1
Q
What 3 agents reduce hyperpigmentation of the skin?
A
- Hydroquinone
- Mequinol
- MBEH (monobenzyl ether of hydroquinone)
2
Q
How do these reduce hyperpigmentation?
- Hydroquinone
- Mequinol
- MBEH (monobenzyl ether of hydroquinone)
A
Inhibit tyrosinase, interfering with the biosynthesis of melanin
3
Q
Temporary lightening
- Can be combined w/ tretinoin or glycolic acid to speed up lightening
A
- Hydroquinone
- Mequinol
4
Q
Irreversible depigmentation
- May cause hypopigmentation at sites distant from the area of application
A
MBEH (Monobenzyl ether of hydroquinone)
5
Q
What 2 agents help w/ reducing hypopigmentation?
A
Psoralens
- Trioxsalen
- Methoxypsoralen
6
Q
What drugs?
- Repigmentation of depigmented macules of vitiligo
- Photo-activated by UVA light
- Topical or oral psoralen
- Risks of psoralen photochemotherapy
- Cataracts and skin cancer
A
Psoralens
- Trioxsalen
- Methoxypsoralen
7
Q
What are the 2 topical medications against sunlight?
A
- Sunscreens
- Sunblock
8
Q
Which med against sunlight?
•Contain chemical compounds that absorb ultraviolet light
A
Sunscreens
9
Q
Which med against sunlight?
•Contain opaque materials such as titanium dioxide that reflect light
A
Sunblock
10
Q
What are the 3 classes of compounds used in sunscreens?
A
- p-aminobenzoic acid (PABA) and its esters
- Most effective available absorbers in the B region
- benzophenones
- Oxybenzone, dioxybenzone, and sulisobenzone
- dibenzoylmethanes
- Avobenzone
11
Q
Sunscreens
- SPF really only measures ___ protection
- What chemical should you look for in sunscreen? (has complete UVA coverage)
- ____ by L’Oreal was recently FDA approved and has better UVA/UVC coverage than ____
- Apply __ mins before going out and replace every __ hours
A
- UVB
- Parsol 1789 or Avobenzone
- Mexoryl (Antheliose)
- 20 / 2
12
Q
Broad spectrum sunscreens add what 3 things?
A
- Oxybenzone
- or
- Avobenzone
- and
- Mexoryl
13
Q
What is a new proposed sunscreen rating system?
A
- UVA protection: 1-4 stars* (low/medium/high/very high protection)
14
Q
Sunblocks
- Contain ____ or ____
- NO chemical rxn required to work (can go out immediately after application)
- Not as good ___ coverage as sunscreen
- Need to reapply ever __ hours
- Apply large amounts to assure good coverage
A
- zinc oxide paste / titanium dioxides
- UVA
- 2
15
Q
_____ refers to the the process of breaking down or dissolving keratin. The result is a softening of the stratum corneum of the epidermis promoting peeling
A
Keratolytic / Destructive Agents
16
Q
What are the 5 Keratolytic / Destructive Agents?
A
- Salicylic acid
- Urea
- Podophyllum resin & podophyllotoxin
- Fluorouracil
- Aminolevulinic acid (ALA)
17
Q
Which Keratolytic / Destructive Agent?
- Used in as a keratolytic agent
- Concentrations of 3-6%
- Greater than 6%, destructive to tissues
- Used in acne treatment, psoriasis, warts
- Care must be exercised when using the drug on the extremities of diabetics or patients with peripheral vascular disease
A
Salicylic Acid
18
Q
Which Keratolytic / Destructive Agent?
- Softening and moisturizing effect on the stratum corneum
- Makes creams and lotions “feel less greasy”
- Humectant (increases water content of the stratum corneum) , used in concentrations of 2-20% in creams and lotions
- Carmol 10, Nutraplus
- Keratolytic agent, 20% concentration and greater
- Hyperkeratosis of palms and soles
- Carmol 20
- Concentrations of 30-50% useful in softening the nail prior to avulsion
A
Urea
19
Q
Which Keratolytic / Destructive Agent?
