Pharmacotherapy for Skin Disorders &
Disorders of the Eyes/Ears
Margaret Draskovich, PhD MPH RN
Professor, UAA SON
● Acne vulgaris – hair & sebaceous gland disorder common in teens; known
as mature or tardive acne when occurs in those over 30 years of age
● Comedomes – acne lesions that can be open or closed; Open known as
blackheads when sebum plugs oil glands & is discolored by melanin;
Closed known as whiteheads occur just under skin surface
● Dermatitis – superficial inflammation of the skin
● Eczema (ectopic dermatitis) – chronic, inflammatory skin disorder with
genetic predisposition
Definitions
Skin Related
● Erythema – redness of the skin
● Excoriation– scratches that break the skin & become crusty with blood &
serous fluid
● Keratolytic – pertaining to the drying & shedding of the outer layer of the
epidermis
● Nits – lice eggs; attach to body hairs
● Pediculicides – drugs that kill lice
● Pruritus – general condition of dry, scaly skin
● Psoralens – oral or topical drugs that produce a photosensitive reaction
when exposed to UV light that reduce the lesions of psoriasis
Definitions
Skin Related
● Psoriasis – chronic inflammatory skin disorder characterized by red, raised
skin patches covered with thick, flaky, silver scales called plaques
● Retinoids – drug class related to vitamin A used to treat inflammatory skin
conditions, dermatologic malignancies, & acne
● Rhinophyma – thickening of soft tissues of the nose giving it a reddened,
bullous, swollen appearance; seen with rosacea
● Rosacea – painful, progressive inflammatory skin disorder of unknown
etiology
● Scabicides – drugs that kill mites
● Seborrhea – contributes to acne vulgaris from excess production of sebum
by oil glands
● Urticaria – hypersensitivity reaction characterized by hives, often
accompanied by pruritus or itching
● Aqueous humor – thin fluid contained in the anterior segment of the
interior eye
● Cycloplegic drugs – dilate pupil & also paralyze ciliary muscle to prevent
lens of eye from moving during assessment
● Glaucoma – eye disease characterized by gradual loss of peripheral vision
advancing to blindness
Definitions
Eye & Ear
Related
● Closed-angle glaucoma – comprises 5% & usually unilateral; may be caused by
stress, impact injury, or meds
● Open-angle glaucoma – most common (90%) & usually bilateral; unknown
cause & often asymptomatic
● Mastoiditis – inflammation of the mastoid sinus; untreated can cause
hearing loss
● Miosis – constriction of the pupil
● Mydriasis – dilation of the pupil
● Mydriatic drugs – dilate pupil to allow assessment of retina
● Otitis externa – inflammation of the outer ear mostly associated with water
(swimmer’s ear)
● Otitis media – inflammation of the middle ear mostly associated with URI,
allergies, or irritation of the auditory tube
Skin Disorder
Causes
● Infectious
● Bacterial – furuncles (boils), carbuncles (abscesses),
impetigo, folliculitis, cellulitis
● Fungal – ringworm, onychomycosis/tinea unguium, tinea
pedis, tinea cruris
● Parasitic – ticks, mites, lice
● Viral – herpes simplex, herpes zoster, varicella, rubeola,
rubella, warts (HPV)
● Inflammatory
● Injury / sun exposure
● Dermatitis disorders & psoriasis
● Combination of: overactive glands, increased hormone
production, or infection
● Neoplastic
● Skin cancers – squamous cell, basal cell, melanoma
● Benign neoplasms – keratosis, keratoacanthoma
● Skin assessment looks at abnormalities in
● Color
● Moisture
● Skin turgor
● Surface lesions
● Types, sizes, character
Skin Disorders
● Diagnosis & classification impacted by overlapping
symptoms, etiology, & possibility that various
stages may alter presentation
● May reflect diseases elsewhere in the body
● May have systemic causes
● Some vague & generalized
● Some specific & easy to identify
Figure 49.2 Interrelationships of the integumentary system with other body systems
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Bacterial
Infections
Fungal Infections
Viral Skin
Infections
● Occur from break in skin defenses
● Most common: Staphylococcus & Streptococcus
● Many mild & self-limiting & treated with topical
antibiotics; Serious deep or systemic require oral or
parenteral antibiotics; Impact of MRSA
● Occur in warm, moist areas of skin
● Tinea pedis (athlete's foot), tinea cruris (jock itch), tinea
capitis (ringworm of scalp), & tinea unguium (nails)
generally mild; treated with topical antifungals
● In immunocompromised patients are serious & require
oral or parenteral antifungals
● Childhood - Varicella (chickenpox), rubeola (measles), rubella
(German measles)
● Adult -Herpes zoster (shingles) & herpes simplex (cold sores
& genital lesions); Topical or oral antiviral therapy with
acyclovir (Zovirax)
Scabies
● Mites (Sarcoptes scabiei) cause scabies
● Female burrows into skin & lays eggs causing intense itching
● Fingers, extremities, trunk, axillary & gluteal folds, pubic area
● Spread by contact with upholstery and linens
● Scabicides kill mites
Skin Parasites
Lice
● Pediculicides kill lice (singular – louse); P. capitus, P. corporis, Phthirus pubis
● permethrin (Acticin, Elimite, Nix) - prototype
● Treatment of choice for lice & scabies
● Kills head & crab lice & mites & eradicates ova
● Cream or lotion; 1% lotion approved for lice; 5% lotion for mites.
