national conference for nurse practitioners chicago, il ...€¦ · acne or rosacea acute short...
TRANSCRIPT
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Commonly prescribed topicals:
Perils and pearls of using corticosteroids and antimicrobials in
skin conditions
MA R G A R E T A . B O B O N IC H, D N P , D C N P , F N P -C , F A A N P
ASS I S TAN T P ROF ESSOR, F RAN C ES P AY N E B OLTON SC HOOL OF N URS I N G
& C WRU SC HOOL OF M ED I C I N E
UN I V ERS I TY HOSP I TALS C ASE M ED I C AL C EN TER
M ARG ARET .B OB ON I C H@UHHOSP I TALS .ORG
National Conference for Nurse Practitioners
Chicago, IL
October 9, 2016
Disclosure
Lilly
AbbVie
©2016 Bobonich
Objectives
1. Describe the pharmacodynamics of topical
corticosteroids and antimicrobials.
2. Discuss important concepts in selecting
appropriate agents to optimize patient outcomes and minimize risks, side effects and
complications.
3. Review three case studies of dermatologic
conditions and selection of topical therapies.
©2016 Bobonich
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Topical Glucocorticosteroids (TCS)
Usually short-term tx for dermatoses
Salzberger & Witten (1952)
Effect vs side effects vs phobia
Indications (vague)
Anti-inflammatory
Anti-pruritic
Vasoconstriction
©2016 Bobonich
TCS Indications
High potency (I to III)
Alopecia areata
Atopic dermatitis (resistant)
Discoid lupus
Lichen planks
Nummular eczema
Lichen sclerosis
Psoriasis
Hand dermatitis (severe)
Medium potency (IV and V)
Asteatotic eczema
Stasis dermatitis
Nummular eczema
Low potency (VI and VII)
Eyelid dermatitis
Diaper dermatitis
Perianal inflammation
Ference, J.D. & Last, A.R. (2009). Choosing Topical Corticosteroid. Am Family Physician, 79(2): 135-140. ©2016 Bobonich
TCS Mechanism of Action
Anti-inflammatory effects
epidermis
Anti-proliferative actions
epidermis & dermis
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Percutaneous absorption
Vehicle
Potency or concentration (vehicle can affect potency)
Frequency
Location
Duration
Occlusion
Quality of barrier
Hydration ↑
Temperature environment or body ↑
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Choice of TCS Vehicle
Foams
Gels
Lotions
Creams
Ointment
Most
alcohol
Least alcohol
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Selection of potency
Vasoconstriction assays & comparative clinical trials
Duration of inflammatory condition
Acute
Chronic
Location
Face, intertriginous and genitals- low (2wks)
Palms/soles- high/super high
Age- Infants & elderly
Condition
Quality of barrier
Exceptions
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Hypothalamic-pituitary adrenal axis
suppression (HPA)
Can occur with any TCS
Increases with steroid absorption
TCS under occlusion
Higher concentrations of TCS
Application over large surface areas
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Calcineurin inhibitors*
Pimecrolimus (Elidel)
Tacrolimus (Protopic)
ALTERNATIVE TO TCSs
Indications: Atopic dermatitis; eczema
Advantage: Do not cause atrophy.
Disadvantages- Not as effective, slower onset, $$$$
SE: burning, stinging, itching
*Black Box Warning: FDA 2006 skin malignancy and lymphoma with long-term use ©2016 Bobonich
So what do I prescribe?
How much?
Brand or generic?
Formulation or vehicle?
What potency?
How often?
Refills?
This is so confusing!
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Pearls for prescribing TCS
Control/monitor QUANTITY and REFILLS
Written instructions: how, when, and when to stop
Do NOT to share
Request the pharmacist label the TUBE not the box
Avoid combination products
Rotational therapy
If not responsive (2 weeks) RETHINK diagnosis
Contraindicated in skin with infection, patients with perioral dermatitis, acne or rosacea
Acute
SHORT courses of HIGH potency
Chronic
Treat with LOW potency
Intermittent better than continuous
©2016 Bobonich
Topicals Corticosteroids
Class 1
Class 2
Super Potency
High Potency
Clobetasol 0.05%
Class 3
Class 4
Class 5
Upper Mid-Potency
Moderate Mid-Potency
Lower Mid-Potency
Fluocinonide 0.05%
Triamcinalone 0.1%
Class 6
Class 7
Mild Potency
Least Potency
Desonide 0.05%
Hydrocortisone 2.5%
Category Potency Examples
Desoximetasone 0.25% cr or 0.05% cr are free of propylene glycol **
MY FAVORITES
FOR
PRESCRIBING
©2016 Bobonich
Dispensing for BID dosing for 2 weeks
Location Adult Dosage
gms FTUs
Child tube size
(gm)
Infant Tube size
(gm)
Entire face &
neck
35 2.5 15 15
One entire hand 14 1 15 15
Entire foot (not both)
28 2 15 15
One entire arm 42 3 30 15
One leg 84 6 30 30
Entire body 30gm for one application
n/a n/a
Rule of thumb: Children = ½ adult amount; Infants (6-12 months) = ¼ adult amount Rule of hands: Area equal to 2 adult hands (palm & fingers) = 1 FTU
1 Finger tip unit (FTU) = 0.5 gm
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FDA approved TCS in children
Class Generic Name Age Group
SUPER Clobetasol propionate 0.05% foam > 12 years
HIGH Fluocinonide 0.1% cream > 12 years
MED Mometasone 0.1% cream/ointment > 2 years
Fluticasone 0.05% lotion/cream > 1 year
LOW Alclometasone 0.05% cream/ointment > 1 year
Prednicarbate 0.1% cream/ointment > 1 year
Fluocinolone acetonide 0.01% in peanut oil > 3 months
Desonide 0.05% hydrogel > 3 months
Hydrocortisone butyrate 0.1% cream > 3 months
http://nationaleczema.org/eczema/treatment/topical-corticosteroids/basics-of-topical-corticosteroids/ ©2016 Bobonich
Corticosteroids in pregnancy
Limited data on safety
Emollient therapy first
Topicals preferred over systemic
Mild to moderate potency
Potential risk: premature rupture of membranes,
interuterine growth restriction, gestational DM, osteoporosis, infection and pregnancy-induced hypertension
Avoid during first trimester if possible
©2016 Bobonich
Localized side effects
Atrophy
Bruising, purpura, skin fragility, striae, telangiectasia, pigment abnormality
Irritation
Infections (secondary)
Dermatitis
Delayed wound healing
Photosensitization
Steroid-induced acne & rosacea
Rebound phenomenon
Tachyphylaxis ©2016 Bobonich
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Systemic side effects*
Ocular
Endocrine Metabolic
Renal & cardiovascular Misc
*Usually seen in extended use of high potency. ©2016 Bobonich
Pearls to reduce steroid side effects
Use potent steroid to gain QUICK control of disease
THEN taper to less potent
Taper instead of abrupt cessation
Reduce frequency (alternate days, weekend, etc)
Use of topical immunomodulators
Caution on flexural surfaces, face, genitals and intertriginous
Avoid occlusion
Employ other topical agents (keratolytics, moisturizers, etc.)
Avoid combination products
©2016 Bobonich
Successful use of topical corticosteroids depends on the
correct diagnosis
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Atopic Dermatitis
“Out of place” or strange
Atopic march
Most common type of eczema
“infantile eczema”, “atopic eczema”
60% cases 1st year, 95% before 4 yrs old
Must have three of the following:
1. Pruritus
2. Typical morphology and distribution
3. Chronically relapsing dermatitis
4. PMH or FHx atopic disease ©2016 Bobonich
Therapeutic approach
Control the Environment
Emollients (jars & tubes)
Moisturizers
Topical corticosteroids
Topical non-corticosteroids
Antihistamines
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Stasis dermatitis
Frequently in presence of venous insufficiency
Pruritus
Eczema
Hemosiderin staining
Ankle (medial) involvement
Varicosities
Edema
Stasis dermatitis:
Can develop into secondary infection, cellulitis, ulcers, etc
Most frequent cause for patients admitted unnecessarily w/misdiagnosis of cellulitis
Dav id CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.
