Integument Exam 3- FINAL
How long should a patient self treat for tineas until they should be referred to their provider?
Which tineas infection/s cannot be self treated?
- tineas capitis
- tinease cruris (once it spreads to the genital area)
What agents are first line for tineas?
- oral agents are used for more severe infections
Which topical fungal products have the same brand name but different active ingredients?
Topical agents used to treat tineas are normally dosed?
once or twice a day
Topical agents used to treat tineas characteristics:
- minimal side effects (dryness, burning)
- most are used once or twice daily
- available in LOW concentrations (1 or 2%)
___________ is first line ORAL therapy treatment for tineas
Oral therapy treatment for tineas
- fluconazole (1st line)
- Itraconazole (severe)
- terbinafine (severe)
Drug of choice to treat tinea capitis?
Which product formulations for tineas are the most efficent?
Which product formulations for tineas are used as adjunct therapy?
- powders (these don't penetrate the area very well, but they keep the area dry)
exclusions from self treatment:
- nails involved
- if the infection is widespread
- if lesions are oozing (refer to provider)
Recommended duration of therapy for tineas is?
Prefer to provider after 4 weeks
A person with tineas pedis should?
wash the area daily
Miconazole Nitrate 2%
What should be considered when choosing a tineas product for a patient?
Patient counseling for tineas treatment:
- keep area dry and clean
- massage medications onto the area
- continue therapy for 2-4 weeks
"Ringworm of the scalp"
"Ringworm of the body"
Is there a cure for psoriasis?
What triggers psoriasis?
- environmental triggers (ex: bug bite)
- cold environments (warm weather is therapeutic)
exacerbating medications for psoriasis
- NSAIDs (naproxen, ibuprofen, meloixcam)
- Antimalarials (hydroxychloroquine), ACE inhibitors (lisinopril)
- Inderal (Beta Blockers)
- Steroid withdrawal
THEY HAVE ALSO ADDED FLUOXETINE !!!!!!!!!
(Finals is the new acronym)
In patients with psoriasis skin cells with be turned over every ______ days
Normal skin is turned over about every month
Diagnosis of psoriasis is based on?
Psoriasis Area and Severity Index
measure the severity and coverage
10 or above is considered severe
ranges from 0-72
Psoriasis treatment should improve PASI by?
at least 75%
- BSA involvement is less than or equal to 5%
- PASI is greater than or equal to 8
- PASI is greater than or equal to 10
- DLQI is greater than or equal to 10
- BSA is greater than or equal to 10
Signs and Symptoms:
- pruritus (itching)
- "emotional toll"
- psoriasis vulgaris
- MOST COMMON TYPE
5 types of Psoriasis
About ______ percent of patients have mild psoriasis that can be treated with topical products alone.
Plaque Psoriasis looks like?
- well defined area
- lesions start as small papules
- red patches with white/silver flakes
- "all psoriasis is not red patches"
- darker skin = gray colored patches
- Auspitz's sign (if you scratch the area it will bleed underneath)
- redness located in the skin folds
- plaques are red and smooth --> not much "scaling"
- triggered by bacterial infection
- small, fine red sclaes
- palms or soles of the hands and feet
- wide spread large area
- patient needs to be in hospital
- may occur gradually
- IMMEDIATE MEDICAL CARE
Drug therapy for psoriasis (rapid remission)
Should you use topical steroids on your face?
Mild to Moderate Psoriasis
- Start with topical agents!!!
- can use moisturizers "ad lib"
Moderate to Severe Psoriasis
- start with an oral product (Methotrexate)
travel to the dead sea and bathe in the sun rays
Emollients for Psoriasis
- apply cream first, then emollient (if using both)
Step Down Therapy
You should always step down therapy if possible
80% of patients have mild psoriasis, which means they can be treated with?
- sticky preparations aren't favorable
- use with caution in children (but can be used)
- cheap, OTC
- apply a couple times a day
- CATEGORY C
- not ideal for cosmetic issues (sticky, and stinky)
- SIDE EFFECTS: carcinogenic in animals, but not humans
- lots of formulations, some are OTC
- Category C
- AVOID IN CHILDREN
- DO NOT USE WITH PHOTOTHERAPY
- just use in localized disease (for risk of toxicity)
- can be combined with a steroid
- we have different classes that are different potency
- class 1 is the most potent
- ointments are the "strongest"" formulations
- LESS THAN 50 GRAMS PER WEEK
- do not use on face or thin skin
- treatment of choice in CHILDREN!!!!!
