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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5200_Библиотеки_им_академика_М_И_Перельмана

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nodules,andpersistentedemaofthecentralpartoftheface.
DIAGNOSTICCRITERIA
The diagnosis ofrosacea is based onthehistoryand clinicalpresentation.Fixed telangiectasia is the hallmark of this disorder. Inpatients younger than age 30, acne should be ruled out.In patients with systemic symptoms, systemic lupus erythematosus should be considered. Bacterial cultures should be performedtoruleoutStaphylococcusaureusandgram-negativefolliculitis.Patientswhodonotrespond tosystemicantibioticsshouldbeevaluatedforDemodexfolliculoruminfestation.Approximately50%of patientsreportocularinvolvement,soanyocularsymptomsshouldbeinvestigated.
Referraltoanophthalmologistshouldbeconsideredifthepractitionersuspectscornealulcerationor
keratitis.
INITIATINGDRUGTHERAPY
Thegoaloftherapyistominimizethedisfiguringeffectsofrosaceaandpreventfurthertissuedamage.As withacne,thepatient’sconcernswithregard toappearance mustbe considered. Patientswithrosacea mayfeelstigmatized.Treatmentduringtheearlyphase(vasodilation)iseasiertotreatwiththeadditionof topicaltherapieswithvasoconstrictiveproperties,discussedlaterinthechapter.
TopicalAntibacterials
Metronidazole
MechanismofAction
Topicalmetronidazole(MetroGel,Noritate)hasanti-inflammatoryproperties(Table15.5).Itisavailable in0.75%and1%strengthsandis appliedonceor twice dailyinathinlayerontheface,avoiding the eyes.
Dosage
Metronidazole is available in forms of cream, gel, and lotion. Initial results should be seen in approximately3weeksandthefulleffectinapproximately9weeks.Patientsarethenmaintainedonthe agent indefinitely with drug holidays as appropriate. Patients who receive concurrent anticoagulant therapyshouldbemonitoredcloselyforanenhancedanticoagulationeffect.
TABLE15.5
OverviewofTopicalAgentsforRosacea
Contraindications
Therearenocontraindications.
SideEffects
Adverseeventsincludeburning,skinirritation,transienterythema,milddryness,andpruritus.
SpecialConsiderations
Leastexpensive generic optionsforthosewithoutinsuranceor thosewithcoveragelimitationsmaybe recommended.
CombinationMedications
Sodium sulfacetamide 10% with sulfur 5% (Sulfacet-R, Clenia, Plexion) also has anti-inflammatory propertieswhenusedtotreatrosacea.
Dosage
Itisappliedonetothricedailyasneededforflares.
Contraindications
Itiscontraindicatedinpatientswithkidneydisease,andcautionshouldbeexercisedinthosesensitiveto sulfadrugs.Applicationtoeyesandareasofdenudedskinistobeavoided.
SideEffects
Adverseeventsincludelocalirritationandallergicdermatitis.
SpecialConsiderations
Rosulaisabrandedcombinationofsulfacetamide10%,sulfur5%,andurea10%.Additionofureahelps tosootheandrelieverednessandinflammation.
AzelaicAcid
Azelaicacid15%(Finacea)isindicatedforthetopicalapplicationformildtomoderaterosacea.
Dosage
Suppliedasgelorfoamformulationappliedonceortwicedaily.Formoreinformationregardingazelaic acid,seeacnesectionearlierinthischapter.
Antiparasitic
Ivermectin
MechanismofAction
Ivermectin1%(Soolontra)isamacrocycliclactoneworkingasatopicalanti-infective.Themechanism ofactionisunknown.Itisusedaloneorincombinationwithotheragents.
Dosage
Itisappliedoncedailyoncleandryface.
SideEffects
Aswithanyofthetopicalagentsonsensitiveskin,localirritation,peeling,andrednessmayresult.
DecongestantsandVasoconstrictors
OxyometazolineHClCream1%(Rhofade),Brimonidine0.33%Gel(Mirvaso)
MechanismofAction
Botharealpha-adrenergic agoniststhatworkthroughdecongestionandvasoconstriction.Thisprovides temporaryexternalconstrictiontosurfacevessels.
Dosage
Applypea-sizedamountsoncedailyinthemorningtoforehead,cheeks,nose,andchin.Thisdrugshows benefitandmaybeeffectiveforupto8to12hours.Itis helpfulinpreventingthesevereformsofthis condition.
Contraindications
These products arenotfor internal consumptionand for topical use only.A safetycap is providedto prevent accidental internal consumption. Caution should be exercised in use with individuals with glaucomaduetoincreasedincidenceriskforangleclosureglaucoma.
