Pharmacologic Treatment of Selected Common Dermatologic Conditions K A R E N HAY E S P HD, A P R N , F N P - B C, ACN P - B C

•13 year old Ana complaining of an itching, spreading rash on her arms and legs. Ana says she attended a picnic yesterday. She has been on Bactrim DS for a UTI for three days.

Patho • Toxicodendron species contain oleoresins known collectively as urushiol. In susceptible individuals, these compounds trigger a type IV delayed hypersensitivity reaction. Usually, the skin is involved; however, the eyes, airway, and lungs may be involved if exposed to smoke from burning plants

Patho • Lesions generally appear within 12-48 hours, although they have been noted to appear earlier. • New lesions may continue to appear for up to 2-3 weeks. Initially, these lesions tend to occur from the slow reaction to adsorbed urushiol • Lesions that appear later are often secondary to contact with contaminated surfaces (eg, clothing, pet hair, gardening tools, camping equipment). Although a common misconception, fluid from the vesicles of a poison ivy rash does not contain urushiol and does not cause new lesions.

Rhus Treatment • Domeboros (one packet) in one pint of water, kept in refrigerator is a good compress. • Zanfel -The only product to remove urushiol, the toxin responsible for the reaction, from the skin after bonding, enabling the affected area to immediately begin healing. After using Zanfel®, itching and pain are relieved quickly, usually within 30 seconds. • Corn starch (one pound in a tub of water as a soak or mixed with a small amount of water to make a paste) helps. So might Calamine, Hydrocortisone cream, Rhule cream/lotion/spray or Sarna lotion. • Antihistamines help itching. Aspirin or Advil can help inflammation and discomfort. • Corticosteroids in refractory or severe cases. • Antibiotics for secondarily infected (usually staph)

Topical Steroids • 7 classes based on potency against hydrocortisone 1% (class 7) • Class 1 (clobetasol) 600 to 1000 times stronger • Do not use Ultra-high potency steroids for longer than 3 weeks • Low to high potency steroids not be used continuously for longer than 3 months • Combination topical steroid and antifungal agents should generally be avoided • Denuded skin absorbs more than intact skin • Once or twice daily application advisable for most diseases • Apply in finger-tip units (one unit equals 0.5 gm) • Side effects: easy bruising, increased fragility, thinning, striae, and worsening of infections- rare systemic effects possible with ultra-potent preparations in large areas

Topical Steroids- know one in each category • Class 1 – ultra potent- clobetasol .0.05% • Class 2- high potent- budesonide 0.025% • Class 3- upper mid-strength- triamcinolone 0.1% • Class 4- mid-strength- betamethasone 0.12% • Class 5- lower mid-strength- fluticasone 0.05% • Class 6- low potent- triamcinolone 0.025% • Class 7- least potent- hydrocortisone 1%

Topical Steroids in Rhus • Use mid to high potency topical steroids twice daily up to 14 days • If greater than 20% of body surface area, consider oral steroids.

• Treat 14 days after initial exposure

Oral steroids in Rhus- 0.5 to 1.0 mg/kg/day • In a randomized, controlled trial of 49 patients with either a 5-day regimen (short-course arm) of oral prednisone (40 mg daily -200 mg total per patient) or a taper (long-course arm) of 30 mg daily for 2 days, 20 mg daily for 2 days, 10 mg daily for 2 days, and 5 mg daily for 4 days (15 days and 340 mg total per patient) • 75% of short-course arm used additional longer courses of prednisone, intramuscular steroids, or topical steroids. •

J Clin Med Res. 2014 Dec; 6(6): 429–434. Published online 2014 Sep 9. doi: 10.14740/jocmr1855w

• No strong evidence on how to use steroids in Rhus • Experts agree that they should be used for “severe” cases but that is not defined (many believe 20-25% rash coverage is severe – 10% in children) • Most review articles do conclude that length of treatment should be at least 14 days from exposure (Medrol dose pack is not appropriate treatment and usually results in rebound of rash)

