Dermatologic Therapy

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Formulary

Effects of Locally Applied Drugs

Types, ofjopical ..Dermatologic ..Medications

LocalTherapy. .Rules...of. Thumb Quantity.of., Cream.. or.ointment ..to.. Prescribe

Specific. Internal. .Drugs... for. .Specific.Diseases

Bibliography

Many hundreds of medications are available for use in treating skin diseases. Most physicians, however, have only a few favorite prescriptions that are prescribed day in and day out. These few prescriptions may then be altered slightly to suit an individual patient or disease. For commonly used preparations, pretyped prescriptions save time and are legible.

Treatment of most of the common skin conditions is simpler to understand when the physician is aware of three basic principles:

1. The type of skin lesion, more than the cause, influences the kind of local medication used. The old adage, "If it's wet, use a wet dressing, and if it's dry, use an ointment," is true in most cases. For example, to treat a patient with an acute oozing, crusting dermatitis of the dorsum of the hand, whether due to poison ivy or soap, the physician should prescribe wet soaks. For a chronic-looking, dry, scaly patch of psoriasis on the elbow, an ointment is indicated because an aqueous lotion or a wet dressing would only be more drying. Bear in mind, however, that the type of skin lesion can change rapidly under treatment. The patient must be followed closely after beginning therapy. An acute oozing dermatitis treated with soaks can change, in 2 or 3 days, to a dry, scaly lesion that requires a cream or an ointment. Conversely, a chronic dry patch may become irritated with too strong therapy and begin to ooze.

2. The second basic principle in treatment is never do any harm and never overtreat. It is important for the physician to know which of the chemicals prescribed for local use on the skin are the greatest irritants and sensitizers. It is no exaggeration to say that the most commonly seen dermatitis is the overtreatment contact dermatitis. The overtreatment is often performed by the patient, who has gone to the neighborhood drugstore, or to a friend, and used any, and many, of the medications available for the treatment of skin diseases. It is certainly not unusual to hear the patient tell of using a strong athlete's foot salve for the treatment of the lesions of pityriasis rosea.

3. The third principle is to instruct the patient adequately regarding the application of the medicine prescribed. The patient does not have to be told how to swallow a pill but does have to be told how to put on a wet dressing. Most patients with skin disorders are ambulatory, so there is no nurse to help them. They are their own nurses. The success or the failure of therapy rests on adequate instruction of the patient or person responsible for the care. Even in hospitals, particularly when wet dressings or aqueous lotions are prescribed, it is wise for the physician to instruct the nurse regarding the procedure.

With these principles of management in mind, let us now turn to the medicine used. It is important to stress that we are endeavoring to present here only the most basic material necessary to treat most skin diseases. For instance, there are many solutions for wet dressings, but Burow's solution is our preference. Other physicians have preferences different from the drugs listed, and their choices are respected, but to list all of them will not serve the purpose of this book.

sauer notes

LOCAL THERAPY

1. The type of skin lesion (oozing, infected, or dry), more than the cause, should determine the local medication that is prescribed.

2. Do not harm. Begin local therapy for a particular case with mild drugs. The concentration of ingredients can be increased as the acuteness subsides.

3. Do not begin local corticosteroid therapy with the "biggest gun" available, particularly for chronic dermatoses.

4. Carefully instruct the patient or the nurse regarding the local application of salves, lotions, wet dressings, and baths. Many salves should be rubbed in for 5 to 10 seconds.

5. Prescribe the correct amount of medication for the area and the dermatosis to be treated. This knowledge comes with experience (see later in this chapter).

6. Change the therapy as the response indicates. If a new prescription is indicated and the patient has some of the first prescription left, instruct the patient to alternate using the old and the new prescriptions.

7. If a prescription is going to be relatively expensive, explain this fact to the patient.

8. For many diseases, "therapy plus" is indicated. Advise the patient to continue to treat the skin problem for a specified period after the dermatosis has apparently cleared. This may prevent or slow down recurrences.

9. Instruct the patient to telephone you if there are any questions or if the medicine appears to irritate the dermatosis.

