Drug Information

Drug Interaction:

FACTS ON FINGER TIPS (MIMS)

1. MELASMA (Also known as CHLOSMA)

Salient Features

Aetiology

1.Often develops during pregnancy, when it is known as melasma gravidarum

2.Also associated with oral contraceptives or hormone replacement therapy

3.Occasionally develops in men

Clinical features

1.Patchy, light or darker brown pigmentation of the face, more marked after sun

exposure

2.Usually symmetrical distribution on the forehead, cheeks, nose,upper lip, chin or neck

Management

1.Many will resolve spontaneously after ceasing the oral contraceptive pill or after

childbirth

2.However, in some cases the condition will persist

3.Sunscreen applications should be strongly advised as they may help to reduce

the likelihood of recurrence and prevent worsening on exposure to the sun

4.Avoidance of sun exposure can improve the appearance

5.There is no specific treatment for this condition

Indication:

13. DISORDERS AND /OR ADVERSE REACTIONS - SKIN -DERMATOLOGICAL SYSTEM - SUMMARY

Refer - Other information

Contents

1.Evidence Based Medicine i. Treatment of Scabies

2.Facts on Finger Tips i.Melasma (also known as Cholasma) ii.Tinea Capritis (Scalp Ringworm) iii.Acne iv. Scleroderma (Systemic Sclerosis) v. Hypertrichosis

3.Disorders and/or Adverse Reactions Items 1 to 14

EVIDENCE BASED MEDICINE (April 2003)

Treatment of Scabies

Comparative effectiveness of various interventions

Beneficial

1. Permethrin - cure rate of about 90%

Likely to be beneficial

1. Crotamiton

Unknown effectiveness

1. Malathion

2. Benzyl benzoate - cure rate of about 50 percent

3. Oral ivermectin

4. Sulphur compounds

Trade-off between benefits and harms

1. Gamma benzene hexachloride (lindane)

KEY POINTS

1. One systemic review of mainly small randomised clinical trials has found that topical permethrine and gamma benzene hexachloride has been linked to rare reports of serious side effects

2. There is limited evidence that crotamiton is safe but less effective than permethrine

3. There is insuffcient evidence on the effects of other topical agents (malathion, benzyl benzoate, and sulphur compounds). On the basis of case series, malathion acheived 80% cure rates but its safety has not been established

4. There is insufficient evidence on the effects of oral invercetin. It s known to be safe in adults based on the experience of its use in onchocerciaciasis, but its safety in elderly and children is uncetain

Adverse Reaction:

FACTS ON FINGER TIPS (MIMS)

2. TINEA CAPITIS (SCALP RINGWORM)

Salient Features

Definition

An infection of the scalp hair with dermatophyte fungi

Epidemiology

More common in children
Spread may be through person-to person contact or through shared hairbrushes and combs

Pathophysiology

The infection may spread from the centre of the scalp outward or, alternatively, from outside in.
Local trauma of scalp skin- for example ,through scratching -helps the infection to spread

Clinical features

The hair becomes brittle, resulting in patchy hair loss.
Perifollicular papules, may be seen, and the hair broken in the follicular orifices look like black dots.
Discoloration of hair.
A well defined inflammatory scalp lesion. These lesions may present a solitary or multiple form
The differential diagnosis includes alopecia areata and other inflammatory scalp lesions, such as psoriasis and eczema

Investigations

Examination of the scalp with Woo’s light may show the characteristic blue-green florescence
Send plucked hair for fungal microscopy. The presence of fungi is revealed by the finding of hyphae and spores
Culture can also be carried out.

Management

May be self-limiting
Griseofulvin or itraconazole are the treatments of choice.
Cultures should be repeated at monthly intervals until there isabsolute certainity that the infection has been cured.

