Chapter 5 The Skin and Dermatologic Drug Therapy

Chapter 5 The Skin and Dermatologic Drug Therapy

Chapter 5 The Skin and Dermatologic Drug Therapy Paradigm Publishing, Inc. 2 Chapter 5 Topics

Anatomy and Physiology of the Skin Sun Exposure, Aging, and Skin Cancer Acne and Dandruff Skin Infections Hair Loss Dermatitis, Eczema, and Psoriasis Wounds and Burns Adverse Drug Reactions on the Skin Herbal and Alternative Therapies Paradigm Publishing, Inc.

3 Anatomy and Physiology of the Skin Integumentary System Is the dermatologic tissue that covers the body Includes the skin, nails, and hair Protects the body from harmful pathogens and harsh substances Helps to regulate the body temperature Paradigm Publishing, Inc. 4 Anatomy and Physiology of the Skin The Skin

Has three layers Epidermis Dermis Subcutaneous tissue Paradigm Publishing, Inc. 5 Anatomy and Physiology of the Skin Epidermis Is the outermost layer Is made up of dead and dried cells generated from the dermis (next layer down)

Dermis Is the living, functioning layer of skin Hair follicles and nail beds form, arteries and veins circulate blood, and nerves provide sensation Melanocytes provide skin pigmentation Paradigm Publishing, Inc. 6 Anatomy and Physiology of the Skin Dermis (continued) Contains sweat, sebaceous, and ceruminous glands Sweat glands make watery secretions all over the body Sebaceous glands secrete oil to lubricate hair and skin Ceruminous glands in the ear canal release waxy

material Subcutaneous Tissue Is the innermost layer made up of elastic fibers (called fascia) and adipose tissue (fat cells) Thickness varies depending on the region of the body Paradigm Publishing, Inc. 7 Anatomy and Physiology of the Skin Skin Problems and the Pharmacy External skin is easy to examine in the pharmacy Pharmacists can inspect an area of the skin Determine if self-treatment is fine or the patient needs to see a physician or dermatologist

If patients have a skin problem, pharmacy technicians can get involved Can help identify patients with likely problems Get the pharmacist to physically assess the problem Paradigm Publishing, Inc. 8 Sun Exposure, Aging, and Skin Cancer Two Types of Skin Aging Intrinsic aging (natural skin aging) Is the loss of collagen and elastin in the dermis Over time, glands make less oil resulting in dryness Subcutaneous tissue shrinks, skin thins, and sagging occurs

Extrinsic aging Is caused by external factors Sun exposure (accelerates the loss of collagen and elastin), air pollutants, smoking, and skin irritation Lesions (skin injuries); genetic predisposition possible Paradigm Publishing, Inc. 9 Sun Exposure, Aging, and Skin Cancer Skin Tumors Caused by constant sunlight exposure and oxidizing chemicals that cause DNA mutation DNA damage can result in Benign tumors such as moles and skin tags Precancer of the skin such as actinic keratosis

Three types of skin cancer Squamous and basal cell carcinomas grow slowly Melanoma is fast-growing; treat early to prevent spreading and becoming life-threatening Paradigm Publishing, Inc. 10 Sun Exposure, Aging, and Skin Cancer ABCDs and the Pharmacy Pharmacists and technicians can help patients Understand how to identify signs of dangerous skin lesions Signs of cancer are categorized into the ABCDs When patches of skin have any of these characteristics, patient should be evaluated medically

Paradigm Publishing, Inc. 11 Sun Exposure, Aging, and Skin Cancer Signs of Skin Cancer: ABCDs Asymmetry one half unlike the other half Border irregularity edges are jagged, not smooth in shape Color variation Diameter patches of tan, brown, black, red, and/

or white larger than 6 mm or the top of a pencil eraser Paradigm Publishing, Inc. 12 Sun Exposure, Aging, and Skin Cancer Drug Therapy Indications: limit sun exposure, prevent damage from ultraviolet radiation, and treat damaged skin Ultraviolet radiation is strongly linked to skin cancer Treating damaged skin is less effective than limiting skin exposure in the first place Patients frequently buy sunscreen and sun block

