Epidermis: keratinocyte, outermost layer-stratum corneum- barrier to external insults
Dermis: between epidermis and subcu tissue-connective tissue
● Sweat glands, sebaceous glands, hair follicles, blood vessels
Acne:
● Begins below surface in sebaceous glands- alteration in keratinization process= extra sebum
production occludes hair follicles creating microcomedones
● Keratin is skin debriding combined with oil can lead to closed or open comedones
● P acnes organisms colonize follicles and create inflammatory environment
● Goal is to control inflammatory environment
● Type:
○ Mild comedonal: includes open (blackheads) and closed white heads
○ Mild to moderate inflammatory acne
■ Includes papules (inflamed comedones), pustules (red ring around the bump), or
both
○ Moderate to severe acnes: nodules and cysts
● Topical abx:
○ Benzoyl peroxide: antibacterial activity against P acnes (1st line for minor acne)
■ Releases active or free radicals that oxidize bacterial production
■ Drying effect, removes excess sebum, may cause photosensitivity, can bleach
clothes and towels, causes mild desquamation, safe in pregnancy, can be used
in children >12 years old
■ Don’t apply at same time as retinoid therapy
○ Erythromycin and clindamycin (may be used in combo with benzyl peroxide)
■ Interrupt protein synthesis at the 50S ribosomal subunit
■ In combo reduces bacterial resistance
■ clindamycin : monitor for diarrhea, can be rare with topical but can be a sign of
colitis and should be stopped
● CI: with hx of chrons, UC, or abx associated colitis
○ Azelaic acid: inhibition of microbial cellular protein synthesis
■ Decreases skin inflammation and concentration of bacteria on skin, normalize
keratinization creating anti comedone effect, decreased microcomedone effect
■ Use cautiously in those with dark skin pigmentation
○ Salicylic acid: over counter
■ Exfoliant to clear comedones and anti inflammatory effects
● Topical retinoids:
○ Tretinoin
○ RetinA:
■ Reduces cohesion between keratinized cells and acts specifically on
microcomedones, causing expulsion of comedones and conversion of closed
comedones to open, also prevents new comedones.
■ It is important to note that it does not have antibacterial properties, but can
enhance the penetration of other topical agents, such as benzoyl peroxide.
○ Adapalene: differin: decreases microcomedone formation and is a modulator of cellular
differentiation, keratinization, and inflammatory processes, which are all important
features of acne.
○ Tazarotene- works by normalizing epidermal differentiation and reducing the influx of
inflammatory cells into the skin.
■ It is not safe in pregnancy, which is a distinct difference in comparison to the two
, other retinoids
○ All: should be avoided in patients with eczema, sunburn or skin abrasions at site of
application
○ CI: in lactating patients, should all not be used at the same time as topical abx, besides
benzoyl peroxide
○ SE: peeling, flaking, dry skin, burning, erythema, pruritus, sunburn, hypopigmentation
○ Educate that acne may get worse before it gets better and treatment benefits take at
least 6 to 8 weeks to really appear; also advise sunscreen
● Oral antibiotics: active against P acnes which transform comedones into inflammatory pustules
and papules, work to prevent future lesions, rather than existing, by decreasing P acnes
colonization
○ Indication for moderate to severe acne and inflammatory acne resistant to topical
therapies
○ Tetracycline family:
○ Azithromycin, bactrim, erythromycin
● Systemic retinoids:
○ Accutane: isotretinoin
■ Reduces sebum production by reducing sebaceous gland size, normalizing
follicular keratinization and indirectly reducing P acnes and its inflammatory
sequela
■ CI: pregnancy, risk of osteoporosis, and should not be used with alcohol
consumption (potentiate toxic effects)
■ SE: cheilitis, dry skin and fragility, hypertriglyceridemia, elevation of glucose
levels, headache, lethargy, fatigue, arthralgia, myalgias, visual disturbances, GI
reactions.
● Rational Drug selection:
○ non inflammatory comedonal acne: topical retinoid or benzyl peroxide
○ Inflammatory papulopustular acne: topical combo therapy of topical abx or retinoid plus
benzoyl peroxide
○ Severe: oral abx combo with topical combo therapy of topical abx or retinoid plus benzoyl
peroxide or all three agents
■ Oral isotretinoin (dermatology)
Topical Corticosteroids: used for anti inflammatory and antimitotic (blocks cell growth),
immunosuppression and vasoconstrictive properties
Differ in potency (group 1 very high to group 7 low strength)
Cream, gel, ointment, lotion- choose depending on diagnosis and location
● Low strength
● Intermediate
● High strength
● Very high strength
● Indications: dermatitis, psoriasis
● Pharmacodynamics:
○ anti- inflammatory, antipruritic and vasoconstrictive properties
○ They depress the formation, release and activity of endogenous chemical mediators of
inflammation, including histamines and prostaglandins. They inhibit the migration of
macrophages and leukocytes into the affected area by reversing vascular dilatation and
permeability. Leads to reduction of edema, erythema, and pruritis
○ Abdorption and distribution can be enhanced by increased skin temperature, hydration,
, and application to denuded areas.
■ Intertriginous areas or skin surfaces with thin stratum corneum layer. Occlusion
can increase skin penetration 10 to 100-fold. This can be helpful for severe cases
and can also lead to adverse effects, as it may become more systemic rather
than topical.
■ Ointments are more occlusive and potent and good for dry, scaly lesions
■ Creams are less occlusive and less potent and good for oozing lesions, where
occlusive may cause worsening effects
■ Lotion are least potent and are good for hair bearing areas
○ CI: don’t use high potency on face, groin or axilla, use in caution in pregnant patients,
children are more susceptible to effects and use lowest effective strength, only use if
benefit outweighs risk
○ AE: local skin irritation and increase the risk for secondary infections, tolerance may
occur with prolonged use
■ Adrenal fxn and growth should be monitored in children who require moderate- to
high potency steroids. Growth can be stunted in patients requiring this level of
steroid therapy
■ Choice of steroid potency is based on area of skin to be treated, condition and
diagnosis. Low to mid potency should be used for children
■ Patients should be educated to use emollients- aquaphor- apply after bath to
prevent flare of dermatitis (eczema)
Topical calcineurin inhibitors
● Pimecrolimus (elidel) : mild to moderate
● Tacrolimus (protopic): approved for moderate to severe disease
○ Indications: atopic dermatitis (short or intermittent long term)
○ Suppresses cellular immunity through inhibiting T cell activation of binding to intracellular
proteins, including calcineurin dependent proteins. Inhibits inflammatory cytokines and
mediators from mast cells
○ CI: do not apply to site of active cutaneous viral infarction
■ Black box warning for long term safety concern because of rare cases of
malignancy
■ Don't use in lactation, cautin in pregnancy
■ Avoid in children younger than 2 yrs and immunosuppressed
○ A/E: local reaction at the site of application. Burning, pruritus, and tingling, headache,
fever, flu-like symptoms, acne, and folliculitis
○ Use topical calcineurin inhibitors for: resistance to steroids, sensitive areas like face, skin
folds, steroid induced atrophy, or long term uninterrupted topical steroid use
Topical Antihistamines and antipruritics:
● Benadryl
○ Provides local relife of itching and swelling because of its effects on h1 receptors,
suppresses the formation of edema and pruritis
○ May provide a local anesthetic quality by blocking the transmission of nerve impulses
○ Used for mild to moderate symptoms of pruritus, don’t use for chicken pox
○ CI: Avoid use >7 da
○ Make sure its closed, if used on large areas the systemic effects, use in greater than 2yrs
olds, safe in pregnancy, caution in lactation, may cause skin irritaiton