Keller EC, Tomecki KJ, Chadi Alraies M. Distinguishing cellulitis from its mimics. Cleve Clin J Med. Aug 2012;79(8):547-52. ©2016 Bobonich
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Stasis Dermatitis
Assess underlying etiology
Topical CCS (Una boot if wet)
Assess for infection or ulceration
Compression and elevation
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Beyond topical steroids
Large body surface areas
Underlying systemic disease
Recalcitrant or severe disease
Thick lesions
Significant impact QOL
Consider comorbidities
Oral, intramuscular, intralesional
intravenous
Steroid sparing agents & therapies ©2014 Bobonich
No clear superior efficacy comparing IM to oral
Advantages vs disadvantages
Clinical preference on individual basis
ORAL INTRAMUSCULAR
ABSORPTION Predictable Variable
COMPLIANCE Relies on patient Total dose administered
DURATION Any time period Select short, intermediate or long-acting
PATIENT HEALTH Req. functional GI tract Not affected by N/V
PATEINT’S ROLE Active control/participation No role or control
CLINICIAN’S ROLE Prescribe and monitor Assured of delivery from IM
DIURNAL VARIATION Some with AM dosing No diurnal variation
Tapering Precise Based on metabolism
Comparison of Oral and Intramuscular Corticosteroids
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Case
Study
©2014 Bobonich ©2016 Bobonich
To treat…........ or not to treat?
Aka: cradle cap, dandruff (misdiagnosis of acne in
adolescence)
Unknown etiology but suspect Pityrosporum (M. furfur)
Inflammation and scale
Clinical presentation varies with age
Distribution of sebaceous glands
Flares
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Seborrheic dermatitis (Seb derm)
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Seb Derm
Treatment
Alternating therapies: anti-yeast shampoos, antifungal topicals, TCS, and calcineurin inhibitors
Cochran Review (2014)
Only minor differences in treatment outcomes and no
clear differences between the agents
Kastarinen, H., Oksanen, T., Okokon, E.O. et al. (2014). Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp.
Cochrane Database Syst. Rev . 5:CD009446.
©2016 Bobonich
Antifungals (superficial fungal infections)
©2016 Bobonich
Topical agents for
superficial fungal infections
Yeast vs dermatophytes
Selection based on organism
Location (skin , hair and nails)
Vehicle
Fungistatic vs fungicidal
Other properties: antimicrobial and anti-inflammatory
Recurrence
Prevention
Systemics
©2014 Bobonich
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Tinea
©2016 Bobonich
Tinea Corporis
“Ringworm”
Very contagious
T. rubrum
Topical or systemic
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Differential Diagnosis
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Tinea Pedis
T. Rubrum, T. mentagrophytes
Several types
Check other body sites
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Tinea cruris
+/- mixed candida &
dermatophytes
Not common kids
Tx with topical azoles 2-4 wks
Oral griseofulvin, if severe
Always check feet
DDX: intertrigo, contact derm, candidiasis, erythasma,
bacterial infection
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DDX Tinea cruris
• Unilateral, half-moon
• Spreads peripherally • Not usually scrotum
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“Diaper” candidiasis
C. albicans 80%
Marginal scaling
Beefy red confluent plaques & erosions
Satellite papules/pustules (hallmark)
Includes skin folds, concave surfaces
No improvement with barrier creams (zinc oxide, A&D, petrolatum, triple paste)
KOH preparation or fungal culture ???
