■ Bentoquatam—for preventive use (Ivy Block)

■ Calamine lotion (Caladryl lotion)

■ Hydrocortisone (Ivy Soothe, Ivy Stat)

■ Isopropanol; cetyl alcohol (Ivy Cleanse)

■ Zinc acetate; isopropanol (Ivy Dry)

■ Zinc acetate; isopropanol; benzyl alcohol (Ivy Super Dry)

A. Treatment of lesions includes calamine lotion and other products that soothe lesions, Burow’s solution compresses, Domeboro solution, and/or Aveeno baths to relieve discomfort.

B. Topical corticosteroids are effective to prevent or relieve inflammation, especially when used before blisters form.

C. Oral corticosteroids may be prescribed for severe reactions and a sedative such as diphenhydramine (Benadryl) may be prescribed.

Systemic Immunosuppressants

■ Azathioprine (Imuran)

■ Cyclosporine (Sandimmune)

■ Methotrexate

■ Oral glucocorticoids

Topical Immunosuppressants

■ Pimecrolimus 1% cream (Elidel)

■ Tacrolimus (Protopic)

A. Description

1. A chronic inflammatory skin disease that is also known as eczema and is characterized by dry and scaly skin.

2. May be treated with moisturizer and topical glucocorticoids; systemic immunosuppressants mayalso  be prescribed if topical treatment is ineffective.

3. Systemic immunosuppressants may include methotrexate, cyclosporine (Sandimmune), or azathioprine (Imuran), and oral glucocorticoids.

B. Topical immunosuppressants

1. Tacrolimus (Protopic 0.03% or 0.1% cream) and pimecrolimus 1% cream (Elidel).

2. Side/adverse effects include redness, burning, and itching; causes sensitization of the skin to sunlight.

3. Tacrolimus increases the risk of varicella-zoster infection in children.

4. Tacrolimus may cause skin cancer and lymphoma.

A. Description

1. Antiinflammatory, antipruritic, and vasoconstrictive actions

2. Preparations vary in potency and depend on the concentration and type of preparation, and method of application (occlusive dressings enhance absorption, increasing the effects).

3. Systemic effects are more likely to occur with prolonged therapy and when extensive skin surfaces are treated.

Topical glucocorticoids can be absorbed into the systemic circulation; absorption is greater in permeable skin areas (scalp, axilla, face and neck, eyelids, perineum) and less in areas where permeability is poor (palms, soles, back).

B. Contraindications

1. Clients demonstrating previous sensitivity to corticosteroids

2. Clients with current systemic fungal, viral, or bacterial infections

3. Clients with current complications related to glucocorticoid therapy

C. Local side/adverse effects

1. Burning, dryness, irritation, itching

2. Skin atrophy

3. Thinning of the skin, striae, purpura, telangiectasia

4. Acneiform eruptions

5. Hypopigmentation

6. Overgrowth of bacteria, fungi, and viruses

D. Systemic side/adverse effects

1. Growth retardation in children

2. Adrenal suppression

3. Cushing’s syndrome

4. Striae, skin atrophy

5. Ocular effects (glaucoma and cataracts)

E. Interventions

1. Monitoring plasma cortisol levels may be prescribed if prolonged therapy is necessary.

2. Wash the area just before application to increase medication penetration.

3. Apply sparingly in a thin film, rubbing gently.

4. Avoid use of a dry occlusive dressing unless specifically prescribed by the health care provider (HCP).

5. Instruct client to report signs of adverse effects to the HCP.

In the adult, intact skin is generally impermeable to most topical medications. However, medications should not be applied to denuded areas unless prescribed because undesired absorption can occur.

■ Aminolevulinic acid (Levulan Kerastick)

■ Diclofenac sodium 3% gel (Solaraze)

■ Fluorouracil (Carac, Efudex, Fluoroplex)

■ Imiquimod 5% cream (Aldara)

A. Description

1. Actinic keratoses are caused by prolonged exposure to the sun and appear as rough, scaly, red or brown lesions usually found on the face, scalp, arms, and back of the hands.

2. Lesions can progress to squamous cell carcinoma.

3. Treatment includes medications and therapies such as excision, cryotherapy, curettage, and laser therapy.

B. Medications include fluorouracil (Carac, Efudex, Fluoroplex), diclofenac sodium (Solaraze), imiquimod 5% cream (Aldara), and aminolevulinic acid (Levulan Kerastick).

