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Dermatology
Other Systemic Drugs
Built from Dermatology, 5th Edition
What’s inside
14 sections · 173 slides
Introduction and general principles
Systemic drugs used in dermatology beyond biologics, retinoids and antimicrobials
- What this deck covers
- Systemic medications covered in other chapters.
- Systemic medications covered in other chapters. (continued)
- Four broad categories of systemic drug
- Categories of systemic drugs used in dermatology based upon mechanism of action.
- Systemic drug categories at a glance
- Choosing a systemic therapy
- Baseline screening before immunosuppression
- Pregnancy and lactation labeling
- REMS programs and parenteral safety
Antimalarials
Hydroxychloroquine and chloroquine — first-line therapy for cutaneous lupus
- History and drug options
- Absorption and metabolism
- Mechanism of action
- Typical dosing
- Dosing for porphyria cutanea tarda
- Ocular toxicity: overview
- Risk factors and types of retinopathy associated with antimalarial therapy.
- Risk factors and types of retinopathy associated with antimalarial therapy. (continued)
- Risk factors and types of retinopathy associated with antimalarial therapy. (continued)
- Eye screening schedule
- Skin discoloration from antimalarials
- Hair changes and drug rashes
- Lichenoid drug eruption from hydroxychloroquine
- Pustular psoriasis induced by hydroxychloroquine
- Psoriasis flares and lab monitoring
- Monitoring guidelines – Antimalarials
- Monitoring guidelines – Antimalarials
- Indications
- Contraindications
- Pregnancy and lactation
- Drug interactions
- Side effects – Antimalarials
Apremilast
An oral small-molecule PDE-4 inhibitor for psoriasis and psoriatic arthritis
- Overview and pharmacokinetics
- Apremilast and PDE-4 inhibitor mechanism of action
- Mechanism of action
- Dosing
- Major side effects
- Side effects – Apremilast
- Plaque psoriasis response to apremilast
- Indications and trial results
- Contraindications, pregnancy, and interactions
Azathioprine
A TPMT-guided immunosuppressant for severe, treatment-resistant skin disease
- History and absorption
- Azathioprine metabolic pathway
- Why TPMT activity matters
- Dosing of azathioprine as determined by baseline thiopurine methyltransferase (TPMT) activity.
- Mechanism of action
- Dosing
- Monitoring guidelines – Azathioprine
- Major side effects: immune suppression
- Hypersensitivity and PPP syndrome
- Side effects – Azathioprine
- Azathioprine hypersensitivity reaction
- Indications
- Contraindications, pregnancy, and interactions
Bleomycin, clofazimine and colchicine
Three older agents with narrow but well-defined dermatologic roles
- Bleomycin: source and use
- Bleomycin.
- Bleomycin: dosing and side effects
- Clofazimine: source and use
- Clofazimine.
- Clofazimine: dosing and side effects
- Colchicine: source and use
- Colchicine.
- Colchicine: dosing and side effects
Cyclophosphamide
A DNA-alkylating agent reserved for severe vasculitis and mucosal disease
- History and pharmacokinetics
- Mechanism of action
- How cyclophosphamide kills cells
- Dosing
- Monitoring guidelines – Cyclophosphamide
- Major side effects
- Side effects – Cyclophosphamide
- Indications
- Contraindications, pregnancy, and interactions
Cyclosporine
A fast-acting calcineurin inhibitor for severe psoriasis flares
- History and formulations
- Pharmacokinetics
- Mechanism of action
- How cyclosporine blocks T cell activation
- Dosing in psoriasis
- Monitoring kidney function
- Monitoring guidelines – Cyclosporine
- Major side effects
- Long-term risk and cancer
- Eruptive sebaceous hyperplasia with cyclosporine
- Side effects – Cyclosporine
- Indications
- Contraindications, pregnancy, and interactions
Dapsone
A sulfone antibiotic repurposed for neutrophil-driven skin disease
- History and pharmacokinetics
- Metabolism
- Mechanism of action
- Dosing
- Monitoring guidelines – Dapsone
- Major side effects: dose-related
- Dapsone hypersensitivity syndrome
- Side effects – Dapsone
- Indications
- Contraindications, pregnancy, and interactions
Hydroxyurea and leukotriene inhibitors
A psoriasis maintenance drug and asthma drugs used off-label in skin disease
- Hydroxyurea: overview
- Hydroxyurea.