● Few systemic effects; local reactions - pruritus, rash, transient
tingling, burning, stinging, erythema, & edema
● Others are pyrethrins (RID) & malathion (Ovide)
● Lindane (Kwell) is used only after other treatments fail
● Potential to cause serious nervous system toxicity
● Nursing Considerations
● Don gloves - assess hair & skin for lice, nits, or scabies (axilla, neckline,
hairline, groin, beltline areas)
● Obtain thorough history – symptom onset & exposure to others
● Use very cautiously in pregnant or lactating women & young children
● Follow application instructions; wear gloves when applying medication
● Cleanse & dry lesions & surrounding area prior to application
● Similar-appearing lesions; pharmacotherapy generally very different
● Acne Vulgaris
Acne &
Rosacea
● Disorder of hair and sebaceous glands
● Affects 80% of adolescents
● Also found in over-30 population (Mature acne or acne tardive)
● Associated Factors with Acne Vulgaris
● Seborrhea: overproduction of sebum by oil glands
● Abnormal formation of keratin that blocks oil glands
● Androgens: stimulate sebum production
● Most common OTC benzoyl peroxide (Clearasil, Triaz, others)
● Tretinoin (Retin-A) is an older drug
● OC’s containing ethinyl estradiol & norgestimate may be used
● Antibiotics sometimes used in combination with acne meds
● Spironolactone good for teenage acne
● Rosacea
● Progressive disorder; onset between 30-50 years of age
● Characteristic symptoms
● Small papules without pus
● Flushed face around nose & cheeks
● Soft tissues of nose may swell — rhinophyma
● Etiology
● Sunlight, stress, increased temperature
● Agents that dilate facial blood vessels
● Women more often affected
Drugs for
Acne &
Rosacea
● Retinoids - tretinoin (Avita, Retin-A, others) – prototype
● Reduce oil production and clogged pores
● Do NOT use if patient is pregnant
● Decreases comedone formation & increases comedome
extrusion
● Used for early treatment & control of mild to moderate acne
vulgaris
● Adverse effects: common reaction is sensitivity to sunlight; very
high doses can cause bone pain, fever, headache, nausea,
vomiting, rash, stomatitis, pruritus, sweating, & ocular disorders
● Resistant acne disorders - Isotretinoin (Accutane) oral
● Contraindicated with depression, suicidal ideation,
pregnancy
● Must sign consent regarding suicidal risks prior to treatment
● Obtain pregnancy test for all females in childbearing years;
need 2 forms BC; I-pledge Program
● Antibiotics
● Estrogen
● Antiprotozoals prescribed if hair follicle mites present
● Benzoyl peroxide - Keratolytic: dries & sheds outer epidermis layer
● Inflammatory skin disorder — pain, redness, & pruritus
● Atopic dermatitis or eczema
● Chronic; genetic predisposition
● Contact dermatitis
● Hypersensitivity response
Dermatitis
● Seborrheic dermatitis
● Seen in newborns & teenagers after puberty
● Stasis dermatitis
● Sign of poor venous circulation
● Pharmacology of Dermatitis
● Topical glucocorticoids most effective treatment
● Relieve local inflammation & itching
● Adverse effects with long-term use
● Irritation, redness, thinning of skin
● Available in creams, lotions, solutions, gels, pads
● Chronic skin disorder - may be genetic immune reaction
Psoriasis
● Symptoms - red patches of skin covered with flaky, silver-colored
scales (plaques)
● Causes extremely fast skin–turnover rate
● Plaques are shed rapidly (4–7 days instead of normal 14 days)
● Underlying skin is inflamed and irritated
● Pharmacotherapy for psoriasis
● Goal - reduce erythema, plaques, scales & improve appearance
● No pharmacological cure
● Topical corticosteroids
● Topical immunomodulators (TIMs) - suppress immune system
● Retinoid-like compounds
Psoriasis
Source: Casi/Fotolia
● Systemic therapies for psoriasis - when topical drugs fail
● methotrexate (Trexall, others) most commonly prescribed
● cyclosporine (Sandimmune, Neoral) immunosuppressive agent
