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Topical Therapeutics Update Adam O. Goldstein, MD Associate Professor University of North Carolina Department of Family Medicine Chapel Hill, NC

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Presentation on theme: "Topical Therapeutics Update Adam O. Goldstein, MD Associate Professor University of North Carolina Department of Family Medicine Chapel Hill, NC"— Presentation transcript:

1 Topical Therapeutics Update Adam O. Goldstein, MD Associate Professor University of North Carolina Department of Family Medicine Chapel Hill, NC

2 Objectives Advance knowledge of topical preparations Avoid major pitfalls in topical therapeutics Learn two therapeutic reasons to preferentially use creams, lotions, ointments or gels Improve ability to use topical steroids while avoiding side effects

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4 Topical therapies Acne Antifungal * Antibacterial Anti-inflammatory * Moisturizers Sun protection Hair Psoriasis Eczema Aging Debridement Parasites Warts

5 Art of Topical Therapeutics- Antifungals How long should you use topical therapy for mild/moderate tinea corporis? Days beyond symptom resolution (Gupta, Drugs, 1998) What is a preferred topical treatment to prevent recurrence of tinea versicolor? Selenium Sulfide 2.5% (Selsun Blue) applied and left on overnight intermittently (1x/month) (Savin, JFP, 1996)

6 Art of Topical Therapeutics- Antifungals Are topical antifungals all the same? Whitfield's ointment (benzoic acid) Undecylenic alkanolamide (Egomycol®, Mycota®, Dr Scholl's® and others) Ciclopirox olamine (Batrafen® cream, powder, solution) Polyenes (not for dermatophytes) Nystatin (Nilstat® cream, ointment; Mycostatin® cream, ointment, paste)(http://www.dermnetnz.org/index.html)

7 Art of Topical Therapeutics- Antifungals Imidazoles Clotrimazole (Canesten®; Clocreme®; Fungizid®) Econazole (Dermazole®; Ecostatin®; Ecreme®; Pevaryl®) Ketoconazole (Nizoral®; Sebizole®) Miconazole (Daktarin®; Fungo®; Micreme®) Tioconazole (Trosyd®) Thiocarbamates Tolciclate (Tolmicen®), Tolnaftate (Tinaderm) Allylamine (higher cure rates and more rapid responses than older topical antifungals for dermatophyte infections) Terbinafine (Lamisil®) Terbinafine(http://www.dermnetnz.org/index.html)

8 Art of Topical Therapeutics: Anti-inflammatory What potential side effect do these topical over-the-counter medications share? Benzocaine 6% Diphenhydramine 1% Neomycin Benzocaine (brand name Lanacane), diphenhydramine (brand name Benadryl), and neomycin (in brand name Neosporin) = Potential topical sensitizers. (Coskey, JAAD, 1983)

9 Art of Topical Therapeutics: Anti-inflammatory Which OTC lotions help control conditions with pruritus as prominent symptom? camphor, pramoxine or menthol are particularly useful in treating pruritus Sarna contains camphor and menthol Gold Bond contains (menthol): Pramagel and Prax contain pramoxin

10 Major pitfalls Prescribing combination products Prescribing combination products topical fungal/corticosteroid preparations topical fungal/corticosteroid preparations Prescribing insufficient amounts Prescribing insufficient amounts Choosing wrong vehicles Choosing wrong vehicles Choosing wrong steroid classes Choosing wrong steroid classes too weak, too strong, or too long too weak, too strong, or too long

11 Prescribing combination topical fungal/corticosteroid preparations Lotrisone (cream/lotion) Lotrisone (cream/lotion) Betamethasone dipropionate/ clotrimazole Betamethasone dipropionate/ clotrimazole Mycolog II, Mytrex (cream, ointment) Mycolog II, Mytrex (cream, ointment) Nystatin/ triamcinolone acetonide Nystatin/ triamcinolone acetonide

