THERAPEUTIC

CHEAT SHEET
THE COMPLETE SERI ES
JANUARY-DECEMBER 2021
Dupilumab
Terbinafine
Gabapentin
Naltrexone
Pregabalin
Bexarotene
OnabotulinumtoxinA
Oral Glycopyrrolate
Thalidomide
Acitretin
 Dupilumab Therapeutic Cheat Sheet
COMPILED BY: AZAM QURESHI, MD • REVIEWED BY: ADAM FRIEDMAN, MD
TRADE NAME
› Dupixent
MECHANISM OF ACTION
› Dupilumab is a recombinant, fully human IgGκ
monoclonal antibody which antagonizes the
α-subunit of IL-4 receptors (IL-4Rα, both types 1 &
2).1 Because the type 2 IL-4Rα must dimerize with
an IL-13 receptor subunit for mutual activation,
dupilumab inhibits downstream signaling of both
IL-4 and IL-13, thereby improving AD symptoms2
FDA APPROVED FOR
› Moderate-to-severe AD in adults and adolescents 6
years or older, refractory to topical therapy or when
other treatments are contraindicated
› Add-on maintenance therapy for moderate-to-
severe asthma in adults and adolescents 12 years
or older with eosinophilic or oral corticosteroid-
dependent asthma
› Add-on maintenance therapy for chronic
rhinosinusitis with nasal polyposis in adults 18
years or older with poorly controlled disease
OFF-LABEL USES
› Chronic pruritus3
› Prurigo nodularis4
› Idiopathic chronic eczematous eruption of aging5
› Allergic contact dermatitis6
› Chronic hand eczema7 and dyshidrotic eczema8
› Chronic urticaria9
› Eosinophilic annular erythema10
› Papuloerythroderma of Ofuji11
› Alopecia areata (AA)12
› Bullous pemphigoid13
DOSING
› Adults 18 years or older: 600mg, followed by
300mg every 2 weeks
› Pediatric patients 6 – 17 years old
› 60+ kg: Loading dose of 600mg,
followed by 300mg every 2 weeks
› 30-60kg: Loading dose of 400mg,
followed by 200mg every 2 weeks
› 15-30kg: Loading dose of 600mg,
followed by 300mg every 4 weeks
SIDE EFFECTS
› Injection site reactions (10%)1
› Conjunctivitis (10%), eye pruritus (1%), keratitis (<1%),
blepharitis (<1%), dry eyes (<1%)1
› Hypersensitivity reactions including urticaria, rash,
erythema nodosum, anaphylaxis, and serum sickness
(<1%)1
› Oropharyngeal pain1
› Eosinophilia1
› Multiple reports of development of AA14,15
› Multiple reports of cutaneous T-cell lymphoma both 1)
worsening in patients with known pre-existing disease, or
2) newly observed in patients receiving treatment for AD16
› Single report of worsening of pre-existing psoriasis17
› Although manufacturer label cites risk of herpes simplex
virus infection (oral or other, 6%), a meta-analysis
conducted including 8 randomized controlled trials
consisting of 2,706 patients showed evidence of no
significant association between dupilumab use and overall
herpesvirus infections1,18
WARNINGS
› Avoid administration of live vaccines while on dupilumab
› Treat patients with helminthic infections prior to initiating
therapy
CONTRAINDICATIONS
› Patients with known hypersensitivity to the drug or any of
its components
PREGNANCY
› Has not directly been studied in pregnant humans, but
available data suggests no increased risk of miscarriages,
adverse maternal or fetal outcomes, or major birth defects
to date1
› Although human IgG antibodies may cross the placenta
and be transmitted to the fetus, an animal study utilizing
a homologous antibody against the IL-4 receptor α-subunit
at doses up to 10-times the maximum recommended
human dose administered from organogenesis through
birth showed no association with adverse developmental
effects1
› No data on the presence of dupilumab in human milk,
effects on milk production, or effects on infants who are
breastfed, but maternal IgG is known to be present in
human milk1
MONITORING
› No recommended monitoring guidelines
 IN DERM
Terbinafine Therapeutic Cheat Sheet
COMPILED BY: ADRIANNA GONZALEZ, MD • REVIEWED BY: ADAM FRIEDMAN, MD
TRADE NAME
› Lamisil
MECHANISM OF ACTION
› An allylamine that inhibits squalene
epoxidase, an enzyme involved in
the biosynthesis of ergosterol, an
essential component of fungal cell
membranes. Inhibition of squalene
epoxidase also leads to intracellular
squalene accumulation, which
eventually causes cell death by
interfering with the growth and
integrity of the fungal cell wall.1
FDA APPROVED FOR
› Oral formulations:
• Onychomycosis of the toenail or
fingernail due to dermatophytes
(fda insert)
• Tinea capitis in patients ≥ 4 years
of age
› Topical formulations:
• Treatment of tinea pedis, tinea
cruris and tinea corporis
PREGNANCY
› Pregnancy category B. However,
studies have found that terbinafine is
safe to use in both its topical and oral
forms during pregnancy.18
› Caution advised while breastfeeding
as it can be found in breast milk.
Treatment not recommended while
nursing.
MONITORING
› Manufacturers recommend periodic
monitoring of liver function. Given
the low rate of clinically meaningful
lab abnormalities, however, it is
increasingly being suggested that lab
monitoring is unnecessary in healthy
individuals.19 There are currently no
guidelines outlining appropriate lab
monitoring.
› Per package insert, in patients
with known or suspected
immunodeficiency, CBC should be
checked if treating for > 6 weeks due
to risk of a decrease in ALC11
CONTRAINDICATIONS
› Active or chronic hepatic disease or
