Acne

Retinoids

• Drugs: tretinoin, adapalene (Differin, + BPO a=Epiduo), tazarotene (Tazorac), dapsone (Aczone)
• MOA: vitamin A analog. Topical form is the first line for acne. Oral form vitamin A analogy is tretinoin (only used in severe acne).
• Other first lines include topical (antibiotics, BPOs); second line for acne is the topicals plus an oral antibiotic.
• Differin due to its well tolerated side effect, it became available as OTC in 2017.
• Limits sun exposure; Use with salicylic acid or astringents will cause more irritation.
• Pregnancy X.

Benzo peroxide (BPO)

• Drugs: Benzaclin (+ clindamycin = Duac)
• Can bleach clothing hair, limit sun exposure.

Isotretinoin

• Drugs: Accutane, Claravis, Myorisan, Zenatane
• MOA: this is a vitamin A analog. Indicated for severe nodular acne.
• Pregnancy X, only dispense through iPLEDGE (for both male and female), must have 2 negative pregnancy tests prior to start
• Do not use with vitamin A (can be too much), tetracycline, steroids, progestin-only contraceptive, St. John’s Worts.

Dandruff

• May be caused by yeast overgrowth.
• Treat with hypoallergenic shampoo: selenium sulfite (Selsun Blue), zinc pyrithone (Head and Shoulder shampoo), coal tar, ketoconazole shampoo.

Fungal infection

• Tinea capitas (scalp), tinea cruris (jock itch, or groin), tinea corporis (body), tinea pedis(foot), tinea unguium (nails)
• Apply to the affected area for 2-4 weeks, even after it appears healed.
• Reduce moisture to infected area.
• Nail/hair infection justifies systemic treatment: azoles (monitor LFT).

Eczema (atopic dermatitis)

• Treatment: topical or oral steroid, antibiotics, antihistamine
• Condition may be caused by calcium channel blockers (dilatory effect cause flushing).
• More severe eczema calls for calcineurin inhibitors (immunosuppressants) such as tacrolimus (Protopic), pimecrolimus (Elidel).
• Warnings: risk of lymphoma and skin cancer.
• Do not bathe, shower, or swim after applying cream, limit sun exposure.
• MedGuide is required with dispensing: calcineurin inhibitors carry cancer risk (lowers immune system too much).

Lice

• Permethrin is the drug of choice, follow up 7-10 days later for 2nd treatment if needed.
• Lindane is not recommended due to neurotoxicity or seizure.

External genital warts

• Imiquimod (Aldara): also approved for basal cell carcinoma and actinic keratosis.
• Apply HS 3 times a week, wash off after 8 hours, for max 16 weeks

Inflammation

• 1st line: OTC steroid cream (e.g: Cortaid, Cortisone)
• Steroid overuse can lead to thinning of skin, striae in skin fold and worsening of acne.
• Hydroxyzine (Atarax, Vistaril, 1^st generation antihistamine): used for general urticaria.

Diaper rash

• Destin: contains Zinc oxide, a desiccant that decreases moisture.

Cuts/abrasion

• The best practice is to leaving wound uncovered, cover only if the area can get dirty
• Neosporin (OTC ung), mupirocin (Bactroban - good staph and strep coverage)
• Make sure tetanus shot is current: every 10 years for adults

Psoriasis

• An autoimmune disorder: chronic, inflammatory with silvery scales and clear edges.
• Treat with coal tar, keratolytic (salicylic acid, sulfur), retinoids, anthralin, calcipotriene (Dovonex - a vitamin D analog, + betamethasone = Taclonex), acitretin (Soriatane), oral steroid

Alopecia

• Finasteride (Propecia)
  • 5-alpha reductase inhibitor, 1mg QD, lower dose than Proscar (treat BPH).
  • Be prepared to be tricked by a question on finasteride dose in BPH treatment, the answer is 5mg QD not 1mg. Notice different indication has different brand name.
  • Risk of sexual dysfunction (disrupt testosterone level).
• Minoxidil (Rogaine - OTC)

• An antihypertensive non-nitrate vasodilator (same class as hydralazine) used for hair regrowth.

Common steroids

• clobetasol - Clobex, Cormax, Olux, Temovate
• mometasone - Elocon
• fluocinonide - Lidex
• desoximetasone - Topicort
• Triamcinolone - Kenalog
• desonide - DesOwen, Desonate
• Corticosteroids potency comparison
  • 50 mg‎ ‎Cortisone (short-acting) = 40 mg‎ ‎Hydrocortisone (short-acting) = 10 mg prednisone (intermediate-acting) = 10 mg Prednisolone (intermediate-acting) = 8 mg Methylprednisolone (intermediate-acting) = 5 mg‎ ‎Dexamethasone (long-acting) = 1.2 mg‎ ‎Betamethasone (long-acting)
  • If a question asks appropriate drug therapy for asthma attack, you should be able to eliminate choices such as 15mg Decadron (dose too high, plus Decadron’s place is in chemo treatment).
  

   

  • **Fludrocortisone (Florinef) is used for its mineralocorticoid activity (causing increased reabsorption of sodium and loss of potassium/hydrogen). Its anti-inflammatory is negligible. For this reason, fludrocortisone cannot be converted to another corticosteroid.

   

  Tattoo care

  • Suggest ice packs for mild swelling or pain
  • Discourage OTC topical antibiotics, diphenhydramine, or hydrocortisone - No data show that they help new tattoos and some may cause skin reactions
  • Advise keeping tattoos out of the sun, cover with clothing, use a broad spectrum sunscreen, as sunlight can fade tattoos
  • Vaccines and other injections can be given through a tattoo after it's healed
  • Do not put transdermal patches on fresh tattoos
  • Patients with tattoos should not avoid getting an MRI

   

  Spider bite

  • 1st line: calcium gluconate
  • 2nd line: IV BZD and opioids (e.g: morphine 15mg or meperidine 88mg) relieve the symptoms of muscle rigidity and spasm, lessen the pain.
  • Latrodectus antivenin is considered up to 48 - 90 hrs after a widow bite. Watch for anaphylaxis reaction due to the serum is made from horse. A sensitivity testing is usually done before the injection.

   

  Last updated on: March 25th, 2018

   

  
  
  
  

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