Mod 9

• Ointments

  Thick, greasy preparations with an oil or petroleum jelly base and little water.

  highest medication absorption of all formulations.

  management of conditions with thickened skin or inflamed skin.

  Not good for weeping or oozing skin conditions or in areas prone to heavy perspiration
• Creams

  Emulsions of oil and water.

  Not as thick as ointments but thicker than lotions.

  Good for inflamed skin and dry sensitive skin
• Lotions

  Water based,

  may contain alcohol or acids which can cause a burning sensation

  Not greasy and easy to spread.

  Good for oily skin
• Gels

  Transparent with water or alcohol base that usually contain cellulose.

  Liquify and have a cooling effect as they dry.

  Good for oily skin
• Foams

  Aerated solutions that spread easily,

  dry quickly and leave little residue

  Good for oily skin and hairy areas
• Powders

  Have a cornstarch or talc base,

  dry and reduce friction between surfaces.

  Good for skin folds and regions with heavy perspiration
• Pastes

  Mixtures of ointment and powder.

  powder increases adherence to the skin.

  Good for areas that are occluded: diaper rash under a diaper
• Topical glucocorticoids uses

  relieve inflammation and itching

  cream, ointment, gel

  enhance the therapeutic response by helping the glucocorticoid penetrate to its site of action.

  The vehicle may provide additional benefits by acting as a drying agent or an emollient
• Glucocorticoid preparations vary widely in potency. These drugs can range in potency from low to super high
• The intensity of the response to topical glucocorticoids depends not only on the concentration and activity of the glucocorticoid but also the vehicle employed and method of application
• Occlusive dressings can increase absorption of topical glucocorticoids by as much as 10-fold
• NPs should not prescribe the high potency or super high potency topical glucocorticoids. This should be done by dermatologist
• Topical glucocorticoids absorption

  The extent of absorption is proportional to the duration of use and the surface area covered.

  Higher where the skin is permeable: axilla, face, eyelids, neck, perineum, genitalia

  Lower from regions where penetrability is poor: palms, soles.

  Absorption through intact skin is lower than through inflamed skin.

  Absorption can be greatly increased by an occlusive dressing
• Topical glucocorticoids Long term and adverse effects

  • Can cause local infection and irritation.
  • prolonged use: atrophy of the dermis and epidermis -> thinning of the skin, striae, purpura, hypopigmentation, and telangiectasias.
  • Long-term therapy may induce acne and hypertrichosis
• Systemic toxicity of topical glucocorticoids

  • Growth delay (in children) and adrenal suppression (in all age groups).
  • More likely under extreme conditions of use
  • Prolonged use of large area treated with big doses of a high-potency agent covered with an occlusive dressing
• Topical glucocorticoids should be applied in a thin film and gently rubbed into the skin. Patients should be advised not to use occlusive dressings including diapers in children and adults
• what are Keratolytic agents?

  Drugs that promote shedding of the stratum corneum.

  Salicylic acid promotes desquamation by dissolving the intracellular cement that binds scales to the stratum corneum.

  Sulfur promotes peeling and drying
• Keratolytic effects are achieved with salicylic acid concentrations between 3% and 6%. >6%, tissue injury is likely
• Systemic toxicity from keratolytic agents is rare but can result when large amounts are used for long periods of time. Symptoms include, tinnitus, hyperpnea and psychologic disturbances
• Sulfur treats: acne, dandruff, psoriasis, and seborrheic dermatitis

  combined with salicylic acid for additive effects
• Nonpharmacologic measures for acne

  Reduce surface oiliness by cleansing with a gentle nonirritant soap a couple of times a day.

  Avoid irritation from vigorous scrubbing or the use of abrasives.

  Avoid oil-based makeup or moisturizing products.

  Comedo extraction and dermabrasion may be indicated for some individuals.

  Dietary changes provide no benefit
• Drugs for acne

  • Topical antibiotics
  • Topical retinoids
  • Oral antibiotics
  • Oral retinoids
  • Keratolytic agents
  • Hormonal agents
• Mild acne

  Managed with topical antibiotics and topical retinoids
• Moderate acne

  Treated with oral antibiotics and comedolytics.

  Hormonal agents (combination oral contraceptives and spironolactone) can be used in young women whose acne is unresponsive to other drugs
• Severe acne

  Principal agent is isotretinoin
• Benzoyl peroxide first line treatment for moderate acne


  Both an antibiotic (without causing resistance) and keratolytic.

  Suppressing the growth of P. acnes

  Reduces inflammation and promoting keratolysis
• Topical clindamycin and erythromycin

  Suppress growth of P. acnes and decrease inflammation.

  Monotherapy quickly leads to resistance, so they are combined with benzoyl peroxide
• Dapsone (Aczone) uses

  oral therapy for leprosy

  Modest decrease in inflammation and number of acne lesions
• Azelaic acid MOA

  A topical keratolytic drug that suppresses the growth of P. acnes and decreases the proliferation of keratinocytes
• Salicylic acid uses and adverse effects

  Topical keratolytic drug for mild to moderate acne.

  Local irritation and peeling

  allergic rxn rare but only when applied to face
• Topical retinoids MOA and uses

  Derivatives of vitamin A that can

  unplug existing comedones, prevent new ones,

  reduce inflammation, improve penetration of other topical agents.

  Approved for acne use are tretinoin, adapalene, tazarotene, and trifarotene
• Oral antibiotics for acne

  Agents of choice are doxycycline and minocycline.

  Alternatives: tetracycline and erythromycin (usually more resistance)

  Azithromycin used in place of tetracycline

  Systemic antibiotic use should be limited to the shortest possible duration, typically 3 months
• Sarecycline

  Oral tetracycline with narrower spectrum

  Lower rates of GI effects and vaginal yeast effects.

  Efficacy rates are about the same
• Isotretinoin uses

  A derivative of vitamin A,

  used to treat severe nodulocystic acne vulgaris.

  Highly effective, can produce complete and prolonged remission
• iPLEDGE program for Isotretinoin

  A risk management program to ensure that no woman starting isotretinoin is pregnant and no woman taking isotretinoin becomes pregnant.

  Includes pregnancy testing, use of two effective forms of birth control, and patient/provider/pharmacist education and registration
• Combination oral contraceptives for acne

  Estrostep, Ortho Tri-Cyclen, Beyaz, Yaz

  Benefits are due primarily to the estrogen, which suppresses ovarian androgen production and increases production of sex hormone–binding globulin
• Spironolactone uses and adverse effects

  Blocks a variety of steroid receptors, including those for aldosterone and sex hormones.

  Added to the regimen after an OC has proved inadequate.

  Adverse effects: menstrual irregularities, breast tenderness, and hyperkalemia
• Sunlight causes sunburns, premature aging of the skin, skin cancer, and immunosuppression. These effects are caused by UV radiation and can be greatly reduced by using a sunscreen
• UVA vs UVB

  UVA: penetrates the epidermis and deep into the dermis -> immunosuppression, photosensitive drug reactions, and photoaging of the skin.

  UVB: penetrates into the epidermis but goes no deeper -> tanning and sunburn
• Both UVA and UVB promote damage to DNA, hence both can cause premalignant actinic keratoses, basal cell carcinoma, squamous cell carcinoma, and malignant and nonmalignant melanoma