- Major use of ______ - condyloma acuminatum
- Application should be restricted to wart tissue only
- Cytotoxic agent with specific affinity for mitotic spindle
- Normal assembly of the spindle is prevented and epidermal mitoses are arrested
- Wash off the preparation 2-3 hours after initial application
- Contraindicated during pregnancy
A
Podophyllum Resin & Podophyllotoxin
20
Q
Which Keratolytic / Destructive Agent?
- Used topically for actinic keratoses
- Erythema, vesiculation, erosion, superficial ulceration, necrosis, and reepithelialization
- Healing process continues for 1-2 months after therapy is discontinued
- Excessive exposure to sunlight during treatment increases the intensity of the reaction
A
Fluorouracil
21
Q
What are the 5 drugs used for warts?
A
- Salicylic acid
- Topical retinoids
- Podophyllum resin
- Imiquimod
- Trichloroacetic acid
(Pretty TITS)
22
Q
Which drug for warts?
- Activates immune cells through the toll-like receptor 7 (TLR7)
- Secrete cytokines (primarily interferon-α (INF-α), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)
- Used for treatment of warts (FDA approved condylomata), actinic keratoses, basal cell and squamous cell carcinoma and lentigo maligna melanoma
A
Imiquimod
23
Q
Which drug for warts?
- Condylomata
- Caution: Serious injuries, including skin damage, burns, swelling, and pain may occur following improper application
A
Trichloroacetic Acid
24
Q
- What are agents for hair growth called?
- What are the 3 agents called?
A
Trichogenic Agents
- Topical minoxidil (Rogaine)
- Finasteride (Propecia)
- Bimatoprost (Latisse)
25
**Which Trichogenic Agent?**
## Footnote
* Reversing the progressive miniaturization of scalp hairs in androgenic alopecia
* Vertex balding is more responsive to therapy than frontal balding
**•MOA:** Stimulation of hair growth is secondary to vasodilation, increased cutaneous blood flow, and stimulation of resting hair follicles.
* The effect is not permanent
* Cessation will lead to hair loss in 4-6 months
Topical minoxidil (Rogaine)
26
**Which Trichogenic Agent?**
_Blocks production of dihydrotestosterone_
* Oral finasteride, 1 mg/d
* Promotes hair growth
* Prevents further hair loss in many men with androgenic alopecia
* Not for use in women of child-bearing age
* Treatment for at least 3-6 months is necessary
* Adverse effects include: decreased libido, ejaculation disorders, and erectile dysfunction.
Finasteride (Propecia)
27
**Which Trichogenic Agent?**
* Prostaglandin analogue
* Eyelashes
* Adverse effects: red or itchy eyes, skin pigmentation, permanent brown pigmentation of iris
Bimatoprost (Latisse)
28
What is the name of the Anti-Trichogenic Agent?
Eflornithine
29
**Anti-trichogenic Agent - Eflornithine**
* Irreversible inhibitor of _____ that catalyzes the biosynthesis of \_\_\_\_\_.
* _____ required for cell division
* (affects rate of hair growth)
* Effective in reducing _____ in 30% of women when applied twice daily for ___ months
* Return to pre-treatment levels __ weeks after discontinuation.
* ornithine decarboxylase / polyamines
* Polyamines
* facial hair growth / 6 months
* 8 weeks
30
**Treatment for Psoriasis**
* _____ psoriasis is most common
* Well demarcated erythematous plaques with overlying \_\_\_\_\_.
* ____ plaque psoriasis is typically symmetric & bilateral
* Plaques may exhibit ____ (bleeding after removal of scale)
* _______ (lesions induced after trauma)
* Initial tx is generall \_\_\_\_\_\_
* \_\_\_\_\_\_.
