Term
| Langerhans cells produce which class MHC |
|
Definition
|
|
Term
| Type I of immune hypersensitivity reaction is?? |
|
Definition
Classic-Rapid
IgE on mast cells and basophils
w/in minutes
e.g. anaphylaxis, flushing, urticaria, pruritis, angiodema, bronchospasm, adrenal/CV reflex |
|
|
Term
| Type II immune hypersensitivity system reaction??? |
|
Definition
Cytotoxic
IgG or IgM
several hours
could be first sign of anaphylaxis
**hemolysis, purpura |
|
|
Term
| Type III immune hypersensitivity reaction?? |
|
Definition
immune complex reaction
IgG or IgM
several hours
*vasculitis, serum sickness, urticaria, angioedema |
|
|
Term
| Type IV immune hypersensitivity?? |
|
Definition
delayed hypersensitivity reaction
NO Antibody, but instead Tcells!!
**contact dermatitis, exanthematous reactions, photoallergic reactions |
|
|
Term
| Drugs against Type I hypersensitivty? |
|
Definition
epinephrine
diphenhydramine
hydrocortisone
brochodilators, IV fluids, H2 antagonists |
|
|
Term
| Treatment for Type IV hypersensitivity? |
|
Definition
| antihistamines or corticosteroids |
|
|
Term
erythema nodosum
characteristic?
treatment? |
|
Definition
*red painful nodules
*treated with discontinue used
*heals with 2-3 weeks after stopping use
*from oral contraceptives, iodides, bromides, penicillins |
|
|
Term
|
Definition
severe
erythema
flaky desquamation (skin sloughs)
loss of fluid
treat with fluids, steroids, pain meds, antibiotics
from: barbs, phenytoin, penicillin, carbamazepine |
|
|
Term
| toxic epidermal necrolysis (TEN) |
|
Definition
life-threatening
mediated by cytotoxic t-cells
30% mortality
treatment: discontinue use; corticosteroids, antihistamines, fluids, antibiotics
from: sulfonamides, barbs, penicillin, phenylbutazone, etc. |
|
|
Term
|
Definition
life-threatening
cytotoxic t cells
symptoms: maculopapular bullae, vesicles, hemorrhagic lesions on mucus membranes
drug culprits: sulfonamides, barbs, penicillins, daptomycin |
|
|
Term
|
Definition
rash or eruption of the skin
2-3 days after drug admin.
most common
treat with AH, wet dressing or systemic corticosteroids if SEVERE |
|
|
Term
|
Definition
|
|
Term
|
Definition
| circumscribed, flat lesion of any shape or size, differing from surrounding skin due to color |
|
|
Term
|
Definition
| small (<1cm), solid elevated lesion (scaly: papulosquamous) |
|
|
Term
|
Definition
| a mesa-like elevated lesion occupying a relatively large surface area in comparison to its height |
|
|
Term
|
Definition
| termed used as synonym for an urticarial lesion (see below) |
|
|
Term
| Drug Agents used in therapy for dermatology. |
|
Definition
H1 antagonist-1st and 2nd gen
H2 antagonist
antidepressants (doxepin)
steroids (hydrocortisone or prednisone)
adrenergics
leukotriene antagonists(zakfirlukast or montelukatst)
antimetabolites |
|
|
Term
| leukotriene receptor antagonists work by?? |
|
Definition
block the cys-LT1 receptor to reduce inflammation/itching
ex: zafirlukast (Accolate)
montelukast (Singulair) |
|
|
Term
| steroids exert effects on immune system in 2 ways: |
|
Definition
1. altered gene expression
2. direct receptor-mediated effects |
|
|
Term
| With steroids, there are (increased/decreased) response to sun, chemical, mechanical, infectious, and immunological stimuli of virtually all types |
|
Definition
|
|
Term
| steroids _________ IL5,6,7 etc... |
|
Definition
|
|
Term
| Name the 2 adverse effects of steroids. |
|
Definition
1. withdrawal of therapy (flare up original disease or acute adrenal insufficiency)
2. metabolic/organ system dysfunction |
|
|
Term
| list some examples of what are the metabolic/organ system dysfunctions |
|
Definition
fluid/electrolyte imbalances
increase BP
increase Glc
infections
osteoporosis
ETC |
|
|
Term
|
Definition
folic acid analog
inhibits dihydrofolate reductase (DHFR)
reduce fxn of very active immunocompetnet cells of skin |
|
|
Term
| What is another name for urticaria? |
|
Definition
|
|
Term
| What are common causes of urticaria? |
|
Definition
Drugs(ACE inhibitors, ASA, sulfa agents)
Foods(shellfish, nuts, choc, strawberries, tomatoes, pork, cowsmilk, wheat,yeast)
Insect stings
Latex
Physical exercise |
|
|
Term
|
Definition
Capillary vasodilatation results in the transudation of fluid into the surrounding tissues
Hives (wheals) –raised, defined, erythematous, pruritic, round to oval lesion that varies in number and size
Several hives can converge and form a large plaque
New lesions can appear even as old lesions are resolving |
|
|
Term
| What are common ACE inhibitors? |
|
Definition
| enalapril,lisinopril,etc. |
|
|
Term
| Contrast acute/chronic urticaria |
|
Definition
acute:onset 12-36 hrs
resolution 1-3 days
chronic:hives greater than 6wks
may last years |
|
|
Term
|
Definition
|
|
Term
|
Definition
thicker plaques extedn into dermis and subcutaneous tissues
more swelling than itching(pruritis) |
|
|
Term
| What are treatments for urticaria? |
|
Definition
prevention
stop ASA
AH1 and 2
corticosteroids
Doxepin - chronic
Epinephrine - airway involvement
Methotrexate - chronic |
|
|
Term
| What are the H1 rec antagonists that are first generation? |
|
Definition
Hydroxyzine 10-25mg BID/QID (50mgQID)
Diphenhydramine 25-50mgBID (50mgQID)
Children: 2-6yo 6.25 (37.5/day)
6-12yo 12.5 (150/day)
Cyproheptadine 4mg TID/QID (8mgQID)
**MORE sedating |
|
|
Term
| What are the H1 rec antagonists that are second generation? |
|
Definition
Fexofenadine
Desloratadine
Loratadine
Cetirizine
**less sedating |
|
|
Term
H1 vs H2
____% are H1
____% are H2 |
|
Definition
|
|
Term
| Describe dosing for H2 rec antag. |
|
Definition
Ranitidine
150 mg BID
Famotadine
20 mg BID |
|
|
Term
|
Definition
CNS-sedation(1st)
*caution in elderly and should only use short term
Stimulation of children
Anticholinergic-drymouth,constipation, blurred vision, dizziness
Weight Gain-Cyproheptadine |
|
|
Term
| what are the corticosteroids used for urticaria adn what are the doses? |
|
Definition
Prednisone-40mg QD 5-10days
Taper: 40 QDx3days
20 QDx3days
10mg QDx3days |
|
|
Term
TRUE or FALSE?
