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Dermatologic Therapies Basic Dermatology Curriculum Last updated June 8, 2011 1.

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Presentation on theme: "Dermatologic Therapies Basic Dermatology Curriculum Last updated June 8, 2011 1."— Presentation transcript:

1 Dermatologic Therapies Basic Dermatology Curriculum Last updated June 8,

2 2 Module Instructions  The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated guide to clinical dermatology and dermatopathology.dermatology glossary  We encourage the learner to read all the hyperlinked information.

3 3 Goals and Objectives  The purpose of this module is to help medical students gain familiarity with common dermatologic treatments.  By completing this module, the learner will be able to: Estimate the amount of topical medication needed for therapy based on frequency of application and body surface area involved Choose appropriate strengths of topical steroids based on age, body location and severity of dermatitis List side effects of prolonged use of topical steroids Discuss the basic principles of medications used to treat acne Discuss the basic principles of topical antifungals, oral antihistamines and topical psoriasis medications

4 4 Principles of Dermatologic Therapy  The efficacy of any topical medication is related to: The active ingredient (inherent strength) Anatomic location The vehicle (the mode in which it is transported) The concentration of the medication

5 Solutions Sprays Gels Foams Creams Oils Ointments Vehicles 5

6  Ointments (e.g. Vaseline): lubricating, occlusive; greasy USE for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesionshyperkeratotic AVOID on hairy and intertriginous (when skin is in contact with skin, e.g. armpits, groin, pannus) areas  Creams (vanish when rubbed in): less greasy, drying effects; not occlusive, can sting, more likely to cause irritation (preservatives/fragrances) USE for acute exudative inflammation, intertriginous areas  Lotion (pourable liquid): less greasy, less occlusive; may contain alcohol (drying effect on oozing lesion); penetrate easily, little residue USE for hairy areas 6

7 Vehicles (cont.)  Oils: less stinging than lotions or solutions USE for the scalp, especially for people with coarse or very curly hair  Gel (jelly-like): may contain alcohol, greaseless, least occlusive; dry quickly USE for acne, exudative inflammation (e.g. acute contact dermatitis); on scalp/hairy areas without mattingcontact dermatitis  Foams (cosmetically elegant): spread readily, easier to apply; more expensive USE for hairy areas; inflammation Sprays: Aerosols (rarely used), pump sprays 7

8 Medication Costs  Topical medications can be very expensive  They are not all covered by insurance  Over the counter (OTC) treatments are generally cheaper than prescriptions  Generics are less expensive than brand name prescriptions  It is helpful to know the costs of the medications you prescribe and be able to tell the patient in advance what they should expect to pay 8

9 What goes into a topical prescription? 9

10 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 10

11 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 Generic name 11

12 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 Generic name Vehicle 12

13 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 Generic name Vehicle Concentration 13

14 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 Generic name Vehicle Concentration Sig (directions) 14

15 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 Generic name Vehicle Concentration Sig Amount 15

16 Topical prescriptions  What goes into a prescription? Desonide cream 0.05% apply to affected area (face) BID PRN for scaling #15 Grams RF3 Generic name Vehicle Concentration Sig Amount Refills 16

17 Now Let’s Review Some Common Types of Medications Used by Dermatologists 17

18 18 Topical Corticosteroids  Topical steroids produce an anti- inflammatory response in the skin  They are effective for conditions that are characterized by hyperproliferation, inflammation, and immunologic involvement  They can also provide symptomatic relief for burning and pruritic lesions

19 19 Topical Corticosteroids  Corticosteroids are organized into classes based on their strength (potency) Therefore, steroids within any class are equivalent in strength  Strength is inherent to the molecule, not the concentration  Know one steroid from each class that would be available to the majority of your patients (the generic in that class)

20 Topical Steroid Strength PotencyClassExample Agent Super highIClobetasol propionate 0.05% HighIIFluocinonide 0.05% MediumIII – V Triamcinolone acetonide ointment 0.1% Triamcinolone acetonide cream 0.1% Triamcinolone acetonide lotion 0.1% LowVI – VII Fluocinolone acetonide 0.01% Desonide 0.05% Hydrocortisone 1% 20