- work fast when compared to other products
- TACHYPHYLAXIS (overtime the product will not work as well, you use step down therapy to avoid this)
T/F: The majority of patients can be treated with topical agents alone
Good counseling point for coal tar?
limit sun exposure due to phototoxicity
Vitamin D Analogues
- Calcipotriene (generic name)
- LESS THAN 100 GRAMS PER WEEK (in adults)
- Apply AFTER light exposure
- effective in CHILDREN
- when used with topical steroids, you don't have to use as much of the steroids
- slow onset compared to topical corticosteroids
- Tazorac (Tazarotene) (Category X... AVOID IN PREGNANCY)
- AVOID IN WOMEN OF CHILD BEARING AGE
- steroid sparing effect (similar to Vit D)
- can cause irritation
- MAJOR PHOTOSENSITIVITY (decreases the amount of phototherapy we need to use)
- ability to do SCAT
- locate plaque, cover the normal skin with something like Zinc oxide, and apply then rub off
- only leave on area for about 2 hours
- older drug
- Not a "go-to drug"
- REFRACTORY PLAQUES (this is a last line option, use when nothing else is working)
- can cause SKIN STAINING
- not as effective as other available products
Topical Calcineurin Inhibitors
- Pimecrolimus (Elidel)
- Tacrolimus (Protopic)
- children must be over age of 2 to use these
- BLACK BOX WARNING: Malignancy!!!!! CANCER!!!!
- not as effective for plaque psoriasis
- used for less common types of psoriasis
What causes skin staining?
Calcipotriene is what class?
Clobetasol belongs to which class?
Does clobetasol have a faster or slower onset time when compared to calcipotriene?
Faster (since it is a corticosteroid)
Topical Calcineurin Inhibitor is most appropriate for which type of psoriasis?
Inverse Psoriasis (in the skin folds)
Phototherapy is used in more __________ diseases when topical corticosteroids are not working as well.
- narrow band and broad brand
- can be combined with coal tar & anthralin... for enhanced efficacy and increased penetration
- have deeper penetration
- works a little better
- greater risk of skin cancer
- RE-PUVA (combined with a topical retinoid)
- a couple times a week
- what product has the highest efficacy? --> RE-PUVA
- similar side effects as a sunburn
- "know it exists"
- can be used safely in pregnant women!!!!!!!!!
What is the most effective form of phototherapy?
RE-PUVA (this contains a retinoid)
Side Effects of Phototherapy
- skin cancer
- Category X
- side effects: very significant which limits its use
- not favorable
- golden standard systemic agent!!!!!
- the dosing is RENALLY dependent
- side effects: alopecia, increased liver function
- supplement with folic acid
- Category X
Cyclosporine (GENGRAF, NEORAL, SANDIMMUNE)
- side effects: nephrotoxicity (depends on duration of therapy) and HTN (depends on DOSE)
- 3A4 substrate !!!!!
- increased risk of drug interactions
- can also treat psoriatic arthritis
Biologic Response Modifiers (BRMs)
- know brand and generic
- these products are typically second line!!!!
- some can increase risk of infections
- TNFa have the highest increased risk of infection
- very expensive
- first biologic approved for psoriasis
- IM product
- Side Effects: decrease t cells
- head to head trial data (we are able to make comparisons)
- PASI Score: how we determine efficacy
- dosed on patient weight!!!!
- efficacy is inversely related to patients weight
- Black Box Warning: suicide ideation and behavior
- REMS PROGRAM IS REQUIRED!!!!!!!!!!
- head to head data
- diarrhea in people with Crohn's Disease
- humanized monoclonal antibody... which means LESS SIDE EFFECTS
- 90% PASI at 2 weeks (very effective)
- Biosimilar is Amjevita
- biosimilar is not a generic though
- has a few biosimilars
- increased risk of infection since it is TNFa
- chimeric (derived from mice)= more side effects
- has a biosimilar
Are biosimilars chemically identical?
Substituting Biologics ???
- These are SUGGESTED, not LAWS
- suggested by national psoriasis foudation
Methotrexate would be most appropriate in which of the following cases?
30 year old male with psoriasis covering > 10% BSA
- methotrexate is oral
- systemic should be used in moderate to severe
Adverse Effects of cyclosporine
- nephrotoxicity (duration dependent)
- hypertension (dose dependent)
What is most likely to cause injection site reactions?? (think chimeric)
Can 2 topical agents be used together for psoriasis?
Exclusions to psoriasis treatment?