Key Points

Topical treatment should not be used in isolation
Treatments should continue until mycological cure can be seen to have occurred
Chronic infections may not fluoresce with Wood’s light

Contra-Indications:

FACTS ON FINGER TIPS (MIMS)

3. ACNE

Salient Features

Pathophysiology

Acne is a disease of the sebaceous follicle
There is an increased sebum excretion
Colonisation of the pilosebaceous duct occurs with ‘Probionibacterium acnes’
Acne may be a sign of Polycystic Ovarian Syndrome or Cushing’s Syndrome
Severe acne fever and musculoskletal synptoms my indicate acne fulminans. This is caused by an immune reaction to P acnes

Clinical features

Open comoedones (blackheads) and closed comedones (whiteheads)
Papules , pustules, noddles or cysts
Scarring, and an oily skin
Remember to examine the chest and back as well the face

Management of mild acne

Topical antibacterial/keratolytic such as benzoyl peroxide preparations, azelic acid
Topical antibiotics such as erythromycin, clindamycin or tetracycline
Topical retinoid and related preparations such as tretinoin, isotretinoin, adapalene
Can be used or alone in combination

Management of moderate acne

Oral antibiotics- tetracyclines, erythromycin, trimethoprim, plus a topical preparation
Consider change of oral antibiotics if no improvement after three months
Anti-androgen, such as cyproterone acetate, plus oestrogen, might be used in females

Management of severe acne

If there is no nodulocystic acne with scarring, refer to a dermatologist for treatment with oral isotretinoin

Key Points

Early recognition and treatment is important to prevent physical scarring and reduce psychological impact.
Differentiate from rosacea, where there are no comedones and papules or pustules occur over an erythematous background with telangiectasia

Dosages/ Overdosage Etc:

FACTS ON FINGER TIPS (MIMS)

4. SCLERODERMA

(SYSTEMIC SCLEROSIS)

Salient Features

Definition

Chronic disease of an unknown cause
Main characteristics: diffuse fibrosis, degenerative changes and systemic vascular damage of the skin and internal organs

Epidemiology

Forty percent of patients have diffuse cutaneous scleroderma and 60% have limited cutaneous scleroderma

Clinical features

Symmetric swelling of the fingers and hands is often an early manifestation, with concurrent development of Raynaud’s phenomenon. As the disease progresses oedema is replaced by indurations, resulting in thick, hard hyperpigmented and tight skin
Oesophageal dysfunction occurs in all patients leading to abnormal swallowing sensation, and can later result in gastroesophageal reflux disease
Diffuse interstitial fibrosis of the lungs occurs in 70% of patients resulting in early impairment in gas exchange leading to external dyspepsia
Myocardial fibrosis occurs in 70% of patients and leads to conduction defects and supraventricular arrhythmias.
Renal involvement results in hypertension and renal failure

Investigations

Usually diagnosed impaired oesophageal motility
Chest X-ray is used to exclude other pathology
Barium swallow demonstrates deposits of calcium around the fingers

Management

There is no specific treatment but various drugs are of value in treating symptoms or organ systems such as ACE inhibitors for hypertension

Key Points

GI disturbances (heart burn, dyspepsia) or respiratory complaints are occasionally the first manifestations of the disease

Other Information:

13. DISORDERS AND /OR ADVERSE REACTIONS - SKIN -DERMATOLOGICAL SYSTEM - SUMMARY

( Ref- Harrisons - Priniciples of Internal Medicine Ninth Edition )

1. Exfoliative dermatitis ( 241 )
2. Toxic epidermal necrolysis ( bullous ) (610)
3. Erythema multiforme or Steven Johnson syndrome ( 245 )
4. Erythema nodosum ( 244 )
5. Fixed dose eruption ( 386 )
6. Photodermatitis ( 260 )
7. Urticaria ( 245 )
8. Nonspecific rashes ( 386 )
9. Pigment changes ( hyperpigmentation ) ( 386 )
10. Alopecia ( 746 )
11. Purpura ( 245 )
12. Lichenoid eruptions ( 386 )
13. Eczema ( contact dermatitis ( 386 )
14. Acne (242)