- Hydroxyurea-induced skin ulceration and mucosal pigmentation
- Hydroxyurea-associated malleolar ulcer
- Side effects – Hydroxyurea
- Hydroxyurea: dosing and monitoring
- Leukotriene inhibitors: overview
- Leukotriene inhibitors.
- Leukotriene inhibitors: cautions
Methotrexate
A folic-acid-blocking antiproliferative, first used in psoriasis in the 1950s
- History and pharmacokinetics
- Mechanism of action
- Two separate mechanisms
- Dosing schedule
- Starting and escalating the dose
- Monitoring guidelines – Methotrexate
- Major side effects
- Risk factors for developing hepatic toxicity from methotrexate. Adapted from reference 33 .
- Monitoring for liver fibrosis
- Methods of monitoring for hepatic fibrosis.
- Serum and imaging tests for hepatic fibrosis
- Serum and imaging tests for hepatic fibrosis (continued)
- Serum and imaging tests for hepatic fibrosis (continued)
- Methotrexate hepatotoxicity monitoring algorithm
- Side effects – Methotrexate
- Indications
- Contraindications
- Counseling patients of childbearing potential
- Methotrexate (MTX) – counseling for patients of childbearing potential.
- Drug interactions
Mycophenolate mofetil
A purine-synthesis blocker that favors fast-dividing lymphocytes
- History and pharmacokinetics
- Mechanism of action of mycophenolic acid
- Mechanism of action
- Dosing
- Monitoring guidelines – Mycophenolate mofetil
- Major side effects
- Side effects – Mycophenolate mofetil
- Indications
- Contraindications, pregnancy, and interactions
Potassium iodide, sirolimus and tacrolimus
An old anti-inflammatory solution and two mTOR/calcineurin-pathway drugs
- SSKI: overview
- Saturated solution of potassium iodide (SSKI).
- SSKI: dosing and side effects
- Side effects – SSKI
- Sirolimus and tacrolimus: overview
- Sirolimus (rapamycin; Rapamune®) and tacrolimus (Prograf®).
- Sirolimus (rapamycin; Rapamune®) and tacrolimus (Prograf®). (continued)
- Viral-associated trichodysplasia in a transplant recipient
- Side effects – Tacrolimus
- Dermatologic uses and side effects
Thalidomide and lenalidomide
From 1960s tragedy to tightly controlled therapy for leprosy reactions and lupus
- History
- REMS safety programs
- Pharmacokinetics and comparison
- Mechanism of action
- Dosing
- Monitoring guidelines – Thalidomide and lenalidomide
- Discoid lupus erythematosus response to thalidomide
- Clinical response in lupus
- Major side effects: thalidomide
- Major side effects: lenalidomide
- Side effects – Thalidomide and lenalidomide
- Subacute cutaneous lupus response to thalidomide
- Extensive subacute cutaneous lupus clearance with thalidomide
- Indications: thalidomide
- Indications: lenalidomide
- Contraindications and interactions
- Pregnancy and lactation
Summary and references
Key numbers to remember, cross-drug indications, and the chapter's source list
- 40–50 days
- Matching disease to drug
- Select cutaneous disorders that can be treated with specific systemic drugs.
- Select cutaneous disorders that can be treated with specific systemic drugs. (continued)
- Select cutaneous disorders that can be treated with specific systemic drugs. (continued)
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Dermatology, 5th Edition (2-Volume Set)