Therapeutic/Treatment Modalities
Beth Haney
OBJECTIVES
After studying this chapter, the reader will be able to:
Identify appropriate treatment modalities for skin diseases and conditions.
Recognize risks and benefits of local, topical, and systemic treatments and medications.
Describe types and potencies of steroid treatments and their applications.
Define the systemic antibiotics related to clinical use, absorption, metabolism, adverse reaction, and dosage.
Identify the pros and cons of vitamin A therapy.
List the steps to applying an Unna’s boot correctly.
KEY POINTS
Knowledge of current and available therapeutic skin treatments is an important aspect of clinical nursing.
Percutaneous absorption in intact skin may be unpredictable, but increased when the skin barrier is broken or compromised.
Patient education regarding importance of compliance to treatment regimen, benefits, and risks is paramount to successful treatment.
Topical modalities should be used with caution on open wounds; choice of topical medication should consider rate of absorption, healing, presence of infection, and possible sensitivities.
The proper application of venous compression therapy such as Unna’s boot is important to positive outcomes.
I. OVERVIEW
The skin is the largest organ of the body; it averages 20 square feet and weighs about 9 pounds. The skin regulates body temperature, protects underlying skin cells from environmental toxins and harmful ultraviolet radiation, and acts as a barrier to prevent water loss, invasion of foreign substances, as well as immune defense. The outermost layer of the epidermis, the stratum corneum, provides these functions through a barrier that consists of fatty acids, cholesterol, and ceramides that reside between cornified cells. When the skin is intact, it also regulates percutaneous absorption. Any insult that removes lipids, water, or protein from the epidermis can severely compromise this protective function. The goal of topical and systemic preparations is to maintain and restore the functions of the skin barrier. For example, alkaline soaps affect the stratum corneum by changing the normal acidity of the skin (normal skin pH is 5.4 to 5.9). Alteration of the acid mantle can decrease bacterial resistance. Absorption rates of medications vary depending on the anatomic site, that is, eyelids, mucous membranes, palms, or soles of the feet.
II. TOPICAL AGENTS
A. Vehicles
Choice of the appropriate vehicle is paramount to successful treatment and determines the rate of the absorption of the active ingredient into the skin. Fat-soluble vehicles, especially natural emollients, are more rapidly absorbed than watersoluble vehicles.
1. Ointment: Consists primarily of greases such as petroleum jelly with little or no water and desirable for dryer lesions/conditions
a. Increases lubrication
b. Translucent
c. Greater penetration of medicine than creams, which increases percutaneous absorption, thus enhancing potency of medications
d. Usually are preservative-free
e. Should not be used in extremely eczematous inflammation or in intertriginous areas, such as the groin due to occlusive properties
f. May cause folliculitis when used in hairy areas
2. Creams: Mixture of organic chemicals (oil) and water emulsion and usually contains preservatives
a. Used for lubrication and easily applied
b. Highly versatile due to ability to use on almost any area of the body and therefore are the most prescribed
c. Do not increase percutaneous absorption
d. Are more cosmetically acceptable
e. Some may cause dryness with extended use, therefore best for acute exudative inflammation
f. White color and can be greasy in texture
g. Can cause side effects such as burning, stinging, and/or allergy depending on components
3. Solutions and lotions: Powder suspended in liquid (may contain water and alcohol as well as other chemicals) and delivers medication as uniform film
a. Suitable for hairy areas, frequently used for scalp due to ease of penetration, and leaves no residue
b. Have greater content of alcohol and water
c. May over dry the skin and wear off easily
d. Absorb moisture, promoting drying
e. May cause stinging and drying in intertriginous areas, such as the groin
4. Gel: Greaseless mixture of propylene glycol and water, and some contain alcohol
a. Easily applied
b. Drying and cooling and good for acute exudative inflammation and pruritic eruptions like poison ivy
c. Aggravates dry, cracked lesions if it contains alcohol
d. May cause burning on eroded skin
5. Powder: Finely ground solid particles
a. Absorptive and promotes drying
b. Decreases skin friction
c. Good vehicle to deliver medication to intertriginous areas
6. Aerosols: Medications suspended in a base and delivered under pressure
a. Similar to a lotion but more drying
b. Useful for applying medication to hairy areas
c. Useful on wet lesions
7. Paste: Powder in ointment and 50% or greater powder content
a. Provides protection
b. Decreases rate of percutaneous absorption
c. Messy
8. Foam
a. Useful for scalp dermatoses and spread between strands of hair until reaches the scalp where the medication is then delivered
b. Good for acute exudative inflammation
c. May cause stinging shortly after application
B. Application of topical agents (Tables 4-1 and 4-2): The objective of topical treatment is to lubricate or medicate, or both. Proper application technique should always be used. Hydrating the skin before application will increase percutaneous absorption. Frequency of application and amount will be dictated by severity of dermatosis and the medication chosen.