1. Exfoliative dermatitis ( 241 )

Erthroderma syndrome ( exfoliative dermatitis ) is an important dermatological complication that may occur as the a result of an extension of a drug reaction, as generalized spreading of a preexiting dermatitis such as posriasis or atopic dermatitis, or in association with lymphoma and leukemia

Adverse reaction - drug ( 385 )
1. Exflioative dermatitis
2. Sulfonamides
3. Barbiturates
4. Phenytoin
5. Phenylbutazone
6. Gold salts
7. Quinidine

2. Toxic epidermal necrolysis ( bullous ) (610)

The syndrome may be localised or rarely generalized (toxic epidermal necrolysis, Ritters
syndrome, Lyells disease or scalded skin syndrome) . In the localized form staphylococci can usually be recovered from the bullous lesions, while in the generalized form they usually cannot be.

Adverse reaction - drug
1. Barbiturates
2. Phenylbutazone
3. Phenytoin
4. Sulfonamides
5. Phenolphthalein
6. Penicillins
7. Allopurinol
8. Iodides
9. Bromides
10. Nalidixic acid

3. Erythema multiforme or Steven Johnson syndrome ( 245 )

Eryhema multiforme syndrome is a characteristic response of the skin and mucous membranes that is related to a number of possible etiologies , including infectious agents and drugs ( especially penicillin, antipyretics , barbiturates, hydantoins and sulfonamides )

Adverse reaction - drug ( 386 )
   1. Sulfonamides
   2. Barbiturates
   3. Phenylbutazone
   4. Chlorpropamide
   5. Thiazides
   6. Sulfones
   7. Phenytoin
   8. Ethosuxide
   9. Salicylates
   10. Tetracyclines
   11. Codeine
   12. Penicillins

4. Erythema nodosum ( 244 )

The erythema nodusum syndrome refers to the occurence of multiple bilateral tender nodules appearing principally on the anterior aspect of the lower extremites and occassionally on the upper extremties and face. The erythema nodusum syndrome is associated with an number of disorders that are unrelated to each other.

Adverse reaction - drug ( 386 )
   1. Penicillins
   2. Sulfonamide
   3. Oral contraceptives

5. Fixed dose eruption ( 386 )

Adverse reaction - drug
   1. Phenolphthalein
   2. Barbiturates
   3. Sulfonamides
   4. Salicylates
   5. Phenybutazone
   6. Quinine

6. Photodermatitis ( 260 )

The photodermatits involves a mild -to -serve erythematous reaction with or without vesicles or bulae. Dense postinflammatiory hyperpigmentation is visible within 3 to 5 days.Perfumes and colognes containing oil of bergamot are known to induce hyperpigmentation with or without eryhema

Adverse reaction - drug ( 386 )
   1. Tetracyclines , particularly demeclocyline
   2. Griseofulvin
   3. Sulfonamides
   4. Sulfonylureas
   5. Thiazides
   6. Furosemide
   7. Phenothizines
   8. Nalidixic acid
   9. Oral contraceptives
   10. Chlordiazepoxide

7. Urticaria ( 245 )

Urticaria is characterized by wheals of which the outstanding feature is their persistence for only a few hours . This short duration differentiates urticarial wheals from other almost identitical papules of erythema nultiforme , which persists for more than 1 or 2 days rather a few hours. An acute onset of urticaria is usually related to ingestion of drugs or certain types of foods ( such as shellfish, fresh berries)

   Adverse reaction - drug ( 386 )
    1. Aspirin
    2. Penicillins
    3. Sulfonamides
    4. Barbiturates

8. Nonspecific rashes ( 386 )

   Adverse reaction - drug
    1. Ampicillin
    2. Barbiturates
    3. Allopurinol
    4. Phenytoin
    5. Methydopa

9. Pigment changes ( hyperpigmentation ) ( 386 )

   Adverse reaction - drug
    1. ACTH
    2. Busulfan
    3. Phenothiiziness
    4. Hypervitaminosis A
    5. Oral contraceptives
    6. Gold salts
    7. Chloroquine and other antimalarials
    8. Cyclophosphamide
    9. Bleomycin

10. Alopecia ( 746 )

Scalp dermatophytoxis ( tinea carpitis) is characterized by areas of alopecia and scaling.