taper doses are not given they are just known |
|
Definition
|
|
Term
|
Definition
TCA with potent H1 and H2 histamine blockade activity
*used for chronic urticaria
Dosage: 10-25mg TID
few side effects at this dosage
Side effects include:
Anticholinergic effects-dry mouth and constipation |
|
|
Term
|
Definition
Corticosteroid resistant chronic urticaria
long history of disease
debilitating symptoms |
|
|
Term
| Which is used first for chronic urticaria |
|
Definition
| tca and then progress to more extensive |
|
|
Term
| What are the areas affected of angiodema? |
|
Definition
skin surface
lips(sore throat,etc)
eye lids
mucosa of GIT
extremities(unilateral)
scrotal swelling |
|
|
Term
| What is epinephrine used for? |
|
Definition
| angiodema with sings of facial or respiratory involvement |
|
|
Term
| What is management for anaphylaxis? |
|
Definition
Epinephrine
1:1000 solution
0.2ml to 1 ml SC or IM
EpiPen®
One dose of 0.30mg (1:1000, 0.3ml) for injection
EpiPen® Jr
One dose 0.15 mg (1:2000, 0.3ml) |
|
|
Term
| What are some counseling points of EpiPen? |
|
Definition
Prefilled, automatic injection device for single use
Available as a single or dual Pack
Inject firmly into the thigh area and hold for several seconds
Can inject through the clothing if necessary
Two doses may be need
Follow-up at local emergency room
Counsel patient on how to inject this b/f they leave the pharmacy |
|
|
Term
| Drugs that inhibit cell wall synthesis |
|
Definition
penicillins
cephalosporins
monobactams
carbapenems |
|
|
Term
| Drugs that inhibit protein synthesis. |
|
Definition
30S types such as tetracyclines, aminoglycosides
50S types suche as erythromycin, clindamycin, chloramphenicol, streptogramins |
|
|
Term
| Drugs that inhibit nucleic acid function or synthesis. |
|
Definition
rifampin
quinolones
antimetabolite sulfonamides
trimethoprim |
|
|
Term
| Drugs that inhibit cell membrane permeability/function. |
|
Definition
|
|
Term
|
Definition
| Darkened – due to deposits of melanin |
|
|
Term
|
Definition
| Lightened – due to lack of melanin |
|
|
Term
|
Definition
| Yellow – increased billirubin or carotene |
|
|
Term
|
Definition
|
|
Term
|
Definition
| dilation of blood vessels |
|
|
Term
|
Definition
| aging lesion that was erythematous |
|
|
Term
| Factors (10) affecting drug choic and drug activity.... |
|
Definition
*identity and drug sensitivity of organism
*status of host defenses/immune fxn
*bacteriocidal(kills) vs bacteriostatic(inhibit growth) MOA
*antimicrobial resistance
*site of infection
*absorption,distribution, PK issues
-->know time- vs conc-dependent!!
*metabolism and elimination pathways
-->renal, hepatic diseases
*pharmacogenetics of host
*drug interactions (inhib:erythromycin or inducers:rifampin)
*pregnancy or nursing |
|
|
Term
|
Definition
|
|
Term
|
Definition
| above the plane of the skin |
|
|
Term
|
Definition
| below the plane of the skin |
|
|
Term
| Distribution of lesions on skin |
|
Definition
| The area that is involved. For example, lesions can be generalized or local to a specific area of the body |
|
|
Term
|
Definition
minimum inhibitory concentration
minimum amount to inhibit growth |
|
|
Term
|
Definition
| blood concentration needs to be greater than MIC for 40-50% time of dosing interval |
|
|
Term
|
Definition
| Area under curve must be greater than 25 times the MIC or peak greater than 10 times the MIC |
|
|
Term
|
Definition
| indicates if the lesions are grouped, linear, or dissemination of the body |
|
|
Term
| 6 Ps of mechanisms of resistance |
|
Definition
1.Penetration- poor(entry into human cell)
2.Porins- decreased (entry into microbe)
3.Pumps- up-regulation(efflux systems)
4.PBPs(pen.bindingproteins)-altered recs
5.Penicillinase-enhanced microbial metab or inactivation of drug(penicillin)
6.Peptidoglycan-variation in structure |
|
|
Term
|
Definition
| helps to determined if individual lesions are round, annular (ring-shaped), or serpiginous (snake-like) |
|
|
Term
|
Definition
| A circumscribed, flat lesion less than 1 cm in diameter that differs from surrounding skin because of its color. |
|
|
Term
|
Definition
| A solid, circumscribed, elevated lesion less than 1 cm in diameter. |
|
|
Term
| Complications of therapy. |
|
Definition
| Development of Resistance Therapy fails from outset DI/Antagonism or PK Hypersensitivities Direct toxicity to host Superinfections(overgrowth) |
|
|
Term
| Describe superinfections. |
|
Definition
overgrowth!
prolonged antibiotic use
broad spectrum agents |
|
|
Term
|
Definition
| A palpable, solid mass of tissue that is differentiated from a papule by the depth of its involvement. |
|
|
Term
| Name some common PO antibiotics in derm practice. |
|
Definition
Tetracycline, Minocycline, Doxycycline – 30S Inhib
Macrolides, e.g. Erythromycin, Clarithromycin – 50S Inhib
Clindamycin (a Lincosamide) – more active than tetracyclines – 50S Inhib
Ampicillin, Amoxacillin - cell wall inhib
Quinolones, e.g. ciprofloxacin – inhibit topoisomerases to interrupt DNA functions
Cephalosporins (e.g. cephalexin) – cell wall inhib
Sulfamethoxazole/Trimethoprim (Bactrim) - antifolate
Metronidazole (especially in Rosacea) – reactive intermediate that damages DNA/enzymes |
|
|
Term
| Name common antibiotics used topically! |
|
Definition
Bacitracin – multiple related components; inhib cell wall synthesis
Chloramphenicol – 50S inhib
Gentamycin – aminoglycoside; 30S inhib
Metronidazole – produces reactive intermediate that damages DNA and other sensitive molecules
Mupirocin – binds & inhibits tRNA-synthetase for leucine
Neomycin – aminoglycoside; 30S inhib
Polymixin B – cationic detergent; interacts as surfactant with negatively charged membrane phospholipids
Povidone-Iodine (Betadyne ointment) – topical antiseptic / antibacterial
Mafenide – α-amino-p-toluene-sulfonamide; acts on large variety of Gneg and Gpos bacteria (commonly used in therapy of burns)
Silver Sulfadiazine (Silvadene cream) – both silver and sulfa component are active against bacteria and fungi (often used in therapy of burns)
Note: If you use the agent only topically, perhaps you will not face the expected adverse effects of systemic use, but you should remain alert for potential signs of systemic toxicity … |
|
|
Term
| Fungi are ________ organisms! |
|
Definition
eukaryotic
*mito, Golgi, ribosomes, etc similar to us! |
|
|
Term
| What is different about fungi. |
|
Definition
rigid cell wall (chitin and/or cellulose)
ergosterol instead of cholesterol!
NO gram stain |
|
|
Term
|
Definition
action on microtubules to disrupt mitosis in certain fungal cells
Mostly topically
dosing issues, questions about efficacy, some adverse effects seen and some drug interactions, which have made the agent more or less trending to obsolete |
|
|
Term
|
Definition
Inhibits a step in conversion of squalene to lanosterol; inhibits squalene epoxidase; thus decreases lanosterol synthesis with accumulation of squalene
End effect is to reduce synthesis of ergosterol in the fungal organism cell membrane
Can be used topically, like a similar agent – naftifine
Well-absorbed, but suffers 40% metab due to first pass effect in liver; 99% protein bound so watch PK of other meds
T1/2 up to 200-400 hrs at SS due to accumulation in skin, nails and fat cells
Drug interactions: Rifampin decreases / Cimetidine increases plasma concentrations of Terbinafine via P450 effects
Not recommended for patients with hepatic failure or marked azotemia (uremia) due to potential large increases in plasma levels of the drug, but drug generally well-tolerated
Rare toxicities: Hepatotox, neutropenia, S-J syndrome or TEN and contraindicated in pregnancy |
|
|
Term
|
Definition
Blocks fungal P450-dependent synthesis of ergosterol
Step of the pathway affected is the demethylation of lanosterol; enzyme is 14-α-sterol-demethylase (ERG11)
Blockade of ergosterol formation disrupts cell membranes ; ↓ATPase and ↓electron transport enzymes
Can also inhibit gonadal and adrenal steroid synthesis in humans, thus suppressing testosterone and cortisol formation
Triazoles have less effects on human P450-dependent steroid synthetic pathways (less enzyme affinity) and a broader spectrum of fungal activity
Triazoles often are preferred clinically for those reasons |
|
|
Term
|
Definition
Over a dozen members of this class
Imidazoles: 2 nitrogens in 5-membered azole ring - e.g., ketoconazole, miconazole
Triazoles: 3 nitrogens in 5-membered azole ring - e.g., fluconazole, itraconazole, voriconazole, posaconazole
Both groups share the same MOA. Triazoles are now preferred in therapy, with fluconazole and itraconazole receiving more common use in therapy of dermatological conditions
Note: Second Gen Triazoles (Voriconazole & Posaconazole) seem to be less used currently in derm conditions, but generally are considered to have stronger activity & broader spectrum |
|
|
Term
| Adverse effects and toxicity of Azoles?? |
|
Definition
Metabolic drug interactions
Itraconazole - Potent CYP 3A4 inhibitor (See Table 48-2 in G&G)
Fluconazole - Inhibits CYP 3A4 and 2C9 – Raises plasma levels of cyclosporine, phenytoin, tacrolimus, theophylline, warfarin
Voriconazole – Inhibits CYP 2C19, 2C9 & 3A4 as does metabolite
Posaconazole – Not known to be CYP inhibitor
Hepatotoxicity –Rare, but can lead to hepatic failure and death. Stop therapy if detected. More common with ketoconazole.