Injectable Steroids in Rhus • In “severe rash” Depo-Medrol 80-120 mg IM single dose or triamcinolone 1 mg/kg IM single dose. • Option for patients who cannot tolerate or comply with administration of oral corticosteroids

Preventing Rhus • Stokogard Outdoor Cream, Ivy Block or Ivy Shield prior to exposure. • Hydrogen Peroxide as a post-exposure wash within 4-6 hours. Not effective once the rash has started. • Soap and water washing of clothes, body, dog, shoes, hunting or sports equipment. Be especially careful to clean nails. • Desensitization available for chronic problems. Total desensitization is not possible.

• 60 yo male presents to the ED with hair loss. He has patchy alopecia with inflammation and scaling of the scalp.

Tinea Hints • Most common dermatologic condition • Dermatophytes grow in nonliving cornified layers of keratinized tissue (skin, hair, nails) • More men; capitis affects more blacks • Contagious with direct and indirect contact • Named according to location • Symptoms variable • Immune response may determine the extent of infection; the use of topical and systemic steroids may encourage the growth. • Scraping scales with 15 blade with 20% KOH added shows branching hyphae

Tinea Hints • 14% of asymptomatic children found to be carriers of dermatophyte for tinea capitis- should monitor in schools • Cruris or Corporis affects up to 20% of population at some time in life • All tinea is contagious spread from humans or animals (dogs, cats, ginea pigs, horses) skin to skin • Diabetic or obese more susceptible to Cruris

Tinea Treatment Type

Treatment

Alternative

Localized (pedis, corporis, cruris)

Topical azole (ketoconazole, miconazole,clotrimazole) cream bid for 2-4 weeks; terbinafine (over age 12) once daily 1-2 weeks (no steroid)

Oral griseofulvin or terbinafine only for refractory case

Extensive (corporis and pedis – moccasin-type)

Oral terbinafine 250 mg/day for 1-2 weeks

Oral terbinafine 500mg/day for 2-4 weeks in refractory cases; griseofulvin 10 mg/kg/d for 4 weeks

Tinea Capitis

Oral griseofulvin 20mg/kg/d for 6 weeks (topical treatment not effective)

Oral terbinafine 125 mg/d for 4 weeks up to 40 kg, then 250mg/d (watch ANC counts)

Onychomycosis

Oral terbinafine 250 mg/day for 3 months (monitor LFT and Cr initially and again with CBC in 6 weeks)

Itraconazole (Sporanox) 200mg bid for 1 week a month for 3 months for fingers; daily for 12 weeks for toes; LFT at baseline

Tinea Treatment • In Capitis, Selenium sulfide shampoo may reduce the risk of spreading the infection by reducing the number of viable spores that are shed • When using topicals, spread 2 cm beyond the rash • Oral agents need lab monitoring – particularly LFT , Cr, CBC

Patient Education tinea • Corporishttp://www.patienteducationcenter.org/articles/ringwormtinea/ • Pedis- http://www.patienteducationcenter.org/articles/athletesfoot-tinea-pedis/ • Cruris- http://www.mayoclinic.org/diseases-conditions/jockitch/basics/definition/con-20021468 • Onychomycosis- http://patient.info/doctor/fungal-nailinfections-pro

• Mike a 54 year old male,

presents to the ED complaining of a painful rash on his back. He describes the rash as tingling, very tender to touch, and itching. On examination, you see a grouping of small blisters. There is a linear distribution with a sharp demarcation of the eruption at the midline of the back.

