Starting on 08/24/2020: On Tuesday 08/25, write 500 words about what you've learned from the attached ppt.

Review of anatomy and physiology of the skin: https://www.the-socioesthetician-international.com/forum/pharm-d-candidate-appe/a-quick-review-of-a-p-of-skin

PPT Commentary: Drug-Induced Skin Reactions: The various types of drug-induced skin reactions can be classified as follows: erythematous reactions, angioedema/anaphylaxis, fixed drug eruptions, drug hypersensitivity syndrome, erythema nodosum, Steven-Johnson Syndrome (SJS), Toxic epidermal necrolysis syndrome (TENS), drug induced pigmentation/photosensitivity, and acneiform eruptions. The following will summarize each of these reactions (with photos), and describe in greater depth the causative agents and clinical presentations of each:

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Drug-Induced Skin Reactions The various types of drug-induced skin reactions can be classified as follows: erythematous reactions, angioedema/anaphylaxis, fixed drug eruptions, drug hypersensitivity syndrome, erythema nodosum, Steven-Johnson Syndrome (SJS), Toxic epidermal necrolysis syndrome (T...

This concise overview of the integumentary system discussed important facts about the functions of the skin and its related structures and the dermatologic issues that patients may experience. The main purpose of the integumentary system is the physical protection of the body from the outside world. Different types of cells make up the layers of the skin and each serves its own purpose. For example, Langerhans cells are involved in the protection against bacteria and microbes. The skin is made up of several layers, each protecting the body in its own way. The outermost layer is called the epidermis, which is made up of 5 layers - stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. It is interesting to note that the epidermis is avascular, meaning there are no blood vessels. The stratum corneum is the most superficial layer in the epidermis and it is in direct contact with the environment. The cells of the stratum corneum are dead but serve to protect the lower layers. Below the epidermis is the dermis, which contains blood and lymph vessels, nerves, hair follicles, and sweat glands. The dermis is composed of two layers of connective tissue, the papillary layer and the reticular layer. The papillary layer contains phagocytes that protect against bacteria and infections, while the reticular layer is denser and is composed of elastin fibers and collagen fibers for skin elasticity, structure, and strength. Underneath the dermis is the hypodermis (the subcutaneous layer) and it connects the skin to the underlying fascia of bones and muscles. The main functions of the hypodermis include insulation, fat storage, and cushion against trauma.

There is a wide range of dermatologic conditions and the severity of the conditions can vary. Common skin conditions that are usually mild include eczema, acne, psoriasis, rosacea, rash, contact dermatitis, and vitiligo. Serious skin conditions include melanoma, SJS, TENS, and shingles. While mild skin conditions can be appropriately managed with topical or oral medications, the more serious skin conditions can affect other parts of the body and cause irreversible damage. For example, there are many types of skin cancer and some tend to be more malignant than others. Basal cell carcinoma (BCC) is the most common type of skin cancer and it usually develops on skin that gets a lot of sun exposure. BCC can be treated if diagnosed early, but if left alone, it can invade the nerves and blood vessels. BCC is also hard to self-diagnose since initial signs may seem harmless, such as a scaly patch of skin on or near the ear. Melanoma is considered to be a more serious type of skin cancer because it can commonly spread to other parts of the body. Similar to BCC, melanoma’s “most important and potentially modifiable environmental risk factor for developing malignant melanoma is the exposure to ultraviolet (UV) rays because of their genotoxic effect” (1). While consistent sunscreen use will not guarantee perfect skin, sun damage is guaranteed to cause more harm than good.

Works Cited:

Rastrelli M, Tropea S, Rossi CR, Alaibac M. Melanoma: epidemiology, risk factors, pathogenesis, diagnosis and classification. In Vivo. 2014;28(6):1005-1011.

