Chapter 20 Topical Medications Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Topical Medications Anorectal Medications Adverse Reactions Emollients, foams, and gels for topical anesthesia or healing of the rectal area Provide symptomatic relief of hemorrhoidal discomfort Long- or short-term use Adverse Reactions Sensitization Hemorrhoids are varicosities or bulging of the hemorrhoidal veins that cause painful swellings at the anus. A variety of hemorrhoidal preparations exist. Each preparation has specific instructions for application. Hydrocortisone foam (Proctofoam-HC) is a steroid preparation that must be gradually decreased before discontinuation. Why is this necessary? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Mouth and Throat Preparations Forms Oral preparations, lozenges, troches, gargles, gels, mouthwashes, sprays Action Soothe minor inflammation in the mouth, release oxygen to provide cleansing, anesthetic properties Mouth and throat preparations are used for relief of minor inflammatory conditions in the mouth such as canker sores, dental irritation, pain after dental procedures, for relief of dryness of the mouth and throat, for treatment of minor throat discomfort, and control of cough caused by colds. The patient should be taught the appropriate administration technique for the product used. Patients should not use these products for longer than 3 or 4 days for normal therapy. Refer to Table 20-2. Has anyone had any experience with these products? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Mouth and Throat Preparations carbamide peroxide (Orajel, Anbesol) clotrimazole (Desenex, Lotrimin) Benzocaine (Cepacol, Chloraseptic) Nystatin (Nystatin) Mouth and throat preparations are used for relief of minor inflammatory conditions in the mouth such as canker sores, dental irritation, pain after dental procedures, for relief of dryness of the mouth and throat, for treatment of minor throat discomfort, and control of cough caused by colds. The patient should be taught the appropriate administration technique for the product used. Patients should not use these products for longer than 3 or 4 days for normal therapy. Refer to Table 20-2. Has anyone had any experience with these products? Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Categories Local anesthetics Antiseptic ointments Ophthalmic antiinfectives Antiglaucoma agents There are many types of ophthalmic preparations. Local anesthetics include drugs such proparacaine (Alcaine) and tetracaine (Pontocaine). Silver nitrate (Silver Nitrate) is the antiseptic ointment put in an infant’s eyes after birth to prevent gonorrheal ophthalmia neonatorum. Ophthalmic antiinfectives include a variety of ointments and drops. Common names are ciprofloxacin (Ciloxan), polymyxin B (Polymyxin-B), and gentamicin (Garamycin). Antiinfective agents also include antiviral agents (ganciclovir [Vitrasert]) that fight cytomegalovirus retinitis in patients with AIDS or are used in the treatment of corneal abrasions (trifluridine [Viroptic]). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Local anesthetics Used in procedures such as tonometry, gonioscopy, cataract surgery, and removal of foreign objects from the cornea There are many types of ophthalmic preparations. Local anesthetics include drugs such proparacaine (Alcaine) and tetracaine (Pontocaine). Silver nitrate (Silver Nitrate) is the antiseptic ointment put in an infant’s eyes after birth to prevent gonorrheal ophthalmia neonatorum. Ophthalmic antiinfectives include a variety of ointments and drops. Common names are ciprofloxacin (Ciloxan), polymyxin B (Polymyxin-B), and gentamicin (Garamycin). Antiinfective agents also include antiviral agents (ganciclovir [Vitrasert]) that fight cytomegalovirus retinitis in patients with AIDS or are used in the treatment of corneal abrasions (trifluridine [Viroptic]). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Antiseptic ointments Prevent gonorrheal ophthalmia neonatorum in newborn infants Silver nitrate used to treat common eye infections, germicidal and astringent action Ophthalmic antiinfectives Treat eye infections caused by bacteria, fungi, or viruses. Antibiotic and Antivirals There are many types of ophthalmic preparations. Local anesthetics include drugs such proparacaine (Alcaine) and tetracaine (Pontocaine). Silver nitrate (Silver Nitrate) is the antiseptic ointment put in an infant’s eyes after birth to prevent gonorrheal ophthalmia neonatorum. Ophthalmic antiinfectives include a variety of ointments and drops. Common names are ciprofloxacin (Ciloxan), polymyxin B (Polymyxin-B), and gentamicin (Garamycin). Antiinfective agents also include antiviral agents (ganciclovir [Vitrasert]) that fight cytomegalovirus retinitis in patients with AIDS or are used in the treatment of corneal abrasions (trifluridine [Viroptic]). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Glaucoma Glaucoma is the leading cause of blindness in the U.S. Damage to the optic nerve occurs when aqueous humor does not exit from the anterior chamber of the eye. This results in the buildup of aqueous humor, increased intraocular pressure (IOP), and loss of vision. Primary open-angle glaucoma (POAG) Wide-angle glaucoma: gradual onset, controlled with medications Glaucoma must be treated with medications unless surgical correction is done. The medications to treat glaucoma use a variety of mechanisms to increase the outflow of aqueous humor. There is no cure for wide-angle or secondary glaucoma. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Glaucoma Primary open-angle glaucoma (POAG) Wide-angle glaucoma: gradual onset, controlled with medications Narrow-angle glaucoma sudden onset acute disorder in irreversible blindness within 1 to 2 days without emergency treatment may be genetic; requires surgery (ocular pain, seeing halos around lights, blurred vision, and photophobia) Optic nerve is damaged when the aqueous humor builds up Glaucoma must be treated with medications unless surgical correction is done. The medications to treat glaucoma use a variety of mechanisms to increase the outflow of aqueous humor. There is no cure for wide-angle or secondary glaucoma. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Antiglaucoma Agents ALPHA2-ADRENERGIC AGONISTS brimonidine (Alphagan) decreases production and can increase outflow of aqueous humor first-line medication for long-term topical treatment of POAG. apraclonidine (Iopidine) short-term therapy preoperatively for laser eye surgeries Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Antiglaucoma Agents Beta blockers Reduce intraocular pressure by reducing the formation of aqueous humor Timolol (Timoptic) Betaxolol (Betoptic) Epinephrine (Epifrin) is a common sympathomimetic antiglaucoma medication. Betaxolol (Betoptic) and timolol (Timoptic) are common beta blockers. Miotics activate the cholinergic system, which reduces intraocular pressure by causing iris sphincter contraction and miosis (pupil constriction). When the pupils are constricted, the anterior chamber angle is opened, allowing an increase in outflow of aqueous humor. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Antiglaucoma Agents Miotics, DIRECT-ACTING CHOLINERGIC AGONIST pilocarpine Pilocar Second-line treatment for POAG lowers IOP indirectly through ciliary contraction. Adverse Effects ›› Retinal detachment Parasympathetic effects (bradycardia) Decreased visual acuity Artificial tears are used to provide tearlike lubrication to relieve dry eyes, eye irritation secondary to wearing contact lenses, or deficient tear production, and are included under the antiinfectives. Other preparations include topical fluorescein stains, which are used to detect foreign bodies or scratches on the eye. One of the biggest categories of medications is the antiglaucoma agents. Glaucoma is a condition in which there is increased intraocular pressure, resulting from either excess production or reduced outflow of aqueous humor (ocular fluid). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Antiglaucoma Agents PROSTAGLANDIN ANALOGS latanoprost (Xalatan) increases aqueous humor outflow through relaxation of ciliary muscle. Travoprost (Travatan) Bimatoprost (Lumigan) topical first-line medications for clients who have POAG and ocular hypertension. When acetylcholinesterase is inactivated, the sphincter of the iris contracts, leading to miosis (pupil constriction) and ciliary muscle constriction, which facilitates an increase in aqueous humor outflow. Physostigmine salicylate is a common acetylcholinesterase inhibitor. Brinzolamide (Azopt) is a common carbonic anhydrase inhibitor. Cholinergic blocking agents raise intraocular pressure and therefore are not used as the primary treatment in the control of glaucoma. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ophthalmic Drugs Antiglaucoma Agents CARBONIC ANHYDRASE INHIBITOR brinzolamide Azopt dorzolamide Trusopt Available in combination with timolol (Cosopt) Second-line treatment for POAG, decreases aqueous humor production. Adverse Effects ›› Localized allergic. Blurred vision, dryness, photophobia When acetylcholinesterase is inactivated, the sphincter of the iris contracts, leading to miosis (pupil constriction) and ciliary muscle constriction, which facilitates an increase in aqueous humor outflow. Physostigmine salicylate is a common acetylcholinesterase inhibitor. Brinzolamide (Azopt) is a common carbonic anhydrase inhibitor. Cholinergic blocking agents raise intraocular pressure and therefore are not used as the primary treatment in the control of glaucoma. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ear disorders Acute otitis media Most often in young children. bacterial or a viral infection causes a buildup of fluid in the middle ear (middle ear effusion). Major indication: acute onset pain. Findings: erythema, bulging tympanic membrane, fever. Incidence of acute otitis media in infants and children can be reduced by yearly influenza vaccination and vaccination with pneumococcal conjugate vaccine (PCV). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Ear disorders Otitis externa “swimmer’s ear,” bacterial infection external auditory canal. Treatment usually resolves infection within 10 days. (topical antimicrobial/anti-inflammatory combination. ■■ Incidence of acute otitis media in infants and children can be reduced by yearly influenza vaccination and vaccination with pneumococcal conjugate vaccine (PCV). Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Otic Preparations ANTIMICROBIALS amoxicillin (Amoxil) amoxicillin/clavulanate (Augmentin) PO (penicillin allergy or penicillin-resistant otitis media) Ceftriaxone (Rocephin) IM, IV (severe illness) Cefuroxime (Ceftin) PO, IM, IV Azithromycin (Zithromax) PO, IV Clindamycin (Cleocin), PO, IM, IV Otic preparations have many uses. It is important to follow package insert directions for administration guidelines. Steroid and antibiotic combinations are also available for more severe infections. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Otic Preparations FLUOROQUINOLONE ANTIBIOTIC PLUS STEROID ciprofloxacin plus hydrocortisone (Cipro HC) otic drops ofloxacin otic drops (Floxin) bactericidal and anti-inflammatory effect Otic preparations have many uses. It is important to follow package insert directions for administration guidelines. Steroid and antibiotic combinations are also available for more severe infections. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Topical Skin Preparations Psoriasis (skin condition consisting of red and silvery-scaled maculopapules) Antipsoriatics accelerate scaling and healing of dry lesions in chronic psoriasis Topical preparations include medicated bar soaps and foams, sulfur preparations, topical antibiotics, and acne medications. A wide variety of steroid medications are also available for dermatologic disorders. Preparations come in mild, intermediate, and strong concentrations. Steroids should not be used if there is a strong indication of bacterial or fungal infections. Fluorinated products should not be used on the face, because they cause thinning of the skin and may leave scars. There are a wide variety of topical skin preparations shown in Table 20-5. It is essential that the health care provider and patient follow the directions for how to apply these medications. In addition, when applying them to a person other than yourself, gloves should be worn to avoid absorption of the medication. Be sure to ask the patient about any complementary or alternative therapies that may have been used. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Topical Skin Preparations Scabies (eruptions due to mite infestation) Scabicides are applied to the skin and used to treat scabies Topical preparations include medicated bar soaps and foams, sulfur preparations, topical antibiotics, and acne medications. A wide variety of steroid medications are also available for dermatologic disorders. Preparations come in mild, intermediate, and strong concentrations. Steroids should not be used if there is a strong indication of bacterial or fungal infections. Fluorinated products should not be used on the face, because they cause thinning of the skin and may leave scars. There are a wide variety of topical skin preparations shown in Table 20-5. It is essential that the health care provider and patient follow the directions for how to apply these medications. In addition, when applying them to a person other than yourself, gloves should be worn to avoid absorption of the medication. Be sure to ask the patient about any complementary or alternative therapies that may have been used. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Topical Skin Preparations Pediculosis (infestation with lice) Pediculicides are used to treat pediculosis Topical preparations include medicated bar soaps and foams, sulfur preparations, topical antibiotics, and acne medications. A wide variety of steroid medications are also available for dermatologic disorders. Preparations come in mild, intermediate, and strong concentrations. Steroids should not be used if there is a strong indication of bacterial or fungal infections. Fluorinated products should not be used on the face, because they cause thinning of the skin and may leave scars. There are a wide variety of topical skin preparations shown in Table 20-5. It is essential that the health care provider and patient follow the directions for how to apply these medications. In addition, when applying them to a person other than yourself, gloves should be worn to avoid absorption of the medication. Be sure to ask the patient about any complementary or alternative therapies that may have been used. Copyright © 2016 by Mosby, an imprint of Elsevier Inc.