Two factors have guided us in the selection of medications presented in this formulary. First, the medication must be readily available in most drugstores; second, it must be a very effective medication for one or several skin conditions. The medications listed in this formulary also are listed in a complete way in the treatment section concerning the particular disease. Instructions for the use of the medications, however, are more nearly complete in this formulary.

formulary

A particular topical medication is prescribed to produce a specific beneficial effect. Effects of Locally Applied Drugs

Antipruritic agents relieve itching in various ways. Commonly used chemicals and strengths include menthol (0.25%), phenol (0.5%), camphor (2%), pramoxine hydrochloride 1%, and coal tar solution (liquor carbonis detergens [LCD]) (2% to 10%). These chemicals are added to various bases for the desired effect. Numerous safe and unsafe proprietary preparations for relief of itching are also available. The unsafe preparations are those that contain sensitizing antihistamines, benzocaine, and related "-caine" derivatives.

Keratoplastic agents tend to increase the thickness of the horny layer. Salicylic acid (1% to 2%) is an example of a keratoplastic agent. Stronger strengths of salicylic acid are keratolytic.

Keratolytics remove or soften the horny layer. Commonly used agents of this type include salicylic acid (4% to 10%), resorcinol (2% to 4%), urea (20% to 40%), and sulfur (4% to 10%). A strong destructive agent is trichloroacetic acid.

Urea in 5% to 10% concentration (Aquacare, Carmol) is moisturizing, while in 20% to 40% (Ultra Mide, Carmol) concentration, it is keratolytic.

Alpha hydroxy acids (lactic acid, glycolic acid) in 5% to 12% concentrations are moisturizers, while in higher concentrations up to 80%, they are keratolytic and can be used in the office for facial peeling, with caution.

Antieczematous agents remove oozing and vesicular excretions by various actions. The common antieczematous agents include Burow's solution packs or soaks, coal tar solution (2% to 5%), and hydrocortisone (0.5% to 2%) and derivatives incorporated in lotions or salves.

Antiparasitic agents destroy or inhibit living infestations. Examples include Elimite cream for scabies, Kwell cream and lotion for scabies and pediculosis, and Nix for pediculosis.

Antiseptics destroy or inhibit bacteria, fungi, and viruses.

Antibacterial topical medications include gentamicin (Garamycin), mupirocin (Bactroban), bacitracin, and neomycin (Neomycin causes an appreciable incidence of allergic contact sensitivity).

Antifungal and anticandidal topical agents include miconazole (Micatin, Monistat-Derm), clotrimazole (Lotrimin, Mycelex), ciclopirox (Loprox), econazole (Spectazole), oxiconazole (Oxistat), naftifine (Naftin), ketoconazole (Nizoral), butenafine HCL (Mentax), and terbinafine (Lamisil). Sulfur (3% to 10%) is an older but effective antifungal and anticandidal agent (see Table..J9-3).

Antiviral topical agents are acyclovir (Zovirax) ointment and penciclovir (Denavir).

Emollients soften the skin surface. Nivea oil, mineral oil, and white petrolatum are good examples. Newer emollients are more cosmetically elegant and effective.

LOCALLY APPLIED GENERIC PRODUCTS

LOCALLY APPLIED GENERIC PRODUCTS

Advantages: Lower cost—you can prescribe a larger quantity at relatively less expense, and patients appreciate your sharing their concern regarding cost.

Disadvantages: With a proprietary product, you are quite sure of the correct potency and bioavailability of the agent, you know the delivery system, and you know the ingredients in the base.

If you prescribe a proprietary medication when a less expensive generic is available, explain to the patient your reason for doing this.