1. Fluorouracil (Carac, Efudex, Fluoroplex)

a. A topical medication that affects DNA and RNA synthesis and causes a sequence of responses that results in healing; results are usually seen in 2 to 6 weeks but may take 1 to 2 months longer for complete healing

b. Side effects include itching, burning, inflammation, rash, and increased sensitivity to sunlight.

2. Diclofenac sodium (Solaraze)

a. A nonsteroidal antiinflammatory topical medication; may take 3 months to be effective

b. Side effects include dry skin, itching, redness, and rash.

3. Imiquimod 5% cream (Aldara)

a. In addition to treating actinic keratoses, this topical medication has been used to treat venereal warts; it may take up to 4 months to be effective.

b. Side effects include redness, skin swelling, itching, burning, sores, blisters, scabbing, and crusting of the skin.

4. Aminolevulinic acid (Levulan Kerastick)

a. A topical medication used in conjunction with blue light photoactivation; the medication is applied and 14 to 18 hours later the medication is activated by exposing the lesions to the blue light.

b. Side effects include burning, stinging, redness, and swelling of the skin; treated areas need to be protected from sunlight and bright indoor lights.

Topical Medications

■ Anthralin (Dritho-Scalp, Psoriatec)

■ Calcipotriene (Dovonex)

■ Coal tar

■ Glucocorticoids

■ Keratolytics (topical salicylic acid; sulfur)

■ Tazarotene (Tazorac)

Systemic Medications

■ Acitretin (Soriatane)

■ Cyclosporine

■ Methotrexate

Systemic Biological Medications

■ Alefacept (Amevive)

■ Ustekinumab (Stelara)

Phototherapy

■ Coal tar and ultraviolet B irradiation

■ Photochemotherapy (PUVA [psoralen and ultraviolet A] therapy)

A. Description

1. Psoriasis is a chronic inflammatory disorder that has varying degrees of severity.

2. Treatment is based on the severity of symptoms and aims to suppress the proliferation of keratinocytes or suppress the activity of inflammatory cells.

B. Topical medications

1. Glucocorticoids

a. Used for mild psoriasis

b. Should not be applied to the face, groin, axilla, or genitalia because the medication is readily absorbable, making the skin vulnerable to glucocorticoid-induced atrophy

2. Anthralin (Dritho-Scalp, Psoriatec)

a. Can cause local irritation and skin redness

b. Is applied to lesions at bedtime and allowed to remain on the skin overnight

c. Client should be informed that the medication can stain clothing, skin, and hair.

3. Tazarotene (Tazorac)

a. Is a vitamin A derivative

b. Local reactions include itching, burning, stinging, dry skin, and redness; other, less common effects include rash, desquamation, contact dermatitis, inflammation, fissuring, and bleeding.

c. Sensitization to sunlight can occur and the client should be instructed to use sunscreen and wear protective clothing.

d. Medication is usually applied once daily in the evening to dry skin.

4. Calcipotriene (Dovonex)

a. Is an analogue of vitamin D

b. May take up to 1 to 3 weeks to produce a desired effect

c. Can cause local irritation; high-dose applications may cause hypercalcemia

5. Coal tar

a. Suppresses DNA synthesis, miotic activity, and cell proliferation

b. Has an unpleasant odor and may cause irritation, burning, and stinging; can also stain the skin and hair

6. Keratolytics

a. Soften scales and loosen the horny layer of the skin, resulting in minimal peeling to extensive desquamation

b. Salicylic acid: Can be absorbed systemically and can cause salicylism, which is characterized by dizziness and tinnitus, hyperpnea, and psychological disturbances; salicylic acid is not applied to large surface areas or open wounds because of the risk of systemic effects.

c. Sulfur: Promotes peeling and drying and is used to treat acne, dandruff, seborrheic dermatitis, and psoriasis

C. Systemic medications

1. Methotrexate

a. Reduces proliferation of epidermal cells

b. Can be toxic; causes gastrointestinal effects such as diarrhea and ulcerative stomatitis and bone marrow depression leading to blood dyscrasias

c. Can be hepatotoxic; hepatic function should be monitored during therapy

2. Acitretin (Soriatane)

a. Inhibits keratinization, proliferation, and differentiation of cells; has antiinflammatory and immunomodulator actions; used for severe psoriasis and reserved for use in those who have not responded to safer medications.

