Integument Exam 3- FINAL

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1

How long should a patient self treat for tineas until they should be referred to their provider?

4 weeks

2

Which tineas infection/s cannot be self treated?

  • tineas capitis
  • tinease cruris (once it spreads to the genital area)
3

What agents are first line for tineas?

Topical Agents

- oral agents are used for more severe infections

4

Which topical fungal products have the same brand name but different active ingredients?

Lotrimin

5

Topical agents used to treat tineas are normally dosed?

once or twice a day

6

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%)
7

___________ is first line ORAL therapy treatment for tineas

Fluconazole

8

Oral therapy treatment for tineas

  • fluconazole (1st line)
  • Itraconazole (severe)
  • terbinafine (severe)
9

Drug of choice to treat tinea capitis?

Griseofluvin

10

Which product formulations for tineas are the most efficent?

  • creams
  • solutions
  • ointments
11

Which product formulations for tineas are used as adjunct therapy?

  • sprays
  • powders (these don't penetrate the area very well, but they keep the area dry)
12

exclusions from self treatment:

  • nails involved
  • genitals
  • face
  • scalp
  • if the infection is widespread
  • if lesions are oozing (refer to provider)
13

Recommended duration of therapy for tineas is?

2-4 weeks

Prefer to provider after 4 weeks

14

A person with tineas pedis should?

wash the area daily

15

LAMISIL AT

Terbinafine

16

TINACTIN

Tolnaftate 1%

17

MICATIN

Miconazole Nitrate 2%

18

LOTRIMIN ULTRA

Butenafine 1%

19

What should be considered when choosing a tineas product for a patient?

  • efficacy
  • compliance
  • cost
20

Patient counseling for tineas treatment:

  • keep area dry and clean
  • massage medications onto the area
  • continue therapy for 2-4 weeks
21

Tinea Pedis

"Athletes Foot"

22

Tinea Cruris

"Jock Itch"

23

Tinea Capitis

"Ringworm of the scalp"

24

Tinea Corporis

"Ringworm of the body"

25

Is there a cure for psoriasis?

NO

26

What triggers psoriasis?

  • genetics
  • environmental triggers (ex: bug bite)
  • stress
  • cold environments (warm weather is therapeutic)
  • smoking
  • alcohol
27

exacerbating medications for psoriasis

  • NSAIDs (naproxen, ibuprofen, meloixcam)
  • Antimalarials (hydroxychloroquine), ACE inhibitors (lisinopril)
  • Inderal (Beta Blockers)
  • Lithium
  • Steroid withdrawal

THEY HAVE ALSO ADDED FLUOXETINE !!!!!!!!!

(Finals is the new acronym)

28

In patients with psoriasis skin cells with be turned over every ______ days

4 days

Normal skin is turned over about every month

29

Diagnosis of psoriasis is based on?

physical examination

30

PASI

Psoriasis Area and Severity Index

measure the severity and coverage

10 or above is considered severe

ranges from 0-72

31

Psoriasis treatment should improve PASI by?

at least 75%

32

Mild Psoriasis

  • BSA involvement is less than or equal to 5%
33

Moderate Psoriasis

  • PASI is greater than or equal to 8
34

Severe Psoriasis

  • PASI is greater than or equal to 10
  • DLQI is greater than or equal to 10
  • BSA is greater than or equal to 10
35

Signs and Symptoms:

  • pruritus (itching)
  • "emotional toll"
  • redness
36

Plaque Psoriasis

  • psoriasis vulgaris
  • MOST COMMON TYPE
37

5 types of Psoriasis

  • plaque
  • inverse
  • guttate
  • pustular
  • erythrodermic
38

About ______ percent of patients have mild psoriasis that can be treated with topical products alone.

80%

39

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)
40

Inverse Psoriasis

  • redness located in the skin folds
  • plaques are red and smooth --> not much "scaling"
41

Guttate Psoriasis

  • triggered by bacterial infection
  • small, fine red sclaes
42

Pustular Psoriasis

  • palms or soles of the hands and feet
43

Erythrodermic Psoriasis

  • wide spread large area
  • patient needs to be in hospital
  • may occur gradually
  • IMMEDIATE MEDICAL CARE
44

Drug therapy for psoriasis (rapid remission)

16-24 weeks

45

Should you use topical steroids on your face?