12 Prescribing combination topical fungal/corticosteroid preparations Nondermatologists (34%) >> than dermatologists (5%) to prescribe combination products for treatment of common fungal skin infections Nondermatologists (34%) >> than dermatologists (5%) to prescribe combination products for treatment of common fungal skin infections Potential savings = $10-25 million. Potential savings = $10-25 million. (Smith, JAAD, 1998)

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14 Preparations Creams Creams Lotions Lotions Ointments Ointments Gels Gels Pastes and Powders Pastes and Powders Soaps Soaps Shampoos, foams & mousse Shampoos, foams & mousse Dressings Dressings Other (e.g. astringents, collodions, tinctures, emollients) Other (e.g. astringents, collodions, tinctures, emollients)

15 Creams

16 Useful for most conditions Useful for most conditions Acceptable to most patients Acceptable to most patients Helps dry out moist lesions Helps dry out moist lesions Tell patients to rub in well Tell patients to rub in well Topical creams generally more potent than lotions Topical creams generally more potent than lotions Because of high water content, preservatives added- (may cause allergy) Because of high water content, preservatives added- (may cause allergy)

17 Lotions

18 Useful for scalp and other hairy areas Useful for scalp and other hairy areas Spreads over wide areas easily Spreads over wide areas easily Cosmetically more acceptable in these areas Cosmetically more acceptable in these areas

19 Ointments

20 Ointments generally > potency than creams Ointments generally > potency than creams Hydrates dry, itchy skin Hydrates dry, itchy skin Greasy feel and cosmetically not elegant Greasy feel and cosmetically not elegant May be used at bedtime May be used at bedtime May occlude hair follicles May occlude hair follicles Increase potency by putting under occlusion Increase potency by putting under occlusion

21 Gels Evaporate quickly Evaporate quickly Cosmetically elegant Cosmetically elegant Useful for most skin conditions Useful for most skin conditions Gels may be irritating d/t alcohol in base Gels may be irritating d/t alcohol in base

22 Pastes and Powders Pastes may be useful in intertriginous dermatitis but are difficult to remove Pastes may be useful in intertriginous dermatitis but are difficult to remove May contain silicones that act as water repellent May contain silicones that act as water repellent Can be aplied sparingly to protect uninvolved skin Can be aplied sparingly to protect uninvolved skin Powders help protect intertriginous areas: Powders help protect intertriginous areas:

23 Soaps Soaps and other cleansing bars are useful to cover large areas of skin Soaps and other cleansing bars are useful to cover large areas of skin Ex. Acne- Ex. Acne- Sulfer soap, benzyl peroxide bars, salicylic acid bars Sulfer soap, benzyl peroxide bars, salicylic acid bars

24 Shampoos and Foams Shampoos and foams (mousse) offer cosmetically elegant ($$) formulations (increasing) Shampoos and foams (mousse) offer cosmetically elegant ($$) formulations (increasing) Examples: Examples: betamethasone valerate mousse, salicylic acid & tar shampoos betamethasone valerate mousse, salicylic acid & tar shampoos

25 Wet dressings Superficial debridement macerated skin Superficial debridement macerated skin Burow's Solution (Aluminum Acetate 1/20, 1/40) Burow's Solution (Aluminum Acetate 1/20, 1/40) 1 packet in 1 pint water 1 packet in 1 pint water Soak 6 layers of gauze in solution, wring out and apply for 15 minutes Soak 6 layers of gauze in solution, wring out and apply for 15 minutes Change dressing q 3-4 hrs Change dressing q 3-4 hrs

26 Tube Sizes to prescribe- (bid application for 10 days) Face and Neck: 30g Face and Neck: 30g Trunk (Front and back): 60g Trunk (Front and back): 60g One Arm: 30g One Arm: 30g One Leg: 60g One Leg: 60g One Hand: 15g One Hand: 15g One Foot: 30g One Foot: 30g

27 Tube Sizes to prescribe Rule of thumb to estimate how much cream or ointment needed to cover area of body Rule of 9S: divide body into 11 areas--head, each arm, anterior chest, posterior chest, abdomen, lumbar/buttocks, half of each leg-- 2 grams/application cream/area

