Chapter 40: Integumentary Medications

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Ever had that awful itch from poison ivy and just wanted it gone, but also kind of wondered what's actually in that lotion making it better?

Oh yeah.

Or maybe you know someone dealing with eczema or acne and the number of creams and pills out there just seems overwhelming.

Totally.

It's confusing and we all just want clear, trustworthy info about skin stuff.

And that's exactly what we're doing today.

We're diving into a really solid resource, the chapter on integumentary medications from the Saunders Comprehensive Review for the NCLE -XPN exam, the seventh edition.

It's basically the core info nurses need.

Think of this as your shortcut through the medical jargon.

We want to pull out the key things you need to know about skin medications,

topicals, pills, the whole lot for all sorts of skin conditions.

Right.

We're aiming to translate that nursing textbook language into something practical that anyone curious about these treatments can understand.

How they work, the effects, the safety stuff.

So you can finally understand why that poison ivy cream worked or what the deal is with different eczema treatments or even how sunscreen actually protects you.

Ready to jump in.

Let's do it.

Okay.

Let's start with something super common, especially in summer poison ivy.

What does the review say are the first things to try?

So that first reaction, the itching, the rash, the basics are things like calamine lotion, that's the classic pink stuff for soothing the itch.

And there are loads of other commercial soothing products too.

Calamine definitely takes me back.

What else for that initial stage?

Aluminum -acetic compresses or solutions are mentioned.

They're astringent, so they help dry things up if it's weeping and also a bit antiseptic.

And colloidal oatmeal baths are great for just general relief, calming down that irritated skin.

Right.

Those are for comfort.

But what about tackling the actual inflammation itself?

That's where topical corticosteroids come in.

The chapter says they work best to prevent or relieve that inflammation,

especially if you catch it before blisters really form.

They calm down the skin's reaction.

Makes sense.

And if it's a really, really bad case, like spreading everywhere.

Yeah.

For severe reactions, oral corticosteroids might be prescribed.

Those work systemically throughout the body.

And antihistamines, like diphenhydramine benadryl is the common one, can help manage the itching.

Okay.

Good plan for poison ivy.

Let's switch to something more chronic, like atopic dermatitis or eczema.

What's the approach there?

Atopic dermatitis.

Yeah.

That's the chronic inflammation, dry, scaly skin.

The first line of attack is usually two things.

Good moisturizers, used consistently, and topical glucocorticoids, again, to manage the flare -ups.

So moisturizers and topicals first.

But what if that's not cutting it for someone?

If the topicals aren't enough, the review mentions systemic immunosuppressants as a potential next step.

These work body -wide to quiet down the overactive immune response causing the eczema.

Interesting.

And it also talks about topical immunosuppressants, right?

Tecralamus and Pymacaralamus.

Yes, exactly.

Those are creams applied directly to the skin.

They target the immune cells locally,

kind of calming the inflammation right where it's happening, without those bigger systemic effects.

Are there specific things to watch out for with those creams?

Side effects?

Definitely.

You might get some redness, burning, or itching where you apply them.

And a really important one, they can make your skin much more sensitive to the sun.

Oh, wow.

Yeah, so using really good sun protection on treated areas is absolutely critical.

Good to know.

Anything else specific about, say, tacrolimus?

Well, with tacrolimus, there's a note about a possible increased risk of the varicella zoster virus in kids.

That's chickenpox and shingles.

And there's also a potential long -term risk noted for skin cancer and lymphoma.

It's something doctors weigh carefully.

Okay, crucial things to discuss with a doctor.

Now, there's a basic safety tip for applying any topical med.

What's that?

Yes.

Really important for anyone applying these, nurse or family member,

wear gloves.

You don't want to absorb the medication yourself.

And of course, wash hands thoroughly before and after.

Simple but essential.

Okay, let's dive deeper into those topical glucocorticoids we keep mentioning.

How do they actually work?

So they do three main things.

They're anti -inflammatory, reducing redness and swelling,

anti -chiridic, so they stop the itch, and vasoconstrictive, meaning they narrow the blood vessels a bit in that area.

And they come in different strength, right?

It's not just the percentage.

Potency depends on the drug, yes, but also the base cream, ointment, lotion and how you apply it,

like putting an occlusive dressing, a sealed bandage over it.

That massively increases absorption.

So covering it makes it much stronger.

Precisely.

And that increased absorption, especially with long -term use or on large areas,

raises the risk of systemic side effects.

Some body areas absorb much more easily, too.