1. Remove any “caked” topical before applying additional topical
a. Remove creams with water.
b. Mineral or cottonseed oil may be used to remove ointments or pastes.
c. Always use gentle motions when removing topical medications.
2. Applying creams and ointments
a. The amount of cream or ointment used depends on the area to be treated.
b. Amount can be calculated as 1 g of cream covers 100 cm2 of skin. One fingertip unit (FTU) is the amount of ointment expressed from a 5-mm nozzle applied from the distal crease of the index finger to the tip and weighs approximately 0.5 g.
TABLE 4-1 Quantity of Topical Cream to Apply and Dispense for Single or Multiple Application(s) | |||||||||||||||||||||||||||||||||||||||||||||
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c. Apply in long downward (direction of hair growth) strokes using the palm of the hand.
d. Only a thin film of medication is necessary.
3. Applying pastes
a. Use tongue depressor if available.
b. May warm container of medication in warm water to soften, thus facilitating application.
4. Applying lotions/solutions
a. Shake well.
b. Pour small amount in the palm of the hand.
c. Pat onto the skin.
TABLE 4-2 Guidelines for Patient Education Regarding Application of Topical Medications | ||||||||||
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d. A brush or gauze may be used for application; avoid use of cotton; it filters out medication and may stick to the skin.
5. Applying sprays and aerosols
a. Shake well.
b. Direct spray to affected area (distance as determined by package insert).
c. Use short bursts when applying.
6. Applying powders
a. Dry affected area thoroughly.
b. “Dust” affected area leaving only a thin layer of powder.
c. Gauze or powder puff facilitates application.
d. Use caution around patients with tracheostomies or respiratory problems.
7. Applying gels
a. Cleanse affected areas.
b. If acne medication, wait a minimum of 30 minutes after cleansing before application to reduce incidence of irritation.
C. Occlusion: This produces a barrier usually by the use of plastic film (Figure 4-1). It enhances absorption by preventing medication evaporation and increasing hydration of stratum corneum by moisture retention. Topical medications penetrate 10 to 100 times more effectively when the stratum corneum is moist.
1. Cleanse skin of debris and other medications with soap and water.
2. Apply prescribed topical thinly while skin is damp.
3. Snugly fit plastic wrap, compress air out, and seal borders with paper tape; airtight dressing is unnecessary.
4. Leave dressing intact for prescribed time, best results are obtained if the dressing is left on for at least 2 hours, and many patients leave dressing on for 8 hours while sleeping. A reasonable schedule is twice daily occlusion for 2 hours or once daily overnight for 8 hours with simple application once or twice daily.
 FIGURE 4-1. Occlusive dressing. (From Carter, P. J. (2011). Lippincott textbook for nursing assistants. Philadelphia, PA: Wolters Kluwer.) |
5. Remove gently and cleanse skin.
6. Problems associated with occlusion.
a. Sweat retention
b. Maceration
c. Folliculitis
d. Atrophy
e. Striae
f. May increase risk for bacterial/fungal overgrowth
7. Long-term occlusion with even a low-potency topical steroid may result in temporary suppression of the hypothalamic-pituitary-adrenal (HPA) axis; this function returns after occlusion is discontinued.
III. TOPICAL MEDICATIONS
Numerous topical medications are available for treating skin disorders—corticosteroids, antifungals, antibacterials, antivirals, scabicides and pediculicides, keratolytics and caustics, and antineoplastics.
A. Topical steroids
1. Used extensively in treating skin disorders
2. Reduce inflammation through their ability to induce vasoconstriction
3. Relieve pruritus
4. Induce remission of many cutaneous disorders
5. Potency ranking—groups from 1 to 7 with 1 being the most potent; most dermatoses may be managed with low to moderately potent topical steroids (Table 4-3).