21 Topical Steroid Strength  Remember to look at the class not the percentage Note that clobetasol 0.05% is stronger than hydrocortisone 1%.  When several are listed, they are listed in order of strength Note that triamcinolone ointment is stronger than triamcinolone cream or lotion because of the nature of the vehicle 21 PotencyClassExample Agent Super high IClobetasol 0.05% HighIIFluocinonide 0.05% MediumIII – V Triamcinolone ointment 0.1% Triamcinolone cream 0.1% Triamcinolone lotion 0.1% Low VI – VII Fluocinolone 0.01% Desonide 0.05% Hydrocortisone 1%

22 Corticosteroid Selection  Super high potency (Class I) are used for severe dermatoses over nonfacial and nonintertriginous areas Scalp, palms, soles, and thick plaques on extensor surfaces  Medium to high potency steroids (Classes II-V) are appropriate for mild to moderate nonfacial and nonintertriginous areas Okay to use on flexural surfaces for limited periods  Low potency steroids (Classes VI, VII) can be used for large areas and on thinner skin Face, eyelid, genital and intertriginous areas 22

23 23 Local Side Effects of Topical Steroids  Local side effects of topical steroids include: Skin atrophy Telangiectasias Striae  The higher the potency the more likely side effects are to occur.  To reduce risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness Acne Steroid Rosacea Hypopigmentation

24 Local Corticosteroid Skin Side Effects Skin Atrophy Striae 24

25 Local Corticosteroid Skin Side Effects Hypopigmentation 25

26 26 Systemic Side Effects of Topical Steroids  Systemic side effects are rare due to low absorption  They can include: Glaucoma (when steroid applied to the eyelid) Hypothalamic pituitary axis suppression Cushing’s syndrome Hypertension Hyperglycemia  The higher the potency the more likely side effects are to occur  To reduce risk, the least potent steroid should be used for the shortest time, while still maintaining effectiveness

27 Duration of Treatment  Duration of treatment is limited by side effects  In general: Super high potency: treat for <3 weeks High and Medium potency: <6-8 weeks Low potency: side effects are rare. Treat facial, intertriginous, and genital dermatoses for 1-2 week intervals to avoid skin atrophy, telangiectasia, and steroid-induced acne  Stop treatment when skin condition resolves To avoid rebound/flares: taper with gradual reduction of both potency and dosing frequency every 2 weeks  If the patient does not respond to treatment within these guidelines, consider referral to a dermatologist 27

28 Prescribing topical steroids The following slides will review how to estimate the amount of medication to prescribe according to the affected body surface area (BSA) 28

29 Estimating BSA: Palm of Hand 1 Palm = 1% BSA Use the size of the patient’s palm, not your own 29

30 Estimating topicals: Fingertip unit  Quantity of topical medication (dispensed from a 5mm nozzle) placed on pad of the index finger from distal tip to DIP joint  Fingertip unit (FTU) = 500 mg = treats 2% BSA 30

31 2 palms 2 times a day = 30 grams / mo 31 1 Palm = 1% BSA FTU = 0.5 G Covers 2 % BSA Covers 2 palms 2 palms = 2% BSA 2 palms 2 times per day = 1 gram per day SO…GIVE 30 GRAMS FOR EVERY 2 PALMS OF AREA TO COVER (FOR 1 MONTH Rx) 1 Palm = 1% BSA

32 Practice Question 1  Take a look at the following photograph and decide how much BSA is affected. Then try to answer the question on the following slide. 32

33 Practice Question  Which of the following prescriptions would you recommend for BID dosing for 1 month duration? Use 2% BSA. a.Fluocinonide 0.05% ointment, apply to affected area (knees) BID, # 30 grams b.Fluocinonide 0.05% ointment, apply to affected area (knees) BID, # 90 grams c.Hydrocortisone 1% ointment, apply to affected area (knees) BID, # 30 grams d.Hydrocortisone 1% ointment, apply to affected area (knees) BID, # 90 grams 33