Scalp, face, armpits, eyelids, groin, they're higher risk than, say, palms, soles, or the back.

You're good to know where absorption is higher.

Are there times you absolutely should not use these?

Yes.

Contradindications include known sensitivity, active systemic infections, fungal, viral, bacterial, or if someone already has complications from glucocorticoid therapy.

What about side effects right on the skin where you apply it?

Locally, you might get burning, dryness, irritation, itching.

With stronger ones or longer use, you can see skin atrophy, thinning skin striae, which are stretch marks, purpura, or easy bruising, telangiacaceus, those little biter veins, sometimes acne -like bumps, or lighter skin patches, or even overgrowth of microbes.

That's quite a list.

And the systemic effects from absorption.

Systemically, especially with prolonged use or in kids, it could affect growth.

Adrenal suppression is a risk where your body makes less natural cortisol, Cushing's syndrome too.

And things like striae and skin thinning can happen systemically, plus eye issues like glaucoma and cataracts.

Definitely powerful stuff.

How might doctors monitor someone on long -term topical steroids?

They might check plasma cortisol levels, especially with long -term use, to watch for that adrenal suppression.

And nurses really focus on teaching proper use.

What are the key instructions for patients?

Wash the area first.

Apply it sparingly.

A thin film is all you need.

Rub it in gently.

Don't cover it with airtight trussings unless the doctor specifically tells you to because of that increased absorption.

And definitely report any side effects.

And a final point about broken skin.

Right.

Intact skin is a pretty good barrier.

But the review warns against putting these on broken or eroded skin unless prescribed, because you can get much more absorption into the system that way.

Very clear.

Okay, let's move to actinic keratosis.

These are sun damage -related, right?

How are they treated?

Exactly.

They're caused by sun exposure over time.

Those rough, scaly, reddish -brown spots you see on sun -exposed areas.

And importantly, they're pre -cancerous.

They can turn into squamous cell carcinoma.

So dealing with them is important.

Are there non -medication ways to treat them?

Yes.

Options include cutting them out, excision, freezing them off, cryotherapy, scraping them, cure -a -tage, or using laser therapy.

And if medication is the route, what are the main topical options?

The chapter covers several.

Fluorosil, diclofenac sodium, imicumod, 5 % cream,

amino -levulinic acid, and ingenol -mebutate.

They all work a bit differently.

Let's take fluorosil first.

Sounds like chemo.

It is essentially a topical chemotherapy.

It messes with the DNA and RNA in those fast -growing abnormal cells, destroying the AK.

Healing takes maybe two to six weeks, sometimes longer for the redness to fade.

Big side effect is sun sensitivity, so strict sun protection is vital.

Itching, burning, inflammation are common too.

Diclofenac sodium, that's an NSAID, like ibuprofen, right?

How does it work topically?

Yeah, it's an NSAID.

Topically, it's thought to reduce inflammation in the lesion.

It's usually a milder treatment, might take up to three months to work fully.

Side effects are usually just local stuff like dry skin, itching, redness.

Then imicumod cream.

I think that's used for other things too.

Correct.

It's an immune response modifier.

It basically tells your own immune system to attack the abnormal cells.

Used for some skin cancers and warts too.

Treatment can take a while, maybe four months, and it can cause pretty noticeable local reactions.

Redness, swelling, itching, burning, sores, crusting.

Immunolevulic acid, that one sounds different.

It is.

It's used with photodynamic therapy, or PDT.

You put the cream on, wait 14 to 18 hours, then expose the area to a special blue light.

The light activates the drug, which destroys the cells.

Side effects are burning, stinging, redness, swelling after the light.

And again, major sun sensitivity afterwards have to avoid sun and even bright indoor light for a few days.

Wow.

Okay.

And the last one.

Ingenal mebutate.

That's a newer one.

It directly kills the abnormal cells pretty quickly, and also triggers inflammation to help clear the lesion.

Treatment is usually really short, just a few days.

But you can get strong skin reactions like redness, peeling, crusting, swelling, even little pustules or breakdown of the skin.

Got it.

That covers the AK meds.

Now we can't talk sun damage without talking sunscreen.

What are the key points from the review?

Well first, UV light is the main culprit for damage not just AKs, but skin cancer too.

Sunscreens basically block that UV radiation.

And they're the chemical ones and the physical ones?

Exactly.

Chemical or organic sunscreens absorb UV and turn it into heat.

Physical or inorganic ones, like zinc oxide or titanium dioxide, create a physical barrier that reflects or scatters the UV rays.