products in a pharmacy Products for skin damage such as actinic keratosis or for skin cancer are usually applied in a physicians office Paradigm Publishing, Inc. 13 Sun Exposure, Aging, and Skin Cancer Rating System for Sunscreens and Sun Blocks SPF Estimates the amount of resistance to burning that products provide Example: An SPF of 8 means a person can spend 8 times longer in the sun than normal time to burn Patient skin type is based on exposure to unprotected sun

for 45 to 60 minutes Products rated 50 or higher are sun blocks Do not allow tanning to occur Paradigm Publishing, Inc. 14 Sun Exposure, Aging, and Skin Cancer Recommended Sunscreen Product Guide Patient Skin Type Suggested SPF Product Always burns, rarely tans 2030

Burns easily, tans minimally 1220 Burns moderately, tans gradually 812 Burns minimally, tans well 48 Rarely burns, tans profusely 24

Never burns, deeply pigmented None needed Paradigm Publishing, Inc. 15 Acne and Dandruff Acne Is the most common skin condition for which treatment, either OTC or prescription, is sought Due to sebum overproduction (glands around hair follicles) Involves pimples, blackheads, and whiteheads Caused by pores and follicles clogged with oily material,

dead skin cells, and dirt Severe acne (nodular acne or acne vulgaris) Can cause deep cysts that permanently damage the dermis OTC products used for mild acne Prescription drugs used for moderate to severe acne Paradigm Publishing, Inc. 16 Acne and Dandruff Rosacea Is categorized as acne, but is a chronic inflammatory disorder in adults Causes redness, visible surface blood vessels, raised bumps on face and cheeks Becomes worse with sun or extreme temperatures

Dandruff Is a malfunction of oil-producing glands around hair follicles on the scalp; overproduction of sebum and cells Results in specks of skin in hair and on scalp; not harmful Paradigm Publishing, Inc. 17 Acne and Dandruff Drugs for Acne Mild to moderate acne Clean the area daily to prevent new blackheads and pimples Repeated acne lesions Use OTC products like benzoyl peroxide Moderate to severe acne

Requires prescription products Start with topical agents and progress to oral agents such as oral contraceptives (for women) or antibiotics like tetracycline Rosacea Use metronidazole or azelaic acid Paradigm Publishing, Inc. 18 Acne and Dandruff Topical Acne Agents Indications: mild acne; in combination with oral agents for moderate to severe acne Mild acne mainstays are benzoyl peroxide and salicylic acid Benzoyl peroxide is a bleaching agent that promotes cell turnover in follicles

Salicylic acid is a keratolytic agent that breaks down and peels of dead skin cells so they do not clog pores Available in facial cleansers, washes, and masks Paradigm Publishing, Inc. 19 Acne and Dandruff Topical Acne Agents (continued) Side effects: dryness, redness, burning, and flaking or peeling skin Cautions: external use only Some are flammable and should be kept away from heat

Paradigm Publishing, Inc. 20 Acne and Dandruff Retinoids Are vitamin A derivatives Mechanism of Action: increase cell turnover in follicles, which pushes clogged material of the pores Mechanism of Action (Acne Vulgaris): change cell development and inflammatory processes to reduce swelling and redness Indications: moderate to severe acne and fine line and wrinkle reduction Indications of Oral Retinoids: severe acne or psoriasis

Paradigm Publishing, Inc. 21 Acne and Dandruff Retinoids (continued) Topical Retinoids Side Effects: burning, peeling, dry skin, redness, and itching Cautions: Do not use with antibiotics Oral Retinoids such as isotretinoin Severe Side Effects: depression, psychosis, pancreatitis, high triglycerides, and hepatotoxicity Cautions: Isotretinoin cannot be used by women who are or might become pregnant Is prescribed and dispensed through a FDA-approved program called iPLEDGE

Paradigm Publishing, Inc. 22 Acne and Dandruff Dandruff Products Active ingredients in most dandruff products are selenium sulfide and pyrithione zinc; both available OTC in shampoo Coal tar shampoos also OTC; used in severe dandruff Ketoconazole, an antifungal is available OTC and prescription Mechanism of Action: slow cell and oil production Reduces skin flaking and itching Severe Side Effects: dermatitis, photosensitivity, and aggravation of prior skin conditions (acne or psoriasis) Paradigm Publishing, Inc.