hepatic dysfunction
› History of allergic reaction to oral
terbinafine
DOSING
› In its oral form, terbinafine comes in 250mg tablets which adult patients
typically take once daily for a number of weeks, depending on the condition
being treated:
• Fingernail onychomycosis: 6 weeks
• Toenail onychomycosis 12 weeks
• Tinea pedis/manum/corporis/cruris: 2 weeks3,4
• Majocchi granuloma, tinea barbae: 2-6 weeks5,6
› Tinea capitis: administered once daily for 6 weeks. Dosage is based on
weight and ranges between 62.5mg to 250mg per day.
› For sporotrichosis, a dose of 500mg twice daily is recommended until 2-4
weeks after lesions resolve7
› Topical terbinafine comes in cream, gel and spray formulations and is
applied to affected areas:
• Tinea corporis/cruris: once daily for 1 week
• Tinea pedis: twice daily for 1-2 weeks
OFF-LABEL USES (ORAL FORMULATION)
› Onychomycosis in the pediatric population2
› Tinea corporis/cruris/faciei3
› Tinea pedis/manum4
› Tinea barbae5
› Majocchi’s granuloma6
› Sporotrichosis (lymphocutaneous and cutaneous)7
› It is important to note that although topical formulations be of benefit in
tinea versicolor, oral terbinafine is ineffective in these cases8
SIDE EFFECTS
› Elevated liver enzymes and hepatotoxicity are likely the most frequently
discussed adverse effect when referring to terbinafine, however, reports of
serious liver injury are extremely rare. Several studies have highlighted the
fact that elevations in liver enzymes are relatively infrequent and, for the
most part, clinically irrelevant. A meta-analysis reported that the risk of LFT
elevation requiring discontinuation of terbinafine was only 0.35%, while the
risk of asymptomatic LFT elevation not requiring treatment discontinuation
was 0.7%9
› GI symptoms including diarrhea, dyspepsia, nausea and abdominal pain
› Disturbance or loss of taste or smell which typically resolves within weeks
of discontinuing medication, although it has been reported to be permanent
in some cases10
› Headache10
› Depressive symptoms which may improve with discontinuation and may
recur when therapy is re-started
› Hematologic adverse effects: Neutropenia, transient decreases in
absolute lymphocyte count, anemia, thrombocytopenia, pancytopenia,
agranulocytosis and thrombotic microangiopathies such as thrombotic
thrombocytopenic purpura and hemolytic uremic syndrome11
› Pruritus10
› Cutaneous reactions reported in the literature: Stevens Johnson
Syndrome (SJS)/Toxic epidermal necrolysis (TEN)12, acute generalized
exanthematous pustulosis (AGEP)13, Drug induced hypersensitivity
syndrome (DIHS) / drug reaction with eosinophilia and systemic symptoms
(DRESS)14, urticaria, erythema multiforme15, psoriasiform eruptions or
psoriasis exacerbation16
› There are several reports of induction or exacerbation of subacute
cutaneous lupus erythematosus (SCLE) which typically develops 1-8 weeks
after starting terbinafine17
DRUG INTERACTIONS
› Terbinafine is a CYP450 2D6 inhibitor and can therefore lead to increased
levels of other drugs metabolized by this enzyme. Therefore, caution is
advised when taken with antidepressants, beta-blockers and class IC
antiarrhythmics.
 IN DERM
Gabapentin Therapeutic Cheat Sheet
COMPILED BY: BLAIR ALLAIS, MD • REVIEWED BY: ADAM FRIEDMAN, MD
TRADE NAME
› Neurontin
› Gralise
MECHANISM OF ACTION
› Exact mechanism unknown.
Structurally related to the
neurotransmitter gamma-
aminobutyric acid (GABA) but has
no effect on GABA binding, uptake
or degradation. In vitro studies
demonstrate binding with high
affinity to the α2δ subunit of voltage-
activated calcium channels.1 This
action thereby reduces calcium
influx and the subsequent release of
excitatory neurotransmitters, thus
increasing the threshold for neuronal
excitation.2
FDA APPROVED FOR
› Postherpetic neuralgia in adults
› Adjunctive therapy in the treatment
of partial onset seizures in adult and
pediatric patients with epilepsy.1
OFF-LABEL USES
› Chronic pruritus
› Uremic pruritus
› Brachioradial pruritus
› Nostalgia paresthetica
› Scalp dysesthesia
› Trigeminal trophic syndrome
› Prurigo Nodularis
› Penodynia
› Vulvodynia
› Erythromelalgia
DOSAGE FORMS AND STRENGTHS
› Capsules: 100mg, 300mg, and 400mg
› Tablets: 600mg and 800mg
› Oral Solution: 250mg/5mL
DOSING REGIMENS
› Postherpetic neuralgia: 300mg on
day 1, 300mg BID on day 2, 300mg
TID on day 3, increasing as needed
up to 1.8-3.6 g/day.2
› For chronic pruritus, initial dosing of
300mg/d and can be increased to
1200mg three times per day.3
› Should be tapered gradually if
discontinuing medication to avoid
withdrawal symptoms such as
seizures.4
SIDE EFFECTS
› Drowsiness, sedation, fatigue
› Dizziness, ataxia
› Peripheral edema
› Drug reaction with eosinophilia and
systemic symptoms1
› Suicidal behavior and ideation1
CONTRAINDICATIONS
› Hypersensitivity to gabapentin or
components of formulation
PREGNANCY
› Category C
MONITORING
› Baseline creatinine
› Monitor for depression, behavior
changes and suicidality
› Schedule 5 controlled substance in
many states. Combination of opioids
and gabapentin potentially increases
risk of acute overdose death.5
 IN DERM