- >10% of BSA
- limit self treatment to mild cases
- recalcitrant cases or loss of responsiveness to previously successful therapy
- children < 2 years of age
- AVOID SALICYLIC ACID IN CHILDREN DUE TO TOXICITY
KEEP IN MIND THAT PREGNANT WOMEN ARE NOT EXCLUDED
Can psoriasis be cured?
No, but managed
Chicken pox antiviral duration of therapy is?
Shingles antiviral duration of therapy is?
Does acyclovir have more or less side effects?
more, compared to Valtrex and Famciclovir
Should a patient with hypertension take NSAIDs?
Complications with mosquito bites
- west nile
- zika virus
Best way to treat West Nile?
- supportive care
What virus can be contracted if you like to travel?
Best way to treat Zika?
- manage the fever with Tylenol
- supportive care
What is the parasitic skin infection that is caused by arachnid mite?
Treatment of scabies
- requires prescription therapy
How should a tick be removed?
remove the tick completely intact with tweezers
Deer ticks can cause?
- the spirochete is key to developing lyme disease
- if the tick has been attached for a few days the transmission has already happened
Prophylactic Antibiotic for ticks HIGH RISK BITE
- single oral dose of doxycycline
high risk = from highly endemic area and if they are attached for 36 hours or more
Treatment of Ticks (EARLY TREATMENT)
◦Doxycycline 100mg BID x 14 days
◦Amoxicillin 500mg TID x 14 days
◦Cefuroxime axetil 500 mg BID x 14 days
Scorpion bite assessment
- symptoms of a bite can be on a grade scale from 1-4
- 1 is mild
- 4 is severe
- scorpions live in dry desert areas
Black widow bite is associated with?
Brown Recluse bite
Necrosis of the skin that creates large, open sores
- coral snake (neurotoxic)
Can fleas transmit bubonic plaque?
_________ spiders are enomous
- the only reason all spiders cannot infect us is because their fangs are too frail/ too short
A "bulls-eye" rash indicates?
Which bug injects anticoagulant?
If a patient is bitten by a scorpion what should they be given?
- initiate treatment as soon as possible
What is the black widow antivenom?
Latrodectus Mactans Antivenin
- there is a high risk when using this. Decreases pain but could cause you to die
What is the snake antivenin?
- CroFab (rattlesnakes, cotton mouth, copperheads, comes from sheep, MAY NEED UP TO 18 VIALS TO TREAT $$$ )
- Anavip (rattlesnakes ONLY)
- Micruris Fulvius (Coral snakes)
Which epinephrine injection will talk to you?
- regular version 0.3 mg
- junior version 0.15 mg
What are the 4 EPA approved skin repellants?
- DEET (this is the best option, higher concentration, longer the protection, generally appropriate for routine use 10-40%)
- Picaridin (less stinky and less irritating than DEET)
- Oil of Lemon Eucalyptus
- it will kill the insects on contact
- use on clothing and equipment, NOT LICE
How often is DEET applied?
every 4-8 hours
Treatment of Stings?
- 1st thing you should do is scrap off the STINGER
- local anesthetic
- skin protectant
What would the treatment of severe stings be?
Short course of corticosteroids
What can be used if patients are highly allergic?
VIT for 5 years
Are warts contagious?
- hands are the most common area
- domed appearance
Periungual and Subungual
- difficult to treat
- around and/or under the nail
What is unique about flat warts?
occur in clusters, fairly small, flat tops
- soles of the feet
- associated with areas of pressure
- can become painful & affect mobility
What is the treatment of choice for warts?
- different formulations
- common & plantar warts ONLY
- pain on liquid is the most common formulation
- 40% concentration is for plantar warts
- lower concentration for common warts
- soak, file, and then apply product
- leave for 8-48 hours
- should see improvement in a week or 2
if the wart is not gone in 12 weeks, what should you do?
Refer the patient to a dermatologist
KNOW THIS FOR THE TEST
- DMEP is the OTC option
- liquid nitrogen (in dermatologists office)
A patient can give themselves _____ treatments of cryotherapy at maximum.
How does the cryotherapy of plantar and common warts differ?
- plantar should be held on for 40 seconds
- common should be held on for 20 seconds
RX therapies of warts
- Imiquimod (Aldara)
- r efractory, not responding to normal therapy
- common and flat warts
- ONLY USED A COUPLE TIMES A WEEK @ bedtime (twice weekly)
- leave on skin for 8 hours
- use for 4 months
- side effects: can lighten or darken the patients skin
- paint onto wart area
- painless when applied, coverage with bandage
- blister will appear- can be painful for the patient
- can be used if patient doesn't respond to salicylic acid