Chapter 42

Agents Used in the Treatment of Skin Conditions

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The Skin The largest organ Several functions

• Protective barrier—microbials and trauma

• Senses temperature changes

• Secretes wastes through sweat glands

• Stores fat

• Synthesizes vitamin D

• Provides a site for drug absorption

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Epidermis

Outer layerThickness is variableBasal layer is where new cells

are formedOld cells migrate to surface

Epidermis

Prickle layer Protein projections connect adjacent

cells Cells become flat and press together Compressed cells become the keratin

layer Keratin layer is the protective barrier

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Dermis

Thicker than the epidermis Provides support and nourishment for

the epidermis Rich supply of blood vessels, nerves,

sweat glands, and hair follicles

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Structures of The Skin

Hair and nail tissueEccrine and apocrine sweat glandsSweat contains water and waste

productsEccrine glands are located

throughout the body

Skin structures

Apocrine glands are associated with a hair follicle – mainly in axillary and pubic areas

Emotional stimuli causes excretion of electrolyte solution

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Skin Structures

Sebaceous glands – connected to hair follicles

Large numbers on head and faceAt puberty, secretes oily mixture

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Drug Classification of Dermatological Agents

Emollients Keratolytics Local anesthetic agents Local antipruritic agents Antibacterial agents

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Emollients

Dry skin causes discomfort, itching, cracking, and predisposition to skin disorders

Treatment is use of emollients Oily in nature: some skin lotions are

emollients Prevents loss of additional skin

moisture

Emollients

Forms occlusive barrier Most contain waxes, fats, and/or oils Most effective when applied after

shower or bath Do not use on skin lesions that are

moist or exudative

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Keratolytics

Some disorders cause a thickening of the keratin layer

Skin becomes brittle and easily cracked

Causes itching and discomfortSalicylic acid, lactic acid, and

acetic acid

Keratolytics

Applied after area has been bathed or soaked

More effective if covered with occlusive dressing

Kept on skin overnight; removed in morning

Repeated applications are effective

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Local Anesthetics and Antipruritic Agents

Inhibits conduction of nerve impulses from sensory nerves

Reduces pain and itching Used topically for insect bites, burns, and plant

allergies

Local Anesthetics and Antipruritic Agents

Poorly absorbed through intact skin Enhanced through damaged skin Local or systemic adverse effects Allergic reaction (locally or

systemically)

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Local Anesthetics and Antipruritic Agents

Topical anesthetics should only be used when absolutely necessary

Avoid in patients with previous hypersensitivity reactions

Avoid in severely traumatized skin

Local Anesthetics and Antipruritic Agents ‘caine’ types Ointment, cream, spray, liquid or gel

forms Some antipruritic products contain

antihistamines Can be associated with development of

local irritation and hypersensitivity reactions

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Antibacterial Agents

Prevents infectionTreats superficial infectionsTreat acne vulgarisAssociated with development of

hypersensitivity

Antibacterial Agents

Topical antibiotic agents are not usually ones that are used systemically

Combination therapy is popularCaution when applying to large

areasSystemic effects may be possible

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Drug Classification of Dermatological Agents

Antiviral agents Antifungal agents Anti-inflammatory agents Antiparasiticidal agents

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Antifungal Agents

Treats two types of fungal infections Dermatophyte organisms Yeastlike organisms

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Dermatophyte Infections

Caused by tinea or others

Most common is ringworm type

Circular pattern

Dermatophyte infections

Scalp, nails, and/or skinAlways superficialMay be known as ‘athlete’s

foot’ or ‘jock itch’

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Dermatophyte Infections

Can live only on dead keratin tissue

Affected area must be replaced with fungus-free tissue

Agents must be continued long-term

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Dermatophyte Infections

Relapses common

Ointment, cream, aerosol, lotion, and powder forms

If burning or irritation develops, discontinue use

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Dermatophyte Infections

Oral treatment may be effective Deposits in newly formed skin cells When new cells reach keratin layer, they

are resistant to fungus Best absorbed with or after a fatty meal Monitor for hypersensitivity

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Yeastlike Infections

Involves warm, moist areas and mucous membranes

Moisture promotes yeast growth Ventilation of area is important Treatment should be continued for 1

week following lesion disappearance

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Antiviral Agents

Most difficult to treatHerpes simplex 1 and 2Topical agents - cannot

completely eradicate Decreases healing time and

pain

Antiviral agents

Topical, oral, or parenteral formsTopical form can cause burning,

stinging, itching, or rashCaution in patients with renal

impairmentMonitor for hypersensitivity

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Anti-Inflammatory Agents

Topically applied corticosteroids Alleviates inflammatory symptoms Irritation or allergic disorders Useful in controlling psoriasis Interferes with normal immunological

responses Reduces redness, itching, and edema Slows rate of skin cell production

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Anti-Inflammatory Agents

Effectiveness depends on potency of drug, vehicle used, skin thickness and integrity, and presence of moisture

