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Chapter 56
Dermatologic Drugs
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Skin
Largest organ of the body
Two layers
Dermis
Epidermis
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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
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5. Topical Dermatologic Drugs
Antimicrobial drugs
Antibacterial drugs
Antifungal drugs
Antiviral drugs
Antiinflammatory drugs
Antineoplastic drugs
Antipruritic drugs (for itching)
Burn drugs
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6. 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
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7. Topical Antimicrobial Drugs
Antibacterial drugs
Antifungal drugs
Antiviral drugs
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Antibacterial Drugs
Most common bacteria are Streptococcus pyogenes and Staphylococcus aureus
Folliculitis
Impetigo
Furuncles
Carbuncles
Cellulitis
Pustules
Vesicles
Papules
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9. Antibacterial Drugs (cont’d)
Most common drugs
bacitracin
neomycin
polymyxin
neomycin and polymyxin B (Neosporin)
mupirocin (Bactroban)
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10. Antibacterial Drugs (cont’d)
mupirocin (Bactroban)
Used topically for Staph and Strep impetigo
Intranasal form for methicillin-resistant S. aureus (MRSA)
Available by prescription
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11. 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
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12. 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.
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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)
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14. 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
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15. 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
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16. 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
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17. 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.
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18. 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
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19. 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
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20. 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
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21. 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
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22. 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
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23. 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
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24. 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
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25. Topical Antipruritic Drugs
Antihistamines
Corticosteroids
Antiinflammatory effects
Antipruritic effects
Vasoconstrictor actions
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26. Other Topical Dermatologic Drugs
Antipsoriatic drugs
tazarotene (Tazorac)
tar-containing products
anthralin (Anthra-derm)
calcipotriene (Dovonex)
etanercept (Enbrel)
alefacept (Amevive)
ustekinumab (Stelara)
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27. 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)
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28. 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
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29. 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
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30. Other Topical Dermatologic Drugs (cont’d)
Topical antineoplastics
fluorouracil (Efudex)
Basal cell carcinoma
Actinic keratosis
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31. Other Topical Dermatologic Drugs (cont’d)
Immunomodulators
pimecrolimus (Elidel)
Treats atopic dermatitis
imiquimod (Aldara)
Treats actinic keratosis, basal cell carcinoma, and anogenital warts
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Wound Care Drugs
Vitamin C (ascorbic acid)
Zinc
Topical wound care drugs
Used to prepare wound bed for healing
Remove nonviable tissue (débridement)
Antibacterial
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33. Wound Care Drugs (cont’d)
sodium hypochlorite (Dakin’s solution)
cadexomer iodine (Iodosorb)
collagenase (Santyl)
biafine topical emulsion
acetic acid (vinegar)
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34. 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.
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35. 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.
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36. Skin Preparation Drugs
isopropyl alcohol (70%)
povidone-iodine (Betadine)
chlorhexidine (Hibiclens)
benzalkonium chloride (Zephiran)
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Herbal Products: Aloe
Used for wound healing
Adverse effects
Diarrhea
Abdominal pain
Dermatitis
Drug interactions
digoxin
Antidysrhythmics
Diuretics
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Nursing Implications
Assess for presence of contraindications, especially drug allergies
Do not apply antiinfective drugs until culture and sensitivity testing (if ordered) are completed
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39. 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
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40. 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
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41. 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
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42. Nursing Implications (cont’d)
Wear gloves when applying topical drugs
Apply dressings (e.g., wet, wet-to-dry, occlusive) as prescribed
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43. 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
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44. 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
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45. Nursing Implications (cont’d)
Provide patient/family teaching as necessary for self-care
Monitor for therapeutic responses
Monitor for adverse effects
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46. 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.
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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.
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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.
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