23 Your Turn Question 1: A patient is picking up a prescription. She mentions that a mole on her leg looks different now, because one side is bigger than the other? What should the technician do? Answer: The asymmetry could be a sign of cancer. The technician should ask the pharmacist to talk to the patient. Question 2: A male patient, age 15, has mild acne. What is the likely treatment? Answer: Benzoyl peroxide and salicylic acid are the first-line therapies for mild acne. Paradigm Publishing, Inc.

24 Skin Infections Fungal Skin Infections Caused mostly by dermatophytes and Candida albicans, a yeast Common types include ringworm, athletes foot, jock itch Use antifungals to treat fungal skin infections Viral Skin Infections Herpes simplex virus, type 1 causes cold sores Herpes zoster causes shingles (reemergence of a systemic viral infection that appears as painful skin lesions) Genital herpes is a sexually transmitted disease HPV causes genital warts that are linked to cervical caner Paradigm Publishing, Inc.

25 Skin Infections Bacterial Skin Infections Caused by overgrowth of Staphylococcus aureus Example: impetigo occurs typically in children and causes pus-filled blisters to break and form yellow crust Localized infections of the superficial skin layers are treated with topical agents Severe skin infections that spread to other soft tissues are treated with systemic agents Paradigm Publishing, Inc. 26

Skin Infections Topical Antibiotics for Bacterial Skin Infections Indications: local skin infections like cuts, scrapes, impetigo, and skin rash Mupirocin used for impetigo and rosacea Mechanisms of Action: varies depending on drug class Side Effects: burning, stinging, pain, rash, dry skin, swelling, and redness Side Effects (used near the nose): headache, runny nose, respiratory congestion, and sore throat Cautions: Keep away from eyes; external use only Paradigm Publishing, Inc. 27

Skin Infections Lice and Scabies Infestation Lice Are parasitic insects that use the human body as a host Feed on human blood, which causes intense itching Head lice are passed through direct contact or by sharing combs, brushes, or hats Pubic lice (crabs) are passed through sexual contact Scabies Are parasitic insects that burrow into the epidermis Feed on cellular material, which causes intense itching Spread by skin-to-skin contact or sharing a bed Treatment for both is OTC; also wash clothing and bedding Paradigm Publishing, Inc. 28

Skin Infections Pediculicides and Scabicides Pediculicides Indication: lice Scabicides Indication: scabies Mechanism of Action: impair CNS of insects, causing death Usage: Spread and left on skin, then washed off Pyrethrin is a first-line drug (OTC) for head lice Permethrin is a first-line drug (OTC) for lice and scabies Side Effects: mild itching, burning, tingling, numbness, rash, headache, dizziness, diarrhea, nausea, and vomiting Paradigm Publishing, Inc. 29

Skin Infections Pediculicides and Scabicides (continued) Lindane (prescription) Indications: lotion used for scabies and shampoo used for lice Side Effects: dermatitis, itching, headache, pain, and hair loss Severe Side Effects: significant and possibly life-threatening Cautions: Can cause seizures; do not use on infants or children Administration: wear gloves and wash hands All pediculicide products for external use only Paradigm Publishing, Inc. 30

Hair Loss Two Major Types of Hair Loss Androgenic alopecia Is most common type affecting men and women (called male-pattern baldness) Treated with minoxidil (OTC solution or foam) or finasteride Side Effects (rare): dermatitis, redness, and itching Takes 4 to 6 months before results are seen Alopecia areata Is a chronic inflammatory disorder affecting hair follicles and may cause total hair loss Treated with potent topical corticosteroids Paradigm Publishing, Inc. 31

Dermatitis, Eczema, and Psoriasis Dermatitis and Seborrheic Dermatitis Dermatitis Is itchy, inflamed skin caused by many factors Causes redness, dry flaky skin, raised or bumpy skin, and pruritus (severe itching) Contact dermatitis Occurs from exposure to irritants or allergenic substances Causes rash; plants cause redness, itching, rash, blisters Seborrheic dermatitis (cradle cap) Is greasy, scaly skin area; sometimes red, brown, or yellow Treatment is good hygiene, topical antihistamines, anti-inflammatory agents, and moisturizers Paradigm Publishing, Inc.