What should you look for when buying sunscreen?

Definitely broad spectrum that covers both UVA and UVB rays.

And an SBF of at least 15, though higher, is generally better.

How soon before going out should you put it on?

Generally about 30 minutes before sun exposure.

But if it contains Pabby or Patamate O, you need to apply it a full two hours beforehand.

Two hours?

Wow.

And how often do you need to reapply?

Reapplication is key.

Every two to three hours is the usual advice and definitely right after swimming or sweating a lot because it washes off.

Any potential issues with sunscreens themselves?

Right.

Allergies or reactions?

Yeah.

A few things.

People allergic to benzocaine, sulfa drugs, or thiazides might react to Pabba, so they should avoid those.

And sometimes sunscreens can cause contact dermatitis, just irritation, or even photosensitivity where an ingredient makes you more sensitive to sun.

And besides sunscreen, what other sun safety tips are important?

Absolutely.

Try to avoid the peak sun hours, roughly 10 a .m.

to 4 p .m.

Wear sunglasses,

protective clothing like long sleeves, and a wide brimmed hat.

Basic stuff, but it really helps.

Great reminders.

Okay, let's tackle psoriasis next.

It's chronic and can vary a lot in severity.

How does the review approach treatment?

Psoriasis, yeah.

Chronic inflammatory thing.

Treatment really depends on how bad it is, where it is.

The main goals are to slow down that super fast skin cell growth, the keratinocytes, and reduce the inflammation driving it all.

What are the options for topical treatments?

For milder cases, topical glucocorticoids are often used, like we've discussed.

But the review cautions against using them long term on sensitive areas like the face, groin, or armpits because of absorption and thinning risks.

It also mentions tazeratine.

What's that?

Tazeratine is a topical retinoid, like a synthetic vitamin A.

Helps normalize cell growth, reduces inflammation, can cause local itching, burning, stinging, dry skin, redness.

And like other retinoids, it makes you sun sensitive, so sunscreen is a must, usually applied once daily in the evening.

Okay.

And calcipotrine.

Sounds like vitamin D.

It is.

It's a synthetic form of vitamin D.

It slows down skin cell production, takes maybe one to three weeks to see results,

mostly causes local irritation, but very high doses over large areas could rarely cause high blood calcium, hypercalcemia.

Then there's the old standby, coltar.

Yeah, coltar has been around forever.

It suppresses DNA synthesis in the skin cells, slowing them down, has its downsides, though the smell isn't great.

It can irritate, sting, stain skin and hair and makes you sun sensitive.

There's also a small mention of potential cancer risk with long -term high dose use.

The review also mentions keratolitics.

What do they do?

Keratolitics help soften and remove the sick scales of psoriasis.

They basically help the outer layer peel off.

Salicylic acid is a common one, but you have to be careful it could be absorbed systemically, especially over large areas or broken skin.

That can lead to salicylism ringing in the ears, dizziness, rapid breathing.

Sulfur is another one, promotes peeling and drying, also used for acne and dandruff sometimes.

So those are the topicals.

What about when psoriasis is more severe, systemic meds?

Yes, for more severe or widespread psoriasis, systemic treatments are needed.

Methotrexate is one, it reduces skin cell growth and inflammation, but it's potent, can cause GI issues, affect bone marrow, and it's toxic to the liver, so you need regular blood tests and liver monitoring.

Critically, it's teratogenic causes birth defects, so strict contraception is vital, and women need to wait a while after stopping it before pregnancy.

Another systemic is acetretin.

Another oral retinoid, helps normalize skin cell growth, reserved for severe psoriasis unresponsive to safer options.

Like methotrexate, it's highly teratogenic, strict contraception needed for women and men, and women need it for three years after stopping.

Huge risk.

It also has lots of other side effects, hair loss, peeling, dry everything, affects lipids, liver function, need monitoring, and no alcohol.

And cyclosporine, that's a strong immunosuppressant.

Yes, it suppresses immune cells involved in psoriasis, can be very effective, but carries a risk of kidney damage, so it's usually for short -term use in severe, resisting cases.

It requires careful monitoring of kidney function and blood pressure.

Okay, now onto the newer systemic biologics.

What's key about these?

These are more targeted therapies, often injections.

Crucially, you need a TB test before starting, as they can reactivate latent TB.

One group is the TNF antagonists, adalamomab, botanarcept, and flixmab.

They block TNF -alpha, a key inflammatory protein.