This presentation was well organized and informative. The skin is the largest organ in our body. It’s easy to take it for granted but as our first line of defense, it shields us from exposure to bacteria so long as we keep it intact. There are three main layers of skin, from outside to inside: the epidermis, the dermis, and the subcutaneous fat. When people say you have thick skin, unfortunately that is just a phrase that suggests you’re shameless - actually having thick skin would be a good thing. Within the epidermis, there are three types of cells: squamous cells, basal cells, and melanocytes. Melanocytes create melanin, which is what gives the skin its color. Although your epidermis is constantly shedding new healthy cells and replacing them at the squamous cell level, it also contains pores which allow oil and sweat to escape in order to maintain ideal body temperature and homeostasis.

Your skin is exposed to the world, fighting off allergens to ensure you stay healthy. A few common ways the skin could react in response are atopic dermatitis, plaque psoriasis, acne, keratosis, cysts, ulcers, or boils. Essentially, if there is a constantly irritant, your skin will toughen up by becoming thicker, patchy, and possibly dry out from conditions such as the weather or physical harm such as scratching.

The second layer of skin is the dermis, which contains collagen and elastic to help support the structure of skin. This is the layer that is affected when wrinkles and cellulite are present. It is the thickest of the three layers. The third layer of skin is the subcutaneous fat, also known as the subcutis or hypodermis layer, and it provides insulation to help maintain body temperature and absorbs shock to protect your vital organs when your body is exposed to damage. The subcutaneous fat’s thickness is determined by genetics rather than lack of exercise and accumulation of what is known as visceral fat.

Although it may seem obvious, there are precautions we can take to prevent damage to our skin whether it be avoiding cuts/bruises or consistency with daily moisturization. As pharmacists, we should be able to identify skin conditions that may occur as side effects to medications. Obvious symptoms are change in pigmentation, allergic reactions, shedding, and other obvious damage such as in SJS and TENS. Being knowledgeable on how to administer epinephrine is valuable as patients could have adverse reactions after immunizations as well. With the use of corticosteroids, OTC products like calamine, and non-pharmacological therapy such as ice/heat compressions, we can suppress the urges to scratch and further irritate the skin, which can recover on its own from minor allergic reactions once the allergen has passed through the system. Topical antihistamines may also be used but in the case of diphenhydramine, it is more effective orally as it is systemically metabolized.

To most effectively eradicate the condition, patients are advised to keep note of their diet, detergent/soap use, skincare products, as well as change all clothing and bedsheets. Starting with a clean slate and slowly introducing one new factor at a time can help determine which is the cause for your skin’s natural response.

The Front Line of Host Defense, https://www.ncbi.nlm.nih.gov/books/NBK27105/

This skin structure overview was a great refresher on the anatomy and physiology of our body’s largest organ. The structures of the skin that were discussed in great detail make up what’s called the integumentary system, and serve many purposes like protection to water, UV light, trauma and microorganisms. We are able to feel sensations like touch, heat, cold, and pain due to the nociceptors in our skin’s complicated structure. There are various layers including the epidermis (made into 5 layers), the dermis (the core) and the hypodermis. The epidermis is outermost and is the first layer of protection, responsible for protection to the outside world and producing cells like keratinocytes. The dermis is considered the core and has layers that provide our skin’s elasticity and strength. The hypodermis is known as an energy saver because it helps the body lose heat and protects it from trauma. Different types of cells in these layers serve functions like producing melanin, protecting us from bacteria and giving our skin and nails strength. A lot of these specific cells like basal or squamous cells can turn into different types of skin cancer.

As a pharmacist, I’m naturally interested in the skin conditions that can be induced from taking a specific medication. Some examples discussed included erythematous reactions, angioedema, drug eruptions, hypersensitivity, SJS, TENS, pigmentation and acne. SJS, or Stevens-Johnson Syndrome, is a toxicity warning that I heard many times throughout pharmacy school when discussing medication therapies. It’s a syndrome usually triggered by medications and can progress into an even more fatal condition called TENS, or toxic epidermal necrolysis syndrome. Drugs like sulfonamides, fluoroquinolones, Allopurinol and Carbamazepine can cause SJS, which is a mucocutaneous and systemic reaction that essentially causes the skin to die and fall off. If patients with SJS have more than 10% skin detachment, they are likely progressing into TENS which is more fatal. These patients are losing their protective barrier which can cause a multitude of symptoms, specifically systemic complications. One of the functions of the skin is to retain heat and protect from microorganisms. With skin falling off, it leaves parts of the body exposed and will require the patient to be treated with temperature regulation and wound care to prevent infections. The causative agent should always be discontinued.