Naltrexone Therapeutic Cheat Sheet

COMPILED BY: ADRIANNA GONZALEZ MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME DERMATOLOGIC DOSING

› Revia
› Depade
› Trexan
MECHANISM OF ACTION
› Naltrexone is a long-acting opioid receptor
antagonist that competitively binds to μ, κ, δ opioid
receptors. In high doses (50mg daily), naltrexone is
continuously bound to receptors. However, with low
dose naltrexone (LDN) (1.5-5mg daily), receptors
are bound intermittently at 2-6 hour intervals leading
to a compensatory increase in endorphins, opioid
growth factors and expression of μ receptors and δ
receptors1
› It is believed to exert antipruritic effects by binding
directly to opioid receptors in the skin and binding
antagonistically to spinal cord dorsal horn neurons
responsible for the perception of itch. This interaction
blocks mast cells, basophils and IgE mediated
histamine release2
› While high dose naltrexone is pro-inflammatory,
LDN has anti-inflammatory effects by acting as a
toll-like receptor 4 antagonist, which in turn leads to
decreased TNF-α, interleukin-6 and nitric oxide1
FDA APPROVED USES
› Opioid use disorder
› Alcohol use disorder
› Pruritus associated with systemic disease, including
uremic pruritus and cholestatic pruritus: 50mg daily3-7
› Pruritus associated with atopic dermatitis: 25-50mg
daily8,9 or naltrexone 1% cream at least twice daily10
› Pruritus associated with burn injuries: 50-100mg
daily
› Hailey-Hailey: 1.5-4.5mg daily11,12
› Lichen planopilaris: 3mg daily13
› Aquagenic pruritus: 25mg daily for 3 months, then
every other day indefinitely14
› Scleroderma: 2-4.5mg at bedtime15
› Guttate psoriasis: 4.5mg daily16
SIDE EFFECTS
› Abdominal cramps
› Nausea
› Arthralgias/myalgias
› Headache
› Sleep disturbances
› Fatigue
› Anxiety
› Hepatotoxicity has been reported in patients treated
for alcohol use disorder, however this risk is very low1
› Dizziness
› Hair loss
› Paradoxical exacerbation of pruritus after long-term
treatment with naltrexone has been reported when
used for cutaneous mycosis fungoides, xerosis cutis
and prurigo nodularis4

CONTRAINDICATIONS
OFF-LABEL USES IN DERMATOLOGY
› Concomitant opioid use
› Hailey-Hailey (LDN)
› Atopic dermatitis
› Lichen planopilaris (LDN) LAB MONITORING
› Guttate psoriasis (LDN)
› Although the risk of the risk of hepatotoxicity is very
› Scleroderma (LDN)
low, baseline liver function tests with repeat testing
› Cholestatic pruritus
at 8-12 weeks should be considered
› Aquagenic pruritus
› Burn injury-associated pruritus
› Uremic pruritus PREGNANCY
› Category C
 IN DERM

Pregabalin Therapeutic Cheat Sheet

COMPILED BY: AZAM QURESHI, MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME SIDE EFFECTS