Damaged skin may increase amount of drug absorbed systemically

Anti-Inflammatory Agents

Increases systemic side effectsOcclusive dressings increase

absorptionPotent agents must be used with

caution on thin skinDo not use in the presence of

fungal infection

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Antiparasitic Agents Parasites live on outer surfaces Lice and scabies Lice is transmitted person to person Lives on head, body, or pubic area Scabies is a mite; burrows under the skin and lays

eggs Drug of choice is lindane Do not use in children under 2 Can cause seizures if applied to open skin CNS toxicity

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Additional Dermatologic Agents Debriding agents Antineoplastic agents Burn treatment agents Eczema agents Psoriasis agents Topical hair agents Agents for diabetic foot ulcer

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Diabetic Foot Ulcers

Leading cause of amputationsMicrovascular and neurological

changes due to long-term elevated blood sugar levels

Increases migration of cells responsible for wound healing to site of ulcer

Diabetic Foot Ulcers

Needs adequate blood supply Gel form helpful for protecting healing

wounds Long-term therapy required – Regranex

promotes healing

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Antineoplastic Agents

Destroys cells that grow rapidlyTopical treatment of solar or actinic

keratosisPremalignant skin lesionsDevelops in fair skinned people

exposed to heavy sunlightAlso used to treat basal cell

carcinomas

Antineoplastic Agents

Use nonmetallic applicatorsProtect skin with rubber glovesWash hands immediatelyAvoid contact with eyes, nose, or

mouthAvoid exposure to sunlight

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Agents Used to Treat Burns

Treatment aimed at preventing infection

Important to prevent toxic absorption into systemic circulation

Blood supply is impairedTopical products may be only way

to prevent infection

Agents used to treat burns

Occludes site to prevent contamination

Applied to burn after cleaning and debriding

Therapy continued until healing well or ready for grafts

Monitor for hypersensitivity and adverse effects

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Minoxidil

Systemically used as an antihypertensive Topically promotes hair growth Dilates local blood vessels Long-term use Caution with patients with heart disease May cause tachycardia, fluid retention, and/or

weight gain Systemic effects more likely if applied to

broken skin

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Topical Debriding Agents Purpose

• Remove dead skin

• Promote healing

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Topical Debriding Agents

Made of enzymes General action

• Digest dead necrotic tissue Specific action

• Made of enzymes that digest:

•Collagen: collagenase (Santyl)

•Fibrin in a blood clot: fibrinolysin (Elase)

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Debriding Agents

Promotes removal of dead tissue Removal of dead tissue enhances formation of

new tissue Wound healing occurs more quickly Second- and third-degree burns and decubitus

ulcers Enzymes selectively digest dead tissue Specific in action

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Eczema S & S of acute or chronic conditions

• Area appears inflamed

• Skin may be dry and may include wet or weepy drainage

• Definition

• Inflammatory skin condition. Symptoms are pustules, redness, vesicles, crusts, skin thickening, and persistent itching and burning.

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EczemaDrug agent

•Pimecrolimus (Elidel)

•Topical immunomodulator

•Adverse effects

•Site irritation

•Headache

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Agents Used to Treat Eczema

Eczema is a chronic inflammatory disease of the skin Itching and scaling of the skin Piecrolimus - short-term and intermittent long-term use - adverse effects include site irritation and headache Tacrolimus - not a steroid - adverse effect is an increased risk for skin infections

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Psoriasis A chronic skin condition

• Consists of painful reddened papules that form plaques with distinct borders

• Other patches appear as silvery yellow-white scales

• Usually located

•Elbows, scalp, knees, and genitalia

• Amevive (alefacept)

• Raptiva (efalizumab)

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Psoriasis Drug agent

• Alefacept (Amevive)

•Immunosuppressant

•Stops the activity of T lymphocytes

•Given intramuscularly

•Adverse effects

•Infection

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Agents Used to Treat Psoriasis

Psoriasis is an autoimmune chronic skin disorder

Plaques on the skin – itching, bleeding, cracking

Alefacept – promotes longer remissions Efalizumab – stimulates body’s immune

response

Agents used to treat burns

Topical medications more effective if blood supply to area damaged

Aim to prevent infection without systemic absorption of toxins

• Silvadene

• Sulfamylon

• Furacin

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Topical Application Methods

Depend on the etiology of the skin problem

Require thorough cleansing of the skin before the agent is applied or reapplied

Must be applied appropriately or the agents will not work

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Nursing Considerations

Perform thorough skin assessmentMinimize factors that promote skin

drying in the elderlyInstruct in proper use of topical

medicationsBe aware that occlusive dressings

may increase absorption

Nursing Considerations

Good hygiene is importantAssess for symptoms of infectionAdminister medications according

to guidelinesTeach diabetic patient the

importance of foot care and daily assessment

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