TABLE 4-3 Potency Ranking of Some Commonly Used Topical Steroids | |||||||||||||||||||||||||||
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6. Possible side effects
a. Atrophy—older skin, inguinal, genital, and perianal areas most predisposed to atrophy and may be irreversible depending on the potency of steroid used
b. Striae—irreversible
c. Telangiectasia—often persists after discontinuation of steroid
d. Acneiform eruptions—develop after months of use and reversible
e. Interfere with epithelialization and collagen synthesis in wound healing
f. Burning, itching, irritation, and/or dryness—usually due to the vehicle
g. Hypo-/hyperpigmentation—reversible on discontinuation of steroid
h. Bruising—reversible
i. HPA axis suppression—results from application of potent (fluorinated) steroids in excess of 50 to 100 g/week in adults and 10 to 20 g in children, for 2 or more weeks, and reversible
j. Steroid rosacea and perioral dermatitis—results from progression from weaker steroids to more potent concentrations. Strong steroids must be discontinued. Erythema and pustules eventually subside, but atrophy and telangiectasias may be permanent.
k. Ocular hypertension, glaucoma, and cataracts when topical steroids are used around the eyes
l. Folliculitis and milia caused from occlusive plastic dressings
m. Hypertrichosis of the face
7. Nursing considerations
a. Assess efficacy of medication regularly.
b. Assess the patient for development of side effects; length of therapy increases the risk of developing side effects.
c. Assess for tachyphylaxis, which is the tolerance to the vasoconstriction properties of topical steroids.
d. Assess for signs of superimposed infections.
e. Assess response related to vehicle—ointment-based preparations are generally more potent than chemically equivalent cream-based agents.
f. Avoid use of topical steroids on the face, perineal area, or axillae unless otherwise indicated; if required, monitor closely.
g. Hydration increases percutaneous absorption; application after soaking the skin in lukewarm water will increase absorption; in steroid-responsive generalized dermatoses, application following a bath or shower is most efficacious.
h. Compromised skin has increased percutaneous absorption.
i. Frequency of application depends on steroid potency and severity of dermatoses.
PATIENT EDUCATIONTopical Medications
Understand preapplication instructions.
Use specified and appropriate technique for application; when multiple products are to be applied, understand the order of application.
Use the medication at specified times only.
The medication is only to be applied to areas for which it is prescribed.
Do not overuse or misuse medications as that can result in serious cutaneous and systemic complications.
Monitor results of therapy.
Do not borrow or lend medications to friends or family members.
Use medications as directed.
Follow up with your health care provider if any problems occur.
B. Topical calcineurin inhibitors (TCI): Tacrolimus 0.03% to 0.1% (Protopic) and pimecrolimus (Elidel)
1. Used for treating intermittent flares of atopic dermatitis (AD) and chronic treatment of AD as alternative to topical steroids
2. These drugs can be used as first line therapy or following treatment with topical steroids.
3. Neither causes certain side effects, such as thinning of the skin (atrophy), or stretch marks (striae), spider veins or discoloration of the skins making them desirable when AD is on face.
4. Side effects
a. Burning and stinging with initial use
b. Possible increased risk of secondary infection from bacterial, viral, and fungal infections
5. Despite a number of epidemiological and clinical studies, no clear link between TCI use and lymphoma risk has been established.
C. Topical antifungals (antimycotic agents)
1. Used to treat fungal or dermatophyte infections (superficial infections of the skin, hair, and nails) and also called tineas
a. Tinea pedis (Figure 4-2)
b. Tinea cruris (Figure 4-3)
c. Tinea corporis (Figure 4-4)
d. Tinea versicolor (Figure 4-5)
e. Tinea rubrum (Figure 4-6)
f. Tinea manuum (Figure 4-7)
2. Antifungal-corticosteroid combinations
a. Used to alleviate the symptoms of inflammation and pruritus secondary to certain types of fungal infection but may lead to worsening symptoms if specific type is not correctly diagnosed
 FIGURE 4-2. Tinea pedis. (From Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
 FIGURE 4-3. Tinea cruris. (From Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
 FIGURE 4-4. Tinea corporis. (From Werner, R. (2012). Massage therapist’s guide to pathology. Philadelphia, PA: Wolters Kluwer.) |
 FIGURE 4-5. Tinea versicolor; note the hypopigmented areas. (From Fleisher, G. R., Ludwig, S., & Baskin, M. N. (2004). Atlas of pediatric emergency medicine. Philadelphia, PA: Lippincott Williams & Wilkins.) |
 FIGURE 4-6. Tinea rubrum; chronic tinea of the sole caused by Trichophyton rubrum. (From Centers for Disease Control and Prevention Public Health Image Library.) |
 FIGURE 4-7. Tinea manuum. (From Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
b. Produce more rapid response/alleviation of symptoms
c. May mask superimposed bacterial infections
d. Use in chronic dermatophyte-induced infections may make evaluation of response or titration of therapy difficult secondary to the topical steroid.