› Lyrica
MECHANISM OF ACTION
› Although the exact mechanism of action is not well-
understood, pregabalin is a gabapentinoid agent
which binds and inhibits the α2δ auxiliary subunit
of voltage-gated calcium channels containing this
specific subunit, thereby disrupting neurotransmitter-
mediated communication between the dorsal root
ganglion and the spinal dorsal horn.6 Pregabalin
reduces the spinal cord release of substance P and
calcitonin gene-related peptide, which are important
mediators in sensation of itch and pain through
interplay with C-fibers.7
FDA APPROVED FOR
› Most commonly: Dizziness, somnolence, dry mouth,
edema, blurred vision, weight gain, difficulty with
concentration & attention8
› Angioedema, hypersensitivity reactions8
› Respiratory depression8
› Suicidal thoughts & behavior (however, evidence is
inconclusive)8
› Seizures with withdrawal8
› Possible creatine kinase elevations, decreased
platelet counts, and PR interval prolongation8
WARNINGS
› Caution in patients with previous episode of
angioedema or in patients on other drugs also
associated with increased risk of angioedema
(ex. angiotensin converting enzyme inhibitors)8

› Neuropathic pain associated with diabetic peripheral

neuropathy or spinal cord injury8 CONTRAINDICATIONS
› Postherpetic neuralgia8
› Fibromyalgia8 › Patients with known hypersensitivity to the drug or
› Partial-onset seizures in patients 1 month and older, any of its components8
adjunctive therapy8

PREGNANCY & BREASTFEEDING

OFF-LABEL USES
› No well-controlled studies studying medication in
› Chronic pruritus9,10 pregnant human women; further study is needed8,22
› Uremic pruritus11 › Recent cohort study providing evidence for lack
› Neuropathic or neurogenic pruritus11 of significantly increased occurrence of major
› Prurigo nodularis12 congenital malformations in offspring of patients
› Brachioradial pruritus13 using medication22
› Notalgia paresthetica14 › Evidence from animal studies suggest increased risk
› Scalp dysethesia15 of fetal abnormalities in offspring of rats and rabbits
› Vulvodynia16 exposed to 16 times the max. recommended human
› Red scrotum syndrome17 dose of medication2
› Pain symptoms associated with acral › Small amounts of medication detected in milk of
erythrodysesthesia or hand-foot-skin reaction18 women who are lactating (about 7% of mother’s
› Acute zoster19 dose, effects on infant breastfed this medication are
› Erythromelalgia20 unknown)8

DOSING MONITORING
› Adult indications; begin dosing at 150mg daily, › Monitor for symptoms of swelling of face, mouth, or
although evidence of efficacy of lower starting doses neck (angioedema may occur with initial or chronic
in management of pruritic diseases8 treatment)
› Diabetic peripheral neuropathy pain; 3 divided doses › Monitor for new or worsening depression, suicidal
daily of 300mg daily within 1 week ideation, behavior
› Postherpetic neuralgia; 2-3 divided doses per day of
› Monitor for respiratory depression
300mg daily within 1 week (max. dose of 600mg daily)
› Adjunctive treatment for partial-onset seizures in
pediatric and adult patients weighing 30kg+
› 2-3 divided doses, max. dose of 600mg daily
› Adjunctive treatment for partial-onset seizures in
pediatric patients weighing <30kg
› 1 month to <4 years; 3 divided doses of 14mg/kg
daily
› 4 years and older; 2-3 divided doses of 14mg/kg
daily
› Fibromyalgia; 2 divided doses daily, 300mg daily within
1 week, max. dose of 450mg daily
› Off-label use in chronic pruritic diseases; evidence for
efficacy of 75mg once daily, with titration upwards
to twice daily dosing, and/or 150mg once daily, with
titration upwards to twice daily dosing, with max. dose
of 600mg daily10,12,21
› Dose adjustment in adult patients with reduced
kidney function8
› Withdrawal recommended over min. of 1 week to
prevent seizures8
 IN DERM

Bexarotene Therapeutic Cheat Sheet

COMPILED BY: ADRIANNA GONZALEZ MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME DERMATOLOGIC DOSING

› Targretin › Oral formulation:
› CTCL: Initial dose of 300 mg/m2/day; may increase up
to a maximum dose of 400 mg/m2/day
MECHANISM OF ACTION › Psoriasis: 0.5 to 3 mg/kg/day
› Topical formulation: bexarotene 1% gel applied 2-4
› Bexarotene is a vitamin A derivative that selectively
times daily
binds and activates retinoid X receptors (RXRs),
which function as ligand-activated transcription
factors that control the expression of genes CONTRAINDICATIONS
that modulate cellular growth, apoptosis and
differentiation › Pregnancy
› Hypersensitivity