Types of Topical Dermatologic Medications Baths

1. Tar bath

Coal tar solution (USP, LCD) 120.0

Sig: Add 2 tbsp to a tub of lukewarm water, 6 to 8 inches deep. Actions: Antipruritic and antieczematous

2. Starch bath

Limit or Argo starch, small box

Sig: Add half box of starch to tub of cool water, 6 to 8 inches deep. Actions: Soothing and antipruritic

Indications: Generalized itching and dryness of skin, winter itch, urticaria

3. Aveeno (regular and oilated) colloidal oatmeal bath Sig: Add 1 cup to the tub of water.

Actions: Soothing and cleansing

Indications: Generalized itching and dryness of skin, winter and senile itch

4. Oil baths (see section on oils and emulsions, below)

Soaps and Shampoos

1. Oilatum soap unscented, Dove soaps, Neutrogena soaps, Cetaphil, Basis Action: Mild cleansing agent

Indications: Dry skin, winter itch

2. Dial soap, Lever 2000

Actions: Cleansing and antibacterial Indications: Acne, pyodermas

3. FS shampoo 120.0

Sig: Shampoo as needed.

Actions: Antiinflammatory, antipruritic, and cleansing Indications: Dandruff, psoriasis of scalp Comment: Contains fluocinolone acetonide, 0.01%

4. Selsun Suspension or Head and Shoulders Intensive Treatment shampoo 120.0

Sig: Shampoo hair with three separate applications and rinses. You can leave the last application on the scalp for 5 minutes before rinsing off. Do not use another shampoo as a final cleanser. Actions: Cleansing and antiseborrheic

Indications: Dandruff, itching scalp (not toxic if used as directed)

5. Tar shampoos: Polytar, T/Gel, X-Seb T, Pentrax, Ionil T, and so on Sig: Shampoo as necessary, even daily.

Actions: Cleansing and antiseborrheic

Indications: Dandruff, psoriasis, atopic eczema of scalp

6. Nizoral shampoo 120.0

Sig: Shampoo two or three times a week. Actions: Anticandidal and antiseborrheic Indication: Dandruff

Wet Dressings or Soaks

1. Burow's solution, 1:20

Sig: Add 1 Domeboro tablet or packet to 1 pint of tap water. Cover affected area with sheeting wet with solution and tie on with gauze bandage or string. Do not allow any wet dressing to dry out. It can also be used as a solution for soaks.

Actions: Acidifying, antieczematous, and antiseptic

Indications: Oozing, vesicular skin conditions

Comment: Do not use over a large area of the body.

2. Vinegar solution

Sig: Add 1/2 cup of white vinegar to 1 quart of water for wet dressings or soaks, as above.

3. Salt solution

Sig: Add 1 tbsp of salt to 1 quart of water for wet dressings or soaks, as above. Powders

1. Purified talc (USP) or Zeasorb powder

Sig: Dust on locally b.i.d. (Supply in a powder can) Actions: Absorbent, protective, and cooling Indications: Intertrigo, diaper dermatitis

2. Tinactin powder, Micatin powder, Zeasorb-AF powder, or Desenex powder

Sig: Dust on feet in morning. Actions: Absorbent and antifungal

Indications: Prevention and treatment of tinea pedis and tinea cruris Comment: The above powders are available over the counter.

3. Mycostatin powder

Sig: Dust on locally b.i.d. Action: Anticandidal Indication: Candidal intertrigo

15.0

Shake Lotions

1. Calamine lotion (USP)

Sig: Apply locally to affected area t.i.d. with fingers or brush.

Actions: Antipruritic and antieczematous

Indication: Widespread, mildly oozing, inflamed dermatoses

2. Nonalcoholic white shake lotion: Zinc oxide

Talc Glycerin

Distilled water q.s. ad

3. Alcoholic white shake lotion: Zinc oxide

Talc Glycerin

Distilled water q.s. ad

4. Colored alcoholic shake lotion:

To alcoholic white shake lotion, add Sun Chemical pigments (brunette shade)

5. Proprietary lotions:

Sarna lotion (with menthol and camphor), Cetaphil lotion

sauer noies

1. Shake lotions 2, 3, and 4 are listed for physicians who desire specially compounded lotions, as I do. One or two pharmacists near your office will be glad to compound them and keep them on hand.

2. To these lotions you can add sulfur, resorcinol, menthol, phenol, and so on, as indicated.

Olive oil q.s. 120.0

Sig: Apply locally to affected area by hand or brush t.i.d. Actions: Soothing, antipruritic, and astringent Indications: Acute and subacute eczematous eruptions

Nivea skin oil, Alpha-Keri

Sig: Add 1 to 2 tbsp to the tub of water.