SideEffects
Sideeffectsincludeerythema,flushing,andburningsensations.
OralAntibiotics
When topical agents have not improved the patient’s condition, oral anti-infective agents may be considered.
MechanismofAction
Antibioticsareusedfortheirantiinflammatoryeffectinlowerdosesasopposedtohigherdosesinacne forantimicrobialproperties.Oralantibioticsareindicatedforpatientswithocularsymptomsandwhen topicalagentsaloneareineffective.
Dosage
Doxycycline(Vibramycin,Monodox,Doryx,Oracea)istheantibioticofchoicefortreatingrosacea.Itis prescribedindosesof20mgtwicedaily,50mgoncedaily,or40mgslow-releasepreparations.After3 to 5 months, the practitioner may consider discontinuing oral agent while continuing topical therapy. Patientsshouldbecautionedtoavoidsunexposurewhiletakingdoxycyclineasdiscussedearlier.
Erythromycin (E-mycin, Ery-Tab) 250 and 500 mg is a useful agent when tetracycline is contraindicated. Dosages and tapering regimens are identical to those used for tetracycline and are discussedearlierinchapter.
Isotretinoin
Isotretinoinmaybeprescribed forpatientswhodo notrespondtooralandtopicalagents.Thedrugis prescribedindoses of0.5 to1.0 mg/kg/dforupto8 months.Precautionsandlaboratoryfollow-upas describedearlierinthischapter.
SelectingtheMostAppropriateAgent
Initialdrugtherapychoicesshouldincludeatopicalagent.Casesthatinvolveocularsymptomsshouldbe treatedwithoralantibioticsinitially.
TABLE15.6
RecommendedOrderofTreatmentforRosacea
Order Agent Comments
Firstline Topicalmedication Improvementtakes6weeks Secondline Oralantibiotics Improvementtakes6weeks Thirdline Oralisotretinoin;considerreferraltodermatologist Teratogenic
First-LineTherapy
Thefirst-linetreatmentofrosaceaconsistsoftopicaltherapy.Ifnoimprovementisseenafter6weeks, second-linetherapybegins.
Second-LineTherapy
Second-linetreatmentconsistsofaddinganoralantibiotic.After2weeks,thedoseisreducedby50%, andthen,after6weeks,theoralantibioticisdiscontinuedaltogetherandthetopicaltreatmentcontinues indefinitely.
Third-LineTherapy
Third-linetreatmentconsistsoforalisotretinoinorreferraltoadermatologist.Table15.6liststhelines oftherapyforrosacea,andFigure15.2outlinesrosaceatreatment.
MONITORINGPATIENTRESPONSE
Asdiscussed throughout this chapter,thepatient’sresponse ismonitored regularlybyobservationand follow-upvisitstoadjustmedicationsandprovidesupportandencouragementduringtherapy.
PATIENTEDUCATION
Patientswithrosaceaneedtorecognizewhattriggerstheircondition.Thegoalofmanagementistoavoid flare-ups.Althougheachpatientrespondsdifferentlytotriggers,commontriggersaresunexposure,strong winds,coldweather,warmenvironment,strenuousexercise,alcoholicbeverages,spicyfoods,hotfoods andbeverages,andstress.
Itis importantthatabroad-spectrumultravioletA(UVA)/ultravioletB(UVB) sunscreenbeusedand appliedroutinely.
Patientsmaybeadvisedtoavoidharshcleansersandavoidskinirritants.Cosmeticfoundationswitha green tint may camouflage redness. Additional information and consumer education may be obtained throughtheNationalRosaceaSociety(1-888-NOBLUSH,http://www.rosacea.org).
FIGURE15–2Treatmentalgorithmforrosacea.
CASESTUDY1
J.S.age16,comestoyourofficeforaroutinephysicalexamination.Younoticethatshehasfacialacne thatsheishidingwithheavymakeup.ShehastriedClearasilinconsistentlywithoutrelief.Sheworks atafast-foodrestaurantas a cookafterschoolandontheweekends.Her motherhasmadeherstop eatingchocolatesandgreasyfoods,butthathasnotseemedtohelpher.Sheisconcernedbecauseher promisin6weeksandshewantsherfaceclear.Onphysicalexamination,thereareopenandclosed comedones,aswellaspapules,onherfaceandback.Noscarringisevident.J.S.confidesthatshehas recentlybecomesexuallyactive.
Diagnosis:AcneVulgaris
1.ListspecifictreatmentgoalsforJ.S.
Answer: Improvement ofappearance, minimize the number andseverity oflesions, andprevent
scaring.
2.Whatdrugtherapywouldyouprescribe?Why?
Answer:Initiallytopicaltherapy. Ifthatisn'teffective, consider oralcontraceptives withethinyl
estradiolandnorgestimateordrospirenonesincesheissexuallyactive.