Herpes Zoster • Varicella virus reactivated from latent state in posterior root ganglia and associated dermatome • Pain precedes rash by 2-3 days • Crops of vesicles on an erythematous base erupt for 3-5 days • Hyperesthestic • Most in thoracic or lumbar region and are unilateral • Few recur, most recover, but some (elderly) may get postherpetic neuralgia for months or years • Differential - pleurisy, trigeminal neuralgia

Zoster Topical Treatment • Wet compresses- Burrow’s solution for 30-60 min 4-6 X daily • NSAIDS • Calamine lotion- antipyretic and mild antiseptic • Lidocaine patches 5%- may help post-herpetic neuropathy- do not use on active blisters • Narcotic analgesics • Oral famciclovir, valacyclovir, and acyclovir may decrease post-herpetic neuralgia and accelerate healing. • Steroid use to prevent neuralgia controversial. Not currently recommended. • Post-herpetic neuralgia may be treated with tricyclic antidepressants.

Antivirals • Acyclovir at 800mg 5 times a day (drug of choice for children), famciclovir at 500mg tid, valacyclovir at 1000mg tid. • May decrease length of time for new vesicle formation and number of days to crusting and acute discomfort • Initiate within 48-72 hours of onset- even if greater than 72 hrs may help with pain • Acyclovir resistance is appearing- famciclovir and valacyclovir may be better options • Duration of treatment 7 day- up to 21 days in immune suppressed

Steroids • Efficacy subject to debate • 40-60mg prednisone daily as early as possible for one week then taper for one more week • Combined with acyclovir has been shown to accelerate resolution of acute neuritis and quality of life • Has not shown to have an effect on Post herpetic neuropathy • Injectable steroid helps with pain acutely but no effect on PHN

Pain control • Can be debilitating • Narcotics- oral oxydodone combined with gabapentin reduces pain in acute event • Pregabalin has shown to have some effect but studies are mixed

Zoster Patient Education • Shingles Vaccine http://www.cdc.gov/vaccines/vpdvac/shingles/vacc-need-know.htm • Patient informationhttp://www.patienteducationcenter.org/articles/shingles-herpeszoster/

MRSA Lesions • Harry, a 23 year old college student presents with several days of a growing lesion. The lesion is in the axilla, started as a painful, red area, but now is growing into a boil that is extremely tender. He has had sone similar lesions in the past that were not this bad and "popped on their own".

What is Appropriate Treatment? • Incision and drainage is the primary treatment • For simple abscesses or boils, I&D alone likely adequate • Do antibiotics provide additional benefit? • Multiple, observational studies: high cure rates with or without antibiotic • 2 large NIH trials ongoing • Decrease in cases since 2005 but there were 19,000 deaths • When cultured, 50% of skin infections are MRSA

Empiric Antibiotics •TMP/SMX 1-2 DS PO twice daily •Note that drug offers poor streptococcal coverage. •May need to combine with cephalexin or penicillin.

•Clindamycin 300mg PO three times a day x 7-10 days Either are effective with 90% cure rate and same rate of adverse events

New Antibiotics for MRSA • Neutralizes MRSA so that it is susceptible to methicillin • Dalbavancin and oritavancin- second-generation lipoglycopeptide antibiotic. Belongs to the same class as vancomycin. Given once weekly IV for 2 weeks • Ceftaroline is a cephalosporin with activity against MRSA • Tedizolid (Sivextro)- twice daily- 600 mg for 10 days • Ceftolozane-tazobactam (Zerbaxa)- q 8 hr IV • Zyvox- 600mg IV or PO bid for 10-14 days

Psoriasis

Psoriasis • Complex immune-mediated disease affects 120 million people. • Can be systemic • Related to stress, smoking, ETOH intake, as is seen with comorbidities such as heart disease, depression, Crohn’s disease, and lymphoma • 5 types- plaque most common

Psoriasis Treatment • Mild- 70-80% • Topical treatments with steroids and vitamin D derivatives • Tacrolimus reserved for face and intertriginous areas which are prone to side effect of steroids

• Moderate to severe • Combination of phototherapy and topical or systemic treatment • Methotrexate and cyclosporine still commonly used • Multiple new agents (TNF inhibitors) and several still in development- specialty treatment