e. Combination medications are more expensive.
3. Antifungal chosen based on the following:
a. Species of dermatophyte
b. Body site involved
c. Severity of infection
d. Duration of infection (days, weeks, years, recurrent)
e. Patient’s age and/or pregnancy status
f. Concurrent medical conditions/drug therapy
4. Possible side effects
a. Skin irritation
b. Overgrowth of fungus when occlusion is used
c. Blistering
d. Stinging
e. Peeling
f. Pruritus
5. Nursing considerations
a. Assess the patient’s history for pre-existing condition that might preclude use of topical antifungal.
b. Assess for any evidence of skin irritation secondary to medication.
c. Assess patient/family/significant other’s knowledge of medication and appropriate application.
d. Moist areas of the body (intertriginous and perineal areas) are particularly prone to fungal infections.
e. Ointment-based antifungal products are not desirable due to their occlusive properties.
PATIENT EDUCATIONTopical Antifungals
Review any preapplication instructions; some products may stain fabric, skin, or hair.
Use appropriate technique for application.
Review frequency of applications.
Medication is only to be used on areas for which it is prescribed; self-medication can have disastrous results.
Need to use full course of medication unless side effects occur.
Review expected results from therapy.
Do not lend medication to friends/relatives.
Keep affected areas dry; use nonocclusive, well-ventilated footwear; wash affected areas thoroughly; and change shoes and socks at least once a day.
D. Topical antipruritics
1. Usually contain camphor, menthol, phenol, or a topical anesthetic; have anesthetic and counterirritant properties that induce cooling; and indicated for the temporary relief of pruritus.
2. Examples
a. PrameGel
b. Sarna lotion and cream
c. Calamine lotion
d. Aveeno anti-itch lotion/cream
e. Pramosone
f. Benadryl cream
3. Nursing considerations
a. May be applied liberally 3 to 4 times/day
b. Underlining etiology of pruritus must be pursued and corrected.
c. Monitor for skin irritation especially with topical antipruritics.
PATIENT EDUCATIONTopical Antipruritics
Antipruritic agents provide relief from itching.
May be applied liberally 3 to 4 times a day.
If no improvement, call health care provider.
Avoid sun exposure to prevent photosensitivity reactions.
Do not ingest.
E. Topical antibacterials
1. May be used in combination with other topical modalities
2. Suitable in treating inflammatory acne vulgaris
3. Suitable for use in open wounds and may facilitate granulation
4. Preparations chosen based on organism cultured and skin problem
5. Examples
a. Bacitracin—used for gram-positive infections and prophylaxis in minor cuts, burns, and abrasions
b. Garamycin—used for aerobic gram-negative and some gram-positive infections
c. Meclocycline sulfosalicylate—used for acne vulgaris
d. Mupirocin—greatest activity against gram-positive organisms such as S. aureus and streptococci. Effective treatment for impetigo and nasal colonization of methicillin-resistant staph aureus carrier state
e. Neomycin sulfate—used for aerobic gram-negative and some aerobic gram-positive infections, although can cause contact dermatitis for sensitive individuals
f. Nitrofurazone—used as adjunct therapy in second-and third-degree burns and in skin grafts/donor sites to prevent rejection due to bacterial contamination
g. Silver sulfadiazine—used for gram-negative and gram-positive infections
h. Erythromycin—indicated for acne vulgaris, rosacea, and folliculitis
i. Chloramphenicol—used for prophylaxis and treating superficial bacterial infections
j. Tetracycline hydrochloride—used for prophylaxis and treatment of superficial infections
k. Clindamycin—skin and soft tissue infections, impetigo, abscesses, and cellulitis
6. Nursing considerations
a. Use contraindicated in patients with a history of prior sensitization
b. Unless otherwise indicated, cleanse affected area with antibacterial soap and water before application.
c. Observe for any signs of allergic reaction—burning, swelling, redness, or worsening of condition.
d. With prolonged use, monitor for superinfections and overgrowth of nonsusceptible organisms, especially fungus.
e. Alcohol-based antibacterial solutions may cause burning upon application.
f. Nasal application of mupirocin may cause headache, cough, itching, and alterations in taste.
