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

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?
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) (

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®) (

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)
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 while
causing 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 pruritus
Sarna contains camphor and menthol
Gold Bond contains (menthol):
Pramagel and Prax contain pramoxin

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

11. Prescribing combination topical fungal/corticosteroid preparations
Lotrisone (cream/lotion)
Betamethasone dipropionate/ clotrimazole
Mycolog II, Mytrex (cream, ointment)
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
Potential savings = $10-25 million.
(Smith, JAAD, 1998)

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

15. Creams

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

17. Lotions

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

19. Ointments

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

21. Gels Evaporate quickly Cosmetically elegant
Useful for most skin conditions
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
May contain silicones that act as water repellent
Can be aplied sparingly to protect uninvolved skin
Powders help protect intertriginous areas:

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

24. Shampoos and Foams
Shampoos 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 water
Soak 6 layers of gauze in solution, wring out and apply for 15 minutes
Change dressing q 3-4 hrs

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

27. Tube Sizes to prescribe
Rule of thumb to estimate how much cream or ointment needed to cover area of body
Rule 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

28. Topical Steroid Potency
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?

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 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.

37. Case 2- answer DO A KOH SCRAPE TO ENSURE NO FUNGUS
KOH is ---; use a high or ultra potency cream for 2 weeks
Consider if secondarily infected with staph
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?

39. Case 3- answer Problem: too much, too soon & too irritating
prescription for two products
both gels
too strong strengths
Back off of gels to creams
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):
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. References
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.
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:

42. THANK YOU!