terbinafine D Ivy Block E Diphenhydramine cream

C Ringworm is a fungal infection. Most cases can be treated with topical OTC antifungal creams or ointments, such as miconazole, clotrimazole, butenafine or terbinafine (these last two are the strongest agents and the usual first-line OTC recommendation).

A patient is purchasing Lamisil AT cream for a fungal foot infection. What is the active ingredient? Answer A Clotrimazole B Butenafine C Terbinafine D Tolnaftate E Undecylenic acid

C Terbinafine and butenafine are the most effective OTC agents for most fungal infections.

A patient asks the pharmacist to recommend a sunscreen that is "broad spectrum". What is the correct meaning of the term "broad spectrum" when used for a sunscreen? (Select ALL that apply.) Answer A It provides and SPF of at least 30. B It provides and SPF of at least 60. C It protects against UVA, which causes aging. D It protects against UVB, which causes burning. E It provides and SPF of at least 15.

CD Sunscreen products are allowed to be labeled "broad spectrum" if they provide protection against both UVA and UVB rays.

A patient asks for help choosing an over-the-counter acne product. She is also asking what causes acne. She had a friend who used the product Duac and asks if she can have it. Which of the following statements are correct? (Select ALL that apply.) Answer A Salicylic acid is a stronger agent than benzoyl peroxide. B Androgens (male sex hormones) are the primary determinant of acne, which is why boys usually get acne worse than girls. In addition, the prescence of an organism called mycobacterium that lives in the skin and fatty acids in oil glands in the skin must be present; all three in combination produce a bad case of acne. C Some women find benefit in treating acne using birth control pills. D Common times to get acne are during puberty, in infants, and women around the time of the menstrual cycle. E Benzoyl peroxide comes in combinations with the antibiotics clindamycin or erythromycin; these require a prescription.

CDE Benzoyl peroxide is a stronger agent than salicylic acid. The organism is called P. acnes; the rest of the statement in the second choice is accurate. Women may be using oral contraception if there is another reason to be on the pill; it is not usually given for acne alone.

The topical retinoids such as tretinoin (Avita, Retin-A), adapalene (Differin) and tazarotene (Tazorac, Avage) are first line prescription agents for treating most cases of acne. Choose the correct statements concerning these agents: (Select ALL that apply.) Answer A They are safe to use in breastfeeding. B They are safe to use in pregnancy. C They are derivatives of vitamin A. D They are applied on each acne pimple as "spot" therapy. E They are applied in a pea sized amount, which is divided into 4 equal parts and applied.

CE

Choose the correct statement concerning Nizoral A-D: Answer A It is first-line treatment for OTC dandruff treatment. B Shampoo daily. C It contains itraconazole. D Rub shampoo in well and leave in for 5 minutes, then rinse out, use twice weekly E Is less expensive than most OTC dandruff shampoos.

D

What is the brand name for imiquimod cream (used primarily for genital/perianal warts)? Answer A ReoPro B Campral C Plenaxis D Aldara E Orencia

D

Which of the following topical steroids is considered a very high potency agent? Answer A Hydrocortisone 2.5% B Hydrocortisone valerate 0.2% C Desonide 0.05% D Clobetasol propionate 0.05% E Fluocinolone acetonide 0.01%

D Clobetasol propionate (Temovate, Clobex) is considered very high potency.

Correct application instructions for topical steroid products should include the following points except: Answer A Overuse of this product can cause thinning of skin, striae in the skin folds, and can worsen acne. B Do not use more than directed. C Higher potency steroids (prescription strengths) are usually applied once daily. D Lower potency steroids (OTC strengths) are usually applied three or four times daily. E All of the above are correct counseling statements.

D High potency prescription steroids are generally once daily. The OTC/lower potency products are generally once or twice daily.

Jennifer Lewis comes to the pharmacy and asks to speak to a pharmacist. She states that she has uncomfortable symptoms of vaginal itching and burning on urination. She states that she has never had this before and just wants it to go away quickly. Which of the following would be the best recommendation for Ms. Lewis? Answer A Mycelex 7 B Vagistat 1 C Fluconazole 150 mg PO x 1 D Refer patient to see a physician for diagnosis; recommend OTC antifungal E Monistat 7

D Ms. Lewis has the classic signs and symptoms of a vaginal yeast infection. However, she has never had a yeast infection before and should be seen by a provider for the initial diagnosis. She is symptomatic and treatment would help, but she should be recommended for follow-up.

Which of the following agents used to treat lice is flammable? Answer A Spinosad B Lindane C Permethrin D Ovide E Benzyl alcohol lotion

D Ovide is flammable. Patients using this agent should not be exposed to heat sources when Ovide is applied, such as blow dryers, cigarettes or cooking flames. AndroGel testosterone gel is another medication that can also catch fire.

Which of the following statements concerning pimecrolimus is correct? Answer A This product can be used in children ages 12 months or older. B Apply a thin layer only to the affected skin areas, once a day. C Use on a continual basis even if resolution of eczema occurs. D Use is associated with lymphomas and skin malignancies. E Oral tacrolimus is preferred for intermittent eczema.

D Warnings for Elidel and Protopic: These drugs are associated with cases of lymphoma and skin cancer; use only as second-line agents for short-term and intermittent treatment of atopic dermatitis (eczema) in patients unresponsive to, or intolerant of other treatments. Pimecrolimus is applied twice daily.

Which of the following statements concerning mupirocin is correct? Answer A The brand name is Bacitracin. B It provides only gram negative coverage. C It does not provide coverage against MRSA and would not be a useful option for MRSA-colonizers. D It is available over the counter. E It is a topical product that provides very good staph and strep coverage.

E Mupirocin (Bactroban) is a prescription-only antibiotic cream or ointment that provides very good staph and strep coverage. It is a commonly used Rx drug for topical skin infections.

What does SPF indicate on a sunscreen product? Answer A The amount of time the product will last if the patient gets wet. B The amount of time the product will last if the patient stays in the sun, up to 5 hours duration. C The product's moisturizing efficacy. D The degree of protection from UVA. E The degree of protection from UVB.

E Sun Protection Factor (SPF) indicates the amount of sunburn protection, or UVB blockade.

If one squeezes out enough steroid cream to stretch the length from the fingertip to the first joint, what approximate area of skin would this amount of medication treat? Answer A About the area of one finger B About the area from the foot to the knee C About one leg, front and back D About the area of the hand and arm E About the area of the hand

E The "finger-tip" unit is used to estimate amount required: the amount that can be squeezed from the fingertip to the first joint covers one adult hand (which on an adult finger would weight about ½ gram).

Jennifer Wong, a 44 year-old Asian female, has struggled with eczema patches since she was a child. She typically uses Aveeno colloidal oatmeal bath. She has never used anything else and found that this product provided moderate relief. She is at her annual physical and the physician has written a prescription for Elidel. Choose the correct statement: Answer A The drug is considered first line for this type of presentation. B It is likely that the insurance company will provide coverage. C She should be using diphenhydramine (oral) or a similar product instead prior to the use of this agent. D She should be using oral steroids instead. E Elidel is not indicated currently.

E Treat eczema first with topical steroids, and only use tacrolimus (Protopic) or pimecrolimus (Elidel) if the patient has failed topical steroids.