32 Dermatitis, Eczema, and Psoriasis Atopic Dermatitis Is a chronic (not curable) condition that appears in childhood and continues into adulthood; also called eczema Not well understood; patients often have elevated IgE levels in their blood Appears as dry, flaky, red skin that is very itchy Severe symptoms (exacerbation) cycle with remissions Common triggers are stress, skin irritants, and food allergies Treatment is to moisturize skin well and topical corticosteroids for flare-ups Paradigm Publishing, Inc.

33 Dermatitis, Eczema, and Psoriasis Psoriasis Is an immunologic condition affecting T cell activity in skin Appears on skin as well-defined plaques (patches) that are raised, silvery or white, flaky, and pruritic Can appear as small or large, painful plaques anywhere on body Severe symptoms (exacerbation) cycle with remissions Triggers are stress and exposure to environmental factors that dry out skin Difficult to treat and may not respond well to drug therapy Paradigm Publishing, Inc. 34

Dermatitis, Eczema, and Psoriasis Diaper Rash Occurs most often in children wearing diapers and also in incontinent adults wearing absorbent undergarments Caused by bacteria that enters damaged surface skin tissue Diaper rash products used for skin irritation and redness Various ingredients in OTC products used for diaper rash Eucalyptol (eucalyptus oil) for antimicrobial activity Zinc oxide, a drying agent Camphor or menthol to provide local anesthetic action Balsam of Peru for wound healing and tissue repair Talc or kaolin for moisture absorption Paradigm Publishing, Inc. 35

Dermatitis, Eczema, and Psoriasis Drugs for Dermatitis, Eczema, and Psoriasis: Corticosteroids Are usually the first choice for dermatitis, eczema, and psoriasis Starts with topical treatment and then oral Use immunosuppressants or immunomodulators if corticosteroids do not work Calamine relieves mild itching from allergic reactions Topical corticosteroids Are anti-inflammatory agents that inhibit redness swelling, itching, and pain in the dermal layer Start with OTC products then prescription if needed Paradigm Publishing, Inc.

36 Dermatitis, Eczema, and Psoriasis Drugs for Dermatitis, Eczema, and Psoriasis: Corticosteroids (continued) Indications (Topical Corticosteroids): Use creams for moist or oozing lesions Use ointments (more potent) for dry, scaly lesions Creams, gels, and ointments are not interchangeable Side Effects: burning, itching, dryness, hair growth, dermatitis, acne, hypopigmentation, and skin thinning Cautions: super-potent topical corticosteroid products should not be used longer than two consecutive weeks Do not apply occlusive wound dressings Paradigm Publishing, Inc.

37 Dermatitis, Eczema, and Psoriasis Drugs for Dermatitis, Eczema, and Psoriasis: Calcineurin Inhibitors Are immunomodulators used sparingly for a short time Mechanism of Action: inhibit T cell activation preventing release of chemical mediators that promote inflammation Indication: severe eczema (when topical corticosteroids do not work) Types: Pimecrolimus (Elidel) and Tacrolimus (Prograf, Protopic) Routes: topical and oral Paradigm Publishing, Inc. 38

Dermatitis, Eczema, and Psoriasis Drugs for Dermatitis, Eczema, and Psoriasis: Calcineurin Inhibitors (continued) Side Effects (common): burning, itching, tingling, acne, and redness at the site of application Side Effects (other): headache, muscle aches and pains, sinusitis, and flu-like symptoms Cautions: associated with increased occurrence of cancer (skin cancer and lymphoma) and do not take with alcohol (topical and oral) Paradigm Publishing, Inc. 39

Dermatitis, Eczema, and Psoriasis Drugs for Dermatitis, Eczema, and Psoriasis: Vitamin D Analogs Are synthetic forms of vitamin D that regulate cell growth and development of skin cells Indication: psoriasis Routes: topical or oral Side Effects: burning, itching, and redness Side Effects (less common): burning, itching, skin irritation, color change at application site, skin thinning Caution: do not use for patients with too much calcium in the blood (such as kidney stones) Paradigm Publishing, Inc. 40