Drugs can also induce allergic reactions like hives or contact dermatitis. Contact dermatitis will usually be local to the drug site caused by topical agents such as procaine or neomycin. Hives will be widespread due to a drug allergy and will cause batches of itchy or red welts all over. Another drug induced skin condition could be photosensitivity, which can be phototoxic or photoallergic. Causative agents include antibiotics, hypoglycemics, antipsychotics, and antidepressants. If drug induced photosensitivity occurred, the first step is to decrease the dose of the suspected agent, and possibly initiate systemic corticosteroids or topical antihistamines. Cold compresses and NSAIDs can be used to help relieve pain and inflammation caused by this skin reaction to medications.

1. High WA. Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis. UpToDate. Waltham, MA: UpToDate; Updated March 12, 2019; https://www.uptodate.com/contents/stevens-johnson-syndrome-and-toxic-epidermal-necrolysis-pathogenesis-clinical-manifestations-and-diagnosis.

From this presentation I was able to get a summary about the structure and function of the skin as well as many skin cancers and skin conditions. The skin is the largest organ we have in our body and it serves many functions such as protection from microorganisms, regulation of sweat and body temperature and sensation of cold, heat, or pain from nocioreceptors. The skin contains many different types of cells such as melanocytes which produce melanin in the skin, basals cells that are the precursors of keratinocytes, keratinocytes are cells that help produce keratin protein that creates the hardness of hair, skin and nails, merkel cells allows the brain communicate and help with our senses, langerhans help introduce macrophages to fight off microorganisms in our body. Each cell type has a very specific and different type of function in the skin. The skin is divided into three different layers known as the epidermis, dermis and hypodermis. The outermost layer of the skin is known as the epidermis, it has 5 different layers known as the stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. Below the epidermis is the dermis, which contains the blood and lymph vessels, hair follicles and sweat glands. Directly below the dermis is the hypodermis. The hypodermis helps connect the skin to the fibrous tissue of the bone and muscles that provides fat storage and insulation. As fat storage helps the body from heat loss it also functions as a cushion to protect the body from trauma.

As the skin is predominantly exposed to UV rays, skin cancer is a common risk factor. Individuals that do not produce enough melanin or lack melanin are at a higher risk for skin cancer as the body cannot absorb the UV rays. There are many different types of skin cancers such as basal cell carcinoma, squamous cell carcinoma, melanoma, DFSP, Merkel cell carcinoma, CTCL, and sebaceous carcinoma. Not all skin cancers are severe and usually can be treated with early detection. Melanomas are considered the most aggressive type of skin cancer. The best method of prevention of skin cancer is by protecting the skin using sunscreen, routine check ups, and avoiding the sun at peak hours. For treatment, invasive procedures may be required if the cancer has become metastatic. Immunotherapy can be given to when surgery may not be effective. Targeted therapies are inhibiting specific cell processes. Radiation may be considered if it cannot be surgery removed or in need of size reduction. Chemotherapy can help kill the cancer cells but it comes with the risk of major side effects. For metastatic melanoma FDA approved Dacarbazine is used. It is usually well tolerated, the major side effect being nausea and vomiting. Bone marrow suppression is mild, and alopecia and fatigue are minimal. It is an alkylating agent which is converted to the active alkylating metabolite Temozolomide which is available orally.. The cytotoxic effects break DNA strands and induce apoptosis. Other agents are available but usually used as second or third line options.

References:

1. Melanoma. (2020, March 10). Retrieved August 26, 2020, from https://www.mayoclinic.org/diseases-conditions/melanoma/diagnosis-treatment/drc-20374888

2. National Center for Biotechnology Information (2020). PubChem Compound Summary for CID 2942, Dacarbazine. Retrieved August 26, 2020 from https://pubchem.ncbi.nlm.nih.gov/compound/Dacarbazine.