Caution: Be careful to avoid slipping in tub.

Actions: Emollient and lubricating

Indications: Winter itch, dry skin, atopic eczema

3. Hand and body emulsions: A multitude of products are available over the counter. Some have phospholipids, some have urea or alpha hydroxy acids, and some are lanolin free.

Sig: Apply locally as necessary.

Actions: Emollient and lubricating

Indications: Dry skin, winter itch, atopic eczema

Derma-Smoothe FS oil (fluocinolone acetonide 0.01%) 120.0

Sig: Moisten scalp hair and apply lotion overnight; wear a plastic cap.

Indications: Scalp psoriasis, lichen simplex chronicus, and severe seborrheic dermatitis

Tinctures and Aqueous Solutions

1. Povidone-iodine (Betadine) solution (also in skin cleanser, shampoo, and ointment)

Sig: Apply with swab t.i.d.

Actions: Antibacterial, antifungal, and antiviral

Indication: General antisepsis

2. Thimerosal tincture (N.F.) Merthiolate tincture,

1:1000

Sig: Apply with swab t.i.d.

Actions: Antibacterial, antifungal, and drying

3. Gentian violet solution: 30.0 Gentian violet, 1%

Distilled water q.s.

Sig: Apply with swab b.i.d. Actions: Antifungal and antibacterial Indications: Candidiasis, leg ulcers

4. Antifungal solutions a. Lotrimin, Mycelex, Loprox, Tinactin, Micatin, Monistat-Derm, Lamisil spray among others 30.0

b. Fungi-Nail

Sig: Apply locally b.i.d.

Comment: Contains Resorcinol, salicylic acid, parachlorometaxylenol, and benzocaine in a base with acetic acid and alcohol.

Pastes

1. Zinc oxide paste (USP) Sig: Apply locally b.i.d.

Actions: Protective, absorbent, and astringent Indication: Localized crusted or scaly dermatoses

Creams and Ointments

A physician can write prescriptions for creams and ointments in two ways: (1) by prescribing proprietary creams and ointments already compounded by pharmaceutical companies, or (2) by formulating one's own prescriptions by adding medications to certain bases, as especially indicated for the particular patient being treated. For the physician who uses the second method, two different types of bases are used:

1. Water-washable cream bases: These bases are pleasant for the patient to use, are nongreasy, and are almost always indicated when treating intertriginous and hairy areas. Their disadvantage is that they can be too drying. A number of medications, as specifically indicated, can be added to these bases ( I.e., menthol, sulfur, tars, hydrocortisone, triamcinolone, antibiotics).

a. Unibase b. Vanicream c. Acid Mantle Creme d. Dermovan e. Unscented cold cream (not water-washable)

2. Ointment bases: These Vaseline-type bases are, and should be, the most useful in dermatology. Although not as pleasant for the patient to use as the cream bases, their greasy quality alleviates dryness, removes scales, and enables the medicaments to penetrate the skin lesions. Any local medicine can be incorporated into these bases.

a. White petrolatum (USP)

b. Zinc oxide ointment (USP)

c. Aquaphor (contains lanolin)

d. Eucerin (contains lanolin)

For the physician who wishes to prescribe ready-made proprietary preparations, these are listed in groups:

3. Antifungal ointments and creams

Lotrimin cream, Mycelex cream, Spectazole cream, Loprox cream, Tinactin cream, Lamisil cream, Oxistat cream, Naftin cream, Nizoral cream, Mentax cream, and others (see Table l9z3.). Action: Antifungal

4. Antibiotic ointments and creams:

Bactroban ointment and cream, Garamycin ointment and cream, Neosporin ointment, Mycitracin ointment, Polysporin ointment. (Antibiotic solutions are discussed in ChapteM.3 under Acne Therapy.)