28 Topical Steroid Potency Low potency (Hydrocortisone 1%, 2.5%; desonide 0.05%) Low potency (Hydrocortisone 1%, 2.5%; desonide 0.05%) Face Groin Intertriginous areas Mid-potency (Hydrocortisone valerate 0.2% cream; triamcinolone acetonide 0.1% lotion, cream; betamethasone dipropionate 0.05% lotion) Thin skin trunk areas Extremity lesions

29 Topical Steroid Potency High potency (triamcinolone acetonide 0.1% ointment; betamethasone dipropionate 0.05% cream; fluocinonide 0.05% cream) Thick skin trunk areas Extremity lesions Very high/superpotent (fluocinonide 0.05% ointment, betamethasone dipropionate 0.05% ointment; clobetasol propionate 0,05% cream, ointment) Very thick skinned areas Palms and soles

30 Pearls Potent steroids often effective given 1x/day Occlusion increases steroid potency x10 Apply shower cap, plastic bag or saran wrap for stubborn areas Occlusion increases risks of atrophy systemic absorption (Volden, Acta Dermato, 1992)

31 ? If Applied for Therapeutic Purposes!

32 Potential Adverse Effects of Topical Steroids Percutaneous absorption and general suppression Skin atrophy or striae Papular or perioral dermatitis

33 Potent Topical Steroids to Face prolonged (usually >6 weeks) application of potent corticosteroids to the face rosacea perioral dermatitis atrophy

34 Case 1 Bob is a 25 year old male who presents with a two month history of worsening itching of his skin. On his initial visit, he presented with the following rash which you diagnosed as eczema. You prescribed him hydrocortisone 2.5% cream, and on follow-up in one week, he states that he is worse. What do you do? Bob is a 25 year old male who presents with a two month history of worsening itching of his skin. On his initial visit, he presented with the following rash which you diagnosed as eczema. You prescribed him hydrocortisone 2.5% cream, and on follow-up in one week, he states that he is worse. What do you do?

35 Case 1-answer Steroid was not strong enough Steroid was not strong enough Consider high potency steroid (triamcinolone acetonide 0.1% ointment; betamethasone dipropionate 0.05% cream; fluocinonide 0.05% cream) for 1-2 weeks, then reduce to medium potency (e.g. triamcinolone acetonide 0.1% cream) Consider high potency steroid (triamcinolone acetonide 0.1% ointment; betamethasone dipropionate 0.05% cream; fluocinonide 0.05% cream) for 1-2 weeks, then reduce to medium potency (e.g. triamcinolone acetonide 0.1% cream) See back in 2 weeks See back in 2 weeks

36 Case 2 Margaret is a 52 year old cafeteria worker who was seen by your partner 2 weeks ago with a red, scaly, itchy rash on her hand. She was prescribed samples of a fungal/topical steroid preparation which she took for 10 days. The rash seemed to improve, so she quit taking the medication. It has now returned, and she wonders if she should should continue taking it. Margaret is a 52 year old cafeteria worker who was seen by your partner 2 weeks ago with a red, scaly, itchy rash on her hand. She was prescribed samples of a fungal/topical steroid preparation which she took for 10 days. The rash seemed to improve, so she quit taking the medication. It has now returned, and she wonders if she should should continue taking it.

37 Case 2- answer DO A KOH SCRAPE TO ENSURE NO FUNGUS DO A KOH SCRAPE TO ENSURE NO FUNGUS KOH is ---; use a high or ultra potency cream for 2 weeks KOH is ---; use a high or ultra potency cream for 2 weeks Consider if secondarily infected with staph Consider if secondarily infected with staph See back in 2 weeks- if no improvement, consider occlusive therapy See back in 2 weeks- if no improvement, consider occlusive therapy

38 Case 3 Paul is a 17 year old high school student with acne whom you saw 4 weeks ago for initial acne consult. You prescribed benzamycin and retin A gel. He used the products for 4 days but noticed increasingly intense stinging, redness and irritation of his skin. He stopped the medications and his condition reverted back to his normal skin. What would you do now? Paul is a 17 year old high school student with acne whom you saw 4 weeks ago for initial acne consult. You prescribed benzamycin and retin A gel. He used the products for 4 days but noticed increasingly intense stinging, redness and irritation of his skin. He stopped the medications and his condition reverted back to his normal skin. What would you do now?