34 Practice Question  Which of the following prescriptions would you recommend for BID dosing for 1 month duration? Use 2% BSA. a.Fluocinonide 0.05% ointment, apply to affected area (knees) BID, # 30 grams (2 palms = 2% BSA = 30 grams for 1 mo BID) b.Fluocinonide 0.05% ointment, apply to affected area (knees) BID, # 90 grams (for a 3 month supply) c.Hydrocortisone 1% ointment, apply to affected area (knees) BID, # 30 grams (need a higher potency steroid for plaque psoriasis on the knees) d.Hydrocortisone 1% ointment, apply to affected area (knees) BID, # 90 grams 34

35 Estimating amounts  It takes ~30 grams to cover an average adult body (for one application)  Here is a rough estimation of amounts to prescribe for BID use for a month: Face grams Extensor surfaces of both arms grams Widespread on trunk, legs, arms: 1-2 pounds (454 grams = 1 lb.) 35

36 Estimating amounts: re-assess of follow-up  The best way to assure you are giving the right amount is to re-assess on follow-up If your patient was given a 60-gram tube, confirm they are using it according to instructions, and ask how long that tube lasts If a 60-gram tube only lasts them 2 weeks, they need 2 of them to last a month 36

37 Estimating BSA: Rule of Nines 37  The “rule of nines” is a good, quick way of estimating the affected BSA  Often used when assessing burns  The body is divided into areas of 9%  Less accurate in children Source: McPhee SJ, Papadakis MA: Current Medical Diagnosis and Treatment 2010, 49 th Edition: Copyright © The McGraw-Hill Companies, Inc.

38 Pediatric Dosing  Children require adjusted dosage  Use a pediatric version of the rule of nines or the patient’s palm to estimate BSA  Remember that children, especially infants have a high body surface area to volume ratio, which puts them at risk for systemic absorption of topically applied medications 38

39 Pediatric Dosing (cont.)  Low potency topical corticosteroids are safe when used for short intervals Can cause side effects when used for extended durations  High potency steroids must be used with caution and vigilant clinical monitoring for side effects in children  Potent steroids should be avoided in high risk areas such as the face, folds, or occluded areas such as under the diaper 39

40 Let’s move on to some more types of medications used by dermatologists Medications commonly used to treat Acne vulgaris 40

41 Benzoyl peroxide  Benzoyl peroxide is a topical medication with both antibacterial and comedolytic (breaks up comedones) properties comedones  Available as a prescription and over-the-counter, as well as in combinations with topical antibiotics  Patients should be warned of common adverse effects: Bleaching of hair, colored fabric, or carpet May irritate skin; discontinue if severe  Available as a cream, lotion, gel, or wash 41

42 Topical Antibiotics  Used to reduce the number of P. acnes and reduce inflammation in inflammatory acne  Do not use as monotherapy (often used with benzoyl peroxide to prevent the development of antibiotic resistance in the treatment of mild-to- moderate acne and rosacea)acnerosacea Erythromycin 2% (solution, gel) Clindamycin 1% (lotion, solution, gel, foam)  Metronidazole 0.75%, 1% (cream, gel) is used in the treatment of rosacea 42

43 Topical Retinoids (tretinoin, all trans retinoic acid)  Topical retinoids are vitamin A derivatives  Used for acne vulgaris; photodamaged skin; fine wrinkles, hyperpigmentation  Patients should be warned of common adverse effects: Dryness, pruritus, erythema, scaling Photosensitivity  Available as a cream or gel  Do not apply at the same time as benzoyl peroxide because benzoyl peroxide oxidizes tretinoin 43