● Doxepin (Zonalon)
○ Histamine blocking of h1 and h2 receptors, inhibiting the activation of the histamine
Dermis: between epidermis and subcu tissue-connective tissue
● Sweat glands, sebaceous glands, hair follicles, blood vessels
Acne:
● Begins below surface in sebaceous glands- alteration in keratinization process= extra sebum
production occludes hair follicles creating microcomedones
● Keratin is skin debriding combined with oil can lead to closed or open comedones
● P acnes organisms colonize follicles and create inflammatory environment
● Goal is to control inflammatory environment
● Type:
○ Mild comedonal: includes open (blackheads) and closed white heads
○ Mild to moderate inflammatory acne
■ Includes papules (inflamed comedones), pustules (red ring around the bump), or
both
○ Moderate to severe acnes: nodules and cysts
● Topical abx:
○ Benzoyl peroxide: antibacterial activity against P acnes (1st line for minor acne)
■ Releases active or free radicals that oxidize bacterial production
■ Drying effect, removes excess sebum, may cause photosensitivity, can bleach
clothes and towels, causes mild desquamation, safe in pregnancy, can be used
in children >12 years old
■ Don’t apply at same time as retinoid therapy
○ Erythromycin and clindamycin (may be used in combo with benzyl peroxide)
■ Interrupt protein synthesis at the 50S ribosomal subunit
■ In combo reduces bacterial resistance
■ clindamycin : monitor for diarrhea, can be rare with topical but can be a sign of
colitis and should be stopped
● CI: with hx of chrons, UC, or abx associated colitis
○ Azelaic acid: inhibition of microbial cellular protein synthesis
■ Decreases skin inflammation and concentration of bacteria on skin, normalize
keratinization creating anti comedone effect, decreased microcomedone effect
■ Use cautiously in those with dark skin pigmentation
○ Salicylic acid: over counter
■ Exfoliant to clear comedones and anti inflammatory effects
● Topical retinoids:
○ Tretinoin
○ RetinA:
■ Reduces cohesion between keratinized cells and acts specifically on
microcomedones, causing expulsion of comedones and conversion of closed
comedones to open, also prevents new comedones.
■ It is important to note that it does not have antibacterial properties, but can
enhance the penetration of other topical agents, such as benzoyl peroxide.
○ Adapalene: differin: decreases microcomedone formation and is a modulator of cellular
differentiation, keratinization, and inflammatory processes, which are all important
features of acne.
○ Tazarotene- works by normalizing epidermal differentiation and reducing the influx of
inflammatory cells into the skin.
■ It is not safe in pregnancy, which is a distinct difference in comparison to the two
, other retinoids
○ All: should be avoided in patients with eczema, sunburn or skin abrasions at site of
application
○ CI: in lactating patients, should all not be used at the same time as topical abx, besides
benzoyl peroxide
○ SE: peeling, flaking, dry skin, burning, erythema, pruritus, sunburn, hypopigmentation
○ Educate that acne may get worse before it gets better and treatment benefits take at
least 6 to 8 weeks to really appear; also advise sunscreen
● Oral antibiotics: active against P acnes which transform comedones into inflammatory pustules
and papules, work to prevent future lesions, rather than existing, by decreasing P acnes
colonization
○ Indication for moderate to severe acne and inflammatory acne resistant to topical
therapies
○ Tetracycline family:
○ Azithromycin, bactrim, erythromycin
● Systemic retinoids:
○ Accutane: isotretinoin
■ Reduces sebum production by reducing sebaceous gland size, normalizing
follicular keratinization and indirectly reducing P acnes and its inflammatory
sequela
■ CI: pregnancy, risk of osteoporosis, and should not be used with alcohol
consumption (potentiate toxic effects)
■ SE: cheilitis, dry skin and fragility, hypertriglyceridemia, elevation of glucose
levels, headache, lethargy, fatigue, arthralgia, myalgias, visual disturbances, GI
reactions.