FDA APPROVED USES

DRUG INTERACTIONS
› Oral bexarotene: Cutaneous manifestations of CTCL
in patients who are refractory to at least one prior › Drugs that affect CYP3A4 may affect bexarotene
systemic therapy1 levels
› Topical bexarotene: Cutaneous lesions in patients › Concomitant use of gemfibrozil leads to increased
with Stage IA and IB CTCL who have persistent or bexarotene serum concentrations and can cause a
refractory disease after other therapies, or who have paradoxical increase in triglyceride levels
not tolerated other therapies › Products containing N,N-diethyl-m-toluamide (DEET)
should be avoided, as bexarotene may increase DEET
toxicity1
OFF-LABEL USES IN DERMATOLOGY
› Oral and topical formulations: Psoriasis2,3 LAB MONITORING
› Topical formulation: alopecia areata4
› Baseline: CBC, lipid panel, LFTs, TSH, free T4
› Lipids should be monitored weekly for the first 2-4
SIDE EFFECTS weeks and then every 8 weeks thereafter
› LFTs should be monitored 1, 2 and 4 weeks after
› Hypertriglyceridemia and hypercholesterolemia can treatment initiation and periodically thereafter
be seen in most patients. About 70% of patients of › CBC and thyroid function tests should be monitored
patients with CTCL at a dose of 300 mg/m2/day periodically throughout treatment
developed triglyceride levels 2.5 times the upper limit › For females: Pregnancy test < 1 week prior to
of normal and 60% developed cholesterol elevations treatment initiation, then monthly
above 300 mg/dL.1,5 Lipid levels should be monitored
and treated with lipid lowering therapy (avoid PREGNANCY
gemfibrozil as mentioned below) or reduction in
dose/cessation of bexarotene if needed to maintain › Bexarotene is pregnancy category X and can lead
triglyceride levels below 400 mg/dL. to severe birth defects. Two reliable forms of
› Central hypothyroidism can be seen in a large contraception must be used for one month prior to
percentage of patients, especially at doses greater therapy initiation, during therapy and for at least one
than 300 mg/m2/day. Thyroid abnormalities are month following therapy discontinuation.
thought to be dose-dependent and are reversible
with discontinuation of bexarotene. Prophylactic
levothyroxine may be initiated 7 days prior or at the
time of bexarotene initiation6
› Headaches
› Transaminitis
› Leukopenia and neutropenia
› Pancreatitis
› Cataracts
› Localized or extensive exfoliative dermatitis
› Xerosis
› Photosensitivity
 IN DERM

OnabotulinumtoxinA for Primary Axillary

Hyperhidrosis Therapeutic Cheat Sheet
COMPILED BY: KAMARIA NELSON, MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME SIDE EFFECTS ASSOCIATED WITH AXILLARY PHH

› Botox › Injection site pain (≥ 3%)1,2,8
› Hemorrhage (≥ 3%)1,2,8
Bruises3
MECHANISM OF ACTION ›
› Non-axillary compensatory sweating (≥ 3%)1,2,8
› OnabotulinumtoxinA is a potent neurotoxin which inhibits › Pharyngitis (≥ 3%)1,2,8
the release of acetylcholine by binding to sites on motor or › Infection (≥ 3%)1,2
sympathetic nerve terminals resulting in the blockage of › Flu-like syndrome (≥ 3%)1,2,8
neuromuscular transmission.1 This is done via cleavage of › Urticaria3
synaptosomal-associated protein 25 (SNAP-25) within nerve › Headache (≥ 3%)1,2
endings which normally docks and releases acetylcholine.1,2 › Fever (≥ 3%)1,2
Injected intramuscularly, there is partial chemical denervation › Neck or back pain (≥ 3%)2
of the muscles and local reduction of muscle activity.1 When › Mild local pruritus (≥ 3%)2
injected intradermally, onabotulinumtoxinA results in chemical
denervation of eccrine glands leading to a reduction in
sweating, thereby improving axillary PHH symptoms.1 WARNINGS
› Product may spread from the area of injection and produce
FDA APPROVED USES symptoms at unintended sites
› Swallowing and breathing difficulties can be life threatening
› Overactive bladder with symptoms of urge urinary and lead to death
incontinence, urgency and frequency, in adults with inadequate › Use with caution in patients with compromised respiratory
response to anticholinergic medication function
› Urinary incontinence due to detrusor overactivity associated › Concomitant neuromuscular disorder may exacerbate clinical
with a neurologic condition effects of treatment
› Neurogenic detrusor overactivity in pediatric patients 5 › Rarely arrhythmias, myocardial infarction (MI) with pre-
years and older with inadequate response to anticholinergic
medication
› Prophylaxis of headaches in adults with chronic migraine CONTRAINDICATIONS
› Spasticity in patients 2 years and older
› Cervical dystonia in adult patients to reduce severity of › Patients with known hypersensitivity to the drug or any of its
abnormal head position and neck pain components
› Severe axillary hyperhidrosis that is inadequately managed by › Infection at the proposed injection site
topical agents in adult patients › Patients with peripheral motor neuropathic diseases,
› Blepharospasm associated with dystonia in patients 12 years amyotrophic lateral sclerosis (ALS) or neuromuscular junction
and older disorders (e.g. myasthenia gravis or Lambert-Eaton syndrome)2
› Strabismus in patients 12 years and older
› Moderate to severe glabellar lines associated with corrugator
and/or procerus muscle activity PREGNANCY
› Moderate to severe lateral canthal lines associated with
› There are no studies or adequate data on risk associated
orbicularis oculi activity
in pregnant women. In animal studies, onabotulinumtoxinA
› Moderate to severe forehead lines associated with frontalis
administration in pregnancy resulted in decreased fetal weight
muscle activity
and skeletal ossification as well as maternal toxicity including
abortions, early deliveries and maternal death.
OFF-LABEL USES IN DERMATOLOGY › The estimated background risk of major birth defects and
miscarriages is 2-4% and 15-20%, respectively.
› Hyperhidrosis for the palms, soles, trunk, craniofacial › No data on the presence of onabotulinumtoxinA in human
region3,5,7 milk, effects on milk production, or effects on infants who are
› Chronic pain disorders2,11 breastfed.
› Frey syndrome2
› Depression2
› Facial asymmetry2 MONITORING
› Platysma and masseter hypertrophy2
› Wound healing12 › No recommended monitoring guidelines
› Hyperhidrosis of less common areas like the groin,
submammary region and gluteal cleft13

