Pharm- headache and dermatology meds

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causes of headaches

Must differentiate between a HA that has an identifiable underlying cause (HTN, tumors, infection (sinus, throat and ears) and hyperthyroidism) and those that do not

No clear cause migraines/cluster)- treat directly

Get CT first thing to rule out tumors



Run in families, women increase migraines around period bc hormones


Headache drug considerations

Abortive or preventative (daily)

Not all pts respond the same- individualize

Many can produce dependence (opiods and egotamine)- attempt to prevent dependence!! and withdrawal procedure needed

Dependent pts will only respond to addicted drug.



Throbbing (moderate to severe)


Physical activity worsens (morning after waking up)

Increase gradually, last 4-72 hrs

Precipitating factors: anxiety, fatigue, stress, menstruation, alcohol, weather changes, and tyramine containing foods

Neurovascular disorder- Dilation and inflammarion of intracranial blood vessels. triggered by neural event


Aura vs no aura

Aura- HA preceeded by visual symptoms (flashes, black spot, zigzag). Take Abortive therapy now!

No aura- more common (70% pts)


Migraines- Abortive therapy

Objective- eliminate HA & N/V

Take on earliest sign of attack

Oral inefective bc of N/V and Gi symptoms

Drug selection depends on intensity


Asprin-like drugs example

Tylenol (needs to be combined with aspirin and caffeine), Naproxen (alieve).

These drugs provide effective relief for mild to moderate migraine attacks.

Ex: Excedrin Migraine consists of ASA, Tylenol and caffeine


Asprin Like drugs

acetaminophen, naproxen, diclofenac

Mild to moderate migraines

May work as well as Sumatriptan (Imitrex) when mixed with Reglan

Acetaminophin should always be mixed or it will cause an Excedrin Migraine


Opiods for Headaches

Only for severe migraines that haven't responded to first line meds

Demerol, Stadol (nasal, preferred because no CNS effects/ abuse potential)

Caution because they cause secondary addictive effects!


Common Serotonin 1B/ID Receptor Agonists (Triptans)

Eletriptan (Relpax)

Rizatriptan ( Maxalt ) *May be the most consistently effective triptan

Sumatritan ( Imitrex ) *First drug in this class available and best understood. Prescribed most bc comfortable.

Zolmitriptan ( Zomig )

Alomotriptan ( Axert )

Frovatriptan ( Frova )


Abortive Therapy Drug Drug Interactions

Ergomar & Triptans- because of prolonged vasospasms. separate by 24hrs (opiods within time)

Ergomar & CYP3A- because it raises ergomar in plasma (intense vasospasms--> Periphrial and cerebral ischema) Avoid Azoles (antifungals) and Marcolides (Biaxin, Erythromycin).

Use Diflucan and grape fruit juice with caution

Egomar daily can cause dependance.


Common Ergot Alkaloids

Erotamine + Caffeine (Cafegot)

Ergotamine (Ergomar)


Preventative therapy for migraines

Reduce frequency/severity

For pts with 3+ a month

For severe attacks that dont respond to abortive alone


Preventative Therapy Meds

Beta Blockers (Inderal)*first line for migraine prevention

Antiepileptic drugs (Depakote, Topamax)

Tri-cyclic Antidepressants (Elavil)

Estrogen/ Birth control for the menstrual migraine


Cluster Headaches

Series. each lasts from 15 minutes to 2 hours.

Severe, throbbing, unilateral, in orbit temporal area near eye

1-2 Attacks daily for 2-3 months with remission

Lacrimation, eye redness, nasal congestion, ptosis, Pupil constriction (same side as headache)

No aura/ N/V, Debilitating, males, not associated with family history.

Treatment- Oxygen, Triptans, Erogot Prep

Prevention- Predisone (steriod), Lithium (bipolar), Verapamil (Calcium Channel blocker)


Tension Headaches

Most common

Moderate, non-throbbing pain


Caused by eye strain, stress, and frustration

Chronic- 15+ days a month for 6mo

Prevention- Elavil (if chronic, also an antidepressant) and new glasses

Treatment- ASA-like meds, Massage, hot baths, and biofeedback


Skin Layers

Epidermis- outtermost. densly packed cells.

Dermis- under Epi. Connective tissue

SubQ- Fat. Protection and insulation


Topical Glucocorticoids

Relieve pain and itching

Potencies varies widely (OTC Cortizone is least potent, cream<ointment)

Absorbed systemically through skin (**axilla, face, eyelids, neck, perineum and gentila)

Side effects- high potency, long time, use of occlusive dressings


Topical Glucocorticoids Reactions

Local Reactions- Increase local infection risk, Irritation, atrophy of skin, hair thinning, and striae

Systemic Toxicity- Growth retardation in kids and adrenal gland supression


Keratolytic Agents

Promote shedding of horny layer

Peeling--> Extensive Desquamation of skin



Most common dermatologic disease (85% teens)

Treatment over 1 bill/year (100M for OTC)

Begins in puberty, starts to clear after, usually entirely gone by 20's, but may continue for decades.

Males more common


Non-Pharm treatments for acne

Gentle cleansing 2-3x a day

No oil based moisturizers



Acne Therapy

Topical- Antimicrobrial and retenoids

Oral- Antibiotics and retenoids

Med selection based on severity


Treatment of mild acne

topical antimicrobials and retinoids.