GI distress with nausea, vomiting & diarrhea fairly common
Skin rash and Alopecia seen fairly commonly
QT Prolongation – Ketoconazole, Voriconazole and Itraconazole
Visual Disturbances & sometimes frank Hallucinations – seen with Voriconazole (up to 30% patients)
Azoles should not be used in pregnancy |
|
|
Term
Penicillin antibiotics act by inhibition of synthesis of the :
Cell membrane
Cell wall
30S ribosome component
Nucleic acids in the cell |
|
Definition
Penicillin antibiotics act by inhibition of synthesis of the :
Cell membrane
Cell wall
30S ribosome component
Nucleic acids in the cell |
|
|
Term
Quinolone antibiotics act by inhibition of ____________ that act to alter ______________ of bacterial DNA.
Protein synthesis components / transcription
Cell membrane integrity / the structure and function
Topoisomerase enzymes / supercoiling
Proofreading of mRNA / translation |
|
Definition
Quinolone antibiotics act by inhibition of ____________ that act to alter ______________ of bacterial DNA.
Protein synthesis components / transcription
Cell membrane integrity / the structure and function
Topoisomerase enzymes / supercoiling
Proofreading of mRNA / translation |
|
|
Term
Transfer of resistance to a daughter cell would be described as:
Acquired and horizontal
Intrinsic and vertical
Acquired and vertical
Empiric and horizontal |
|
Definition
Transfer of resistance to a daughter cell would be described as:
Acquired and horizontal
Intrinsic and vertical
Acquired and vertical
Empiric and horizontal |
|
|
Term
A classic case of inhibition of P-450 mediated drug metabolism is exemplified by the drug ____________, while the antibiotic _______________ is well-known to induce p450 metabolism.
a) chloramphenicol / erythromycin
b) erythromycin / rifampin
c) fluconazole / metronidazole
d) ciprofloxacin / tetracycline |
|
Definition
A classic case of inhibition of P-450 mediated drug metabolism is exemplified by the drug ____________, while the antibiotic _______________ is well-known to induce p450 metabolism.
a) chloramphenicol / erythromycin
b) erythromycin / rifampin
c) fluconazole / metronidazole
d) ciprofloxacin / tetracycline |
|
|
Term
The MOA of the topical antibiotic mupirocin is inhibition of:
a) nucleic acid synthesis
b) cell membrane function & integrity
c) Leu-tRNA synthetase
d) fMet-tRNA binding in the A site |
|
Definition
The MOA of the topical antibiotic mupirocin is inhibition of:
a) nucleic acid synthesis
b) cell membrane function & integrity
c) Leu-tRNA synthetase
d) fMet-tRNA binding in the A site |
|
|
Term
) The antifungal agent Terbinafine would be expected to cause an accumulation of the toxic substance _________ and a decreased amount of the required substance ____________.
a) ergosterol / lanosterol
b) cholesterol / squalene
c) lanosterol / ergosterol
d) squalene / ergosterol |
|
Definition
) The antifungal agent Terbinafine would be expected to cause an accumulation of the toxic substance _________ and a decreased amount of the required substance ____________.
a) ergosterol / lanosterol
b) cholesterol / squalene
c) lanosterol / ergosterol
d) squalene / ergosterol |
|
|
Term
|
Definition
| An elevated, flat lesion greater than 1 cm in diameter. |
|
|
Term
|
Definition
| A transitory, elevated papule or plaque caused by edema of the skin. |
|
|
Term
|
Definition
| Hives; an eruption of itching wheals. |
|
|
Term
|
Definition
| Blister; a small, circumscribed, elevation of the skin filled with clear fluid. |
|
|
Term
|
Definition
| A vesicle greater than 0.5 cm in diameter. |
|
|
Term
|
Definition
| A vesicle or bulla (usually less than 1.0 cm in diameter) filled with a purulent exudate. |
|
|
Term
|
Definition
(encrusted exudates). Crusts result when serum, blood, or purulent exudate dries on the skin surface and are characteristic of injury and pyogenic infection. Crusts may be thin, delicate, and friable (A) or thick and adherent (B). Crust are yellow when formed from dried serum, green or yellow-brown when from purulent exudates, or brown or dark red from from blood. Picture B demonstrates a superficial honey-colored crust.
|
|
|
Term
|
Definition
| A macule is a circumscribed, flat lesion that differs form surrounding skin by its color. Macules can have any size or shape. They may be the result of hyperpigmentation (A), hypopigmentation (B), vascular abnormalities, capillary dilatation (erythema) (C), or purpura (extravasating RBC). |
|
|
Term
|
Definition
A papule is a small, solid, elevated lesion. Papules are < 1 cm, and projects above the surrounding skin. Papules may result from metabolic deposits in the dermis (A), local dermal cellular infiltrates (B), hyperplasia of the dermis or epidermis (C).
Papules with scaling are papulosquamous lesions |
|
|
Term
| Scales are loose ________________ cells and can be white, yellow, or brown, shinny or dull, and dry or greasy |
|
Definition
|
|
Term
| Tumors are elevated lesions > 2-3 cm (usually rounded). Used to describe ______ NOT ________________. |
|
Definition
|
|
Term
|
Definition
| A plaque (A) is a mesa-like elevation that occupies a relatively large surface area in comparison to the height above the surface. |
|
|
Term
|
Definition
| Lichenification (C) represents thickening of the skin and accentuation of skin markings. Lesions of lichenification are not as well defines as most plaques and often show signs of scratching, such as excoriations and crusts |
|
|
Term
|
Definition
| A vesicle is a circumscribed, elevated lesion that contains fluid (A). A bullae is a vesicle > 0.5 cm. Picture B shows multiple translucent vesicles that are extremely vulnerable, collapses easily, and can lead to crusting (see arrows). |
|
|
Term
|
Definition
| Cysts are a sac-like lesion that contains fluid or solids - but they are not translucent. |
|
|
Term
|
Definition
| A wheal is like a plaque, but is edematous, pruritic and of transient duration. The color can be red to pink. |
|
|
Term
|
Definition
| Purpura describes red lesions from blood extravasation. If the lesion is "pin point" size it is called petichea. If it is > 2cm it is an ecchymoses. |
|
|
Term
|
Definition
Excoriations are from abrasion to the skin such as from trauma from fingernail scratching. Excoriations can result in exudates and crusting.