DOSING
› Axilary: 50 Units per axilla (diluted as 2.5-5 mL per 100 U of
onabotulinumtoxinA)1,8,12
› 0.1 to 0.2 mL distributed into 10 to 15 sites spaced 1-2 cm apart
› Palmar: 75-100 Units per palm3
› 0.05 to 0.1 mL injected into 5-50 sites spaced 1-1.5 cm apart
› Plantar: 100-200 Units per foot3
› Craniofacial:
› Forehead: 40 Units13
› Forehead and frontal scalp: 50-100 Units3
› Forehead and scalp boundaries: 200 Units3
› Forehead and entire scalp: 300 Units3,13
› Groin: Ideal dose has not been established; case reports have
suggested 50 Units per inguinal fold13
 IN DERM

Oral Glycopyrrolate Therapeutic

Cheat Sheet
COMPILED BY: AZAM QURESHI, MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME SIDE EFFECTS 9-10

› Glycate® › Most commonly (occurring in 15% or more patients):
› Robinul® and Robinul® Forte vomiting, dry mouth, constipation, flushing, nasal congestion,
› Cuvposa® sinusitis, upper respiratory tract infection, headache,
urinary retention
› Other side effects that may be less common:
MECHANISM OF ACTION › Mydriasis, increased intraocular pressure
› Competitive inhibitor of acetylcholine at M3 muscarinic › Arrhythmias
receptor on post-synaptic neurons, thereby inhibiting › Hypohidrosis
sympathetic stimulation of eccrine sweat gland and sweat › Impotence
production3 › Urinary hesitancy
› Decreased gastric motility and secretion,
pseudo-obstruction
FDA APPROVED FOR › Compensatory hyperhidrosis11

› Chronic drooling (Cuvposa®)4

CONTRAINDICATIONS 9-10
OFF-LABEL USES › Hypersensitivity to glycopyrrolate
› History of myasthenia gravis
› Primary focal hyperhidrosis1-3 › History of severe ulcerative colitis, toxic megacolon,
› Axillary hyperhidrosis paralytic ileus, obstructive disease of GI tract,
› Facial hyperhidrosis intestinal atony, obstructive uropathy
› Pediatric and adolescent hyperhidrosis › Unstable cardiovascular status
› Hailey-Hailey disease9 › Glaucoma

DOSING PREGNANCY & BREASTFEEDING 9-10

› Children up until age 19: variable dosing regimens have › No adequate and well-controlled studies of the effects of
been utilized, weight-based dose of 0.05-0.06 mg/kg/day oral glycopyrrolate on pregnant humans, further study is
in 1 or 2 divided doses supported by recent literature4 needed
› Adults: variable dosing regimens have been utilized, › Given glycopyrrolate serves as an anti-cholinergic
1 to 2 mg once or twice daily, titrating upwards weekly medication, it may suppress lactation
based on treatment response and tolerability supported › It is not known if glycopyrrolate is present in breast milk
by literature1,2,4
› Maximum of 8 mg per day2,7,8
MONITORING 9-10
› Monitor for heart rate, bowel sounds & movements
WARNINGS › No recommended lab monitoring
› Patients should proceed cautiously if they have history
of cardiovascular disease, gastroesophageal reflux,
bladder obstructions, or glaucoma9-12
› Neonates: Dosage forms may contain propylene glycol,
which has previously been shown to be associated with
metabolic acidosis, seizures, renal failure, and central
nervous system depression with excessive systemic
administration (>3,000 mg/day)9-10
 IN DERM

Thalidomide Therapeutic Cheat Sheet

COMPILED BY: EMILY MURPHY, MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME SIDE EFFECTS