NO

46

Mild to Moderate Psoriasis

  • Start with topical agents!!!
  • can use moisturizers "ad lib"
47

Moderate to Severe Psoriasis

  • start with an oral product (Methotrexate)
48

Climatotherapy

travel to the dead sea and bathe in the sun rays

49

Emollients for Psoriasis

  • apply cream first, then emollient (if using both)
50

Step Down Therapy

You should always step down therapy if possible

51

80% of patients have mild psoriasis, which means they can be treated with?

Topical products

52

Coal Tar

  • 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
53

Salicylic Acid

  • 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
54

Topical Corticosteroids

  • 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)
55

T/F: The majority of patients can be treated with topical agents alone

True (~80%)

56

Good counseling point for coal tar?

limit sun exposure due to phototoxicity

57

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
58

Retinoids

  • 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)
59

Anthralin

  • 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
60

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
61

What causes skin staining?

Anthralin

62

Calcipotriene is what class?

Vitamin D3

63

Clobetasol belongs to which class?

Topical Corticosteroid

64

Does clobetasol have a faster or slower onset time when compared to calcipotriene?

Faster (since it is a corticosteroid)

65

Topical Calcineurin Inhibitor is most appropriate for which type of psoriasis?

Inverse Psoriasis (in the skin folds)

66

Phototherapy is used in more __________ diseases when topical corticosteroids are not working as well.

Mild

67

UVB Therapy

  • narrow band and broad brand
  • can be combined with coal tar & anthralin... for enhanced efficacy and increased penetration
68

UVA Therapy

  • 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
69

Excimer Laser

  • "know it exists"
  • can be used safely in pregnant women!!!!!!!!!
70

What is the most effective form of phototherapy?

RE-PUVA (this contains a retinoid)

71

Side Effects of Phototherapy

  • erythema
  • pruritus
  • skin cancer
  • hyperpigmentation
  • blisters
72

Non-biologics are?

oral

73

Biologics are?

normally injections

74

Acitretin (SORIATANE)

  • Category X
  • side effects: very significant which limits its use
  • not favorable
  • non-biologic
75

Methotrexate (RHEUMATREX)

  • golden standard systemic agent!!!!!
  • the dosing is RENALLY dependent
  • side effects: alopecia, increased liver function
  • supplement with folic acid
  • Category X
  • non-biologic
76

Cyclosporine (GENGRAF, NEORAL, SANDIMMUNE)

  • side effects: nephrotoxicity (depends on duration of therapy) and HTN (depends on DOSE)
  • 3A4 substrate !!!!!
  • increased risk of drug interactions
  • non-biologic
77

Apremilast (OTEZLA)

  • can also treat psoriatic arthritis
  • non-biologic
78

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
79

Alefacept (AMEVIVE)

  • first biologic approved for psoriasis
  • IM product
  • Side Effects: decrease t cells
80

Guselkumab (TREMFYA)

  • SubQ
  • head to head trial data (we are able to make comparisons)
81

Tildrakizumab-asmn (IlUMYA)

  • SubQ
  • PASI Score: how we determine efficacy
82

Ustekinumab (STELARA)

  • SubQ
  • dosed on patient weight!!!!
  • efficacy is inversely related to patients weight
83

Brodalumab (SILK)

  • SubQ
  • Black Box Warning: suicide ideation and behavior
  • REMS PROGRAM IS REQUIRED!!!!!!!!!!
84

Secukinumab (COSENTYX)

  • head to head data
  • diarrhea in people with Crohn's Disease
85

Ixekizumab (TALTZ)

  • humanized monoclonal antibody... which means LESS SIDE EFFECTS
  • 90% PASI at 2 weeks (very effective)
86

Adalimumab (HUMIRA)

  • TNFa
  • SubQ
  • Biosimilar is Amjevita
  • biosimilar is not a generic though
87

Entanercept (ENBREL)

  • TNFa
  • has a few biosimilars
  • increased risk of infection since it is TNFa
88

Infliximab (REMICADE)

  • chimeric (derived from mice)= more side effects
  • TNFa
  • has a biosimilar
89

Are biosimilars chemically identical?

