Medical Therapy in Medical Therapy in Dermatology Dermatology 55thth year year

Lecture 1Lecture 1By Dr Faraedon KaftanBy Dr Faraedon KaftanConsultant DermatologistConsultant DermatologistCollege of MedicineCollege of MedicineUniversity of SulaimaniUniversity of Sulaimani

2011 2011

Medical therapy in DermatologyMedical therapy in Dermatology

consists of:

I- General aspects of treatment

II- Topical Therapy

III- Systemic Therapy

IV- Phototherapy V- Radiotherapy & reactions to ionizing radiation

VI- Physical therapies

VII- Laser therapies

VIII- Dermatological Surgical procedures

I. General aspects of treatment General principles: • Same as for other branches in medicine in addition to

particular topical therapy .• During history taking: many patients say they have had no

treatment (only few ointments)• Patients may be unaware of the potential harm that can be

done by topical therapy (self-administrated or iatrogenic) • Instruction on how to use any remedy is much more

important than in other branches of medicine• Dermatologists are always available but Dermatologists still

have to persuade many patients that no specific treatment is available for their problem

• Consultation is central dermatological aspect which demands great skill in communication techniques thus Improving Dr.- patient communication is necessary

The dermatological consultation2 types of dermatologists:

1. Dermatologists who like to see their patients completely naked in order not to miss other dermatological pathology: seeing a patient initially entirely naked may lead to loss of valuable data

2. Dermatologists who like to see their patients dressed:

the patient’s dress provides

a. Psychosocial information

b. The gait of the patient into consulting room gives useful information

• The depressed patient has a (droop), slow in responses to questions

• The anxious patient is moving in all directions at the same time & sitting on the edge of the chair, twirling a ring on a finger & quivering lips or the moistening of an eye in responses to a question

• The language of description: burning sensation in photosensitivity eruptions as porphyria

• The patient who brings in an enormous bag of medicaments, all of which have done ‘nothing at all’ to help, indicate a psychological or a psychiatric aspect to the case

• In dermatitis artefacta; taking good history is necessary

• Little matchboxes & plastic bags containing detritus are very characteristic of patient with delusions of parasitosis

Patients consult dermatologists because they:1. want help with their skin problems2. require information3. require medical treatment4. require explanation 5. require understanding and emotional support• Patients need to know the answers to 3 basic

questions: 1. why me? 2. why now? 3. why this particular disease?• The patients values a doctor who listens• Eye contact is vital to get meaningful data, vice

versa doctors with a mechanistic interrogative style (who offer no eye contact) lose meaningful verbal communication.

Body image, self-esteem & leper complex:• Body image is largely cutaneous• Skin disease affecting any part of the body surface

may produce depression in body image, self-esteem, confidence & 2ndary depression

• Sites: scalp, hair, face, hands and genital area• The stigma of skin disease can produce a leper

complex which compels the patient to withdraw from society, therefore the dermatologist should reassure the patient by touching the patient at some stage during the consultation

Side effects: especially should be considered in1. Elderly: they are taking drugs prescribed, OTC (by hands) &

herbal medicine2. New drugs3. If major SEs are not explained4. Pregnancy 5. Lactation6. Children & Neonates: because of immature renal and liver

function7. Poor renal function leads to the accumulation of drug &

metabolite(s) in the body increasing the risk of SEs 8. In liver disease: - The reduction (↓) in 1st-pass metabolism may lead to toxic

drug levels - Reduced (↓) protein binding may lead to increased

bioavailability & SEs

Therapy: General management

Explanation:

1. Chronicity or irreversible changes

2. In autoimmune diseases or atopic dermatitis: it is Not easy to explain the etiology

3. patient’s questions should be answered

4. In CD or Urticaria: one should listen to patient’s Explanation

5. The patient’s memory of drug or topical medicaments given is usually defective, especially if self-administered

Avoidance of aggravating factors:TemperatureHumidityAppropriate clothing: should not be too constricting, too hot or too harshIrritants should be avoided Sensitizers should be avoided Man patients believe that skin disease is a

manifestation of dirt or germs to be removed with vigour or exorcized with soap and water

