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The efficacy of any topical medication is related to:
- The active ingredient (inherent strength)
- Anatomic location
- The vehicle (the mode in which it is transported)
- The concentration of the medication
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lubricating, occlusive; greasy·
USE for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesions·
AVOID on hairy and intertriginous (when skin is in contact with skin, e.g. armpits, groin, pannus) areas
ointments
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less greasy, drying effects; not occlusive, can sting, more likely to cause irritation (preservatives/fragrances)·
USE for acute exudative inflammation, intertriginous areas
creams
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less greasy, less occlusive; may contain alcohol (drying effect on oozing lesion); penetrate easily, little residue·
USE for hairy areas
Lotion
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less stinging than lotions or solutions·
USE for the scalp, especially for people with coarse or very curly hair
oils
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may contain alcohol, greaseless, least occlusive; dry quickly·
USE for acne, exudative inflammation (e.g. acute contact dermatitis); on scalp/hairy areas without matting
Gel
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spread readily, easier to apply; more expensive·
USE for hairy areas; inflammation
foams
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Aerosols(rarely used), pump sprays
sprays
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medication costs
- Topical medications can be very expensive
- They are not all covered by insurance
- Over the counter (OTC) treatments are generally cheaper than prescriptions
- Generics are less expensive than brand name prescriptions
- It is helpful to know the costs of the medications you prescribe and be able to tell the patient in advance what they should expect to pay
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Topical corticosteroids
- Produce an anti-inflammatory response in the skin
- They are effective for conditions that are characterized by hyperproliferation, inflammation, and immunologic involvement
- They can also provide symptomatic relief for burning and pruritic lesions
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Mech of topical steroids
- induction of phospholipase A2 inhibitory proteins, called lipocortins.
- Control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes by inhibiting the release of their common precursor arachidonic acid.
- (Blocks phospholipase A2 and prevents the production of arachidonic acid.)
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How are topical steroids organized?
- based on their strength (potency)
- Each one in a class has = strength
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Potency of class I and ex agent
- Super high
- Clobetasol propionate 0.05%
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potency of class II and ex agent
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potency of class III-V and ex agent
- Medium
- Triamcinolone acetonide in ointment cream & lotion 0.1%
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potency of class VI-VII and ex agent
- Low
- Flocinolone acetonide 0.01%
- Desonide 0.005%
- Hydrocortisone 1%
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Super high potency(Class I) are used for
- severe dermatoses over nonfacial and nonintertriginous areas
- Scalp, palms, soles, and thick plaques on extensor surfaces
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Medium to high potencysteroids (Classes II-V) are used for
- mild to moderate nonfacial and nonintertriginous areas
- ok to use on flexural (joints) surfaces for limited periods
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Low potency steroids (Classes VI, VII) can be used for
- Large areas and on thinner skin·
- Face, eyelid, genital and intertriginous areas
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Local SE
- Skin atrophy
- Telangiectasis (visible blood vessels)
- Striae
- Acne
- Steroid Rosacea
- Hypopigmentation
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How are SE more likely to occur?
How can you reduce risk?
- The higher the potency the more likely side effects are to occur. The longer you use it the more likely SE are to occur ·
- To reduce risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness
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Systemic SE
- are rare due to low absorption
- Glaucoma (when steroid applied to the eyelid)
- Hypothalamic pituitary axis suppression
- Cushing’s syndrome (moon facies)
- Hypertension
- Hyperglycemia
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The higher the potency used...
- more likely SE are to occur
- To reduce risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness
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duration of tx for super high potency
treat for <3 weeks
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Duration of tx for High and Medium potency
<6-8weeks
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Duration of tx for low potency
side effects are rare. Treat facial, intertriginous, and genital dermatoses for 1-2week intervals to avoid skin atrophy, telangiectasia, and steroid-induced acne
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500 mg treats=
2% BSA (2 palms)
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2 palms 2 times a day=
1 gram/day
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How many grams does it take to cover an avg adult body? for one application
~ 30 grams
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How many grams to cover the face?