for severe conditions
● Biologic therapies - alefacept (Amevive), adalimumab (Humira),
others
● Minor, first-degree burns
● Affect only outer layers of epidermis
● Analogous to sunburn
● Signs & symptoms - erythema, intense pain, nausea, vomiting,
chills, edema, & headache
Minor Burns &
Sunburn
Minor Burns &
Sunburn
● Sunburn
● Common problem in general population especially light-skinned
complexion & lack of sun protection
● Sun exposure dangers - eye injury, cataracts, skin cancer
● Best treatment is prevention
● Sunscreens – liquids/lotions applied for chemical or physical
protection
● Chemical sunscreens - absorb the spectrum of UV light;
● Include those that contain benzophenone for protection
against UVA rays
● Cinnamates, p-aminobenzoic acid (PABA) work against
UVB rays
● Physical sunscreens - zinc oxide, talc, & titanium dioxide
● Reflect or scatter light
● Prevent penetration of both UVA and UVB rays
● Parsol is another sunscreen product being used (lip balm)
● Treatment
● Relieve symptoms with soothing lotions, rest
● Prevent dehydration
● Topical anesthetics for minor burns include benzocaine
(Solarcaine), dibucaine (Nupercainal), lidocaine
(Xylocaine), & tetracaine HCl (Pontocaine)
● Aloe vera is popular natural therapy
for minor skin irritations & burns
● Nursing Considerations
● Assess sunburn - location, portion of body surface area,
edema, erythema, blistering
● Severe cases - assess for fever, chills, weakness, shock
● Assess skin for secondary infections; topical medications
are then contraindicated
● Topical benzocaine (Solarcaine) may cause
hypersensitivity reaction - do trial application on small
area of skin
Figure 50.1 Internal structures of the eye
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Glaucoma
● Increased intraocular pressure resulting in optic nerve damage &
visual-field loss
● Leading cause of preventable blindness
● Etiology
● Often primary condition without identifiable cause
● Most frequent in those over 60 years of age
● Associated with genetic factors
● Can be secondary to certain conditions: eye trauma, diabetes,
inflammation, hemorrhage, tumor, cataracts
● Risk Factors
● Long-term use of some medications
● glucocorticoids, antihypertensives, antihistamines,
antidepressants
● Hypertension
● Migraine headaches
● Severe nearsightedness or farsightedness
● Normal aging
Glaucoma Types
● Types of Glaucoma: Closed-angle & Open-angle
● Both result from buildup of aqueous humor (excess production
or blockage of outflow)
● Differences between types
● How quickly it occurs
● Whether there is narrowing of anterior angle
● Diagnosed with tonometry which measures IOP
Closed-Angle
● Closed angle; also called acute or narrow-angle glaucoma - 5%
● Usually unilateral - caused by stress, impact injury, or meds
● Iris pushed over drainage area causing angle to narrow & close
with sudden increase in IOP
● Symptoms: dull-to-severe eye pain, bulging iris, headache,
bloodshot eyes ‘red-eye’, foggy vision with halos
Open- Angle
● Open-angle - 90%
● Usually bilateral
● IOP develops slowly over years
● Asymptomatic
● Iris does not cover opening
● Treated with medications
● Medical emergency requiring surgery
Figure 50.2 Forms of primary adult glaucoma: (a) Normal eye anatomy; (b) in chronic open-angle glaucoma, the
anterior chamber angle remains open, but drainage of aqueous humor through the canal of Schlemm is impaired;
(c) in acute closed-angle glaucoma, the angle of the iris and anterior chamber narrows, obstructing the outflow of
aqueous humor
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● Goal is to prevent damage to optic nerve by lowering IOP
● Treatment begins
● When IOP is between 21 and 30 mm Hg or
● When signs of optic nerve damage or visual-field changes are
present regardless of IOP
● Combination therapy may be necessary to achieve goal