44 44 Topical Acne Treatment: Side Effects  Topical acne treatments are often irritating and can cause dry skin When using retinoids or benzoyl peroxide, consider beginning on alternate days. Use a moisturizer to reduce their irritancy.  Topical agents take 2-3 months to see effect  Patients will often stop their topical treatment too early from “red, flakey” skin without improvement in their acne  Patient education is a crucial component to acne treatment

45 45 Oral Antibiotics  Tetracycline, doxycycline, minocycline  Use for moderate to severe inflammatory acne  Often combined with benzoyl peroxide to prevent antibiotic resistance  If the patient has not responded after 3 months of therapy with an oral antibiotic, consider: Increasing the dose, Changing the treatment, or Referring to a dermatologist

46 46 Oral Treatment: Side Effects  Tetracyclines (tetracycline, doxycycline, minocycline): Are contraindicated in pregnancy and children age <8 years May cause GI upset (epigastric burning, nausea, vomiting and diarrhea can occur) Can cause photosensitivity (patients may burn easier, which can be easily managed with better sun protection). Recommend sun block with UVA coverage for all acne patients on tetracyclines

47 Oral Tetracyclines: Patient Counseling  Major side effects: Tetracycline: GI upset, photosensitivity Doxycycline: GI upset, photosensitivity Minocycline: GI upset, vertigo, hyperpigmentation  Patients need clear instructions If taking for acne, it is okay to take them with food and dairy products for tolerability of GI side effects Take with full glass of water; avoids esophageal erosions Tetracyclines do NOT interfere with birth control pills It takes 2-3 months to see improvement 47

48 48 Oral Isotretinoin  Oral isotretinoin, a retinoic acid derivative, is indicated in severe, nodulocystic acne failing other therapies  Should be prescribed by physicians with experience using this medication  Typically given in a single 5-6 month course  Isotretinoin is teratogenic and therefore absolutely contraindicated in pregnancy Female patients must be enrolled in a FDA-mandated prescribing program in order to use this medication Two forms of contraception must be used during isotretinoin therapy and for one month after treatment has ended

49 49 Isotretinoin Side Effects  Common side effects of isotretinoin include: Xerosis (dry skin) Cheilitis (chapped lips) Elevated liver enzymes Hypertriglyceridemia  Individuals with severe acne may suffer mood changes and depression and should be monitored  Severe headache can be a manifestation of the uncommon side effect pseudotumor cerebri

50 Topical Antifungals 50

51 Topical Antifungals  There are several classes of topical antifungal medications  Some classes are fungistatic (stop fungi from growing), others are fungicidal (they kill the fungi)  Not all conditions are treatable with topical antifungals (specifically, hair infections and nail infections do not respond to topical treatment and require systemic treatment) 51

52 Topical Antifungals  The following are some examples of topical antifungals: Imidazoles (fungistatic): Ketoconazole (Rx & OTC), Econazole, Oxiconazole, Sulconazole, Clotrimazole (Rx & OTC), Miconazole (OTC) –Useful to treat candida and dermatophytes Allylamines and benzylamines (fungicidal): Naftifine, Terbinafine (OTC), Butenafine –Better for dermatophytes, but not candida Polyenes (fungistatic in low concentrations): Nystatin –Better for candida, but not dermatophytes 52

53 Advantages of Topical Antifungals  Topical antifungals are preferred for most superficial fungal infections of limited extent.  Advantages include: Relatively low cost Acceptable efficacy Ease of use Low potential for side effects, complications, or drug interactions 53

54 Oral Antihistamines 54

55 Antihistamines  Antihistamines are the most widely used agents for pruritus and chronic urticaria pruritusurticaria  1 st Generation H 1 antagonists are sedating Anticholinergic side effects (e.g. memory impairment, confusion, dry mouth, blurred vision) are dose-limiting Use as a sleep aid at night for patients with pruritus Use with caution in elderly due to increased fall risk, CNS and anticholinergic effects  2 nd Generation H 1 antagonists are minimally sedating and require less frequent dosing than 1 st generation H 1 antihistamines 55

56 Antihistamines  The following are examples of H 1 antihistamines: 1 st Generation Diphenhydramine (OTC) Hydroxyzine (Rx, generic) Chlorpheniramine (OTC)  For most pruritic dermatoses that are not urticaria, 1 st generation H 1 antihistamines primarily work through their sedative effect rather than their anti-histaminic properties 56 2 nd Generation Cetirizine (OTC) Loratadine (OTC) Fexofenadine (OTC)

57 Medications used in Psoriasis 57

58 Skin Kinetics 58  Some dermatoses are associated with a higher rate of epidermal turnover For example, the epidermis of psoriasis replicates too quicklypsoriasis  Topical therapies that inhibit keratinocyte proliferation are used in the treatment of psoriasis  They include: Vitamin D analogs Coal tar Tazarotene

59 Psoriasis Treatment: Topical Vitamin D Analogs 59  Calcipotriene (calcipotriol) Inhibits keratinocyte proliferation Most common side effect is skin irritation  Calcitriol Inhibits keratinocyte proliferation Stimulates keratinocyte differentiation Inhibits T-cell proliferation On more sensitive areas, less skin irritation than calcipotriol

60 Psoriasis Treatment 60  Tar 2-5% Antiproliferative effect Disadvantages: stain clothing/hair/skin; messy; increases photosensitivity Can be combined with salicylic acid to penetrate thick plaques  Tazarotene 0.05% and 0.1% Topical retinoid used for acne, rosacea, psoriasis Disadvantages: skin irritation; teratogenic; increases photosensitivity Can be combined with a Class II corticosteroid to reduce irritation

61 Take Home Points  The efficacy of any topical medication is related to the strength, location, vehicle, and concentration  Topical medications can be very expensive  When writing a prescription for a topical medication, include: generic name, vehicle, concentration, directions, amount, # of refills  Corticosteroids are organized into classes based on their strength (potency)  Skin atrophy, acne, striae, and telangiectasias are potential local side effects of corticosteroid use  It takes ~30 grams to cover an average adult body (for one application) 61

62 Take Home Points  Use benzoyl peroxide with topical antibiotics to prevent the development of antibiotic resistance in acne treatment  Lack of adherence is the most common cause of treatment failure in acne patients; patient education is crucial  Topical antifungals are preferred for most superficial fungal infections of limited extent  Antihistamines are the most widely used agents for pruritus and chronic urticaria  2 nd Generation H1 antihistamines are less sedating that 1 st generation H1 antihistamines  Many of the topical medications used in psoriasis inhibit keratinocyte proliferation 62

63 Acknowledgements  This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from  Primary authors: Alina Markova, Sarah D. Cipriano, MD, MPH; Timothy G. Berger, MD, FAAD; Patrick McCleskey, MD, FAAD.  Peer reviewers: Peter A. Lio, MD, FAAD; Ron Birnbaum, MD.  Revisions: Sarah D. Cipriano, MD, MPH. Last revised June,

64 References  Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web- Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from:  Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for the use of topical glucocorticosteroids. American Academy of Dermatology. J Am Acad Dermatol 1996; 35:615.  Ference J, Last A. Choosing Topical Corticosteroids. Am Fam Physician 2009;79 (2):  Goldstein B, Goldstein A. General principles of dermatologic therapy and topical corticosteroid use. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA,  Hettiaratchy S, Papini R. ABC of burns. Initial management of a major burn: II – assessment and resuscitation. BMJ. 2004;329:

65 References  High Whitney A, Fitzpatrick James E, "Chapter 219. Topical Antifungal Agents" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:  Limb Susan L, Wood Robert A, "Chapter 230. Antihistamines" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:  Nelson A, Miller A, Fleischer A, Balkrishnan R, Feldman S. How much of a topical agent should be prescribed for children of different sizes? J Derm Treat 2006; 17:  Weller R, Hunter J, Dahl M. Clinical Dermatology. 2008; 55.  Wolff K, Johnson R. Fitzpatrick’s Atlas of & Synopsis of Clinical Dermatology. 2009; Sixth Ed. 65


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