5. Antiviral ointments a. Zovirax ointment (acyclovir)

b. Denavir (penciclovir cream)

6. Corticosteroid ointments and creams (Tabje..5-i)

Otc For Desonide Cream

Table 5-1 Potency Ranking of Some Commonly Used Topical Corticosteroids*

a. Hydrocortisone preparations (.5% and 1% hydrocortisone creams and ointments are available over the counter and generically)

• Hytone 1% and 2.5% cream and ointment b. Desonide preparations

• Tridesilon cream and ointment

• DesOwen cream and ointment c. Triamcinolone preparations

• Kenalog ointment and cream

• Aristocort ointment and creams

• Also available generically d. Other fluorinated corticosteroid preparations: See T§.ble,..5.:l for a listing of these preparations, which are ranked according to potency.

sauer notes

1. Over-the-counter 0.5% or 0% Cortaid ointment (not the cream) has proved effective and well tolerated as an emergency nonprescription treatment.

2. Psorcon ointment is the only group I medication that has Food and Drug Administration approval to be used under occlusive dressing or for more than 2 consecutive weeks.

3. Do not use group I topical agents for longer than 2 weeks, or more than a 45-gram tube per week. A rest period must follow for 2 weeks.

7. Corticosteroid antibiotic ointments and creams Cortisporin ointment

8. Corticosteroid antifungal-antiyeast preparations a. Lotrisone cream b. Mycolog II cream and ointment sauer notes

COMPOUND PREPARATIONS

Compound proprietary preparations are frequently prescribed, particularly by family practice physicians and nondermatologic specialists. Physicians should know the ingredients in these compound preparations and should know the side effects. Here are some popular compounds:

Mycolog II cream: Contains mycostatin and triamcinolone. Beware: It is not beneficial for fungus (tinea) infections; the triamcinolone after long-term use can cause atrophy, striae and telangiectasia of the skin especially in intertriginous areas and on the face.

Lotrisone cream: Contains clotrimazole (Lotrimin) and betamethasone dipropionate. Beware: The betamethasone with long-term use can cause atrophy, striae and dilated vessels especially in intertriginous areas and on the face.

Vioform-hydrocortisone cream (Vytone): Contains Vioform plus 1% hydrocortisone. Beware: The Vioform causes a moderate yellow stain on the skin and clothing.

Cortisporin ointment: Contains 1% hydrocortisone with Neosporin, Polysporin, and bacitracin. Beware: Neomycin allergies occur infrequently.

9. Antipruritic creams and lotions a. Eurax cream b. Sarna lotion c. Prax lotion d. PramaGel e. Doxepin (Zonalon) cream (may cause drowsiness)

10. Retinoic acid products:

Retin-A cream (0.025%, 0.05%, 0.1%) and Retin-A gel (0.01% and 0.025%), Retin-A Micro (0.1%) Actions: Anti-acne comedones and small pustules (especially the gel) and antiphotoaging

Indications: Acne of comedonal and small pustular type; aging wrinkles on face; removal of mild actinic keratoses, freckles, molluscum contagiosum, and flat warts Differin (adapalene gel 0.1%) Action: Retinoic acid receptor binder Indications: Acne of comedonal and small pustular type. Avita (tretinoin 0.025%) cream and gel

Action: Anti-acne Indications: Acne of comedonal and small pustular type.

11. Miscellaneous creams, ointments, and gels a. MetroGel (metronidazole 0.75%) 15.0 Noritate Cream (metronidazole 1%) 30.0

Indications: Rosacea, perioral dermatitis b. Dovonex ointment (also comes as cream and scalp solution) 30.0 or 100.0 Action: Antipsoriatic Comment: Moderately expensive c. Tazorac gel 0.05% and 0.1% Action: Antipsoriatic

Comment: Very expensive, contraindicated in women with childbearing potential.