* Plaque
* silvery scale
* Chronic
* Auspitz sign
* Koebner phenomenon
* High potency topical steroid
* Phototherapy
31
**Which Topical drug for Psoriasis?**
* Vitamin D3 analog
* Cream, ointment or scalp solution
* Rare reports of hypercalcemia
* May be used in combination with topical steroids or in rotation
Dovonex
32
**Which Topical drug for Psoriasis?**
* Liquor carbonis detergens (LCD) and liquor picis carbonis (LPC)
* Shampoo, soap and ointment
* Treatment for dandruff and psoriasis
* Denorex, Balnetar, Tegrin, T/Gel, and Neutar
Tars
33
**Which Topical drug for Psoriasis?**
* Binds to beta and gamma retinoid receptors
* Topical synthetic retinoid general prescribed with topical corticosteroids
* ADE-skin irritation, photosensitivity
* Topical Retinoid
Tazarotene
34
**Which systemic drug for Psoriasis?**
## Footnote
•Binds to alpha, beta and gamma retinoid receptors—inhibits expression of IL-6 (proinflammatory cytokine)
**•MUST NOT** be used by women who are pregnant or may become pregnant while undergoing treatment or at any time for at least 3 years after treatment is discontinued
* Ethanol **MUST** be strictly avoided during treatment with acitretin and for 2 months after discontinuing therapy
* Patients **MUST NOT** donate blood during treatment and for 3 years after acitretin is stopped
Retinoid metabolite
* **Acitretin**
35
**Which systemic drug for Psoriasis?**
* Phosphodiesterase-4 enzyme inhibitor
* decreases intracellular levels of cAMP
* Decreases expression of inflammatory mediators
* Such as IL-23, TNF-ɑ, nitric oxide synthase
_ADEs_
* Diarrhea
* Nausea
* URI
Apremilast
36
**Which systemic drug for Psoriasis?**
* Folate antagonist
* Prevents the action of folic acid on cellular function
* 2.5mg and 10mg tablets and solution for injection
* 15 mg Weekly, but can vary
* Single or divided dose
_Contraindications_
* Avoid in pregnancy and breastfeeding (category X)
* Males are advised not to father children while on MTX or for at least 3 months afterwards
Methotrexate
37
**Which systemic drug for Psoriasis?**
* Should not be taken by patients with low blood counts (anemia, leukopenia, thrombocytopenia)
* Not for patients with severe liver disease
* Controversy about liver biopsy at accumulated 1.5 gm
* Use with caution in patients with mild liver disease, kidney disease (CrCl \< 50ml/min), infections, obesity or diabetes.
_•Labs:_
CBC, LFTs, Creatinine, Chest Xray
Methotrexate
38
What are the 2 types of Biologic Agents for Psoriasis?
* **Tumor necrosis factor alpha (TNF alpha) blockers**
* Enbrel
* Humira
* Remicade
* Simponi
* Blocks excess cytokine
* **Interleukin 12/23**
* Stelara
* associated w/ psoriasis inflammation
39
**Which Biologic Agent for Psoriasis?**
* Injected in legs, abd, arms typically by individual or family member
* Enbrel
* Humira
* Simponi
40
**Which Biologic Agent for Psoriasis?**
* Subcutaneous injection by health care provider
Stelara
41
**Which Biologic Agent for Psoriasis?**
* IV infusion in office or infusion center
* Half life: 9 days
* Antibody
Remicade
42
3 contraindications for Biologic Agents for Psoriasis
* Immunocompromised
* Active infection
* Screen for tuberculosis (TB)
43
2 risks of using biologic agents in Psoriasis
* Increase risk of infection
* Impact on developing fetuses or nursing infants is not known...
44
3 common side effects of biologic agents for psoriasis
* Respiratory infections
* Flu-like symptoms
* Injection site reactions
45
Rare Side Effects of Biologic Agents for Psoriasis
* **Serious nervous system disorders**
* MS, szs, optic neuritis
* **Hemolytic anemia**
* **Lymphoma**
46
Onset of benefit for immunotherapy / biologic agent?
(Humira, Enbrel, Remicade)
2 - 4 weeks
47
**Which Biologic Agent for Psoriasis?**
* Half life: 5 days
* Receptor
Enbrel
48
**Which Biologic Agent for Psoriasis?**
* Half life: 12-14 days
* Antibody
Humira
49
**SE of which Immunotherapy?**
* Injection site rxns, URI (colds, sinusitis, bronchitis)
Humira & Enbrel
50
**SE of which Immunotherapy?**
* Infusion rxns (itching, hives, rash, nausea, HA)
* URI (colds, sinusitis, bronchitis)
Remicade