Check oral mucosa and mother breasts/nipples
if breast feeding
Dx of yeast is not always a SLAM DUNK! ©2016 Bobonich
Diaper candidiasis therapies
• Nystatin cream is DOC
Imidazoles- not as effective, irritating
Allylamines- not as effective
• If severe inflammation- okay to uses hydrocortisone 1% ointment for a couple days (LIMITED TIME)
• May need tx oral nystatin for oral thrush (mother’s nipples)
• Refer if severe and not responsive to tx. Reconsider Dx
• Never use combination products
• Clotrimazole/betamethasone diproprionate (Lotrisone)
• Nystatin/triamcinolone acetonide (Mycolog)
©2016 Bobonich
Class & Indications Generic name Dermatophyte Yeast Gram + Gram - Anti-inflammatory
Polyenes (fungistatic)
Candidiasis Nystatin 0 ++++
Azoles (fungistatic)
Tinea
Pityriasis/tinea versicolor
Candidiasis
Seborrheic dermatitis
Miconazole + +++
Clotrimazole + +++
Ketoconazole + +++ ++ ++
Oxiconazole + +++
Econazole + +++ + + +
Sertaconazole + +++ ++
Allylamines/ Benzylamine (fungicidal)
Tinea
Pityriasis/tinea versicolor
Naftifine + + +++
Terbinafine +++ + +++
Butenafine ++++ ++ +++
Other Agents
Tinea; Onychomycosis; Candidiasis
Pityriasis/tinea versicolor; Seborrheic
dermatitis
Ciclopirox ++ ++++
C. Albicans
+++ +++ +++
Pityriasis/tinea versicolor
Seborrheic dermatitis
Selenium sulfide
(RX & OTC)
+++
Pityrosporum
Bobonich& Nolen (2015)
Indications and Effectiveness of Topical Antifungals
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Betamethasone
dipropionate/clotrimazole (Lotrisone)
Indications: Tinea cruris or corporis- twice daily for 1 week
Tinea pedis- twice daily for 2 weeks.
Not recommended for children under
17 years old or diaper dermatitis
High potency topical corticosteroid
Railan, D., Wilson, J.K, Feldman, S.R. & Fleischer, A. B. (2002). Pediatricians who prescribe clotrimazole-betamethasone diproprionate (Lotrisone)
often utilize it inappropriate settings regardless of their knowledge of the drug’s potency. Dermatology Online Journal, 8(2):3. ©2016 Bobonich
Case
Study
Tinea
Capitis
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Tinea capitis
T. tonsurans 90 to 95%
School children and adolescents
Alopecia, papules, pustules, inflammation, scale
May have: boggy scalp, secondary infections, and lymphadenopathy.
“Kerion”
TOC: systemics
Griseofulvin 5-10 mg/kg/day (higher off-label)
Prevent further transmission ! ©2016 Bobonich
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Clinical pearls treating superficial fungal
Remember high rate of reinfection
Maybe secondary infections
? systemics for extensive involvement & comorbidities
Examine entire body (esp. hands, feet & groin)
Hair and nails require longer treatment- 6 to 12 wks
Fungistatic and fungicidal
Social history is very important for dx and tx
Environmental control is essential
If not responsive, RETHINK diagnosis
©2016 Bobonich
Tinea Versicolor
Pityrosporum
More often in adolescents and young adults
Hypopigmented, oval, sometimes scaly lesions
Involving mostly trunk, neck, upper extremities
Selenium sulfide or ketoconazole shampoos
NO LONGER use oral antifungal (ketoconazole)
BLACK BOX WARNING !
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Clinical presentations of tinea versicolor
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Antibacterials for superficial
wounds
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Antibacterial agents
High local concentrations of drug
Minimal systemic absorption>> reduced risk and side effects
Minor or superficial wounds
Usually NOT for burns and deep wounds
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Factors influencing route of administration
Size and location
Depth and underlying structure
Mechanism of injury or etiology
Comorbidities
Suspected organism
Allergies and sensitivities of causative organism
Circulation
Socioeconomic
Time
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Name Bactericidal against
MOA COMMENTS
Bacitracin Gram + and Neisseria sp.