39 Case 3- answer Problem: too much, too soon & too irritating Problem: too much, too soon & too irritating prescription for two products prescription for two products both gels both gels too strong strengths too strong strengths Back off of gels to creams Back off of gels to creams Use only one formulation for first week Use only one formulation for first week

40 References Gupta AK, Einarson TR, Summerbell RC, Shear NH. An overview of topical antifungal therapy in dermatomycoses- A North American perspective. Drugs 1998; 55(5): Gupta AK, Einarson TR, Summerbell RC, Shear NH. An overview of topical antifungal therapy in dermatomycoses- A North American perspective. Drugs 1998; 55(5): Savin R. Diagnosis and treatment of tinea versicolor. J Family Pract 1996; 43(2): Savin R. Diagnosis and treatment of tinea versicolor. J Family Pract 1996; 43(2): Coskey RJ. Contact dermatitis caused by diphenhydramine hydrochloride. J Amer Acad Dermato 1983; 8(2): Coskey RJ. Contact dermatitis caused by diphenhydramine hydrochloride. J Amer Acad Dermato 1983; 8(2): Smith ES, Fleischer AB, Feldman SR. Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, J Amer Acad Dermatol 1998; 39(1): Smith ES, Fleischer AB, Feldman SR. Nondermatologists are more likely than dermatologists to prescribe antifungal/corticosteroid products: an analysis of office visits for cutaneous fungal infections, J Amer Acad Dermatol 1998; 39(1): Duweb GA, Abuzariba O, Rahim M, et al. Occlusive versus nonocclusive calcipotriol ointment treatment for palmoplantar psoriasis. Int J Tissue Reactions 2001; 23(2): Duweb GA, Abuzariba O, Rahim M, et al. Occlusive versus nonocclusive calcipotriol ointment treatment for palmoplantar psoriasis. Int J Tissue Reactions 2001; 23(2):

41 References Volden G. Successful treatment of chronic skin diseases with clobetasol propionate and a hydrocolloid occlusive dressing. Acta Dermato-Vener 1992; 72(1): Volden G. Successful treatment of chronic skin diseases with clobetasol propionate and a hydrocolloid occlusive dressing. Acta Dermato-Vener 1992; 72(1): Bruner CR, Feldman SR, Ventrapragada M, Fleischer AB Jr. A systematic review of adverse effects associated with topical treatments for psoriasis. Dermatology Online Journal 2003; 9(1): 2. Bruner CR, Feldman SR, Ventrapragada M, Fleischer AB Jr. A systematic review of adverse effects associated with topical treatments for psoriasis. Dermatology Online Journal 2003; 9(1): 2. Housman TS, Mellen BG, Rapp SR, Fleischer AB Jr, Feldman SR. Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference. Cutis 2002; 70(6): Housman TS, Mellen BG, Rapp SR, Fleischer AB Jr, Feldman SR. Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference. Cutis 2002; 70(6): Bikowski J. The use of therapeutic moisturizers in various dermatologic disorders. Cutis 2001; 68(5S):3-11. Bikowski J. The use of therapeutic moisturizers in various dermatologic disorders. Cutis 2001; 68(5S):3-11. Goldstein BG, Goldstein AO. General principles of dermatologic therapy and topical corticosteroid use. UpToDate.com online Goldstein BG, Goldstein AO. General principles of dermatologic therapy and topical corticosteroid use. UpToDate.com online Purdon CH, Haigh JM, Surber C, Smith EW. Foam drug delivery in dermatology. Am J Drug Deliv 2003; 1: Purdon CH, Haigh JM, Surber C, Smith EW. Foam drug delivery in dermatology. Am J Drug Deliv 2003; 1:

42 THANK YOU!


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