3. (n.d.). Retrieved August 26, 2020, from https://www.uptodate.com/contents/cytotoxic-chemotherapy-for-metastatic-melanoma?search=dacarbazine

The power point gave a great overview of the structure and function of skin as well as touching upon the various skin cancers and dermatologic conditions. Our skin has many functions, such as acting as a barrier to protect us from microogranism, chemicals, and UV light damage. It also regulates our body’s temperature by sweating and helps us feel touch via nociceptors. The skin and all of it’s structures make up the integumentary system. The different types of skin cells include basal cells, keratinocytes, melanocytes, merkel cells, and langerhans cells. The epidermis is the outermost layer of the skin and is made up of 5 layers: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum. The dermis is considered the “core” of the integumentary system, and the hypodermis lies below the dermis. Unlike the epidermis which does not contain blood vessels, the dermis contains blood and lymph vessels, nerves, and other structures such as hair follicles and sweat glands.

There are several types of skin cancers such as basal cell carcinoma, squamous cell carcinoma, melanoma, merkel cell carcinoma, CTCL, DFSP, and sebaceous carcinoma. Prevention is very important when talking about skin cancer. UV radiation that is produced by tanning beds is a group 1 carcinogen, which is in the same category as tobacco or asbestos. The risk does not outweigh the benefit. It is also important to provide the public with proper education on sun protection. Australia started a SunSmart program (slip on clothing, slop on sunscreen, slap on a hat, seek shade, and slide on sunglasses) and they attribute this program to the decrease in the incidence of skin cancer in young adults.

Linos E, Katz KA, Colditz GA. Skin Cancer-The Importance of Prevention. JAMA Intern Med. 2016;176(10):1435-1436. doi: 10.1001/jamainternmed.2016.5008.

After reviewing the presentation, I received an overview of skin structure and function. The presentation first went on to define the layers of the skin, type of skin cells that exist within each layer, and what each layer of the skin is comprised of. The skin makes up the integumentary system, which acts as a barrier to protect the skin from the outside world. Following this, we see the epidermis is made up of 5 layers including the Stratum Basale, Stratum Spinosum, Stratum Granulosum, Stratum Lucidum, and Stratum Corneum. We are also able to review skin function and how it serves a to protect, regulate, and provide sensation (with the help of nociceptors). The different layers of the skin also include the dermis and the hypodermis. After understanding the cells involved, the different layers of the skin, and the purpose of this system, it went on to define different dermatological conditions that exist, such as skin cancers and drug induced skin conditions, along with causes, diagnosis, treatments/management, etc.

Something that caught my eye was DFSP, otherwise known as Defmatofibrosarcoma Protuberans. This is a rare type of soft tissue sarcoma that is developed deep in the skin layers (usually the connective tissue in the dermis). This type of sarcoma can be described as tentacle that can grow into surrounding fat, muscle, and bone. Usually found on the torso, but can also be seen on the arms, legs, head, and neck. It usually appears as a bruise or a scar and lumps of tissues form near the skin as it grows, hence protuberans. This is usually diagnosed by skin examination, skin biopsy, and imaging tests such as MRI’s to help determine whether or not cancer cells exist and where exactly the cancer has spread to.

Kevin O'Halloran, MD; Jonathan Courtney. “What Is Dermatofibrosarcoma Protuberans?” Liddy Shriver Sarcoma Initiative, Liddy Shriver Sarcoma Initiative, Dec. 2012, sarcomahelp.org/dermatofibrosarcoma-protuberans.html#:~:text=Dermatofibrosarcoma%20Protuberans%20(DFSP)%20is%20a,fat%2C%20muscle%20and%20even%20bone.

“Nonmelanoma Skin Cancer.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 28 Jan. 2020, www.mayoclinic.org/diseases-conditions/dermatofibrosarcoma-protuberans/cdc-20352949.