Interferes bacterial wall synthesis
Common sensitizer; rare but serious anaphylaxis w/application
to ulcer bed
Polymyxin B Gram – and P. aeruginosa
Increases permeability bacterial cell
membrane
Usually combined with bacitracin or neomycin for broad spectrum
Topical antibacterial agents- OTC
©2016 Bobonich
Name Bactericidal against
MOA COMMENTS
Neomycin
Gram + and –
S. aureus
Aminoglycoside;
inhibits protein
synthesis
Common sensitizer; Optimum coverage
combined w/bacitracin & polymyxin B
(Neosporin); risk ototoxicity and
nephrotoxicity if systemic absorption
Mupirocin MSSA, +/- MRSA,
Streptococci
Inhibits RNA and
protein synthesis
Rare sensitization; Less effective is incr.
serum or exudate or weeping wounds
(highly protein bound); used for
eradicating nasal staph carriage
Retapamulin Gram +/MRSA Inhibits protein
synthesis
Shorter tx time BID for 5days
Broader spectrum than mupirocin
Gentamycin Gram + and -; esp
P. aeruginosa; not
good against
strains of Strep or
Neisserias
Aminoglycoside;
inhibits protein
synthesis
Stinging common SE; uncommon
sensitization but common cross-
reactivity with neomycin sensitivity
patients; risk ototoxicity and
nephrotoxicity if systemic absorption
Topical antibacterial agents- Prescribed
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Impetigo
Treatment
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Topical Antivirals
©2016 Bobonich
Topical agents for herpes simplex (HSV)
Most are FDA approved for ≥ 12 year
Usually in combination with systemic
Suppression vs episodic
Newer agents/formulations
Most not FDA Indicated for genital HSV
Combination products
Consider comorbidities
©2016 Bobonich
Acyclovir 5% (Zovirax)
Herpes Labialis (cream)
Adults (≥12 years) – For “cold sores” apply 5 times daily for 4
days. Cover lesions and symptomatic area (tingling). Start at the earliest sign or symptom (prodrome).
Genital Herpes (Ointment)
Apply ointment to all of the affected areas/lesions, 6 times daily for 7 days.
Pregnancy Category B; Lactation- unknown
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Acyclovir
Combination
acyclovir 5%/hydrocortisone 1% (Xerese) for herpes labialis
Buccal mucosa tablets
acyclovir (Sitavig) for herpes labialis
©2016 Bobonich
Penciclovir 1% (Denavir)
Inhibits replication within the cell d/t inhibits viral
DNA polymerase
Maintains higher cellular concentration for longer
time within cell (compared to acyclovir)
Indication Recurrent herpes labialis (≥12 years old)
Dosage- every 2 hours for 4 days
©2016 Bobonich
Docosanol (Abreva)
Prevents replication by inhibiting fusion of virus
and host
Shortens healing time and reduces symptoms
Pediatrics- ≥12 years old
Indications- herpes labialis ; not genital herpes
Dosage- 5 times daily till gone (max 10 days)
SE- minimal
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Take home message
Consider topical therapy for inflammatory
conditions and infections
Treatment must be individualized
Compare topicals vs systemics
Cultures are an important diagnostic tool
Rethink diagnosis if not responsive in 2 weeks
Consider differential diagnoses
©2016 Bobonich
“The eyes see only what the mind knows”
Resources
Berth-Jones, J. (Ed.). (2010). Chapter 73 Topical therapy. Rook’s Textbook of Dermatology (8th ed., pp. 73.1-73.52). Chichester, West Sussex UK: Wiley-Blackwell. Bobonich, M.E. & Nolen, M.N (2015). Dermatology for Advanced Practice Clinicians. Philadelphia, PA: Lippincott. Chi, C., Wang, S., Mayon-White, R., & Wojnarowska, F. (2013, September 4, 2013). Pregnancy Outcomes AfterMaternal Expsosureto Topical Corticosteroids; A UK Population-Based Cohort Study. Journal of the American Medical Association, E 1-7. Gupta, R., High, W.A, Butler, D., & Murase, J.E. (2013) Medicolegal aspects of prescribing dermatologic medications during pregnancy. Seminars in Cutaneous Medical Surgery, 32(4), 209-216. Habif, T. P. (2010). Topical Therapy and Topical Corticosteroids. In Clinical Dermatology. A color guide to diagnosis and therapy. (5th ed., pp. 75-90). China: Elsevier. Wolverton, S. (2013). Comprehensive Dermatologic Drug Therapy, 3rd Ed. London: Elsevier.
©2016 Bobonich