PATIENT EDUCATIONTopical Antibacterials
Understand treatment objectives and if unclear, ask questions.
Use correct application techniques, including preapplication process.
Need to use full course of medication.
Use medication only on affected areas.
Call health care provider if side effects develop.
Consult with health care provider if no improvement in 3 to 5 days.
F. Topical antivirals
1. Acyclovir and penciclovir (Denavir)—used to prevent or treat herpetic viral infections and reduce viral shedding; mode of action is interference with viral replication but is less effective than systemic therapy (Figures 4-8 and 4-9).
 FIGURE 4-8. Herpes labialis. (From Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
 FIGURE 4-9. Herpes zoster; drying hemorrhagic crusts appear in a “zosteriform” distribution. (From Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
2. n-docosanol (Abreva) cream—OTC and may shorten episode by hours or 1 day
3. Contraindicated with hypersensitivity to any components
4. Use cautiously during lactation, renal impairment.
5. Possible side effects: burning/stinging, pruritus, or rash
6. Nursing considerations
a. Ointment must thoroughly cover all lesions.
b. Initiate treatment as soon as possible after onset of symptoms, within 24 hours if possible.
c. Monitor for side effects and process.
PATIENT EDUCATIONTopical Antivirals
Understand treatment objectives and if unclear, ask questions.
Use appropriate application of topical medications.
Important to complete therapy
Understand possible side effects and what to do should they occur.
The use of other creams or ointments may delay healing and may cause spreading of lesions.
Contact health care provider if symptoms not relieved by 7 days.
G. Scabicides and pediculicides
(See Chapter 16 for further detail on infestations and the treatments indicated.)
H. Keratolytics/caustics
1. Keratolytics dissolve and separate the stratum corneum in diseases where hyperkeratosis is a manifestation; caustics have an antimitotic action.
2. Examples
a. Coal tar (cream, shampoo, ointment, gel, lotion, soap, bath solution)
b. Salicylic acid (cream, gel, ointment, patch, shampoo, solution)
c. Anthralin
d. Cantharidin
e. Podophyllum resin
f. Resorcinol
g. Silver nitrate
h. Sulfur
i. Trichloroacetic or bichloroacetic acid
3. Possible side effects
a. Irritation
b. Burning
c. Pain
d. Inflammation
e. Increased dryness
f. Erosions
g. Blistering
h. Hyperpigmentation
i. Hearing loss, tinnitus, dizziness, confusion, headache, and hyperventilation with salicylic acid if salicylism develops
j. Bleeding, dizziness, hematuria, and vomiting may be seen as side effects of podophyllum resin.
4. Nursing considerations
a. Use with caution in pregnant or lactating women.
b. Do not apply to face, groin, axillae, mucous membranes, and broken or inflamed skin.
c. Do not apply caustics to intertriginous areas.
d. Do not use occlusion with caustics.
e. Salicylic acid is contraindicated for use in children under 2 years of age, diabetics, or individuals with impaired circulation.
f. Do not apply salicylic acid to moles, birthmarks, unusual warts with hair, genital warts, or warts on mucous membranes.
g. Prolonged use of salicylic acid can lead to salicylate toxicity.
h. When applying caustics, protect uninvolved skin by applying petrolatum.
i. Apply caustics only to affected areas.
PATIENT EDUCATIONKeratolytics
Understand treatment objectives and if unclear, ask questions.
Use correct application of topical medications.
Be aware of possible side effects of treatment.
Important to complete therapy.
Apply topicals only to affected areas and avoid surrounding skin.
Topical is not to be applied to broken skin, wounds, or cuts.
Do not use occlusion unless directed to do so.