Germicides in inappropriate concentrationsAdvice to stop scratching & give treatment to stop

itching

II- Topical Therapy • is quite attractive & of advantage because of:  

1. direct delivery and

2. reduced systemic toxicity • There is a vehicle which contains an active

ingredient

Topical Therapy A. Prescribing topical treatment: 1. Drug concentration: 2. Choice of vehicle: 3. Frequency of application: 4. Quantity to be pplied: 5. Advice to patients: 6. Hazards associated with topical

treatmentsB. Formulation of skin topical treatmentC. Topical treatments (Drugs) used in the management of skin disease

1. Drug concentration: 3 ways:A. %: 1% = 1 gm of drug in 100 g of the formulation

e.g.: - 60% Salicylic acid ointment in plantar warts or corns - 0.003% calcitriol in psoriasis= 3 µ/gB. For liquid preparations: - 1% solution contains 1 g of drug in 100 ml of the formulation: - w/w= (weight in weight) - w/v= (weight in volume)C. Solution in parts: - 1 part in 1000 KMNO4 contains 1 g in 1 L of solution = 0.1% (w/v)

2. Choice of vehicle: • Topical medication must be applied to the skin in a suitable

vehicle (active agent in the formulation)• The choice of vehicle depends on: 1. The anatomical site to be treated 2. The condition of the skin• Rules:1. Bland preparations (least likely to irritate) in acutely inflamed

skin2. Wet medications (lotions or creams) in moist or exudative

skin eruptions3. Occlusive Ointments in dry skin lesions4. Shampoos, lotions, gels or mousses in hair-bearing skin5. Cosmetic properties of the vehicle when treating the face: Lotions in oily skin in acne Emollient cream in rosacea

Vehicles are: A. Cream B. Gel C. Lotion D. Ointment E. Paste F. Powders G. Paints H. Collodions I. Microspoges J. Liposomes

3. Frequency of application:• Active preparations applied once or twice/day • Excessive frequency of application: causes

- SEs

- Unnecessary systemic exposure to the drug• Emollients should be applied frequently enough to

maintain their physical effect (several applications daily)

4. Quantity to be pplied:• A useful guide is the fingertip unit (FTU) which equals ½ g.  • One FTU is the amount of topical agent that can be applied

to the terminal phalynx of the index finger.• The whole body requires 20-30 g of ointment/single dose  • In an adult:

   - face or neck – 1 g   - trunk (each side) – 3 g   - arm – 1 ½ g   - hand – ½ g   - leg – 3 g   - foot – 1 g

Emollients• are useful in dry-skin disorders due to their ability to re-

establish the surface lipid layer and enhancing rehydration of the epidermis. 

• There are several emollient ointments, creams and oils added to baths.

Fingertip unit (FTU): applied to the terminal phalynx of the index finger

5. Advice to patients: Explain:- Timing of the application: After bathing in many

cases e.g. scabies- Irritation: tretinoin, 5-FU- Occlusion, bandaging or other dressing * Occlusion increases the level of penetration of a

drug into the skin * Polythene gloves on the hands * Clingfilm on the feet or limbs * Self-adhesive hydrocolloid dressings on the limbs

or trunk * Wet wrap bandaging in Rx of AD * Paste bandages to ↑ penetration & prevent

scratching

6. Hazards associated with topical treatments:

- Irritant reactions

- Allergic reactions

- Systemic SEs (rare)

B. Formulation of skin topical treatment

Vehicle• must provide rapid delivery of the drug to the

SC & into the viable layers of the skin • Must be soothing• Comfortable to use• Cosmetically acceptable• Must provide a chemical environment in which

the drug remains sufficiently stable prior to use to have a practical shelf life

Constituents of vehiclesConstituents of vehicles

1. Lipids:

2. Emulsifiers:

3. Humectants:

4. Penetration enhancers:

5. Preservaties:

6. Solvents:

C. Topical treatments used in the management C. Topical treatments used in the management of skin diseaseof skin disease

1. Antiperspirants:

2. Antibiotics: Bacitracin, clindamycin, erythromycin, fusidic acid, gentamycin sulphate, Metronidazole, mupirocin, neomycin & framycetin, polymixin B, silver sulfadiazine, tetracyclines

• Resistance and sensitization are potential problems.

