Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Chapter 56 Dermatologic Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Skin Largest organ of the body Two layers Dermis Epidermis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Functions of the Skin Protective barrier for the internal organs Senses changes in temperature, pressure, or pain Regulates body temperature Excretes fluid and electrolytes Stores fat Synthesizes vitamin D Provides a site for drug absorption Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Dermatologic Drugs Antimicrobial drugs Antibacterial drugs Antifungal drugs Antiviral drugs Antiinflammatory drugs Antineoplastic drugs Antipruritic drugs (for itching) Burn drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Dermatologic Drugs (cont’d) Emollients (soften skin) Keratolytics (cause softening and peeling of the stratum corneum) Local anesthetics Topical vasodilators Débriding drugs (promote wound healing) Sunscreens Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Antimicrobial Drugs Antibacterial drugs Antifungal drugs Antiviral drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Antibacterial Drugs Most common bacteria are Streptococcus pyogenes and Staphylococcus aureus Folliculitis Impetigo Furuncles Carbuncles Cellulitis Pustules Vesicles Papules Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antibacterial Drugs (cont’d) Most common drugs bacitracin neomycin polymyxin neomycin and polymyxin B (Neosporin) mupirocin (Bactroban) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antibacterial Drugs (cont’d) mupirocin (Bactroban) Used topically for Staph and Strep impetigo Intranasal form for methicillin-resistant S. aureus (MRSA) Available by prescription Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antibacterial Drugs (cont’d) silver sulfadiazine (Silvadene) Topical antiinfective Used to prevent or treat infection at the site of second- and third-degree burns Adverse effects: pain, burning, and itching Do not use in patients who are allergic to sulfonamide drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question The nurse is assessing a patient who has been diagnosed with MRSA on the right arm. The nurse anticipates use of which medication to treat the MRSA? bacitracin neomycin polymyxin B mupirocin (Bactroban) Correct answer: D Rationale: Mupirocin (Bactroban) is an antibacterial product available only by prescription. It is used on the skin for treatment of staphylococcal and streptococcal impetigo. It is used topically and intranasally to treat nasal colonization with MRSA. The drug is applied topically three times daily and intranasally twice daily to treat MRSA colonization. Adverse reactions are usually limited to local burning, itching, or minor pain. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Antiacne Drugs Acne is caused by Propionibacterium acnes Drugs used to treat acne benzoyl peroxide erythromycin tetracycline isotretinoin (Amnesteem) clindamycin (Cleocin T) tretinoin (Renova, Retin-A) Oral contraceptives (for female patients with acne) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antiacne Drugs (cont’d) benzoyl peroxide Causes death of the anaerobic P. acnes bacteria by slowly releasing oxygen Antibacterial, antiseptic, drying, and keratolytic actions Keratolytic: softens scales and loosens the outer layer of the skin May cause peeling skin, redness, or sensation of warmth Produces improvement in 4 to 6 weeks Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antiacne Drugs (cont’d) clindamycin (Cleocin T) Antibiotic Used topically to treat acne Adverse reactions are usually limited to minor local skin reactions, including burning, itching, dryness, oiliness, and peeling Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antiacne Drugs (cont’d) isotretinoin (Amnesteem, Claravis, Sotret) Treatment of severe recalcitrant cystic acne Inhibits sebaceous gland activity and has antikeratinizing (anti–skin hardening) and antiinflammatory effects The company that produced the brand name Accutane has withdrawn it from the market Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question A woman who is taking isotretinoin calls the office to say that she thinks she may be pregnant. What will the nurse instruct the patient to do first? Stop the isotretinoin immediately. Reduce the dosage of the isotretinoin to every other day. Switch to tretinoin (retinoic acid). Consult an obstetrician. Correct answer: A Rationale: While she will need to consult an obstetrician to verify her pregnancy, if she suspects that she is pregnant, she must stop the medication immediately because it is a pregnancy category X drug and a known teratogen. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Antiacne Drugs (cont’d) isotretinoin (cont’d) Stringent guidelines for prescribing and use Required patient counseling regarding use of two forms of contraception and not becoming pregnant during use Required “iPLEDGE” program for safety Monitor for signs of depression, suicidal ideations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antiacne Drugs (cont’d) tretinoin (retinoic acid, vitamin A acid) (Renova, Retin-A) Used to treat acne Also used to reduce dermatologic changes associated with sun damage Stimulates the turnover of epithelial cells, resulting in skin peeling Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Antiacne Drugs (cont’d) Main adverse effects are local inflammatory reactions, which are reversible when therapy is discontinued Common adverse effects are excessively red and edematous blisters, crusted skin, and temporary alterations in skin pigmentation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Fungal Infections Difficult to eradicate Therapy may be prolonged Several weeks to 1 year Topical fungal infections caused by Candida albicans: a yeastlike opportunistic fungus present in the normal flora of the mouth, vagina, and intestinal tract Dermatophytes: tinea or ringworm infections Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Antifungal Drugs clotrimazole (Lotrimin, Mycelex-G) Lozenge for oral candidiasis (thrush) Vaginal suppository or cream for yeast infections Other forms used for other fungal infections miconazole (Monistat) Topical cream Vaginal suppository or cream Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Antiviral Drugs acyclovir (Zovirax) and penciclovir (Denavir) Both used to treat initial and recurrent herpes simplex infections Do not cure viral skin infections, but may reduce healing time and pain Systemic drugs have been shown to be better for controlling viral skin conditions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Anesthetic Drugs Used to reduce pain or pruritus associated with Insect bites Sunburn Poison ivy exposure Also used to numb the skin before a painful injection Ointments, creams, sprays, liquids, jellies EMLA: lidocaine/prilocaine combination Ela-max: lidocaine Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Topical Antipruritic Drugs Antihistamines Corticosteroids Antiinflammatory effects Antipruritic effects Vasoconstrictor actions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Other Topical Dermatologic Drugs Antipsoriatic drugs tazarotene (Tazorac) tar-containing products anthralin (Anthra-derm) calcipotriene (Dovonex) etanercept (Enbrel) alefacept (Amevive) ustekinumab (Stelara) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Other Topical Dermatologic Drugs (cont’d) Topical ectoparasiticidal drugs to treat pediculosis (Phthirus pubis, Pediculus humanus corporis, Pediculus humanus capitis) and scabies (Sarcoptes scabiei) lindane (Kwell) malathion (Ovide) crotamiton (Eurax) benzyl alcohol 5% (Ulesfia) spinosad (Natroba) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Other Topical Dermatologic Drugs (cont’d) Topical hair growth drug minoxidil (Rogaine) For men and women Systemic hair growth drug finasteride (Propecia) Finasteride is classified as a pregnancy category X drug Women are not to handle this drug without gloves or crush this drug, thereby making it airborne Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Other Topical Dermatologic Drugs (cont’d) Sunscreens Rated by sun protection factor (SPF), which is a number ranging from 2 to 50 (or higher) in order of increasing potency of UV protection Only those with SPF of 15 or greater may state they reduce the risk of skin cancer and early skin aging Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Other Topical Dermatologic Drugs (cont’d) Topical antineoplastics fluorouracil (Efudex) Basal cell carcinoma Actinic keratosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Other Topical Dermatologic Drugs (cont’d) Immunomodulators pimecrolimus (Elidel) Treats atopic dermatitis imiquimod (Aldara) Treats actinic keratosis, basal cell carcinoma, and anogenital warts Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Wound Care Drugs Vitamin C (ascorbic acid) Zinc Topical wound care drugs Used to prepare wound bed for healing Remove nonviable tissue (débridement) Antibacterial Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Wound Care Drugs (cont’d) sodium hypochlorite (Dakin’s solution) cadexomer iodine (Iodosorb) collagenase (Santyl) biafine topical emulsion acetic acid (vinegar) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Classroom Response Question At 1300 the nurse assesses a patient who has just returned to the oncology unit after receiving radiation therapy. The patient tells the nurse that his skin “burns a little” in the area that was radiated. The nurse notes an order for biafine topical emulsion. When will the nurse apply the biafine? 1315 1400 1530 1700 Correct answer: D Rationale: Biafine topical emulsion should not be applied within 4 hours of radiation therapy. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Classroom Response Question A patient has an infected stage II pressure ulcer that contains some necrotic tissue and some normal, healing granulation tissue. The patient is taking warfarin (Coumadin). Which product would be most appropriate for wound care? sodium hypochlorite (Dakin’s solution) hydrogen peroxide collagenase (Santyl) Sterile water Correct answer: C Rationale: Collagenase (Santyl) is good for patients taking anticoagulants or in whom surgery is contraindicated. Collagenase (Santyl) selectively removes necrotic tissue, does not harm normal tissue, and is approved for use with infected wounds. Dakin’s solution can aid in debridement; however, it is partly toxic and irritating to healing tissue. Hydrogen peroxide can also be harmful to normal cells. Sterile water does not aid in debridement. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Skin Preparation Drugs isopropyl alcohol (70%) povidone-iodine (Betadine) chlorhexidine (Hibiclens) benzalkonium chloride (Zephiran) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Herbal Products: Aloe Used for wound healing Adverse effects Diarrhea Abdominal pain Dermatitis Drug interactions digoxin Antidysrhythmics Diuretics Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Nursing Implications Assess for presence of contraindications, especially drug allergies Do not apply antiinfective drugs until culture and sensitivity testing (if ordered) are completed Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) For isotretinoin (Amnesteem) Ensure that strict guidelines are in place for monthly pregnancy testing and prescription renewal Monitor liver function before and during therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Assess area affected thoroughly before applying medication Keep in mind that systemic absorption is higher in the very young and very old because the skin may be more permeable Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Follow specific manufacturer’s guidelines for administration techniques Cleanse the area thoroughly to remove debris and residual medication; follow specific recommendations Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Wear gloves when applying topical drugs Apply dressings (e.g., wet, wet-to-dry, occlusive) as prescribed Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Document Site of application Drainage (color, amount) Swelling, temperature Odor, color, pain, or other sensations Type of treatment given Patient’s response Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Protect affected area from sunlight Do not double up on dose if a dose is missed Ensure proper disposal of contaminated dressings Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implications (cont’d) Provide patient/family teaching as necessary for self-care Monitor for therapeutic responses Monitor for adverse effects Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study Jane is a 17-year-old patient who is being seen in the dermatology clinic for treatment of acne vulgaris. The nurse practitioner prescribes benzoyl peroxide topically four times a day. Jane tells the nurse that she wants take the drug more frequently so the acne will go away quickly. What information will the nurse provide to Jane? “Improvement is usually seen in 1 week.” “If you want faster results, a pill form of benzoyl peroxide will be used.” “Overuse of this drug can result in painful, reddened skin.” “Benzoyl peroxide causes the skin to blister or swell to clear the acne.” Correct answer: C Rationale: Overuse of this drug and also of tretinoin is common in teenage patients who are attempting to cure their acne quickly. The result can be painful, reddened skin, which usually resolves on return to use of these medications as prescribed. Benzoyl peroxide generally produces signs of improvement within 4 to 6 weeks. Benzoyl peroxide is available in multiple topical dosage forms. Blistering or swelling of the skin is generally considered an allergic reaction to the product and is an indication to stop treatment. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) A few months later, it is determined that Jane is not responding to treatment and is now prescribed isotretinoin. Which statement will the nurse include when teaching Jane about isotretinoin therapy? “Call your prescriber immediately if you experience any signs of depression.” “If you should become pregnant, the dose of isotretinoin will be cut in half.” “Isotretinoin is administered by subcutaneous injection directly into the acne areas.” “Isotretinoin should not be used with any form of birth control.” Correct answer: A Rationale: There have been case reports of suicide and suicide attempts in patients receiving this medication. Educate patients to report any signs of depression immediately to their prescribers. Isotretinoin is one of relatively few medications that are classified as pregnancy category X drugs. This means that it is a proven human teratogen. It is imperative that female patients of childbearing age be counseled and agree not to become pregnant during use of the drug. It is now officially required that at least two reliable contraceptive methods be used by sexually active women during therapy with isotretinoin and for 1 month after completion of therapy. Isotretinoin is available only for oral use. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) During a regular follow-up visit, Jane points out a sore that she has developed on her mouth. She is diagnosed with herpes simplex. Which medication does the nurse anticipate Jane will receive? miconazole (Monistat) acyclovir (Zovirax) clotrimazole (Lotrimin) anthralin (Anthra-Derm) Correct answer: B Rationale: Herpes simplex is a viral infection. Acyclovir (Zovirax) and penciclovir (Denavir) are topical antiviral drugs available to treat viral infections such as herpes simplex. Miconazole (Monistat) is a topical antifungal drug. Clotrimazole (Lotrimin, Mycelex-G) is available as a lozenge for the treatment of oropharyngeal candidiasis. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.