Treatment of Moderate Acne

Oral antibiotics- doxycycline, minocycline

Comedolytics- Retenoids and azelic acid


Treatment of severe acne

Isotrtinoin (Accutane)

Can also use Birth control (Spironolactone)

*work up to accutane because of the many side effects it has. Severe may have oral and topical combo



Derivitive of Vitamin A (retinol)

Unplug existing comodomes

Prevent new development

Improve penetration of other topicals

May be used alone or in cobo with other antimicrobrials



Comedones are the skin-colored, small bumps (papules) frequently found on the forehead and chin of those with acne. A single lesion is a comedo.

Open comedones are blackheads; black because of surface pigment (melanin), rather than dirt.

Closed comedones are whiteheads; the follicle is completely blocked.


Acne and antibiotics

Moderate to severe

Supress growth of P.acnes and decrease inflammation

Can be combined with topical retenoid


Isotretinon (Accutane)

Used in severe, nodulitic, disfiguring, acne vulgaris.

Serious side effects

Cant be used in pregnancy (cat. X)


Isotretinon (Accutane) Expected Results

Decrease sebum production and sebacious gland size, decrease inflammation, keratinization.

Quick and incomplete absorption from GI tract (food greatly increases absorption)

1/2 life is 10-20 hours


Isotretinon (Accutane) Side Effects

Most Common- Nose bleeds, Lip/Eye inflammation, dry&itchy skin/nose/mouth, Pain/tenderness/stiffness of muscles bones and joints, Back Pain

Less common- Rash, headache, hair loss, palm and sole peeling

Rarely- Cataracts, optic neuritis, papilledema, pseudotumor cerebri, depression

Increases triglyceride levels (measure before and after treatment, Alcohol increases too much, should avoid it.)


Isotretinon (Accutane) Drug Interactions

Tetracyclines (doxycycline, minocycline) & Vitamin A increase Side effects

Increases risk for pseudotumor cerebri and pappilledema

Vitamin A (cousin) combo can produce toxicity (dont inbreed)

Discontinue VitA and tetracyclines when starting accutane


iPLEDGE Program

Strict risk management program for women taking accutane

No babies!!

2 negative preggo tests to start accutane, and one every month of treatment

Must use 2 birth controls entire time


"The Pill" for acne

4 combos approved: Estrostep, Ortho-Tricyclin, Beyaz and Yaz

May take at least 6mo to improve (benefits are d/t estrogen.. Decrease androgen, increased globulin)

15+, Want to take BC, have period, not respond to other acne treatments

May get blood clots if you smoke!



UVA- penetrates dermis and deep into EpiD. primary cause of photosensitive drug reactions and photoaging

UVB- penetrates only dermis


Benefits of sunscreen

Impedes penetration of UV into skin

Protects against sunburn, photoaging, and photosensitive rxns to drugs

Decrease risk of squamous cell carcinoma

Unclear if it protects against basal cell


2 types of sunscreen

Organic (Chemical) Screen: Most of the approved sunscreens are organic. Most of them absorb UVB, and only 6 of them absorb UVA (broad spectrum)

Inorganic (Physical) Screens: Act primarily as a barrier. Rather then absorb, the reflect and scatter the light. Preventing penetration into the skin (Zinc Oxide). These protect limited areas (Nose, Mouth, Tips of Ears)


Side effects of sunscreen

Contact dermatitis and photosensitivity


Broad Spectrum sunscreens

Protect against UVA and UVB

SPF 15+ (cant claim to protect against photoaging or cancer if 15-)

Highly protective- BS, 15+. Protects against skin cancer and photoaging

Moderately Protective- BS, 2-14. Sunburn only

Least protective- Only UVB and sunburn protection


Atopic Dermatitis (eczema)

Chronic Inflammatory skin condition

Scaly skin with intense puritus-> scratching and rubbing

Increased infection risk

Associated with allergies

Caused by abnormal T-lymphocyte activity


Atopic Dermatitis (eczema) Treatment

Moisturizers (cetaphil, eucerin) --> Topical steroids (glucocorticoids)--> topical immunosuppressants (humera) with caution


Seborrheic Dermatitis/ dandruff

Chronic, relapsing inflammation and scaling of scalp and face

Because of inflammatory reaction to Pit. Ovale (yeast)


Seborrheic Dermatitis/ Dandruff Treatment

Topical ketoconazole (Antifungal)

Ketoderm cream, 1/2% Nizoral shampoo, and gel (2x daily for 4 weeks)

Gel is daily for 2 weeks

Glucocorticoids accelerate response

After it is controlled- remission maintained with yeast supressing drug (Nizoral), pvrithone zinc (head n shoulders), and selenium sulfide (selsun blue)


Drugs for Hair loss

Minoxidil (topical, orig. for HTN)

MOA unknown, not many Side effects, delays loss and stimulates growth, may take months, only 1/3 get hair back, will lose within 3-4 months of stopping

Finasteride (oral, orig for BPH, AKA propecia)

Treats androgenic alopecia, Decreases Dihydrotestosterone (DHT) to lessen shrinkage of follicles. 1 mg reduces DHT by 65%. Modest regrowth (50% pts). Reduced libido, ED, impaired ejaculation.



Staph Aureus Bacterial infection (contagious)

Children 2-5yo

Treated with antibiotics (topical, severe is oral)

Topical- Mupirocin (Bactroban) ointment or cream

oral- Keflex, Doxycycline, Augmentin, Clindamycin

Looks like honey comb around nose and lips. clears in 10 days.