12. Scabicidal and pediculicidal preparations a. Eurax cream and lotion Action: Scabicidal b. Kwell (lindane) lotion and cream Actions: Scabicidal and pediculicidal c. Elimite cream Action: Scabicidal d. Nix creme rinse Indications: Head lice, nits

13. Sunscreen creams and lotions:

Aminobenzoic acid (and the esters of PABA) and octyl dimethyl paba (Padimate O), octocrylene, octyl salicylate, microfine zinc oxide, avobenzone (Parsol 1789), zinc oxide, cinnamates (octyl-methoxycinnamate), titanium dioxide, oxybenzone (benzophenone-3) are effective ultraviolet light blockers. There are many products on the market. Any sunscreen with a sun protective factor (SPF) of 15 or above offers effective sun-damage protection, if used correctly, frequently, early in age, and, for light-complexioned or sun-sensitive people, in the summer and winter. One sun-blocking agent is RVPaque cream. Sig: Apply to exposed areas before going outside. Action: Screening out ultraviolet rays

Indications: Polymorphous light eruption, photoaging, systemic and chronic lupus erythematosus, possible prevention of skin precancers and skin cancers, especially in light-complexioned people

Aerosols and Foams

1. Various local medications have been incorporated in aerosol and foam-producing containers. These include corticosteroids, antibiotics, antifungal agents, antipruritic medicines, and so on.

2. Kenalog spray (63-gram can), and Diprosone aerosol are effective corticosteroid preparations for scalp psoriasis and seborrhea.

Corticosteroid Medicated Tape

1. Cordran tape (also comes as a patch)

Indications: Small areas of psoriasis, neurodermatitis, lichen planus

Medicated Skin Patches

Several are available for transdermal delivery of such agents as nitroglycerin, EMLA patch for topical anesthesia, nicotine antismoking patches, and hormones.

Fluorouracil Preparations

See section on actinic keratosis therapy in Chapter^,. Local Agents for Office Use

1. Podophyllum in cpd. tincture benzoin Podophyllum resin (USP) 25% Cpd. tct. benzoin q.s. ad 30.0

Sig: Apply small amount to warts with cotton-tipped applicator every 4 or 5 days until warts are gone. Excess amount may be washed off in 3 to 6 hours after application, to prevent irritation. Action: Removal of venereal warts

Comment: Other podophyllum proprietary preparations such as condylox are marketed.

2. Trichloroacetic acid solution (saturated)

Sig: Apply with caution with cotton-tipped applicator. (Have water handy to neutralize.) Indications: Warts on children, seborrheic keratoses, xanthelasma

3. Modified Unna's boot a. Dome-Paste Bandage b. Gelocast c. Compression Gelatine bandage with zinc oxide and glycerine then wrapped with Coflex flexible wrap Indications: Stasis ulcers, localized neurodermatitis (lichen simplex)

4. Ace bandage, 3 or 4 inches wide Indications: Stasis dermatitis, leg edema local therapy rules of thumb

Students and general practitioners state that they are especially confused by dermatologists' reasons for using one chemical for one skin lesion and not another, or one chemical for unrelated skin diseases. The answer to this dilemma is not easily given. More often than not, the major reason for our preference is that experience has taught us, and those before us, that the particular drug works. Some drugs do have definite chemical actions, such as antiinflammatory, antipruritic, antifungal, or keratolytic actions, and these have been listed in the Formulary. But there is no definite scientific explanation for the beneficial effect of some of the other drugs, such as tar or sulfur on cases of psoriasis.

In an attempt to solve this apparent confusion, here are some generalizations summarizing our experience.

sauer notes

1. I use compounded preparations with liquor carbonis detergens (LCD), sulfur, resorcinol, and salicylic acid every day in my practice.

2. These chemicals can be used to complement the corticosteroids in a mixture.

3. When prescribing one of these chemicals, always begin with the lower percentage of the drug. Increase the percentage only when a stronger action is desired.

4. I am quite aware of the arguments against the use of pharmacy-compounded prescriptions. They have worked exceptionally well for me and for my patients.