● Mechanisms of action
● Decrease IOP by increasing outflow of aqueous humor, or
● Decrease formation of aqueous humor
● Many anti-glaucoma drugs affect ANS
Drugs for
Glaucoma
Drugs for
Glaucoma
● Prostaglandins: latanoprost (Xalatan) - prototype
● Mechanism of action - believed to reduce IOP by increasing outflow of
aqueous humor
● Primarily treats open-angle glaucoma
● Adverse effects: conjunctival edema, tearing, dryness, burning, pain,
irritation, itching, photophobia &/or visual disturbances, sensation of
foreign body in eye, eyelashes on treated eye may grow thicker &/or
darker, changes in pigmentation of iris of treated eye & periocular skin
● Beta-adrenergic blockers - timolol (Timoptic, Timoptic XE) prototype
● Mechanism of action - decrease production of aqueous humor
● Adverse effects - local burning and stinging upon instillation; with
systemic absorption bronchoconstriction, dysrhythmias, hypotension
● Primary used to reduce elevated IOP in chronic open-angle glaucoma
● Nursing Considerations
● Determine history of heart block, bradycardia, HF, COPD
● Establish baseline BP & pulse & teach patient how to check
● Review normal heart rate & BP parameters
● Determine factors that could decrease compliance - lack of
knowledge of disease, dexterity or skill in inserting eye drops,
dosing schedule
● Alpha2-adrenergic agonists - decrease production of aqueous humor
● Carbonic anhydrase inhibitors - decrease production of aqueous humor
● Nonselective sympathomimetics (mydriatics) - dilate pupil to increase
outflow
● May cause increased IOP, increased BP & HR; rarely used for glaucoma
● Cholinergic agonists (miotics) - constrict pupil to allow more room for
outflow
● Osmotic diuretics - reduce formation of aqueous humor
Drugs Used
During Eye
Examinations
● Mydriatics
● Dilate pupil to allow better visualization
● Causes photophobia, can increase IOP,
can cause CNS effects
● Cycloplegics
● Cause both dilation & relaxation of ciliary muscle
● Causes severe blurred vision, angle-closure glaucoma
attacks, loss of near vision
● Vasoconstrictors
Drugs for Eye
Irritation &
Dryness
● Cycloplegics
● Mydriatics
● Lubricant drugs
● Lubricate eye's surface
● Penetrate specific area of eye
Figure 50.3 Structures of the external ear, middle ear, and inner ear
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● Major sensory functions - hearing; equilibrium & balance
● Three important structural areas
● Outer ear
● Middle ear
● Inner ear
The Ear
● Ear inflammation- Otitis
● External otitis - associated with water (swimmer's ear)
● Otitis media - associated with URI, allergies, auditory tube
irritation
● Inner ear infections
● Mastoiditis - inflammation of mastoid sinus
● Associated with chronic or recurrent bacterial otitis media
● Can result in hearing loss if untreated
Drugs for Ear
Disorders
● Antibiotics used to treat infections
● Topical (eardrops) for external ear
● Systemic for middle & inner ear infections; also for extensive
outer ear infections
● Topical corticosteroids used when inflammation present
● Nursing Considerations – Otic Therapy
● Assess baseline hearing & auditory status; symptoms
● Assess current medical conditions
● Obtain information regarding hypersensitivity (hydrocortisone,
neomycin sulfate, polymyxin B)
● Many otic medications contraindicated with perforated eardrum
● chloramphenicol contraindicated
● Side effects - burning, redness, rash, swelling
● When instilling otic preparations
● Cleanse ear thoroughly
● Remove cerumen through irrigation
● Warm to body temperature (but not higher) before instillation
● While these conditions are not often life-threatening there can
be serious complications that require diligent assessment and
evaluation by the nurse.
Conclusion ● They are often uncomfortable for the patient to deal with & it is
important to assess patient understanding of pharmacotherapy
interventions.