Excoriations are from abrasion to the skin such as from trauma from fingernail scratching. Excoriations can result in exudates and crusting. |
|
|
Term
|
Definition
| Erosions describe superficial destruction of the skin - epidermis. |
|
|
Term
|
Definition
| Fissures describe linear breaks in the skin to the dermis (F only). |
|
|
Term
|
Definition
| Ulcer is used to describe the depth of a lesion. The skin is destroyed to the dermis or subcutaneous layers. Ulcers can have irregular, but sharp, borders |
|
|
Term
|
Definition
| Telangiectasia describes enlargements of the capillaries near the skin. The may be visible through the skin. An example would be a "spider vein". |
|
|
Term
|
Definition
| Folliculitis: Inflammation of the hair follicle caused by an infection ( generally S. aureus), irritation or physical injury to the hair follicle. |
|
|
Term
|
Definition
| Abscess: Walled of collection of pus and is associated with localized inflammation ( acute or chronic) and tissue distruction. Generally occurs is areas where frication occurs or minor trauma. Area affected include surface beneath a belt, anterior thighs, buttocks , groin, axillea and waist |
|
|
Term
|
Definition
| Furuncle( Boil) : A deep seated nodule or abscess that is painful, firm, red, and hot . This type of lesion is generally associated with S.aureus |
|
|
Term
|
Definition
| Carbuncle: a cluster of furuncles |
|
|
Term
|
Definition
| Cellulitis: a fast spreading bacterial infection below the surface of the skin characterized by redness, warmth, inflammation that generally affects extremities and is associated with staph or strep bacteria. |
|
|
Term
|
Definition
| Impetigo: common , contagious superficial skin infection that generally affects children and is associated with S. aureus. Starts as a vesicle and generally involves the face but can spread to any body surface |
|
|
Term
|
Definition
| Ecthyma: a superficial infection that generally occurs on the legs or buttocks. Primarily affects children and is often associated with poor hygiene. Is similar to impetigo and is associated with strep and staph bacteria. |
|
|
Term
|
Definition
| Fascia: a sheet or band of fibrous tissue that covers underlying tissue and separates different layers of tissue . Encloses muscle or organs |
|
|
Term
| Describe necrotizing fasciitis. |
|
Definition
| Necrotizing fasciitis: a gas- forming necrotic infection of the superficial and deep fascia. Can result in thrombosis and gangrene or underlying tissues. It is caused by multiple pathogens and is associated with diabetes. |
|
|
Term
| MJ is a 55 year-old make that presents to your pharmacy complaining that his leg hurts. While looking at his right lower leg you notice the leg is red, warm and swollen. He said that that the redness started yesterday and that last night he noticed it was warm. The pain started this morning. What type of infection is this patient most likely suffering from? |
|
Definition
|
|
Term
| BR is a 68 yo diabetic patient that presents to clinic complaining that he has an elevated, round lesion on his leg. He has had this lesion for a week now and it is not painful to touch nor red. When asked to further describe this lesion, BR stated that it looks like “there is fluid in it” and it measures less than 0.5 cm. What type of lesion does BR have? |
|
Definition
|
|
Term
|
Definition
Trichophyton rubrum
T. mentagrophytes |
|
|
Term
|
Definition
|
|
Term
| Distal subungual onychomycosis |
|
Definition
most common
parmesan cheese toenails
begins in the distal area of the nail bed |
|
|
Term
| white superficial onychomycosis |
|
Definition
Toe nail infection only
Involvement of the surface of the nail. Nail plate does not become thickened
Nail is soft, dry and can be easily scraped off. |
|
|
Term
| proximal subungual onychomycosis |
|
Definition
Infection that begins at the nail fold/cuticle area and then moves moves distally
At this point of involvement may see separation of the nail from nail bed
*ppl on immunosuppressants (HIV mostly)
*lower CD4 counts |
|
|
Term
|
Definition
Nails appearance is generally opaque and does not crumble
Color is yellow-brown
Most commonly affects all finger nails |
|
|
Term
| People at risk of onycomycosis |
|
Definition
Diabetes
Use of immunosuppressants and systemic antibiotics
HIV/AIDS
present at a younger age (20-30)
proximal subungual onychomycosis
Geriatric population (> 60)
Institutional living
communal bathing
Athletes
Tinea pedis
Health Clubs |
|
|
Term
| What are the pathogens of onycomycosis? |
|
Definition
Dermatophytes
Trichophyton rubrum
Trichophyton mentagrophytes
Yeast
Candida albicans
Candida parapsilosis
Nondermatophytes
Aspergillus and Scopulariopsis |
|
|
Term
| Clinical presentation/symptoms of onycomycosis? |
|
Definition
Thickening of the nail (hyperkeratosis)
Discoloration of the nail ( white or brown)
Brittleness
Onycholysis (separation of the nail from the bed)
Paronychial inflammation
Recurrent tinea pedis
Pain |
|
|
Term
| Diagnosis of onycomycosis based off what? |
|
Definition
History/clinical symptoms
KOH prep of nail clippings
Fungal culture
Nail biopsies |
|
|
Term
| Ideal agents for onycomycosis have what characteristics? |
|
Definition
Good concentrations in the nail bed and matrix
High clinical/mycologic cure rate
Low rate of relapse
Short term therapy that is efficacious
Few ADR’s and drug interactions
Cost-effective |
|
|
Term
| What are treatment options for onycomycosis? |
|
Definition
Nail removal
Topical therapy
Griseofulvin
Ketaconazole
Itraconazole
Fluconazole
Terbinafine |
|
|
Term
| Disadvantages of nail removal for onycomycosis |
|
Definition
Patient discomfort
Permanent nail deformity
High relapse rate |
|
|
Term
| Describe basic nail care. |
|
Definition
Nails should be kept short and clean
Nails should be cut straight across
File hypertrophic nails
Use of cotton gloves for dry work
Use vinyl gloves for wet work
Clean all nail instruments after use
Avoid nail salons
Avoid high heels and narrow toed shoes
Apply antifungal foot powder daily |
|
|
Term
| Describe Topical Nail Therapy |
|
Definition
Nail lacquers
PenLac®
Antifungal agents
Solutions (Clotrimazole, Tolnaftate,Terbinafine
Creams ( Clotrimazole,Tolnaftate, Terbinafine)
Powder (Tolnaftate)
Low cure rate and High relapse rate
Cannot penetrate harden nail mass
Requires multiple daily applications and long duration of therapy
May use as adjunctive therapy with oral antifungal agents |
|
|
Term
|
Definition
First oral agent approved for onychomycosis
Fungistatic
Disadvantages
High rate of resistance
High rate of relapse
Low cure rate
Long duration of therapy 6-18 months of therapy
Intolerable adverse drug reactions |
|
|
Term
| Fluconazole not used with patients with ___________ ________. |
|
Definition
|
|
Term
| What are the therapeutic considerations for onycomycosis? |
|
Definition
Concomitant Disease States
Drug interactions
Azoles (fluconazole and itraconazole)
Adverse drug reactions
Terbinafine and fluconazole tend to be better tolerated
Cost |
|
|
Term
| Tinea pedis is another word for ___________ |
|
Definition
|
|
Term
| Describe interdigital tinea pedis. |
|
Definition
Interdigital (toe web infection)
Most common
Maceration appearance (soggy and wet)
Dry scaly fissure appearance
4th and 5th toe most commonly involved
Itching is the most common symptom |
|
|
Term
| What is moccasin type of tinea pedis? |
|
Definition
Moccasin