NO

90

Substituting Biologics ???

  • These are SUGGESTED, not LAWS
  • suggested by national psoriasis foudation
91

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

92

Adverse Effects of cyclosporine

  • nephrotoxicity (duration dependent)
  • hypertension (dose dependent)
93

What is most likely to cause injection site reactions?? (think chimeric)

REMICADE (inflixmab)

94

Can 2 topical agents be used together for psoriasis?

Yes

95

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

96

Can psoriasis be cured?

No, but managed

97

Chicken pox antiviral duration of therapy is?

5 days

98

Shingles antiviral duration of therapy is?

7 days

99

Does acyclovir have more or less side effects?

more, compared to Valtrex and Famciclovir

100

Should a patient with hypertension take NSAIDs?

No

101

Complications with mosquito bites

  • malaria
  • west nile
  • zika virus
102

Best way to treat West Nile?

  • supportive care
103

What virus can be contracted if you like to travel?

Zika Virus

104

Best way to treat Zika?

  • manage the fever with Tylenol
  • supportive care
105

What is the parasitic skin infection that is caused by arachnid mite?

scabies

106

Treatment of scabies

  • requires prescription therapy
107

How should a tick be removed?

remove the tick completely intact with tweezers

108

Deer ticks can cause?

Lyme disease

  • the spirochete is key to developing lyme disease
  • if the tick has been attached for a few days the transmission has already happened
109

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

110

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

111

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
112

Black widow bite is associated with?

PAIN

113

Brown Recluse bite

Necrosis of the skin that creates large, open sores

114

Crotalid Species

  • rattlesnakes
  • copperheads
  • cottonmouths
115

Elapid Species

  • coral snake (neurotoxic)
116

Can fleas transmit bubonic plaque?

Yes

117

_________ spiders are enomous

Majority

- the only reason all spiders cannot infect us is because their fangs are too frail/ too short

118

A "bulls-eye" rash indicates?

Lyme Disease

119

Which bug injects anticoagulant?

Mosquitos

120

If a patient is bitten by a scorpion what should they be given?

ANASCORP

- initiate treatment as soon as possible

121

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

122

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)
123

Which epinephrine injection will talk to you?

Auvi-Q

124

Epi-Pen

  • regular version 0.3 mg
  • junior version 0.15 mg
125

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)
  • IR3535
  • Oil of Lemon Eucalyptus
126

Permetherin

  • pesticide
  • it will kill the insects on contact
  • use on clothing and equipment, NOT LICE
127

How often is DEET applied?

every 4-8 hours

128

Treatment of Stings?

  • 1st thing you should do is scrap off the STINGER
  • icepack
  • local anesthetic
  • hydrocortisone
  • skin protectant
129

What would the treatment of severe stings be?

Short course of corticosteroids

130

What can be used if patients are highly allergic?

VIT for 5 years

Venom Imunnotherapy

131

Are warts contagious?

Yes

132

Common Wart

  • hands are the most common area
  • "cauliflower-like"
  • domed appearance
133

Periungual and Subungual

  • difficult to treat
  • around and/or under the nail
134

What is unique about flat warts?

occur in clusters, fairly small, flat tops

135

Plantar Warts

  • soles of the feet
  • associated with areas of pressure
  • can become painful & affect mobility
136

What is the treatment of choice for warts?

Salicylic Acid

137

Salicylic Acid

  • 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
138

if the wart is not gone in 12 weeks, what should you do?

Refer the patient to a dermatologist

KNOW THIS FOR THE TEST

139

Cryotherapy

  • DMEP is the OTC option
  • liquid nitrogen (in dermatologists office)
140

A patient can give themselves _____ treatments of cryotherapy at maximum.

3

141

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
142

RX therapies of warts

  • Imiquimod (Aldara)
  • Cantharadin
143

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
144

Cantharidin

  • 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