They work well, but increase the risk of serious infections, sepsis, fungal, TB, hepatitis B reactivation, avoided inactive infection, heart failure, certain neuro conditions,

small lymphoma risk too.

Another one mentioned is eustekinumab, how's that different?

Eustekinumab targets different immune proteins, IL -12 and IL -23, also an injection.

Suppresses immunity, so risks of infection and maybe cancer.

Side effects like colds, headache, injection site reactions, avoided if you have cancer history or active infection.

No live vaccines while on it.

And sucnumab.

Sucutumab targets IL -17A, another inflammatory cytokine.

Also an injection.

Side effects can be cold symptoms, diarrhea, upper respiratory infections.

Pregnancy safety isn't fully established.

Lastly, for psoriasis, phototherapy.

Right, light therapy.

Two main types.

One uses coal tar applied for hours, then UVB light exposure.

The other is photochemotherapy, or PUVA.

You take a photosensitizing pill, an ethyl saline, then get UVA light exposure.

PUVA can work for severe cases, but can cause itching, nausea, redness, and long -term increases risk of skin aging and skin cancer.

Wow, that's a ton of options for psoriasis.

Okay, let's shift to something really common, acne.

How does the review approach acne treatment?

It lays out a sort of step -by -step approach based on severity.

Mild acne might just need gentle cleansing, avoiding oily products, maybe some extractions.

Topicals like antimicrobials or retinoids come next.

For moderate acne, maybe add oral antibiotics plus topicals.

Severe acne often needs oral isotretinoin.

Hormonal treatments like birth control pills or spironal lactone can help some women.

Often it's combination therapy.

How do these different meds actually work against acne?

They tackle it from different angles.

Some kill the P.

acnes bacteria.

Others reduce inflammation directly.

Some help exfoliate, unplug pores.

Those are keratolitics or comelitics.

Some normalize how skin cells shed inside the follicle.

A few even slightly thin the skin.

Any general tips for applying the topical ones?

Yeah, wash and dry the area first.

Wash hands after applying.

Avoid eyes, lips, inside the nose, broken or irritated skin.

Keep it on the affected areas.

Let's talk topical antibiotics.

Benzoyl peroxide is everywhere, over the counter.

Right.

Benzoyl peroxide kills bacteria and helps kill the skin a bit.

It can be drying and irritating, the redness, burning.

If it's too irritating, use it less often.

Some products have sulfites, so watch out if you have that allergy.

What about prescribed topical antibiotics like clindamycin or erythromycin?

Those also suppress the P.

acnes bacteria.

To prevent resistance, they're often combined with benzoyl peroxide.

You can even get combo products.

And Dapsone.

Dapsone is another topical with antibacterial and anti -inflammatory action.

Side effects can include oily skin, peeling, dryness, redness.

Okay, on to the topical retinoids.

Tretinoin is probably the most famous.

Tretinoin, yeah, vitamin A derivative.

Stop any extra vitamin A supplements.

Besides acne, it's used for fine wrinkles and dark spots.

Can cause local irritation, blistering, peeling, burning, swelling.

Don't use harsh scrubs with it.

And big one makes you very sun sensitive.

SPF 15 plus and protective clothing are essential.

How does adipine compare?

Adipine is similar.

Regulates cell turnover, anti -inflammatory.

Also causes sun sensitivity.

Burning, itching, right after applying.

Redness, dryness, scaling are common.

Important note.

Acne might look worse for the first few weeks before it gets better.

Usually around 8 -12 weeks.

Tizarotene is another retinoid.

Yep.

Another vitamin A derivative, so stop supplements.

Also used for psoriasis and wrinkles.

Can cause itching, burning, dry skin.

And definitely makes you sun sensitive.

And azelaic acid.

Azelaic acid has antibacterial and anti -inflammatory effects.

Used for acne and rosacea.

Can cause temporary burning, itching, stinging, redness.

One thing to note.

It can sometimes cause hypopigmentation or lightening of the skin.

Especially in people with darker skin tones.

What about oral antibiotics for acne?

Things like doxycycline, minocycline, tetracycline, erythromycin.

They work slowly.

Maybe 3 -6 months for good results.

Usually you switch to a topical for maintenance once things are under control to limit long term antibiotic use and resistance risks.

Okay, now the big one for severe acne.

Isotretinoin.

Lots of warnings with this one.

Absolutely critical.

Isotretinoin is an oral retinoid.

Very effective for severe cystic acne that hasn't responded to anything else.

But the side effects list is long.