Affects the soles of the feet
Apperance
Hyperkeratotic (thickening of soles)
Erythema
White and silver scales
Entire sole is involved |
|
|
Term
| Describe inflammatory (bullos) tinea pedis |
|
Definition
Inflammatory or bullous
Rare
Resembles contact allergic dermatitis
Starts as a web infection
Vesicles form on the soles of the feet
Vesicles may form into a bullae
Risk of secondary infection |
|
|
Term
| Describe ulcerative tinea pedis |
|
Definition
Ulcerative Type
Invasive involvement of interdigital into the dermis
Maceration
Secondary infection |
|
|
Term
|
Definition
Dermatophytid
Hand involvement |
|
|
Term
| What is first line treatment for tinea pedis? |
|
Definition
Topical therapy
If maceration or wet lesions are present consider aluminum acetate foot soaks |
|
|
Term
| What is oral therapy for tinea pedis? |
|
Definition
Oral therapy
Griseofulvin
500 mg per day for 6-12 weeks
Children 7 mg/kg/day for 6-12 weeks
Fluconazole
150 mg once a week for 1 month
Terbinafine
250 mg per day for 2 weeks |
|
|
Term
| How do you monitor treatment for tinea pedis? |
|
Definition
Re-evaluate at the end of each treatment phase
Base line CBC and LFT
If treatment extends beyond 1 month recheck LFT |
|
|
Term
|
Definition
“Ring worm of the scalp
Involves the scalp hair follicles and skin
Affects school age children
Rare in adults but they can be asymptomatic carriers
Higher incidence in African-Americans |
|
|
Term
| Describe presentation of tinea capitis. |
|
Definition
Presentation
Scalp alopecia
Circular
“Black dot”
Broken off hair shafts
Dandruff |
|
|
Term
| Symptoms of tinea capitis? |
|
Definition
Symptoms
Hair loss
Pain and tenderness
Flaking or scaling |
|
|
Term
| Treatment of tinea capitis? |
|
Definition
Treatment
Ketoconazole shampoo
Topical antifungal solution and lotions
Selenium sulfide
Topical steroids |
|
|
Term
| What are the antifungal creams?? |
|
Definition
Tinactin
Clotrimazole
Lamisil |
|
|
Term
| What are the oral therapy for tinea capitis? |
|
Definition
Oral agents
Griseofulvin
15 mg/kg for 6-8 weeks(pediatrics)
330 mg QD for 4-6 weeks (adults) (ultramicronized)
Fluconazole
50 mg QD for 4-6 weeks or 6 mg/kg per day (adults and pediatrics)
8 mg/kg once weekly x 4-16 weeks
Itraconazole
5 mg/kg/day or 100 mg QD for 4-6 weeks (adults and pediatrics)
**Terbinafine
125 mg QD for 4-6 weeks
250 mg QD for 4-6 weeks (adults) |
|
|
Term
|
Definition
Lesions resemble tinea corporis
Involves the hair follicles of the beard and mustache
Triggering factors
Men who work around animals
Consider diagnosis in an infection being treated with antibiotics that does not resolve |
|
|
Term
| Symptoms of tinea barbae? |
|
Definition
Symptoms
Pruritus
Tenderness and pain |
|
|
Term
| Why does tinea barbae require oral therapy? and what kinds? |
|
Definition
Requires oral therapy because topical therapy cannot penetrate hair follicles
Griseofulvin
Fluconazole
Itraconazole
Terbinafine |
|
|
Term
|
Definition
“Ring worm”
Presentation
Circular lesions
Demarcated borders.
Distribution
Trunk and limb involvement
Triggering factors
Humid climates
Daycare settings
Animal contact
Symptoms
Mild pruritus |
|
|
Term
| What is the treatment for tinea corporis? |
|
Definition
Treatment
Localized infections will respond to topical antifungal therapy
Apply twice a day 2-3 weeks
Advise patient to continue therapy 1 week after resolution of symptoms
Aluminum acetate (wet lesions)
Apply dressings for 20-30 minutes 2-6 times per day |
|
|
Term
| What are the oral therapy options for tinea corporis? |
|
Definition
Oral therapy (extensive infections or multiple lesions)
Griseofulvin
330 or 500 mg QD x 2- 4weeks
5-7 mg/kg/d 2-6 weeks
Fluconazole
150 mg Q week for 2-6 weeks
Ketoconazole
200 mg to 400 mg QD x 2 weeks
Itraconazole
100-200 mg QD for 2 weeks
Terbinafine
250 mg QD for 1-2 weeks |
|
|
Term
|
Definition
“Jock Itch”
Triggering factors
Warm and humid environment
Tight, occlusive clothing
Obesity
Men have the highest incidence of infection
High rate of relapse |
|
|
Term
| Describe presentation of tinea cruris. |
|
Definition
Presentation
Demarcated scaling plaques
Erythematous
Bilateral |
|
|
Term
| Describe distribution of tinea cruris. |
|
Definition
Distribution
Thighs and groin region
Can extend to the buttocks
Penis and scrotum involvement is rare |
|
|
Term
| symptoms of tinea cruris? |
|
Definition
Symptoms
Pruritus
Inflammation |
|
|
Term
| Describe treatment of tinea cruris. |
|
Definition
Treatment
Topical therapy
First line
Apply twice daily for 10 days
Advise patient to continue application every after lesions have disappeared
Powder
Absorbes moisture
Recommend medicated or nonmedicated
Aluminum acetate solution
Topical Steroid/Antifungal combination
Lotrisone
Clotriamazole and betamethasone
Mycolog II
Nystatin and triamcinolone |
|
|
Term
| Oral therapy for tinea cruris? |
|
Definition
Oral therapy
Extensive involvement
Griseofulvin
330-500 mg per day for 2-4 weeks
Ketoconazole
200 –400 mg QD 2 weeks
Fluconazole
150 mg Q week for 2-4 weeks
Itraconazole
100 –200 mg QD for 2 weeks
Terbinafine
250 mg QD for 2- 4 weeks |
|
|
Term
| What is the presentation of tinea manuum? |
|
Definition
Presentation
Thickened scaling skin on palms
Erythema appearance
Coinfection Tinea pedis
Infection patter
One hand and two feet or two hands and one foot |
|
|
Term
| What is treatment of tinea manuum? |
|
Definition
Treatment
Prevent onychomycosis or tinea pedis
Treatment is common with topical agents
Oral agents
Terbinafine 250 mg QD for 14 days
Itraconazole 200 mg QD for 7 days
Griseofulvin 500 mg QD for 21 days |
|
|
Term
| What is tinea versicolor? |
|
Definition
“Pityriasis Vericolor”
Caused by the yeast P. orbiculare
Normal flora
Highest numbers in areas with increased sebaceous glands
Trigging factors
Heat and humidity, Cushing’s disease, pregnancy, malnutrition, burns, corticosteroids, immunosuppression, oral contraceptive agents |
|
|
Term
| What is treatment for tinea veriscolor? |
|
Definition
Treatment
Topical agents
Selenium Sulfide
Apply 10 minutes daily for 7 consecutive days
Ketoconazole, Miconazole, Clotriamizole, Econazole
Apply one to two time a day for 2-4 weeks
Keratolytic soaps may prevent reoccurence |
|
|
Term
| Treatment for tinea versicolor? |
|
Definition
Treatment
Systemic agents
Ketoconazole
400 mg single dose or 200 mg QD for 5 days
Itraconazole
200 mg daily for five days
Fluconazole
300- 400 mg as a single dose ( may repeat in 2 weeks) |
|
|
Term
|
Definition
Indications
Tinea corporis, Tinea cruris, Tinea manuum, Tinea pedis
Therapeutic role
Side effects
Dermatitis |
|
|
Term
| Disadvantages of topical agents for tinea anything. |
|
Definition
Disadvantages
Less efficausious in the treatment of extensive infections or hyperkeratotic areas (palms or soles)
Long duration of therapy
Poor patient compliance
High relapse rate |
|
|
Term
| Describe topical agent formulations for tineas. |
|
Definition
Formulations
Ointment
Hyperkeratotic lesions
Lotions/Solutions
Hairy areas of the body
Moist or weeping lesions
Prevent maceration
Creams
Scaling, dry lesions
Powders
Prevention
Adjunctive therapy
Reduce maceration and moisture
Cost |
|
|
Term
| What is the largest organ of our body? |
|
Definition
|
|
Term
|
Definition
>2 sq yards (16-18 sq ft)
>10 pounds |
|
|
Term
1 sq inch contains:
____ million cells
____ fat glands
____ sweat glands
____ hairs
_______ nerve endings |
|
Definition
~30
~100
~600
~65
thousands of |
|
|