● Rational Drug selection:
○ non inflammatory comedonal acne: topical retinoid or benzyl peroxide
○ Inflammatory papulopustular acne: topical combo therapy of topical abx or retinoid plus
benzoyl peroxide
○ Severe: oral abx combo with topical combo therapy of topical abx or retinoid plus benzoyl
peroxide or all three agents
■ Oral isotretinoin (dermatology)
Topical Corticosteroids: used for anti inflammatory and antimitotic (blocks cell growth),
immunosuppression and vasoconstrictive properties
Differ in potency (group 1 very high to group 7 low strength)
Cream, gel, ointment, lotion- choose depending on diagnosis and location
● Low strength
● Intermediate
● High strength
● Very high strength
● Indications: dermatitis, psoriasis
● Pharmacodynamics:
○ anti- inflammatory, antipruritic and vasoconstrictive properties
○ They depress the formation, release and activity of endogenous chemical mediators of
inflammation, including histamines and prostaglandins. They inhibit the migration of
macrophages and leukocytes into the affected area by reversing vascular dilatation and
permeability. Leads to reduction of edema, erythema, and pruritis
○ Abdorption and distribution can be enhanced by increased skin temperature, hydration,
, and application to denuded areas.
■ Intertriginous areas or skin surfaces with thin stratum corneum layer. Occlusion
can increase skin penetration 10 to 100-fold. This can be helpful for severe cases
and can also lead to adverse effects, as it may become more systemic rather
than topical.
■ Ointments are more occlusive and potent and good for dry, scaly lesions
■ Creams are less occlusive and less potent and good for oozing lesions, where
occlusive may cause worsening effects
■ Lotion are least potent and are good for hair bearing areas
○ CI: don’t use high potency on face, groin or axilla, use in caution in pregnant patients,
children are more susceptible to effects and use lowest effective strength, only use if
benefit outweighs risk
○ AE: local skin irritation and increase the risk for secondary infections, tolerance may
occur with prolonged use
■ Adrenal fxn and growth should be monitored in children who require moderate- to
high potency steroids. Growth can be stunted in patients requiring this level of
steroid therapy
■ Choice of steroid potency is based on area of skin to be treated, condition and
diagnosis. Low to mid potency should be used for children
■ Patients should be educated to use emollients- aquaphor- apply after bath to
prevent flare of dermatitis (eczema)
Topical calcineurin inhibitors
● Pimecrolimus (elidel) : mild to moderate
● Tacrolimus (protopic): approved for moderate to severe disease
○ Indications: atopic dermatitis (short or intermittent long term)
○ Suppresses cellular immunity through inhibiting T cell activation of binding to intracellular
proteins, including calcineurin dependent proteins. Inhibits inflammatory cytokines and
mediators from mast cells
○ CI: do not apply to site of active cutaneous viral infarction
■ Black box warning for long term safety concern because of rare cases of
malignancy
■ Don't use in lactation, cautin in pregnancy
■ Avoid in children younger than 2 yrs and immunosuppressed
○ A/E: local reaction at the site of application. Burning, pruritus, and tingling, headache,
fever, flu-like symptoms, acne, and folliculitis
○ Use topical calcineurin inhibitors for: resistance to steroids, sensitive areas like face, skin
folds, steroid induced atrophy, or long term uninterrupted topical steroid use
Topical Antihistamines and antipruritics:
● Benadryl
○ Provides local relife of itching and swelling because of its effects on h1 receptors,
suppresses the formation of edema and pruritis
○ May provide a local anesthetic quality by blocking the transmission of nerve impulses
○ Used for mild to moderate symptoms of pruritus, don’t use for chicken pox
○ CI: Avoid use >7 da
○ Make sure its closed, if used on large areas the systemic effects, use in greater than 2yrs
olds, safe in pregnancy, caution in lactation, may cause skin irritaiton
● Doxepin (Zonalon)
○ Histamine blocking of h1 and h2 receptors, inhibiting the activation of the histamine