I. Antineoplastics
1. Used for treating reactive and proliferative cutaneous malignancies
2. Exert action through different mechanisms.
a. Cycle specific are more effective against proliferating cells.
b. Phase specific are more effective against a specific phase of the cell cycle.
c. Interfere with the synthesis of deoxyribonucleic acid (DNA) through different mechanisms
3. Categories of antineoplastics.
a. Alkylating agents—nitrogen mustard (mechlorethamine) and BiCNU (carmustine)
b. Disrupt the structure of DNA through nonspecific cell cycle manner
c. Interfere with normal cell division in rapidly proliferating tissue
4. Used in treating T-cell lymphoma (mycosis fungoides)
a. Antimetabolites—5-fluorouracil
b. Interfere with the synthesis of nucleic acids and proteins
c. Phase specific and inhibits RNA and DNA synthesis
5. Used in treating superficial basal cell carcinomas, multiple actinic leukoplakia, or solar keratosis
a. Retinoid X receptors bexarotene gel (Targretin) 1% for the topical treatment of resistant T-cell lymphoma
b. Bexarotene gel inhibits the growth of some tumor cell lines of hematopoietic and squamous cell origin.
c. The exact mechanism of action in the treatment of T-cell lymphoma is unknown.
d. Affects cellular differentiation and proliferation and also downregulates CCR4 and E-selectin expression, affecting malignant T-cell trafficking to the skin
6. Possible side effects
a. Pain
b. Pruritus
c. Hyperpigmentation
d. Irritation
e. Inflammation
f. Burning
g. Scarring
h. Swelling
i. Alopecia
j. Photosensitivity
k. Scaling
l. Contact dermatitis
7. Nursing considerations
a. Apply with care near eyes, nose, and mouth.
b. Always wear gloves when applying.
c. Can cause photosensitivity.
d. Avoid occlusion.
e. Erythema, scaling, blistering, burning, and pruritus are expected results of topical treatment with 5-fluorouracil.
f. Nitrogen mustard is applied total body with exception of the groin.
g. Nitrogen mustard may be applied in liquid form or compounded in a petrolatum base.
h. Inspect skin before and during treatment.
PATIENT EDUCATIONAntineoplastics
Understand the treatment objectives; if unclear, ask questions.
Important to complete therapy.
Use correct application of topical and wash hands thoroughly after application.
Be aware of possible side effects of treatment.
Possibility of increased photosensitivity; avoid sun exposure and/or use a sunscreen of at least SPF 30 daily.
If using 5-fluorouracil, there are various stages of inflammation that will occur, including redness, scaling, blistering, burning, and itching, which are expected; therapy is discontinued when ulceration and erosion begin and occurs in 2 to 12 weeks depending on diagnosis.
This is a potent prescription medication, which should not be shared with others or used for other skin conditions than the one that it has been prescribed to treat.
J. Vitamin A/retinoids
1. Used in treating noninflammatory acne, photoaging, hyperpigmentation, flat warts, molluscum contagiosum, senile comedones, and actinic keratosis and to enhance percutaneous absorption of other topical agents; metabolized in the skin (Figures 4-10, 4-11 and 4-12).
2. Mechanism of action
a. Initiates increased cell turnover in both normal follicles and comedones
b. Reduces cohesion between keratinized cells
c. Causes skin peeling and extrusion of comedones; new comedone formation is prevented with continued use
d. Improves skin turgor and reduces fine wrinkling
e. Improves circulation, which improves skin color
 FIGURE 4-10. Acne of the face. (Image provided by Stedman’s.) |
 FIGURE 4-11. Actinic keratosis; keratotic papule characteristic of a hypertrophic actinic keratosis. (From Goroll, A. H., & Mulley, A. G. (2009). Primary care medicine. Philadelphia, PA: Wolters Kluwer.) |
3. Possible side effects
a. Erythema
b. Peeling
c. Thinning of stratum corneum increasing risk of sunburn/sun damage
d. Increased susceptibility to irritation from wind/cold
e. Dryness
f. Edema
g. Blisters
h. Stinging
4. Nursing considerations
a. Use with caution in pregnant or lactating women.
b. Avoid applying around eyes, mouth, angles of the nose, and mucous membranes.
c. Increases risk of sunburn.
d. Astringents, alcohol-based lotions, and acne soaps may not be tolerated while using retinoids.
 FIGURE 4-12. Molluscum contagiosum. (From Goodheart, H. P. (2003). Goodheart’s photoguide of common skin disorders (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.) |
PATIENT EDUCATIONRetinoids
Understand treatment objectives, and if unclear, ask questions.