Term
| Which are thicker? eyelid, palms, soles? |
|
Definition
eyelid 0.5 mm
palms >2 mm
soles >4 mm |
|
|
Term
| What are the basic functions of the skin? |
|
Definition
thermoregulation
protection
synthesis/storage of nutrients
sensation
excretion and secretion |
|
|
Term
| Epidermis is made up of what 5 layers? |
|
Definition
Outward in:
stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum germinativum |
|
|
Term
| Describe stratum germinativum. |
|
Definition
1: Stratum germinativum
Deepest layer, contains large stem cells where new cells are generated, forms epidermal ridges which extend down (inward) into the dermis to increase nutrient diffusion; skin surface contours follow the ridge patterns to form fingerprints; contains melanocytes and nerve receptors (touch) |
|
|
Term
| Describe stratum spinosum. |
|
Definition
2: Stratum spinosum
Originates from the daughter cells of S. germinativum layer, continues to divide to increase the thickness of the epidermis |
|
|
Term
| Describe stratum granulosum. |
|
Definition
3: Stratum granulosum
Consists of cells displaced from the spinosum layer, cells stop dividing and make a large amount of a protein called Keratin |
|
|
Term
| Describe stratum lucidum. |
|
Definition
4: Stratum lucidum
A glassy clear layer that covers the S. granulosum in thick skin of the palms and soles; cells are flattened, densely packed and filled with keratin |
|
|
Term
|
Definition
5: Stratum corneum
Most superficial layer, consists of 15-30 layers of flattened and dead epithelial cells that have accumulated large amounts of keratin; dead cells remain tightly connected by desmosomes (a bipartite structural attachment between cells, a.k.a macula adherens)
Note: It takes 2-4 wks for a cell to move from S. germinativum to S. corneum. Dead cells remain in the S. corneum for an additional 2 wks before being shed (so total of 4-6 weeks before sloughed away |
|
|
Term
| Which layer of epidermis determines whether a drug can permeate the skin or not? |
|
Definition
| stratum corneum (most superficial layer) |
|
|
Term
| Which layer of the skin contributes most to the thickness of skin? |
|
Definition
thick = epidermis
thin = s. lucidum of epidermis is where the difference between thick and thin occurs |
|
|
Term
| What is a Langerhan cell? |
|
Definition
| immature dendritic cell (professional APC with MHC II) |
|
|
Term
| What cell does Langerhan cells present antigen to? |
|
Definition
|
|
Term
| Once Langerhan cells pick up antigen, then what happens? |
|
Definition
they go to lymph nodes to the Tcell area to teach naive cells to watch out for that antigen
**They secrete chemokines and produce adhesion molecules that attract and bind naïve T cells |
|
|
Term
| Where are Langerhan cells located in the epidermis? |
|
Definition
Reside in the lower 2 levels:
Stratum germinativum and stratum spinosum |
|
|
Term
| What holds keratinocytes together? |
|
Definition
| desmosomes aka cellular glue |
|
|
Term
| Melanocytes produce and contain ________ |
|
Definition
|
|
Term
| What layers contain melanin? |
|
Definition
| S. germinativum and S. spinosum |
|
|
Term
|
Definition
| It is a nerve cell that is a sensory receptor for touch |
|
|
Term
| Which interleukins do keratinocytes produce? |
|
Definition
|
|
Term
| Keratinocytes are responsive to which vitamins |
|
Definition
|
|
Term
| What are the 2 layers of dermis? |
|
Definition
Papillary layer (most superficial)
reticular layer (more deep) |
|
|
Term
| Describe Papillary layer of dermis. |
|
Definition
most superficial dermis layer
loose connective tissue
contains capillaries and nerves(pain/touch) |
|
|
Term
| Describe reticular layer of dermis. |
|
Definition
more deep layer of the dermis
collagen and elastic fibers
rich in vessels and nerves
areas of epidermis project downward close to sweat and sebaceous glands and near to hair follicles |
|
|
Term
| What is the sweat gland NT? |
|
Definition
| ACh, regardless of sympathetic system |
|
|
Term
| Sweat glands are part of which layer of skin? |
|
Definition
|
|
Term
|
Definition
simple, coiled, tubular glands
originating in the dermis and rising through the epidermis to the skin surface
**test chloride levels in sweat to check for cystic fibrosis |
|
|
Term
| What are the 2 types of sweat glands? |
|
Definition
eccrine (regulate temp and waste excretion)
apocrine (scent) |
|
|
Term
| Describe eccrine sweat glands. |
|
Definition
most common type
found nearly everywhere on skin
highest number in skin of palms and soles and forehead
**regulate temp and waste excretion |
|
|
Term
| Describe apocrine sweat glands. |
|
Definition
found in axillae, perineum, and other areas
*scent |
|
|
Term
| What is a major difference between eccrine and apocrine sweat glands? |
|
Definition
Eccrine - surface
Apocrine - do not reach surface directly, they go to hair shaft |
|
|
Term
| Describe sebaceous glands and where they are found. |
|
Definition
*found in dermis
*branced areolar glands located over the surface of the skin (except palms, soles, side of feet)
*most sebaceous glands open to hair follicles
*in lips and mammary papillae, they open directely on skin surface |
|
|
Term
| What is sebaceous gland function? |
|
Definition
*glands secrete Sebum, which is a mixture of squalene, cholesterol, wax esters, cholesterol esters, and TGs
*secretion is sensitive to sex hormone changes |
|
|
Term
| What are the functions of sebum? |
|
Definition
*prevents hair from becoming brittle
*moisturizes skin and prevents dehydration
*bactericidal action
***Excessive sebum secretion is a major cause of acne during adolescence |
|
|
Term
|
Definition
*layer of tissue below the dermis
*NOT part of the skin
*composed of adipose and areolar tissue |
|
|
Term
| What is the hypodermis function? |
|
Definition
*stores fat
*insulates lower level tissues to prevent heat loss
*absorbs shocks to protect deeper tissues (muscles) |
|
|
Term
| What are the types of hair and the function of hair? |
|
Definition
vellus - nonpigmented
lanugo - fine, fetal hair
terminal - large, mature hair
**protection
**sensory
**abrasion resistance |
|
|
Term
|
Definition
Hair bulb with papilla
*contains capillaries and nerve endings
*papilla contains melanocytes which determine hair color
*external layer fo hair follicle formed from Dermis and internal layer is formed from epidermis
*as cells divide, the daughter cells are pushed toward the surface, keratinize, and dies
*as we age, hair color lightens due to:
-decreased melanin
-presence of air bubbles in hair shaft |
|
|
Term
| Describe the growth phases of hair follicles. |
|
Definition
Anagen - active growth of hair (85-90% and lasts 4-8yrs)
Catagen - degeneration (1%)
Telogen - resting (10-15% and lasts 4 months) |
|
|
Term
| When resting _______ phase is complete, the hair follicle converts to _______ phase and the new anagen hair pushes out the telogen hair after 2-4 months. |
|
Definition
|
|
Term
| How many cycles of hair growth are there in a lifetime? |
|
Definition
|
|
Term
| What are 6 reasons of increased hair loss? |
|
Definition
1.drugs
2.dietary factors
3.radiation
4.high fever
5.stress
6.hormonal factors |
|
|
Term
| What are the nails functions? |
|
Definition
|
|
Term
| Describe the different parts of nails and characterize them. |
|
Definition
Nail plate: hard, translucent, formed from S. corneum
Nail Bed: highly vascularized, consists of S. Germinativum and S. Spinosum
