W#11 Pharma Peer replies

POST # 1 CRYSTAL

This post is regarding the rational drug choice, pharmacokinetics/dynamics, interactions, side effects, monitoring, and patient education for eczema. 

Eczema is a topical skin disease that involves itching and inflammation and is usually chronic. The skin is dry, red with oozing and crusting, and looks leathery (Weston & Howe, 2019). Although the etiology of eczema is unknown, findings have proved that eczema patients have high immunoglobulin E (IgE) antibody levels but the exact cause has not been found yet (Woo & Robinson, 2016, p. 958). Typically, atopic dermatitis is seen more frequently in children where it presents on the limbs, trunk of the face, and scalp. In older children and adolescents, they appear with a leathery distribution particularly in the antecubital and popliteal folds as well as the wrists, ankles, and neck. Lastly, adults present with more localized leathery areas, but some adults still present with oozing and redness, chronic hand eczema, facial dermatitis, and eyelid dermatitis (Weston & Howe, 2019).   

Treatment for atopic eczema requires different pharmacological interventions at different stages of eczema. For instance, an acute exacerbation will require a topical corticosteroid such as a low-potency steroid as hydrocortisone (Hytone, Cortisporin, Cortaid) 1%, 2.5%, 0.5%, which can be cream, lotion, or ointment, a thin layer is all that is needed. In addition, other topical agents used are in categories of intermediate, high, and super high potency strengths as well as immunomodulators for short term use (Woo & Robinson, 2016, p. 959-960). These hydrocortisone agents have anti-inflammatory, antipruritic, and vasoconstrictive results which are needed to either prevent, decrease, or control the frequency or severity of more exacerbations. The corticosteroid is applied to and absorbed through the skin, it inhibits the “formation, release, and activity of the endogenous mediators of the inflammation.” Therefore, the steroid stops the movement of “macrophages and leukocytes, resulting in reversal of vascular dilation and permeability” (Woo & Robinson, 2016, p. 959). Additional factors that affect the absorption of the corticosteroid include intact or abraded skin, formulation, and use of an occlusive dressing. Warning for neonates, infants, and young children as absorption is increased. In addition, rectal absorption is more potent than topical prescriptions resulting in systematic effects  (Lexicomp, 2020). Different stages of eczema can use different types of hydrocortisone, for instance, ointments are generally used for scaly areas as they are more occlusive and potent. Creams are less potent and occlusive and used more during the acute or management phase. While lotions contain the most water and are encouraged to be used after a warm bath or shower (Woo & Robinson, 2016, p. 959). 

Drug interactions involved with hydrocortisone include aldesleukin which is a neoplastic drug that when combined with a hydrocortisone it becomes diminished resulting in a risk X. Another drug interaction is calcipotriene in which a topical hydrocortisone will diminish the calcipotriene but if necessary, monitoring the efficacy of calcipotriene with hydrocortisone valerate and administering the drugs 10-12 hours apart can decrease this interaction. Furthermore, there are side effects with hydrocortisone agents including acneiform eruption, atrophic striae, burning sensation of the skin, folliculitis, hyper trichosis, hypopigmentation, maceration of the skin, miliaria, perioral dermatitis, pruritus, secondary skin infection, skin atrophy, skin irritation, and xeroderma (Lexicomp, 2020). Monitoring of hydrocortisone involves inspecting the skin on a regular basis for skin atrophy and hypothalamic-pituitary axis suppression which could lead to adrenal crisis in children (Lexicomp, 2020). 

Education for a patient with eczema will include explaining that there is not a cure for eczema but with good management of medication and lifestyle changes the itching can be controlled. Education on changing any abrasive or heavily scented daily products should be replaced with fragrance-free items, use of mild body soap, short stints in the shower or bath with warm water, and applying an emollient to wet skin to lock in moisture. Furthermore, a warm oatmeal bath may soothe any itching or open areas, and last, if the eczema is due to the climate, a suggestion to move to a climate with more humidity (Kim, 2020).   

References 

Kim, B. S. (2020). Atopic dermatitis. Medscape.  https://emedicine.medscape.com/article/1049085-overview#a1

Lexicomp. (2020). Hydrocortisone (topical): Drug information.  https://www-uptodate-com.regiscollege.idm.oclc.org/contents/hydrocortisone-topical-drug-information?search=hydrocortisone%20topical&source=panel_search_result&selectedTitle=1~146&usage_type=panel&display_rank=1#F8116319

Weston, W. L. & Howe, W. (2019). Overview of dermatitis (eczema). UpToDate.  https://www-uptodate-com.regiscollege.idm.oclc.org/contents/overview-of-dermatitis-eczema?search=eczema&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Philadelphia, PA: F.A. Davis Company