› Thalomid › Teratogenicity (see pregnancy below)
› Peripheral neuropathy: proximal muscle weakness and lower
extremity sensory loss (motor changes are often reversible,
MECHANISM OF ACTION but sensory function may not be).1,7,10
› Thalidomide has multiple mechanisms, which can be grouped › Thromboembolic events11
into four categories:1 › Common effects:1,7,7,12
› Drowsiness (very common)
1. Hyponosedative effects: penetrates the central nervous system and
causes sedation by unknown mechanism (use: pruritic conditions like › Constipation (very common)
prurigo nodularis).1 › Nausea
2. Immunomodulatory effects: thalidomide inhibits Tumor Necrosis Factor › Fatigue
alpha, resulting in decreased helper T cells and slightly increased › Mood changes (anxiety or agitation)
suppressor T cells (uses: Erythema Nodosum Leprosum, sarcoidosis,
chronic graft-versus-host disease, prurigo nodularis).1–3 › Xerostomia and xerosis
› Brittle nails
3. Anti-inflammatory effects: decreases neutrophil chemotaxis (uses:
chronic cutaneous lupus erythematosus, pyoderma gangrenosum, › Peripheral edema
aphthous stomatitis).1,4 › Pruritus

4. Neural and vascular effects: thalidomide is hypothesized to have › Irregular menses

direct effects of neural tissue (use: prurigo noduarlis).1 It also inhibits › Hyperglycemia
angiogenesis (use: Kaposi Sarcoma).1
› Bradycardia
› Red palms
FDA APPROVED FOR 5
› Decreased libido
› Dizziness and orthostatic hypotension
› Erythema Nodosum Leprosum (ENL)
› Rare effects:1
› Acute cutaneous manifestations of moderate to severe ENL
› Endocrine defects (hypothyroidism, hypoglycemia,
› Maintenance therapy for prevention of ENL recurrence adrenocorticotropic hormone stimulation)
› Not indicated for monotherapy in the presence of moderate to › Leukopenia
severe neuritis
› Seizures
› Multiple myeloma, in combination with dexamethasone › Exfoliative or erythrodermic reactions
› Hypersensitivity reaction

OFF-LABEL USES
› Very effective:1,6,7 DRUG INTERACTIONS
› Aphthous stomatitis and HIV-associated oral stomatitis › Use with caution in combination with other drugs that cause:1,5
› Behçet disease › Sedation/CNS depression (alcohol, sedating H1 antihistamines,
› Cutaneous features of lupus erythematosus antipsychotics, benzodiazepines, antidepressants,
anticholinergics)
› Prurigo nodularis
› Bradycardia
› Moderately effective:1,6,7 › Peripheral neuropathy (isoniazid, metronidazole)
› Actinic prurigo › Thromboembolic events (bisphosphonates, corticosteroids)
› Uremic pruritus › Oral contraceptive pills are included; benefit may
outweigh risk but it is important to consider non-
› Langerhans cell histiocytosis
hormonal birth control options.
› Cutaneous sarcoidosis
› High risk use with CYP3A4 inducers (anticonvulsants,
› Recurrent erythema multiforme
rifampin, griseofulvin) that impair the efficacy of oral
› Chronic graft-versus-host disease contraceptive pills.1
› Jessner lymphocytic infiltrate of the skin
› Live vaccines: should be given 3 months after completion
› Possibly effective:1,6,7 of therapy.1
› Kaposi Sarcoma
› Lichen planus
CONTRAINDICATIONS1
› Pyoderma gangrenosum
› Absolute:
› Hypersensitivity to thalidomide
DOSING (ORAL) › Patients with peripheral neuropathy
› ENL: 100 to 300 mg daily (up to 400 mg daily for severe › Pregnancy and women of childbearing potential without strict
disease);1,5 for 7 days, followed but another 7 days for contraception or abstinence
non-responders.8,9 › Men engaging in sexual intercourse with women of childbearing
potential without latex condoms
› MM: 200 mg daily 5

› Doses vary for off label indications, typically 50 to 300 mg daily.1 › Relative:

› Hepatic or renal impairment
› Neuritis or other neurologic disorders
MONITORING › Congestive heart failure or hypertension
› REMS program: prescribers and pharmacists › Significant constipation
must be registered.1,5 › Hypothyroidism

› Female patients must use 2 reliable forms of birth control.
› Pregnancy tests required 1 month before therapy, within 24 hours
of starting therapy, and 1 month after therapy. During therapy,
pregnancy tests are needed weekly for 4 weeks followed by
monthly.
› Fertile men must use latex condoms given thalidomide has been
detected in semen.13,14
› Perform neurologic exam to monitor for neuropathy monthly
for 3 months, then every 3-6 months.1
› Baseline CBC and hepatic function panel; monitor monthly
until dose is stable, then every 2-3 months.1
› Live vaccines: should be given 3 months after completion
of therapy.1
PREGNANCY
› Category X: severe teratogenic effects. During 21 to 36 weeks
gestation, there is almost 100% risk of birth defects, the
most common being phecomelia (underdevelopment of arms
and legs).1,7 Birth defects or fetal death can occur after only
one dose.5
› Thalidomide is only available through a restricted distribution
program, THALOMID Risk Evaluation and Mitigation Strategy
(REMS) program.
 IN DERM