Nail Root: site of nail growth |
|
|
Term
| How long does it take fingernails and toenails to grow from matrix to free edge? |
|
Definition
Fingernails: 5.5 mos
Toenails: 12-18 mos |
|
|
Term
| What are some general considerations for topical therapy of skin? |
|
Definition
1.Regional Anatomic variation
*thickness and lipid conc. of S.corneum
2.Drug Metabolism
*CYP enzymes in keratinocytes
3.Altered or hydrated barrier function
*absorption increased
4.Vehicle
*alter drug absorption
5.Age
*children have greater SA/vol ratio |
|
|
Term
|
Definition
| Fick’s Law quantifies the amount of a substance diffusing across a given surface area in a certain amount of time under a specified concentration gradient of the substance (“Flux”). Various expressions of the formula have been used, e.g. see below and others as well. |
|
|
Term
| What are some common drugs responsible for drug allergies? |
|
Definition
*penicillin and related antibiotics
*sulfonamides
*barbiturates
*anticonvulsants
*insulin preparations
*local anesthetics
*iodine preparations |
|
|
Term
| What is the most common organ affected by drugs? |
|
Definition
|
|
Term
| Many drug/skin reactions are non-immunologic in nature. What does this imply? |
|
Definition
*Due to direct toxic effect on skin tissue
*Due to direct action to release histamine from mast cells
*Does not involve antibodies |
|
|
Term
| Usually an immunogenic molecule is at least ________ MW |
|
Definition
|
|
Term
|
Definition
Urticarial Eruptions (Hives)
: acute or intermediate reaction
: lesions (hives) raised from a few mm to larger (cm)
: treat with H1 & H2 blockers
: systemic corticosteroids in severe cases
: symptoms clear in 1-2 days
Drug culprits commonly involved
e.g. heparin, penicillin, or codeine. |
|
|
Term
| What is a fixed drug reaciton |
|
Definition
: oval lesion with dusky red-blue appearance
: lesion can reoccur 30min - 8hr after rechallenge (any site, but oral mucosa and genitalia most common locations)
: Drug treatment may not be very effective (anti-H & steroids)
: lesion typically heals 7-10 days after drug termination |
|
|
Term
| Describe nonimmune photoallergies. |
|
Definition
Photosensitive (Non immune)
: skin becomes sensitive to
sun exposure
(UVA and UVB)
: either phototoxic – effect
seen within hrs of exposure
or photoallergic – response
within 1-2 days
: treatment – discontinue drug use
Culprits: topical corticosteroids; amiodarone, carbamazepine, furosemide, naproxen, oral contraceptives, phenothiazines, retinoids, sulfonamides, sulindac, tetracyclines, thiazides |
|
|
Term
| What is alopecia and what causes it? |
|
Definition
Alopecia
- often a toxic reaction
(alopecia medicamentosa)
- interfere with normal growth phases of the hair
Drug culprits:
e.g. – warfarin, heparin, chemotherapy drugs |
|
|
Term
| What is acneiform eruptions and its culprits? |
|
Definition
Acneiform eruptions
- acne like lesions, usually on neck, chest or back
- 2-4 week time to onset
- uniform size and symmetrical distribution
Culprits: e.g. – ACTH, oral contraceptives, corticosteroids (“steroid acne”), iodide, lithium |
|
|
Term
| Compare TEN vs Stevens-Johnson Syndrome |
|
Definition
TEN
>30% of the body
*mucosal involvemtn is mild
*more diffuse lesions, large areas of skin slough away
*severe skin pain
*maximal intensity occurs at 1-3 days
STEVENS-JOHNSON SYNDROME
<10% of body
*mucosal involvent is severe
*patchy targetoid lesions, cough, fever, headache
*mild skin pain
*maximal intensity occurs at 7-15 days |
|
|
Term
| Describe first generation H1 AH. |
|
Definition
First generation H1 Antagonists
Hydroxyzine (Atarax), Chlorpheniramine, Diphenhydramine, Cyproheptadine (Periactin)
Pass the BBB (anticholinergic CNS sedation) |
|
|
Term
|
Definition
Second generation H1 Antagonists
Loratadine (Claritin) and Cetirizine (Zyrtec)
Do not penetrate CNS, non-sedating, but metab by CYP3A4 & 2D6
Avoid use with imidazole antifungals and macrolide antibiotics (P450) |
|
|
Term
|
Definition
H2 Antagonists (~15% of skin “H” receptors are H2 type)
Cimetidine (Tagamet), Ranitidine (Zantac), Famotidine (Pepcid) and Nizatidine (Axid). Use caution with cimetidine (interactions!!)
In addition to H2 block, may have immunomodulating properties? |
|
|
Term
| Describe Leukotriene Receptor Antagonists. |
|
Definition
Leukotriene Receptor Antagonists – block the cys-LT1 receptor (predominantly) to reduce inflammation / itching (also asthma)
Zafirlukast (Accolate)
Montelukast (Singulair) |
|
|
Term
| Describe antidepressants. |
|
Definition
Antidepressants (H1 blockade is key, maybe H2)
Tricyclic antidepressants (biogenic amine reuptake blockers; increase NE and/or Dopamine effective levels at the neurotransmitter receptor in the synapse)
Antihistaminic and anticholinergic sedating properties
Central mood-elevating effects as used in psychiatry
Doxepin (Adapin, Sinequan) used by oral route
Topical cream of doxepin (Zonalon) also available, and said to be equivalent to lower level oral doses |
|
|
Term
| Describe some of the oral/parenteral steroids. |
|
Definition
Oral / Parenteral Steroids
Hydrocortisone (IV) for anaphylaxis or serious disease conditions, also methyprednisolone used IV for serious eruptions and drug reactions
Prednisone (oral) used for milder conditions, with a 3 day to 1 week tapered-dose course. Has 11-keto function on the “C” ring so must be reduced to the 11βOH derivative in liver for activity. Avoid use in severe liver failure.
In therapy of conditions we have discussed, steroids exert profound effects on immune system function, both via altered gene expression and direct receptor-mediated effects; many effects are “permissive” in nature
Decreased response to sun, chemical, mechanical, infectious and immunological stimuli of virtually all types
Both antibody and cell-mediated processes are affected
Decreased functions of virtually all components and immune pathways such as functions of lymphocytes, macrophages, monocytes, endothelial cells, basophils, fibroblasts, eosinophils and decreased actions of inflammatory cytokines such as IL-1, IL-2, IL-3, IL-6, IL-8, IL-12 and TNF-α |
|
|
Term
| AH selection for children |
|
Definition
Hydroxyzine
< 6 years 10 mg BID-QID
6-12 years 10-25 mg BID-QID
Do not exceed 50 mg per day
Do not exceed 100 mg per day
Diphenhydramine
2 to <6 years 6.25 mg BID- QID
6 to 12 years 12.5 mg to 25 mg BID-QID
Do not exceed 37.5 mg per day
Do not exceed 150 mg per day
Cyproheptadine
2-6 years 2mg Q 8-12 hours
7-14 years 4 mg Q 8-12 hours
Do not exceed 12 mg
Do not exceed 16 mg per day |
|
|
Term
| Describe angiodema treatment plan. |
|
Definition
Diphenhydramine or Hydroxyzine Plus Prednisone or Medrol dose pack
If signs of respiratory involvement
Give epinephrine IM or SQ and follow-up with an antihistamine and corticosteroid |
|
|
Term
| 2nd gen AH selection for adults |
|
Definition
Fexofenadine(Allegra)-180mgQD(180mgBID)
Desloratadine(Clarinex)-5mgQD(10mgQD)
Loratadine(Claritin)-10mgQD(20mgBID)
Cetirizine(Zyrtec)-10mgQD(10mgBID) |
|
|
Term
| 2nd generation AH for children |
|
Definition
Fexofenadine(Allegra)-2-11 yrs 15mgBID
Desloratadine(Clarinex)-1-5yrs 1.25mgQD
6-11 yrs 2.5mgQD
Loratadine(Claritin)-2-5 yrs 5mgQD
>6yrs 10mgQD
Cetirizine(Zyrtec)-6-12 mos 2.5mgQD
1-5yrs 2.5mgQD–BID
>6yrs 5-10mgQD |
|
|
Term
|
Definition
Acute onset of skin and mucosal lesions that may progress to GI symptoms, respiratory involvement, peripheral involvement, shock and death.