30-45 grams
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How many grams to cover extensor surfaces of both arms?
120-150 grams
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How many grams to cover widespread on trunk, legs, and arms?
1-2 pounds
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How many grams are in a pound?
454 grams = 1 lb
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what is the best way to assure you are givin the right amount?
re-assess on follow-up
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What isa good, quick way of estimating the affected BSA?
The "rule of nines"
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when is the rule of nine most often used?
when assessing burns
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when is the rule of nines less accurate?
in children
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Potentsteroids should be avoided in high risk areas such as the
theface, folds, or occluded areas such as under the diaper
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Choosing a topical depends on:
- Severity
- Location
- Application area
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Debris & bacteria collect in these clogged pores which then leads to:
papules and pustules with erythema and edema
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Benzoyl peroxide
- Is topical medication with both antibacterial and comedolytic (breaks up comedones)properties
- used to treat acne vulgaris
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Common adverse effects of benzoyl peroxide:
- Bleaching of hair, colored fabric, or carpet·
- redness & peeling, dry skin
- May irritate skin; discontinue if severe- or decrease amount
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Indication for Azelaic acid: Finacea (gel), Azelex (cream)
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Topical Retinoids are derivatives of what?
vitamin A
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Indication for topical retinoids?
- Photodamaged skin
- Fine wrinkles
- Hyperpigmentation
- Acne
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Common adverse effects of topical retinoids?
- Dryness
- Pruritus
- Erythema
- Scaling
- Photosensitivity
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How is it available?
Cream or gel
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Can you apply it at the same time as benzoyl peroxide?
No, benzoyl peroxide oxidizes tretinoin
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What are the retinoid drugs?
- Adalapene
- isotretinoin
- Tazarotene
- Acitretin
- Bexarotene
- Targretin gel
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MOA of retinoids
- Bind and activate RARs and RXRs
- (Retinoic acid receptors & Retinoid X receptors)
- Results in increased growth factor release, epidermal hyperplasia and thickened skin.
- Desquamation and peeling then occur
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Adverse effects of Tretinoin:
- dryness
- Redness
- peeling
- photosensitivity
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Which of the following is less irritating and why?
-Adapalene
-Tretinoin
- Adapalene
- Its a water-based gel
- It resembles tretinoin in structure, but tretinoid has alcohol
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What should you advise pts about adapalene?
- it causes increased sensitivity to the sun (like tretinoin)
- apply it at night and use SPF during the day
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Indications for Tazarotene
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CI for Tazarotene (Tazorac):
- Preg! its cat X
- get a preg test before starting tazorac
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Newest anti-wrinkle retinoid:
- Avage (tazarotene)
- it is the SAME as tazorac- just approved for a different indication
- Avage= wrinkles
- Tazorac= acne & psoriasis
- all the retinoids help reduce fine wrinkles, rough skin, & brown spots.
- wrinkles reappear when the retinoid is stopped
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How long can a topical agent take to see effect?
2-3 mo
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topical acne SE
- Irritating
- dry skin
- All topical meds can cause photosensitivity
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BBW for isotretinoin (Accutane)
appropriate use
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CI for isotretinoid (Accutane)
- Preg- cat X
- breastfeeding
- Tetracycline- combo may increase risk for pseuotumor cerebri
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What is a common SE seen in teens taking Accutane?
- Muscle and joint pain
- 1/3 develop back pain- imp to know if taking this med and playing sports
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SE of Accutane
- Xerosis (dry skin)
- Cheilitis (chapped lips)
- Elevated liver enzymes
- Hypertriglyceridemia
- Mood changes, depression
- HA- severe HA may be manifestation of pseudotumor cerebri
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Dosing of Accutane
- 1x regime for 2x daily
- give for 15-20 weeks
- may repeat 1x after a period off of 2 mo
- you are writing Rx monthly- have to take preg test every mo to get Rx
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