Tars (coal tar solution TLCD1. 3% to 10%: crude coal tar, 1% to 5%: anthralin. 0.1% to 1%)

Consider for use in cases of:

Atopic eczema Psoriasis

Seborrheic dermatitis Lichen simplex chronicus

Avoid in intertriginous areas (can cause a folliculitis). SULFUR (SULFUR. PRECIPITATED. 3% TO 10%)

Consider for use in cases of:

Tinea of any area of body Acne vulgaris and rosacea Seborrheic dermatitis

Pyodermas (combine with antibiotic salves) Psoriasis

Resorcinol (resorcinol monoacetate. 1% to 5%)

Consider for use in cases of:

Acne vulgaris and rosacea (usually with sulfur)

Seborrheic dermatitis

Psoriasis

Salicylic Acid (1% to 5%. higher with caution)

Consider for use in cases of: Psoriasis

Lichen simplex chronicus, localized thick form Tinea of feet or palms (when peeling is desired) Seborrheic dermatitis

Avoid use in intertriginous areas.

Menthol (.25%): Phenol (.5% to 2%): Camphor (1% to 2%)

Consider for use in any pruritic dermatoses. Avoid use over large areas of body.

Hydrocortisone and Related Corticosteroids (hydrocortisone powder , .5% to 2%)

Consider for use in cases of:

Contact dermatitis of any area Seborrheic dermatitis

Intertrigo of axillary, crural, or inframammary regions

Atopic eczema

Lichen simplex chronicus

Avoid use over large areas of body. New topical corticosteroids (such as fluticasone) with lower incidence of side effects and still with high potency may soon be available.

Fluorinated Corticosteroids Locally

These chemicals are not readily available as powders for personal compounding, but triamcinolone, fluocinolone, and others are available as generic creams and ointments. Consider for use with or without occlusive dressings, in cases of:

Psoriasis, localized to small area (see Chap 14)

Lichen simplex chronicus (see Chap, 11)

Lichen planus, especially hypertrophic type Also anywhere that hydrocortisone is indicated Avoid use over large areas of the body.

sauer notes local corticosteroid therapy

1. Avoid prescribing strong local corti-costeroid preparations for generalized body use.

2. Do not prescribe the most potent ("biggest-gun") corticosteroid therapy on the initial visit.

3. The fluorinated corticosteroids should not be used on the face and intertriginous areas, where long-term use can result in atrophy and telangiectasia of the skin. There are exceptions.

4. The potent corticosteroids have a definite systemic effect.

5. Fluorinated corticosteroid prescriptions only rarely should be written for p.r.n. refills.

6. Continued long-term use of a local corticosteroid can result in a diminished effectiveness (tachyphylaxis).

7. The pros and cons of prescribing generic corticosteroids are discussed early in the chapter.

Quantity of Cream or Ointment to Prescribe

Several factors influence any general statements: severity of the dermatosis, acute or chronic dermatosis, base of the product (a petrolatum-based ointment spreads over the skin farther than a cream), whether dispensed in a tube or jar (patients use less from tubes), and the intelligence of the patient.

• 15 grams of a cream used b.i.d. will treat a mild hand dermatosis for 10 to 14 days.

• 30 grams of a cream used b.i.d. will treat an arm for 14 days.

• 60 grams of a cream used b.i.d. will treat a leg for 14 days.

• 480 to 960 grams or 1 to 2 lb of a cream used b.i.d. will treat the entire body for 14 days. This is seldom a practical prescription, but unmedicated white petrolatum or a cream base is economical to use over a large surface area. Other therapeutic agents should be used to make the dermatosis less extensive (i.e., internal corticosteroids).

specific internal drugs for specific diseases

As in all fields of medicine, certain diseases can be treated best by certain specific systemic drugs. These drugs may not be curative, but they should be considered when beginning to outline a course of management for a particular patient. Many factors influence the decision to use or not use such a specific drug. Here follows a list of skin diseases and some systemic medicines considered specific (or as specific as possible) for the disease. For proper dosage and contraindications, check the appropriate sections in this book or in current books on therapy.

Acne vulgaris or rosacea in the scarring stage: antibiotics, spirinolactone, and in women birth control pills. For severe cases of cystic acne in men or women without indication of pregnancy, isotretinoin (Accutane) is indicated.

Acquired immunodeficiency syndrome (AIDS): Many systemic drugs are used, directed as specifically as possible against opportunistic organisms, tumors, and the human immunodeficiency virus.