Patient complains of feeling hot, flushed and can be have difficulty breathing.
In some patients hives may be the presenting symptom
Females > Men
Age (20-40)
Effects higher economic status
Biphasic reaction
Do not underestimate severity of reaction
Severity is not based upon initial reaction |
|
|
Term
| Describe topical nail treatment advantages and disadvantages. |
|
Definition
Cannot penetrate harden nail mass
Requires multiple daily applications and long duration of therapy
May use as adjunctive therapy with oral antifungal agents |
|
|
Term
| Doses and Dosage forms for Griseofulvin. |
|
Definition
Dosage Forms
Microsize ( Grifulvin®)250 mg and 500 mg
Need to take with a fatty meal to increase absorption
Ultramicrosize ( Gris-Peg®)125, 165, 250 and 330 mg
Increased absorption
Suspension 125mg/ml
Dose
500 mg QD – BID |
|
|
Term
| What are monitoring parameters for Griseofulvin? |
|
Definition
Monitoring Parameters
Baseline AST,ALT and CBC.
Repeat AST and ALT if treatment is greater than 6 weeks |
|
|
Term
| Griseofulvin adverse reactions. |
|
Definition
Potential cross reactivity with Penicillin
Derived for Penicillium species
ADR’s
Skin rashes or urticaria
GI
Photosensitivity
Toxic epidermal necrolysis
Sore throat, fever or rash should be reported immediately
Drug Interactions
Anticoagulants, oral contraceptives, cyclosporine and salicylates
Phenobarbital will decrease griseofulvin serum concentrations |
|
|
Term
| Describe ketoconazole (Nizoral) |
|
Definition
Not effective
Risk of drug interactions and hepatoxicity |
|
|
Term
| Describe fluconazole(Diflucan) |
|
Definition
Most studies involved toe nails
Fungistatic - inhibits the synthesis of ergosterol
Advantages
Good nail bed and matrix penetration
Can be detected in toenails 6 months after D/C
Good absorption that is not influenced by gastric acid, food, antacids or H2 blocker
Disadvantages
Lacks indication
Has not been as extensively studied for this use
In Clinical practice most common dosage regimen is 150 mg q week x 3 months with re-evaluation at 3 months
Treatment duration range 3 to 12 months
80% of Fluconazole is excreted unchanged in the urine |
|
|
Term
| Describe fluconazole monitoring parameters, DIs, and adverse side effects. |
|
Definition
Monitoring parameters
Base line AST,ALT and CBC. Consider AST and ALT monthly if therapy is longer than 6 weeks.
Drug Interactions
Increase the effects of warfarin, cyclosporine, theophylline, phenytoin, sulfonylureas
Decrease the effects or oral contraceptives
Adverse Side Effects
GI – nausea, diarrhea and abdominal pain, elevated liver enzymes
Pulse dosing decrease incidence |
|
|
Term
| Describe Itraconazole(Sporanox). |
|
Definition
Fungistatic - inhibits the synthesis of ergosterol
Better for Candida infections
FDA indication for onychomycosis
Good concentration in nail matrix and nail bed
Achieve concentrations that are detectable for 6 months following D/C of TX |
|
|
Term
| Describe Itraconazole dosing. |
|
Definition
Dosage Regimen
Toenails (FDA approved)
200 mg daily for 12 weeks
Fingernails (FDA approved)
200 mg BID for 7 days per month for 2 monthly cycles. Must separate treatment courses by 3 weeks |
|
|
Term
| Describe Itraconazole monitoring parameters and DIs. |
|
Definition
Monitor parameters
Baseline AST,ALT and CBC. Consider AST and ALT monthly if therapy is greater than 1 month
Multiple Drug Interactions
Warfarin, H2 blockers, PPI, DDI, Ritonavir, Indinavir, Benzodiazepines, Lovastatin, Simvastatin, Cyclosporine, Tacrolimus, Phenytoin, Phenobarbital, Carbamazepine, Rifamycins |
|
|
Term
| Describe adverse effects of Itraconazole. |
|
Definition
Adverse Effects
GI (nausea, vomiting, diarrhea, and abdominal pain )
Headache
Dizziness
Rash
Elevated liver enzymes |
|
|
Term
| Describe black box warnings for Itraconazole. |
|
Definition
FDA Black Box Warnings
Hepatoxicity
CHF
Contraindicated in patients with CHF, cardiac dysfunction, or a history of CHF
Black box warning recommending discontinuing itraconazole if signs or symptoms of CHF develop
Tissue sampling is recommended for confirmatory diagnosing |
|
|
Term
| Describe disadvantages of Itraconazole. |
|
Definition
Disadvantages
Multiple drug interactions
Expensive
Must be taken with full meal
Acidic environment for absorption
Antacids, H2 blockers, PPI will reduce absorption
Achlorhydria (don’t produce much acid)
Cola beverage will improve absorption |
|
|
Term
| Describe Terbinafine(Lamisil). |
|
Definition
First line therapy in private practice
FDA indication
Studies show this agent is more effective than Itraconazole
Fungicidal |
|
|
Term
| Describe dosing for Terbinafine |
|
Definition
Dosage Regimen
Fingernail
250 mg QD for 6 weeks
Toenail
250 mg QD x 12 weeks |
|
|
Term
| Describe Terbinafine and its warnings, monitoring parameters, and DIs. |
|
Definition
FDA Warnings
Hepatotoxicity
Liver failure and death
Not indicated in patients with chronic or active hepatic disease
Monitoring parameters
Base line AST,ALT and CBC. Consider monthly AST and ALT if therapy is greater that 6 weeks
Drug Interactions
Tricyclic antidepressants, (SSRI’s ( fluoxetine, paroxetine)
Venlafaxine
Cyclosporine |
|
|
Term
| Describe adverse effects of Terbinafine. |
|
Definition
Adverse Effects
GI- diarrhea, abdominal pain, nausea, and flatulence
Rash
Taste disturbances
Elevated liver enzymes |
|
|
Term
|
Definition
Advantages
Fewer drug interactions
Fewer adverse drug interactions
Fungicidal activity
Pregnancy Category B |
|
|
Term
| Ciclopirox and terbinafine together?? |
|
Definition
Minimizes resistance
Shortens length of therapy |
|
|
Term
| Describe Systemic therapy for antifungals. |
|
Definition
Immunocompromised patients
Diabetic patients
Extensive or invasive infection
Inflammatory infection
Hyperkeratotic involvement of palms or soles
Failure of two forms of topical therapy
Monitoring Parameters
t Base line CBC , AST, and ALT(all oral antifungal agents)
t If treatment extends beyond 1 month recheck AST and ALT (all oral fungal agents)
Itraconazole
FDA warning of hepatotoxicity
Congestive Heart Failure
Contraindicated in patients with CHF, cardiac dysfunction, or a history of CHF
Black box warning recommending discontinuing itraconazole if signs or symptoms of CHF develop |
|
|