Wounds and Burns Decubitus Ulcers (Pressure Sores, Bedsores) Are severe wounds involving tissue damage through the epidermis and dermis Caused by constant pressure applied to an area of skin Appear where skin covers bony protrusions that receive constant pressure when lying or sitting down Prevent by turning or repositioning patients every 2 hours Treat by cleaning and removing necrotic (dead) tissue while the wound heals on its own Some drugs promote regranulation, the process of building new skin layers over a wound area Paradigm Publishing, Inc. 41

Wounds and Burns Burn Wounds Are caused by heat and thermal injury or by electrical and chemical sources Treatment and prognosis depend on the severity and amount of body surface area affected Affected surface area is estimated by dividing the body into sections, each representing 9% of the total surface Treatment at a burn center is needed for third-degree burns over a significant portion of the body Patients with burns over 80% or more of their bodies are not likely to survive long term Paradigm Publishing, Inc. 42

Wounds and Burns Burn Wound Staging Degree Damage First-degree burn Surface epidermal layers damaged, causing redness and possibly peeling, but no blisters Seconddegree burn Third-degree burn

Epidermis and dermis skin layers damaged, causing redness, blisters, swelling, and pain Destruction of epidermis and dermis layers, possible damage to tissue underneath. Permanent scarring . Requires medical treatment. Paradigm Publishing, Inc. 43 Adverse Drug Reactions on the Skin Adverse Drug Reactions on the Skin A couple of the most common reactions to medication show up on the skin Pharmacists often counsel patients on these potential side effects

Skin rash is the most common sign of allergy Pharmacy technicians must make sure to ask and document any drug allergies and the symptoms Important to maintain patient safety Paradigm Publishing, Inc. 44 Your Turn Question 1: Soon after taking a new drug, a patient develops an itchy rash. What could have caused this to happen? Answer: The patient might be allergic to the drug. A rash is the most common reaction for a drug allergy. Question 2: Topical corticosteroids come in various forms, including ointment and cream. How is the purpose of the

ointment form different than the cream corticosteroid form? Answer: Ointments are best for dry, scaly lesions. Creams are best for moist or oozing lesions. Paradigm Publishing, Inc. 45 Adverse Drug Reactions on the Skin Photosensitivity Is a frequent side effect of many drug therapies Is excessive response to solar exposure where the skin easily burns after a short time in the sun Avoid sunburns by using sun block and clothing Many drugs associated with photosensitivity (see Table 5.9)

Pharmacy technicians should apply warning label Paradigm Publishing, Inc. 46 Adverse Drug Reactions on the Skin Drug Allergy Rashes Rashes from drug allergies appear as urticaria (hives) and pruritus (intense itching) Reaction often appears soon after taking a new medication Allergic reactions can progress in severity Anaphylaxis Is a severe and potentially fatal reaction to drug therapy causing airway swelling and difficulty breathing Should stop drug use immediately

Treatment is antihistamines, corticosteroids, and epinephrine Paradigm Publishing, Inc. 47 Adverse Drug Reactions on the Skin Stevens-Johnson Syndrome Is rare skin reaction that can become life-threatening Starts as a localized rash that, if left untreated, spreads deeper, causing layers of skin to slough off Results in severe infection and temperature problems Caused by specific drug therapies Heparin-Induced Thrombocytopenia (HIT) Is a rare allergic reaction to heparin (an anticoagulant)

that can become life-threatening Diffuse red, pruritic rash and stop drug immediately Paradigm Publishing, Inc. 48 Herbal and Alternative Therapies Topical skin care products and cosmetics Addition of various natural substances added as moisturizers to creams and lotions Lanolin, cocoa butter, and vegetable or seed oils Works to supply added oils and moisturize Vitamins E, A, and D are emollients added to moisturizers Aloe vera Has healing and anti-inflammatory properties

Used for mild psoriasis and burn wounds Concentrations in many OTC lotions and oil too low to treat conditions or disorders Paradigm Publishing, Inc. 49 Summary OTC topical agents and retinoids are used for acne, in addition to daily cleansing Topical antibiotics are used for acne and impetigo Pediculicides are used for head, body, and pubic lice Topical corticosteroids and calcineurin inhibitors are used for dermatitis and eczema Vitamin D analogs are used for psoriasis Some drug reactions such as allergies, photosensitivity, and

Stevens-Johnson manifest on the skin Paradigm Publishing, Inc. 50

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