   Adverse reaction - drug ( 386 )
    1. Cytotoxics
    2. Ethionamide
    3. Heparin
    4. Oral contraceptives ( withdrawal )

11. Purpura ( 245 )

A purpuric eruption demands immediate exploration for its etiology. Purpura arises in the skin of the vasculrized dermis and is almost always confined to the dermis. The purpuric macules gradually disappears after days oe weeks, depending on their size

   Adverse reaction - drug ( 386 )
    1. Corticosteroids
    2. Aspirin

12. Lichenoid eruptions ( 386 )

   Adverse reaction - drug
    1. Chlorpropamide
    2. Gold salts
    3. Antimalarials
    4. PAS
    5. Methyldopa
    6. Phenothiazines

13. Eczema ( contact dermatitis ( 386 )

   Adverse reaction - drug
    1. Topical antimictobials
    2. Topical local anesthetics
    3. Topical antihistamines
    4. Cream and lotion perservatives
     5. Lanolin

14. Acne (242)

The major disease of the subaceous gland in humans is acne vulgaris which occurs predominantly on the face, and to a lesser degree, on the back, chest,and shoulders. It is characterized by a variety of clinical lesions. These lesions may be either noninflammatory or inflammatory papules and nodules. The noninflammatory papules are called omedones, and these may be either open (blackheads) or closed (whiteheads)

   Adverse reaction - drug
    1. Anabolic and androgenic steroids
    2. Corticosteroids
    3. Bromides
    4. Iodides
    5. Oral contraceptives
    6. Isoniazid
    7. Troxidone

Patient Information:

FACTS ON FINGER TIPS (MIMS)

5. HYPERTRICHOSIS

Salient Features

Definition and epidemology

1. Excessive hair growth on sites that are normally hairy

2. A relatively common disorder

3.More common in females

Aetilogy

1.May be familial or part congenital disorder

2.Most may be acquired

3.They may be idiopathic , or due to:

- metabolic disorders , such as underlying cancer

- endocrine disorders, such a Graves disease or polycystic ovarian syndrome

- nutrional disorders , such as anorexia, nervosa

- iatrogenic causes, such as corticosteroids, cyclosporin A or phenytoin

Pathophysilogy

1.Excessive hair growth which may be lanugo or vellus type

2.The process does not seem to be androgen dependent

Clinical features

1.May be localised or genealised

2.Common sites for localised excessive hair growth include the ears

(particularly in male Asians) and eye brows

3.Localised hair growth may also occur in people with melanocytic naevi or

underlying disease ,for example, the faun tail in people with spina bifida

4. A generalised male pattern of hair growth my occur in women

(sometimes known as hirusutism)

5.Latrogenic hair growth is often generalised

Management

1.Shaving and hair removal creams usually suffice with mild to moderate disease

2.Electrolysis and diathermy permanently destroys hair folicles

3. Anti-androgen drugs help in severe disease

Key Points

1.Refer patients if you suspect an underlying congenital or important

acquired condition

2. Be alert to physiological morbidity as a consequence of hypertrichosis

DISORDERS AND/OR ADVERSE REACTIONS - 13.SKIN -DERMATOGICAL SYSTEM -SUMMARY

Drug Interaction

Indication

Adverse Reaction

Contra-Indications

Dosages/ Overdosage Etc

Other Information

Patient Information

Drug Interaction:

Indication:

Adverse Reaction:

Contra-Indications:

Dosages/ Overdosage Etc:

Other Information:

Patient Information:

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