Nose bleeds, dry lips, eyes, skin, mouth, joint and muscle pain, back pain.

Less common.

Rash, hair loss, headache, reduced night vision, major sun sensitivity.

It raises triglycerides, so need blood tests, avoid alcohol.

And crucially, it's linked to depression stop immediately if mood changes occur.

And the most critical warning is pregnancy, right?

The most critical.

It is extremely teratogenic, causes severe birth defects.

Absolutely cannot be used during pregnancy.

Any woman who could become pregnant must be in the IPL -Edge program.

Can you explain IPL -Edge a bit more?

It's a strict risk management program.

Ensures no woman starts it if pregnant.

And no one gets pregnant while on it or shortly after.

Requires monthly pregnancy tests using two effective forms of birth control.

Strict rules for doctors, patients, pharmacists.

Everyone involved has to be registered and follow the rules precisely.

It's all about preventing fetal exposure.

Understood.

The review also mentions hormonal meds for women.

Right.

Certain birth control pills or spironolactone, which is an anti -androgen.

They work by reducing androgen activity, which lowers sebum production.

Spironolactone is also teratogenic, so contraception is vital.

Side effects can include breast tenderness, irregular periods, and high potassium levels.

Okay.

Covered acne thoroughly.

Last section.

Burn products.

What are the main ones?

The review focuses on two key topical antimicrobials.

Silver sulfateazine and mafinate acetate.

Silver sulfateazine is broad spectrum.

Kills bacteria and yeast.

The silver releases slowly.

Main use is preventing infection, sepsis, and burn wounds.

Doesn't usually cause acidosis.

Apply a 116 -inch layer.

Keep the burn covered.

Watch out for rash, itching, skin discoloration, and especially leukopenia low white blood cells.

Need regular blood counts.

And mafinate acetate.

Mafinate acetate penetrates deep burns better.

Even dead tissue.

It inhibits bacteria.

Big difference.

It can cause metabolic acidosis because it inhibits carbonic anhydrase.

You might see hyperventilation.

Need to monitor blood gases, electrolytes.

Also applied as a thin layer.

Can cause pain on application, rash, bone marrow issues, anemia, and that acidosis.

Keep burns covered.

If hyperventilation happens, Teladoc immediately might need to stop it for a day or two if acidosis occurs.

Does it mention any others, briefly?

Yeah, Boxx mentions basatracein for first -degree burns.

And polvodone iodine as an antiseptic.

Though used cautiously on big burns due to iodine absorption.

The review includes a critical thinking scenario about applying topical steroids, right?

Highlighting absorption differences.

Exactly.

It emphasizes that places like the face absorb more than, say, the soles of the feet.

Reinforces applying thinly only where needed to minimize systemic effects.

Basic but crucial nursing knowledge.

And finally, it wraps up with practice questions.

Let's hit the key takeaways from those.

Sure.

The salicylic acid question flags tinnitus -ringing ears as a sign of toxicity.

Skin cancer prevention emphasizes a combination of sunscreen, protective clothes -shat sunglasses, and self -exams.

Not just avoiding midday sun.

Silver sulfidazine question points to monitoring white blood cell count for leukopenia.

Maffinid acetate highlights watching for hyperventilation as a sign of metabolic acidosis.

Right.

For isotretinoin, checking triglyceride levels before starting is key.

And remembering the interaction with vitamin A supplements is critical.

The topical corticosteroid question reinforces knowing high absorption areas like armpits versus low ones like the back or palms as a laic acid.

Itching is a common side effect.

Yeah.

And the silver sulfidazine teaching point is that it shouldn't normally sting.

If it does, report it.

And finally, chemical sunscreens need that 30 -minute head start before sun exposure.

Wow.

Okay.

We have really covered a huge amount of ground today.

From poison, IV, and eczema to psoriasis, acne, even Bermcare medications.

They really have.

And I think the big picture is clear.

These integumentary meds, whether creams or pills, work in many different ways.

They all have potential side effects, local and systemic.

And they absolutely require careful, informed use.

Proper application, monitoring.

It's all key for safety and effectiveness.

It definitely makes you think, especially with so many skincare products available everywhere now, over the counter, online.

How can people best sort through all that information to make choices that are actually safe and right for their skin?

That's a great question.

And it really highlights why talking to healthcare professionals, doctors, nurses, pharmacists, is so important for getting personalized advice that you can trust.

Absolutely.

Well, I think we can confidently say we have thoroughly worked our way through the entire chapter on integumentary medications from the Saunders Comprehensive Review.