b. Is embryotoxic and teratogenic: Medication is contraindicated during pregnancy; pregnancy must be ruled out and two reliable forms of contraception need to be implemented before the medication is started (contraception must be implemented at least 1 month before treatment starts and be continued for at least 3 years after treatment is discontinued).

c. If pregnancy occurs during treatment with the medication, the medication is discontinued immediately and possible termination of the pregnancy is discussed.

d. Dermatological effects include hair loss, skin peeling, dry skin, rash, pruritus, and nail disorders; other effects include rhinitis from mucous membrane irritation, inflammation of the lips, dry mouth, dry eyes, nosebleed, gingivitis, stomatitis, bone and joint pain, and spinal disorders.

e. Can be hepatotoxic; can elevate triglyceride levels and reduce levels of high-density lipoprotein cholesterol

f. Medication should be taken with meals to facilitate absorption; alcohol must be avoided.

g. This derivative of vitamin A can cause vitamin A toxicity if taken at the same time as vitamin A supplements.

h. Should not be taken concurrently with tetracycline because it can cause increased intracranial pressure

3. Cyclosporine

a. An immunosuppressant that inhibits proliferation of B and T cells

b. Can be toxic and cause kidney damage

c. Used for severe psoriasis and reserved for use in those who have not responded to safer medications

D. Systemic biological medications

1. Alefacept (Amevive)

a. The medication reduces the number and activity of memory CD4+ T lymphocytes; therefore the medication is contraindicated in clients with human immunodeficiency virus infection.

b. CD4 T-cell counts should be monitored before each dose and discontinued if the count falls below 250 cells/mL.

c. Risk of cancer is increased and the medication should not be administered to a client with a history of malignancy; medication should be discontinued if cancer develops.

d. Can cause chills, cough, pruritus, myalgia, and inflammation and pain at the intramuscular injection site

2. Ustekinumab (Stelara)

a. A human monoclonal antibody

b. Can decrease the activity of the immune system and increase the risk for certain types of cancer

c. Side effects of the medication include upper respiratory infections, headache, and tiredness.

d. Contraindicated in clients who have a history of cancer; also contraindicated in clients with infection, or reversible posterior leukoencephalopathy syndrome (rare condition that affects the brain and can cause death)

e. The client should not receive any live virus vaccines because the viruses used in some types of vaccines can cause infection in those with a weakened immune system; in addition, the HCP needs to be informed if anyone in the household needs a vaccine.

f. The client should not receive the bacille Calmette-Guérin (BCG) vaccine during the 1 year before taking or 1 year after taking the medication.

g. The client should inform the HCP if he or she is receiving phototherapy, has any other medical condition, is pregnant or plans to become pregnant, or is breast-feeding or plans to breast-feed.

E. Phototherapy

1. Coal tar and ultraviolet B irradiation: Treatment that involves the application of coal tar for 8 to 10 hours; coal tar is washed off and the area is exposed to short-wave UV radiation (ultraviolet B, or UVB)

2. Photochemotherapy (PUVA [psoralen and ultraviolet A] therapy)

a. Combines the use of long-wave radiation (ultraviolet A, or UVA) with oral methoxsalen (photosensitive medication)

b. Can cause pruritus, nausea, erythema; may accelerate the aging process of the skin; may increase the risk of skin cancer

A. Description

1. Acne lesions that are mild may be treated with nonpharmacological measures such as gentle cleansing two or three times daily (oil-based moisturizing products need to be avoided), dermabrasion, or comedo extraction.

2. Mild acne is usually treated pharmacologically with topical agents (antimicrobials and retinoids).

3. Moderate acne is usually treated with oral antibiotics and comedolytics.

4. Severe acne is usually treated with isotretinoin (Amnesteem or Claravis).

5. Hormonal medications such as oral contraceptives and spironolactone (Aldactone) may be prescribed to treat acne in female clients.

6. Combination therapy may be prescribed to treat the acne.

7. Actions of the medications may include suppressing the growth of Propionibacterium acnes, reducing inflammation, promoting keratolysis, unplugging existing comedones and preventing their development, and normalizing hyperproliferation of epithelial cells within the hair follicles; some medications cause thinning of the skin, which facilitates penetration of other medications.

8. For topical applications: Site should be washed and allowed to completely dry before application; hands should be washed after application.

9. All topical products are kept away from the eyes, inside the nose, lips, mucous membranes, hair, and inflamed or denuded skin.