Alopecia areata: corticosteroids in any of four forms—topical, intralesional or rarely parenteral, oral Atrophie blanche vasculitis: pentoxifylline (Trental), corticosteroids Creeping eruption: thiabendazole

Darier's disease: vitamin A, for controlled periods of time, and possibly isotretinoin, acitretin Dermatitis herpetiformis: dapsone and sulfapyridine Granuloma annulare: intralesional corticosteroids

Herpes simplex: acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex), foscarnet sodium (Foscavir). Herpes zoster: acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex)

Inflammation of the skin from many causes: antibiotics are indicated, in some cases, when local therapy is inadequate for control. Nonsteroidal antiinflammatory drugs are beneficial for some diseases.

Kawasaki's syndrome: intravenous gamma globulin and aspirin

Keloids: intralesional corticosteroids, 585-nm pulsed dye laser, 30 second liquid nitrogen cryosurgery and silicon gel sheets for 12 to 24 hours each day for at least 2 months.

Lichen simplex chronicus: intralesional corticosteroids

Lupus erythematosus: for systemic lupus erythematosus, use corticosteroids or immunosuppressive agents with care; for discoid form, use hydroxychloroquine and related antimalarials (beware of eye damage).

Mycosis fungoides: corticosteroids, antimetabolites, retinoids, and a 2b-interferon Necrobiosis lipoidica diabeticorum: intralesional corticosteroids Pemphigus: corticosteroids and antimetabolites

Pruritus from many causes: antihistamines and tranquilizer-like drugs. Selected cases can be treated with oral corticosteroids. Psoriasis, localized: intralesional corticosteroids

Psoriasis, severe: corticosteroids, psoralens and ultraviolet light (PUVA), methotrexate, cyclosporine (Neoral), and, in men or postmenopausal women, acitretin (Soriatane)

Pyodermas of skin: systemic antibiotics are valuable, when indicated. Sarcoidosis: possibly corticosteroids, antimalarials

Sporotrichosis: saturated aqueous solution of potassium iodide and ketoconazole (Nizoral) Syphilis: penicillin or other antibiotics

Tinea of scalp, body, crural area, nails: griseofulvin and, for selected cases, ketoconazole (Nizoral) and itraconazole (Sporanox), terbinafine hydrochloride (Lamisil) Tuberculosis of the skin: dihydrostreptomycin, isoniazid, p-aminosalicylic acid, and rifampin Urticaria: antihistamines and corticosteroids

1. There are potential side effects from any systemic therapy. Be aware of these possible reactions by being knowledgeable concerning every drug you prescribe.

2. The risk/benefit ratio for your patient must always be considered.

3. Be aware of cross-reactions with a patient on multiple medications.

BIBLIOGRAPHY

Arndt KA. Manual of dermatologic therapeutics, ed 5. Philadelphia, Lippincott-Raven, 1995. Barranco VP. Clinically significant drug interactions in dermatology. J Am Acad Dermatol 1998;38:4.

Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for the use of topical glucocorticosteroids. J Am Acad Dermatol 1996;35:615.

Epstein E. Common skin disorders, ed 4. Philadelphia, WB Saunders, 1994.

Jackson EM. AHA-type products proliferate in 1993. Cosmetic Dermatol 1993;6:11.

Katz HI. Dermatologist's guide to adverse therapeutic interactions. Philadelphia, Lippincott-Raven, 1997.

Korting HC, Kerscher MJ. Glucocorticoids with improved benefit/risk ratio: do they exist? J Am Acad Dermatol 1992;27:87.

Lin AN, Reimer RJ, Carter DM. Sulfur revisited. J Am Acad Dermatol 1988;18:553.

Olsen EA. A double-blind controlled comparison of generic and trade-name topical steroids using the vasoconstriction assay. Arch Dermatol 1991;127:197. Physician's Desk Reference. Oradell, NJ, Medical Economics, published yearly.

Wolverton SE. Monitoring for adverse effects from systemic drugs used in dermatology. J Am Acad Dermatol 1992;26:661.

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