Presentation on theme: "Topical Therapeutics Update"— Presentation transcript:
1 Topical Therapeutics Update Adam O. Goldstein, MDAssociate ProfessorUniversity of North CarolinaDepartment of Family MedicineChapel Hill, NC
2 Objectives Advance knowledge of topical preparations Avoid major pitfalls in topical therapeuticsLearn two therapeutic reasons to preferentially use creams, lotions, ointments or gelsImprove ability to use topical steroids while avoiding side effects
5 Art of Topical Therapeutics- Antifungals How long should you use topical therapy for mild/moderate tinea corporis?7-14 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 ImidazolesClotrimazole (Canesten®; Clocreme®; Fungizid®)Econazole (Dermazole®; Ecostatin®; Ecreme®; Pevaryl®)Ketoconazole (Nizoral®; Sebizole®)Miconazole (Daktarin®; Fungo®; Micreme®)Tioconazole (Trosyd®)ThiocarbamatesTolciclate (Tolmicen®) , Tolnaftate (Tinaderm)Allylamine (higher cure rates and more rapid responses than older topical antifungals for dermatophyte infections)Terbinafine (Lamisil®)(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%NeomycinBenzocaine (brand name Lanacane), diphenhydramine (brand name Benadryl), and neomycin (in brand name Neosporin) =Potential topical sensitizers.(Coskey, JAAD, 1983)A familiar scenario involves one of these creams applied to a minor lesion. After several days, the lesion gets larger as it is applied to increasingly large area whilecausing a contact dermatitis.
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 pruritusSarna contains camphor and mentholGold Bond contains (menthol):Pramagel and Prax contain pramoxin
10 Major pitfalls Prescribing combination products topical fungal/corticosteroid preparationsPrescribing insufficient amountsChoosing wrong vehiclesChoosing wrong steroid classestoo weak, too strong, or too long
16 Creams Useful for most conditions Acceptable to most patients Helps ‘dry out’ moist lesionsTell patients to rub in wellTopical creams generally more potent than lotionsBecause of high water content, preservatives added- (may cause allergy)
20 Ointments Ointments generally > potency than creams “Hydrates” dry, itchy skinGreasy feel and cosmetically not elegantMay be used at bedtimeMay occlude hair folliclesIncrease potency by putting under occlusion
21 Gels Evaporate quickly Cosmetically elegant Useful for most skin conditionsGels may be irritating d/t alcohol in base
22 Pastes and PowdersPastes may be useful in intertriginous dermatitis but are difficult to removeMay contain silicones that act as water repellentCan be aplied sparingly to protect uninvolved skinPowders help protect intertriginous areas:
23 SoapsSoaps and other cleansing bars are useful to cover large areas of skinEx. Acne-Sulfer soap, benzyl peroxide bars, salicylic acid bars
24 Shampoos and FoamsShampoos and foams (mousse) offer cosmetically elegant ($$) formulations (increasing)Examples:betamethasone valerate mousse, salicylic acid & tar shampoos
25 Wet dressings Superficial debridement macerated skin Burow's Solution (Aluminum Acetate 1/20, 1/40)1 packet in 1 pint waterSoak 6 layers of gauze in solution, wring out and apply for 15 minutesChange dressing q 3-4 hrs
26 Tube Sizes to prescribe- (bid application for 10 days) Face and Neck: gTrunk (Front and back): 60gOne Arm: gOne Leg: gOne Hand: gOne Foot: g
27 Tube Sizes to prescribe Rule of thumb to estimate how much cream or ointment needed to cover area of bodyRule of 9’S: divide body into 11 areas--head, each arm, anterior chest, posterior chest, abdomen, lumbar/buttocks, half of each leg--2 grams/application cream/area
32 Potential Adverse Effects of Topical Steroids Percutaneous absorption and general suppressionSkin atrophy or striaePapular or perioral dermatitis
33 Potent Topical Steroids to Face prolonged (usually >6 weeks) application of potent corticosteroids to the facerosaceaperioral dermatitisatrophy
34 Case 1Bob 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 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
36 Case 2Margaret 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 KOH is ---; use a high or ultra potency cream for 2 weeksConsider if secondarily infected with staphSee back in 2 weeks- if no improvement, consider occlusive therapy
38 Case 3Paul 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 prescription for two productsboth gelstoo strong strengthsBack off of gels to creamsUse only one formulation for first week
40 ReferencesGupta 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):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): 43-7.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 ReferencesVolden 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.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.Goldstein BG, Goldstein AO. General principles of dermatologic therapy and topical corticosteroid use. UpToDate.com online 2005.Purdon CH, Haigh JM, Surber C, Smith EW. Foam drug delivery in dermatology. Am J Drug Deliv 2003; 1: