Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 104 Drugs for the Skin

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.2 Fig Anatomy of the skin. A, Major structures of the skin. B, Growth layers of the epidermis.

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.3 Drugs for the Skin  Topical glucocorticoids (cream, ointment, or gel)  Uses  To relieve inflammation and itching  Drying agent  Adverse effects  Stretch marks  Purpura  Telangiectasia  Hypertrichosis  Possible systemic toxicity

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.4 Topical Glucocorticoids  Adverse effects  Local reactions Thinning of the skin Thinning of the skin Stretch marks Stretch marks Purpura Purpura Telangiectasia Telangiectasia Hypertrichosis Hypertrichosis Possible systemic toxicity Possible systemic toxicity

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.5 Topical Glucocorticoids  Adverse effects  Systemic toxicity More likely with higher doses and long-term therapy More likely with higher doses and long-term therapy Growth retardation in children Growth retardation in children Adrenal suppression Adrenal suppression  Administration  Apply in a thin film and gently rub into the skin  Do not use occlusive bandages (or tight-fitting diapers and plastic pants)

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7 Keratolytic Agents  Promote shedding of horny layer of the skin  Primary agents and uses  Salicylic acid – warts, corns  Sulfur – acne, dandruff, psoriasis, seborrheic dermatitis  Benzoyl peroxide

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.8 Treatment for Acne  Nondrug therapy  Cleansing  Drug therapy  Benzoyl peroxide  Antibiotics Topical – clindamycin Topical – clindamycin Oral – tetracycline antibiotics, isotretinoin, hormonal agents Oral – tetracycline antibiotics, isotretinoin, hormonal agents  Retinoids Tretinoin (Retin-A) Tretinoin (Retin-A) Adapalene (Differin) Adapalene (Differin)

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10 Topical Drugs for Acne  Benzoyl peroxide  Retinoids  Tretinoin  Adapalene  Tazarotene  Azelaic acid  Dapsone

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.11 Oral Drugs for Acne  Antibiotics  Agents of choice Doxycycline (Vibramycin), minocycline (Minocin) Doxycycline (Vibramycin), minocycline (Minocin)  Alternatives (resistance is common) Tetracycline (Sumycin), erythromycin (Ery-Tab) Tetracycline (Sumycin), erythromycin (Ery-Tab)  Isotretinoin (Accutane)  Teratogenic  Triglyceride levels must be monitored  Hormonal agents

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.12 Sunscreens  Sun exposure  Promote tanning  UV radiation can also cause burns, premature aging of the skin, skin cancer, and immunosuppression  Sunscreens impede the penetration of UV radiation to viable cells of the skin

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.13 Fig Range of UVB and UVA protection conferred by FDA-approved sunscreens.

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.14 Sunscreens  Organic screens  Also known as chemical screens  Absorb UV radiation and then dissipate it as heat  15 of the approved sunscreens  Inorganic screens  Also known as physical screens  Scatter UV radiation  Titanium oxide and zinc oxide  Now micronized and are clear for applying to skin

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.15 Sun Protection Factor  SPF is an index of protection against UVB radiation  SPF does not address UVA protection  Methods for obtaining SPF are not precise  Relationship between SPF and protection against sunburn is not linear (SPF 30 is not twice as much protection as SPF 15)

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.16 Sunscreens  Water and sweat resistance  Adverse effects of sunscreens  Proposed changes regarding sunscreen testing and labeling  UVB rating and labeling  Using a sunscreen effectively

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.17 Treatment for Psoriasis  Psoriasis – red patches with silver scales  Common, chronic inflammatory disorder that follows an erratic course  Initial episode usually develops in early adulthood  Subsequent attacks may occur spontaneously or in response to triggers  Varying degrees of severity  Symptoms come from:  Accelerated maturation of epidermal cells  Excessive activity of inflammatory cells

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.18 Treatment for Psoriasis  Topical drugs  Glucocorticoids  Calcipotriene (Dovonex)  Tazarotene (Tazorac)  Anthralin  Tars  Biologic agents  Alefacept (Amevive)  Efalizumab (Raptiva)  Tumor necrosis factor inhibitors (Enbrel)

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.19 Treatment for Psoriasis  Systemic drugs (conventional agents)  Methotrexate  Acitretin (Soriatane)  Glucocorticoids  Cyclosporine (Neoral)  Procedures  Phototherapy  Coal tar plus ultraviolet B irradiation

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.20 Actinic Keratoses (AK)  Rough, scaly, red or brown papules caused by chronic exposure to sunlight  Half of all skin cancers in U.S. begin as AK  Drugs for AK  Fluorouracil  Diclofenac sodium  Imiquimod  Aminolevulinic acid plus blue light

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.21 Drugs for Atopic Dermatitis (Eczema)  Glucocorticoids  Topical immunosuppressants  May cause skin cancer or lymphoma  Tacrolimus  Pimecrolimus

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.22 Agents Used to Remove Venereal Warts  Physical measures  Cryotherapy, electrodesiccation, laser surgery, and conventional surgery  Topical drugs  Podophyllin (must be applied by physician)  Can be applied at home  Imiquimod  Podofilox  Kunecatechins

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.23 Miscellaneous Drugs for Skin  Agents to remove common warts  Antiperspirants  Deodorants  Drugs for seborrheic dermatitis and dandruff

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.24 Drugs for Hair  Treat hair loss  Topical minoxidil  Finasteride (Propecia)  Treat unwanted facial hair  Eflornithine (Vaniqa)

Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.25 Impetigo  Most common bacterial infection of the skin – Staphylococcus aureus is most common  Usually seen in children 2 to 5 years of age  Two forms  Bullous  Nonbullous  Drugs for impetigo (see Table 104-5)

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Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc.27 Local Anesthetics  Can be applied topically to relieve pain and itching associated with skin disorders  Benzocaine  Lidocaine  Pramoxine