B. Topical antibiotic products

1. Benzoyl peroxide

a. Can produce drying and peeling

b. Severe local irritation (burning, blistering, scaling, swelling) may require reducing the frequency of applications.

c. Some products may contain sulfites; monitor for allergic reactions.

2. Clindamycin (Cleocin) and erythromycin (Erythroderm)

a. Both products may be prescribed to prevent emergence of resistance.

b. Combination therapy with benzoyl peroxide can be prescribed to prevent emergence of resistance; fixed-dose combinations include clindamycin/benzoyl peroxide (BenzaClin) and erythromycin/benzoyl peroxide (Benzamycin).

3. Dapsone (Aczone): Side effects include oiliness, peeling, dryness, and erythema of the skin.

C. Topical retinoids

1. Tretinoin

a. A derivative of vitamin A (vitamin A supplements should be discontinued during therapy)

b. In addition to treating acne, it may be prescribed to reduce fine wrinkles, skin roughness, mottled hyperpigmentation such as that which occurs with age spots.

c. Can cause localized side effects such as blistering, peeling, crusting, burning, and swelling of the skin

d. The use of abrasive products and keratolytic products should be discontinued before using tretinoin because they can cause localized side effects.

e. Medication sensitizes the skin to ultraviolet light (UVL); the client needs to be instructed to apply a sunscreen with a sun protection factor (SPF) of 15 or greater and to wear protective clothing when outdoors because the medication increases susceptibility to sunburn.

2. Adapalene (Differin): Similar to tretinoin and sensitizes the skin to UVL; side effects include burning and itching after application, redness, dryness, and scaling of the skin.

3. Tazarotene (Tazorac)

a. Is a derivative of vitamin A (vitamin A supplements should be discontinued during therapy)

b. In addition to acne, it is used to treat wrinkles and psoriasis.

c. Can cause itching, burning, and dry skin and sensitizes the skin to UVL.

4. Azelaic acid (Azelex) can cause burning, itching, stinging, and redness of the skin; it can also cause hypopigmentation of the skin in clients with a dark complexion.

D. Oral antibiotics

1. Includes doxycycline (Vibramycin), minocycline (Dynacin, Minocin, Solodyn), tetracycline (Sumycin), and erythromycin (Ery-Tab)

2. Improvement develops slowly with the use of oral antibiotics and may take 3 to 6 months for some improvement to be noted; following control of symptoms the client is usually switched to a topical antibiotic.

E. Isotretinoin (Amnesteem or Claravis).

1. Derivative of vitamin A (vitamin A supplements should be discontinued during therapy); in addition, the use of tetracyclines can increase the risk of adverse effects and should be discontinued before use of isotretinoin

2. Used to treat severe cystic acne; reserved for persons who have not responded to other therapies, including systemic antibiotics

3. Side effects include nosebleeds; inflammation of the lips or eyes; dryness or itching of the skin, nose, or mouth; pain, tenderness, or stiffness in the joints, bones, or muscles; and back pain.

4. Less common side effects include rash, hair loss, peeling of the skin, headache, and reduction in night vision.

5. Causes sensitization of the skin to UVL

6. The medication elevates triglyceride levels, which should be measured before and during therapy; alcohol consumption should be eliminated during therapy because alcohol could potentiate elevation of serum triglyceride levels.

7. The medication may cause depression in some clients; if depression occurs, the medication should be discontinued. Isotretinoin (Amnesteem or Claravis) is highly teratogenic and can cause fetal abnormalities. If prescribed, the client needs to follow strict rules of the iPLEDGE Program.

It must not be used if the client is pregnant.

F. iPLEDGE Program

1. A risk management program that ensures that no woman starting isotretinoin is pregnant and that no woman taking this medication becomes pregnant

2. Access to the medication is controlled through a central automated system.

3. Strict rules must be followed by the client, HCP prescribing the medication, pharmacist dispensing the medication, and the wholesaler of the medication to ensure safety and to ensure that no woman is pregnant on initiation of therapy or becomes pregnant while taking the medication.

4. Web site on the iPLEDGE Program from the U.S. Food and Drug Administration:

1. Hormonal medications such as oral contraceptives and spironolactone (Aldactone) may be prescribed to treat acne in female clients.

2. These medications decrease androgen activity, resulting in decreased production of sebum (substance that combines with keratin to create a plug within a pore).

3. Spironolactone is teratogenic; therefore contraception during its use is necessary.

4. Adverse effects of spironolactone include breast tenderness, menstrual irregularities, and hyperkalemia.