• Topical Metronidazole is used for 1. rosacea

2. Acne 3. folliculitis 4. impetigo 5. infected eczema  

3. Antifungal agents: allylamines, imidazoles, morpholines, polyenes, ciclopirox olamine, tolnaftate, undecylenic acid, other antifungal agents

For fungal infection of the skin & Candidiasis

4. Antiparasitic agents: Topical Parasiticidals : pyrethroids, malathion, Permethrin, Benzyl benzoate, Lindane. for Scabies & pediculosis

5. Antiviral agents: acyclovir & penciclovir, idoxuridine

For HS & HZ

6. Astringents: Topical Antiseptics : KMNO4, aluminium acetate, silver nitrate

For Skin sepsis & leg ulcers

7. Topical Corticosteroids (Cs) :

Anti-inflammatory, anti-proliferative, vasoconstrictive; different strengths available. For: 1. Eczema 2. DLE 3. LP

3. lichen sclerosus, 4. mycosis fungoides,

5. photodermatoses, 6. pityriasis rosea,

7. psoriasis.

Topical steroids• Have revolutionized the practice of

dermatology since they were introduced in the late 1950s.

• are associated with potential (SEs) especially if they are used incorrectly.

• are 4 groups according to their strength. • As a general rule, use the weakest possible

steroid that will do the job. However, sometimes it is appropriate to use a potent preparation for a short time to make sure the skin condition clears completely.

Topical Cs Potencies:

1. Mild (Low) potency : • e.g.: HC: Hydrocortisone 0.5-2.5% (Cream/Ointment)

2. Moderate (Mid) potency: e.g.: (Cream/Ointment)

• (2-25 times as potent as HC) • Clobetasone butyrate (Eumovate Cream) • Triamcinolone acetonide (Aristocort Cream/Ointment, Viaderm

Cream/Ointment, Kenacomb Ointment)

3. High potency: e.g.: (Betnosam) • (I50-100 times as potent as HC) • Betamethasone valerate (Beta Cream/Ointment/Scalp Application,

Betnovate Lotion/C Cream/C Ointment, Daivobet 50/500 Ointment, Fucicort)

• Betamethasone dipropionate (Diprosone Cream/Ointment) • Diflucortolone valerate (Nerisone C/Cream/Fatty Ointment/Ointment) • Hydrocortisone 17-butyrate (Locoid C/Cream/Crelo Topical

Emulsion/Lipocream/Ointment/Scalp Lotion) • Mometasone furoate (Elocon Cream/Lotion/Ointment) • Methylprednisolone aceponate (Advantan Cream/Ointment)

4. Super High potency: e.g.: Clobetasol (Dermovate) Cream/Ointment

• (up to 600 times as potent as HC) • Betamethasone dipropionate (Diprosone) Cream/Ointment)

Skin absorption of topical steroids• Steroids are absorbed at different rates from

different parts of the body. • A steroid that works on the face may not

work on the palm. But a potent steroid may cause side effects on the face. For example:

• Eyelids and genitals absorb 30%• Face absorbs 7%• Armpit absorbs 4% • Forearm absorbs 1% • Palm absorbs 0.1% • Sole absorbs 0.05%

SEs of topical steroidsI. Local Skin SEs: 1. Skin thinning (atrophy) 2. Striae: stretch marks 3. Easy bruising and tearing of the skin. 4. Perioral dermatitis: POD (rash around the mouth) 5. Telangiectasia: Enlarged blood vessels 6. Susceptibility to skin infections. 7. Tinea incognito: Disguising infection 8. Acneform eruption: No comedones 9. Allergy to the steroid cream.II. Internal SEs• Adrenal gland suppression • Cushing's syndrome

SEs of Topical Cs Potencies:

* The risk of these SEs depends on the

1. Strength of the steroid

2. Length of application

3. Site treated

4. Nature of the skin problem.

* If you use a potent steroid cream on your face as a moisturiser, you will develop the SEs within a few weeks.