Use correct application technique as described by your health care provider.
Avoid using keratolytics, alcohol-based products, abrasive cleansers, astringents, and topical products containing spice or lime.
Topical moisturizer can be used if skin becomes too dry.
Apply topical medication after thoroughly cleaning and drying the skin.
Possibility of increased sensitivity to sun; use a sunscreen of at least SPF 30.
Important to adhere to prescribed regimen.
IV. INTRALESIONAL THERAPY
A. Intralesional steroids
1. Injected directly into or just beneath the lesion
2. Provides a reservoir of medication that lasts for several weeks to months
3. Used to supplement other treatment modalities
4. Conditions treated
a. Psoriasis
b. Alopecia areata
c. Cystic acne
d. Hypertrophic scars/keloids
e. Chronic eczematous inflammation and lichen simplex chronicus
f. Discoid lupus (use lidocaine/steroid solution as for herpes zoster)
5. Most commonly used mixture: 2.5 to 10 mg/mL suspension of triamcinolone acetonide
6. Other mixtures
a. 10 mg/mL—effective for chronic eczematous inflammation, acne, and hypertrophic scars/keloids
b. 10 mg/mL diluted with 1% Xylocaine or physiologic saline—effective for acne and discoid lupus
c. 2.5 to 5.0 mg/mL—effective in suppressing inflammation
7. Possible side effects
a. Prolonged, continuous use may lead to adrenal suppression.
b. Atrophy may result after multiple injections in same site.
8. Nursing considerations
a. Injections may be painful.
b. Atrophy can result from multiple treatments.
c. Multiple treatments may be necessary in some conditions such as keloids.
d. Vial of steroid solution must be shaken thoroughly before drawing up solution.
e. If syringe of medication is not used immediately, syringe should be shaken immediately prior to injection.
B. Intralesional antineoplastic agents.
1. Bleomycin sulfate
a. Useful in treating recalcitrant periungual or plantar warts and Kaposi sarcoma
b. Solution: 1 unit/mL in physiologic saline (dissolve 15 unit vial of bleomycin in 15 mL of sterile physiologic saline)
c. Inject 0.1 to 1.0 mL until wart blanches.
2. Vinblastine
a. Useful in treating Kaposi sarcoma
b. Solution: 0.1 to 0.5 mg/mL q4wk
c. Maximum total dose to be used is 2 mg.
3. Interferon alfa-2b, recombinant, and interferon alfa-n3
a. Treatment indications
i. Genital warts that are unresponsive to all forms of conventional treatment, imposing significant social or physical limitations
ii. Kaposi sarcoma
iii. Basal/squamous cell cancers
b. Possible side effects
i. Injection site reactions—redness, pain, swelling, and discoloration
ii. Flu-like symptoms
4. Nursing considerations
a. A thorough history to determine presence of underlying medical problems (cardiac, liver, or renal)
b. Medication must be refrigerated.
c. Initial treatment for warts will be 3 times/week for 3 weeks.
d. Flu-like symptoms can be managed with acetaminophen.
PATIENT EDUCATIONAntineoplastic Agents
Understand treatment objective, and if unclear, ask questions.
Understand possible side effects and how to handle.
Important to adhere to prescribed treatment regimen.
V. SYSTEMIC MEDICATIONS
A. Antibiotics: Act to prevent or treat infection from pathogenic microorganisms
1. Macrolides: Azithromycin and erythromycin—highly effective; one of the safest antibiotics; topical erythromycin is the drug of choice in treating acne and folliculitis.