3.Whataretheparametersformonitoringthesuccessofthetherapy?
Answer:Responseoflesionsandappearance.
4.Describespecificpatienteducationbasedontheprescribedtherapy.
Answer:Donotuseexcessivetopicalmedicationsthinkingmoreisbetter;realizethatthetherapy
takestimetowork.
5.Listoneortwoadversereactionsfortheselectedagentthatwouldcauseyoutochangetherapy.
Answer:Severeirritationoftheskininuseoftopicalpreparation.
6.Whatwouldbethechoiceforsecond-linetherapy?
Answer:Oralantibiotics.
7.Whatover-the-counterordietarysupplementwouldyourecommendtoJ.S.?
Answer:Teatreeoil,zinc.
8.WhatdietaryandlifestylechangesshouldberecommendedforJ.S.?
Answer:Eatlowglycemicfoods.
9.Describeoneortwodrug–drugordrug–foodinteractionsfortheselectedagent.
Answer:Twotopicalpreparationsshouldnotbeusedatthesametime.
CASESTUDY2
R.K.is a 30-year-oldfemale withirregular menstrual cycles due to depo-provera. She haspainful cystic nodules at the jawline. She has tried multiple over-the-counter (OTC) topical agents with
limited success. She has currently been using OTC salicyclic acid washes and creams due to sensitivitytobenzylperoxide(BPO)products.
Diagnosis:AcneVulgaris
1.Whatotherquestionsregardingskincareshouldbeelicited?
Answer: It is important to elicit that the client is using proper cleansing and moisturization.
Noncomedeogenicoroil-freemakeupandskincareproductsareencouraged.Preventoverdrying ofskinwhichcouldleadtomorelesions.
2.Whichclasswouldyouconsiderasfirst-lineagents?Whenisanappropriatetimeforafollow-up visit?
Answer: With the knowledge of sensitivity to BPO, theremaining choices include azelaic acid and/or topical dapsone. Prepare the client for the necessary time needed to see improvement. Realisticexpectationsshouldbesetregardingslowimprovementover6to8weeks.Haveclients returnsoonertoensuretheproductsarebeingused.
3.  Upona returnvisit withminimal improvement,whatothertherapeutic considerationsshouldbe discussed?Second-lineoptionsconsidered?
Answer:Atthispointconsideraddingspironolactonewhichisverybeneficialforhormone-related painfuljawlinecysticacne.Perhapsotheroptionsofbirthcontrolcouldbeconsidered.Discussion with an endocrinologist may also be considered. Finally, one might recommend low-dose isotretinoinifothertherapieshavenotbeensuccessful.
4.Ifconsideringaddinganoralagent,whatwouldbeyourinitialdrugofchoice?Why?
Answer:For youngerindividuals, oralantibioticsare usuallytheoralagentofchoice;however,
womenwithcysticacnehavehadincreasedsuccessusingspironolactone.Safeforlongperiodsof timeandminimalsideeffectsmakethisthedrugofchoice.
5.Atwhatpointisitrecommendedtoconsultwithdermatologyorconsiderchangingcontraception?
Answer: A two month follow up appointment would be warranted. If minimal improvement,
referraltodermatologyand/orchangingoralcontraceptionisrecommended
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patientswithacne.JournalofAmericanAcademyofDermatology,81(3),848–851. Bobonich,M.,&Nolen,M.(2015).Dermatologyforadvancedpracticeclinicians.Philadelphia,PA:WoltersKluwer. Burris, J., Rietkerk, W., & Woolf, K. (2013). Acne: The role of medical nutrition therapy. Journal of the Academy of Nutrition and
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Grove, G., Zerweck, C., & Gwazdauskas, J. (2013). Tolerabilityand irritation potential of fourtopical acne regimens in healthy subjects.
JournalofDrugsinDermatology,12(6),644–649. Habif,T.,Dinulos,J.,Chapman,M.S.,&Zug,K.A.(2018).Sk indisease:Diagnosisandtreatment.NewYork:Elsevier. Leyden,J.,Berk,D.,et al.(2017).Efficacy tosafetyoforalsarecycline forthetreatmentofmoderatetosevere facialacne. Journal of
AmericanAcademyofDermatology,6(6),AB113. Maloney,M.,&Stone,S. (2011).IsotretinoinandIPledge:Aviewofresults.JournalofAmericanAcademyofDermatology,65(2),418–
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Saint-Jean,M.,et al.(2019). Adultacne in womenisnotassociated witha specifictype of Cutibacteriumacnes. Journal of American
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UNIT
4
PharmacotherapyforEyeandEarDisorders
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