Acitretin Therapeutic Cheat Sheet

COMPILED BY: AZAM QURESHI, MD • REVIEWED BY: ADAM FRIEDMAN, MD

TRADE NAME DOSING6-9

› Soriatane1 › Psoriasis-related indications: 0.25-1mg/kg once daily
with food
MECHANISM OF ACTION1,2 › Pityriasis rubra pilaris: 0.5mg/kg once daily with food
› Chemoprevention of NMSC in transplant patients:
› Vitamin A derivative retinoic acid metabolite of etretinate 0.2-0.4 mg/kg once daily with food
› First binds cytosolic retinoic acid-binding protein, which › Ichthyoses, keratodermas, other indications: variable dosing
serves to facilitate transport to the nucleus, where subsequent regimens have been reported, usually started at low dose and
binding to retinoic acid receptors (RARs) and retinoid X titrated upwards depending on disease response and toleration
receptors (RXR) occurs, thereby serving to modulate of medication
nuclear transcription › Maximum recommended dose of 75mg daily
› Normalizes keratinocyte differentiation in epithelium, reduces
expression of proinflammatory cytokines (ex. IL-6), migration
SIDE EFFECTS1,3,10,11
inhibitory factor-related protein-8 (MRP-8), and IFN-y, thereby
exerting anti-inflammatory and anti-proliferative effects › Dose-dependent
› Severe birth defects in women pregnant while on medication
FDA APPROVED FOR1 or within 3 years of stopping medication
› 2 negative pregnancy tests required prior to initiation of
› Severe plaque-type psoriasis treatment
› Generalized or localized pustular psoriasis › Hepatotoxicity
› Hypertriglyceridemia, very rarely leading to pancreatitis
Dry mouth, lips, nose, eyes, skin, pruritus
OFF-LABEL USES3-5 ›
› Fragile skin
› Inflammatory dermatoses › Rhinorrhea, epistaxis
› Erythrodermic psoriasis › Alopecia
› Nail psoriasis › Arthralgias
› Palmoplantar pustulosis
› Pityriasis rubra pilaris › Myalgias
› Lichen planus › Headaches
› Lichen nitidus › Nausea
› IgA pemphigus
› Pemphigus vegetans
› Photosensitivity
› Darier’s disease › Reduced night vision
› Post-irradiation morphea › Skeletal hyperostosis
› Granuloma annulare
› Hyperkeratotic hand eczema
› Acneiform eruptions secondary to EGFR inhibitors WARNINGS1
› Hidradenitis suppurativa
› Erosive pustular dermatosis of scalp › May cause increased sensitivity to ultraviolet light, which may
› Ichthyoses and keratodermas warrant dose reduction in concurrent phototherapy treatments
› Neoplastic diseases › Avoid dietary supplements with vitamin A, which may
› Chemoprevention of non-melanoma skin cancer (NMSC)
in transplant patients exacerbate or trigger side effects of acitretin
› Actinic keratosis
›
›
Bowen’s disease
Langerhans cell histiocytosis CONTRAINDICATIONS1
› Porokeratosis
› Infectious conditions › Women who are pregnant or desire to get pregnant
› Recalcitrant warts within 3 years of stopping medication
› Bowenoid papulosis › Severe renal or hepatic impairment
› Buschke Lowenstein tumor › Hypertriglyceridemia
› Blastomycosis-like pyoderma
› Concurrent use of methotrexate or tetracycline medications,
› Connective tissue diseases
› Lupus erythematosus which may increase risks of hepatitis and increased
› Lichen sclerosis intracranial pressure, respectively
› Graft versus host disease › Concurrent use of alcohol
› Mucosal disorders › Previous allergy to acitretin
› Oral leukoplakia
› Genodermatoses
› Pachyonychia congenita PREGNANCY & BREASTFEEDING1
› Lipoid proteinosis
› Acrokeratosis verruciformis › Pregnancy category X; contraindicated during pregnancy,
› Other within 3 years of pregnancy, and during breastfeeding
› Elephantiasis nostras verrucosa
› Keratosis lichenoides chronica
› Lichen amyloidosis MONITORING10
› Arsenical keratosis
› Baseline blood work, to be repeated every 3 months
during treatment:
› Fasting lipid profile, blood glucose
› Liver function tests
› Complete blood count
› Serum creatinine
› Serum pregnancy testing for women who are capable of getting
pregnant (performed monthly during treatment, every 3 months
for 3 years following completion of treatment