a. Members of macrolide group
b. Bacteriostatic—inhibits protein synthesis
c. Bactericidal in high concentrations
d. Pharmacokinetics
i. Inactivated rapidly by gastric acid
ii. Dissolves poorly in water
iii. Distributed well to most tissues with the exception of cerebrospinal fluid (CSF)
iv. Transported across the placenta and excreted in breast milk
v. Metabolized in the liver and excreted in the bile and small amount excreted in urine
vi. Peak serum concentration level occurs 1 to 4 hours after a single 250-mg dose of erythromycin in a fasting patient and 2.5 to 3.2 after dose of azithromycin
e. Pharmacotherapeutics
i. Broad spectrum of antimicrobial activity, effective against the following:
(a) Pneumococci
(b) Group A Streptococci
(c) Staphylococci aureus (not effective against methicillin-resistant S. aureus)
(d) Gram-negative and gram-positive bacteria
(e) May be used in patients with penicillin allergy who have group A beta hemolytic streptococci or S. pneumoniae infection
ii. Dosage/indications
(a) Erythromycin—Adults: 250 mg PO qid × 10 days, 333 mg PO q8h, or 500 mg PO q12h (base or stearate), 400 mg PO q6h or 800 mg PO q12h (ethylsuccinate); pediatric dose (base and ethylsuccinate): children greater than 1 month: 30 to 50 mg/kg/d PO in divided doses q6-8h (max. 2 g/d as base or 3.2 g/d as ethylsuccinate); 30 to 50 mg/kg/d PO divided q6h (max. 2 g/d as stearate).
(b) Azithromycin—Adults: 500 mg PO qd on first day, then 250 mg/d PO for 4 additional days (total dose 1.5 mg): children 6 month and older: 10 mg/kg PO (not greater than 500 mg/dose) on first day, then 5 mg/kg PO (not greater than 250 mg) for four additional days.
(c) Skin and soft tissue infections
(i) Chlamydia trachomatis urethritis
(ii) Erythrasma
(iii) Gonorrhea
(d) Strep. pyogenes infections
(i) Lymphangitis
(ii) Impetigo
(iii) Ecthyma
(e) S. aureus infections
(i) Folliculitis
(ii) Furunculosis
(iii) Infected dermatitis
iii. Adverse reactions
(a) Commonly causes nausea and vomiting when taken on an empty stomach
(b) Diarrhea
(c) Cholestatic hepatitis with fever, abdominal pain, nausea, vomiting, eosinophilia, and elevated serum bilirubin
(d) Stevens-Johnson syndrome and toxic epidermal necrolysis (azithromycin)
iv. Drug interactions
(a) Theophylline
(b) Cyclosporine
(c) Carbamazepine
(d) Warfarin
(e) Digitalis
(f) Ergotamine
(g) Methylprednisolone
(h) Pimozide
(i) Diltiazem
(j) Ketoconazole
(k) Verapamil
2. Penicillins
a. Derived from strains of Penicillium notatum and Penicillium chrysogenum, which are common molds seen on bread or fruit.
b. First generation
i. Penicillin G and penicillin V
ii. Newer semisynthetic penicillinase—resistant
(a) Oxacillin
(b) Cloxacillin
(c) Dicloxacillin
c. Second generation
i. Amoxicillin and clavulanate (Augmentin)
ii. Ampicillin
iii. Amoxicillin
iv. Ampicillin/sulbactam (Unasyn)
d. Third generation
i. Ticarcillin (Ticar)
ii. Ticarcillin/potassium clavulanate (Timentin)
e. Fourth generation
i. Piperacillin (Pipracil)
ii. Piperacillin sodium and tazobactam sodium (Zosyn)
f. Pharmacokinetics
i. Kills bacteria by destroying the cell walls, bactericidal
ii. Natural penicillins (penicillin G and V) effective against the following:
(a) Gram-positive organisms
(b) Gram-negative organisms
(c) Anaerobic organisms
iii. Penicillinase-resistant penicillins (cloxacillin, dicloxacillin, nafcillin, oxacillin)
(a) S. aureus
(b) S. epidermidis
(c) Some streptococci infections
iv. Absorption
(a) Oral absorption varies and limited by gastric acidity and binding with food. All should be taken on an empty stomach with the exception of amoxicillin.
(b) Completely and rapidly absorbed throughout the body after parental administration.
(c) Distributed widely in fluids/tissue including liver, kidneys, bones, muscle, and placenta and enters breast milk
(d) Does not readily enter CSF
(e) Minimally metabolized in the liver
(f) Excreted unchanged and primarily through the kidneys
v. Peak serum concentrations vary from onehalf hour to 24 hours depending on route of administration.
g. Pharmacotherapeutics
i. Broad spectrum of antimicrobial activity
(a) Procaine penicillin used for susceptible strains of gonorrhea
(b) Benzathine penicillin G preferred for syphilis
(c) Dicloxacillin: Treatment of osteomyelitis, suspected or proven staphylococcal infections, and most streptococci and S. aureus infections
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