* If you use 1% HC cream on your hands for 25 years, you will have done no harm at all (except for having wasted a lot of money!)

Dermovate (Clobetasol propionate) or Dermodin should never be used on the following areas:

1. Face

2. Axillae

3. Groin

Skin thinning

Stretch marks

Bruising

Prominent capillaries

POD

8. Cytotoxic & antineoplastic agents: bleomycin, 5-Fluorouracil, T4 endonuclease, mechlorethamine, imiquimod, diclofenac, podophyllin & podophyllotoxin

9. Depigmenting agents: Hydroquinone, Monobenzyl ether of Hydroquinone, additional phenol derivatives, retinoic acid, Kligman cream, azelaic acid, Kojic acid, liquiritin

10. Depilatories:

11. Dithranol: Topical Dithranol: Anti-proliferative for Psoriasis

12. Emollients:13. Immunomodulators: (syn. Calcineurin

inhibitors): Tacrolimus (Talimus), pimecrolimus, ciclosporin (cyclosporin)

14. Retinoids: Retinol (syn. Vitamin A), Retinoic acid, adapalene, bexarotene, tazarotene

• Topical Keratolytics: 1. benzoyl peroxide & tretinoin for Acne, 2. Salicylic acid for scaly eczemas and warts

15. Sensitizing agents:

16. Sunscreens:17. Tars: wood tars, shale tars, coal tar• Topical Coal tar: Presumed anti-inflammatory and

anti-proliferative effects. 1. Eczema 2. Psoriasis18. Vitamin D analogues: (deltanoids, secosteroids): Tacalcitol (1,24 dihydroxycholecalciferol),

calcipotriol, (calcipotriene,MC 903), Maxacalcitol (22-oxa-calcitriol)

Topical Vitamin D analogues: Inhibit keratinocyte proliferation and promote differentiation. for Psoriasis.

19. Traditional remedies: camphor, dyes, menthol20. Miscellaneous agents: capsaicin, minoxidil,

nicotinamide

III- Systemic Therapy • is for more serious condition & infectionsIndications: 1. Systemic Cs therapy: Prednisolone: for: 1. Bullous disorders, 2. CT disease, 3.

vasculitis2. Sex hormones & related compounds:

Systemic Antiandrogens: Cyproterone: for: Acne (only in ♀s)

3. Systemic Antihistamines H1Blockers: for: 1. Eczema, 2. Urticaria

& other antiallergic drugs:

4. Systemic NSAI therapy:

5. Cytokines:

6. Interferons:

7. ILs: Interleukinns:

8. Essential fatty acid:

9. Systemic Retinoids: Acitretin, Isotretinoin: (13-cis retinoic acid: Retane), for:

A. Keratinization disorders B. Acne

10. A. Systemic Immunosuppressants: Cyclosporin, Gold: for: 1. Psoriasis 2. Atopic eczema 3. Bullous disorders 4. LE

10. B. Systemic Cytotoxics: a. Alkylating agents b. Antimetabolites c. Ciclosporin (Cyclosporin): d. Fumaric acid esters (fumarates) Methotrexate, Hydroxyurea, Azathioprine: for: 1. Psoriasis, 2. Sarcoidosis, 3. Bullous disorders, 4. Chronic actinic (solar) dermatitis Methotrexate: 3 tab./week, each tab=2.5 mg Total dose of MTX should not exceed 1 gm in the patient’s life

11. PUVA:12. Photopheresis:13. Plasmapheresis:14. Intravenous Igs:15. Gold (Na thiomalate)16. Chelating agents:17. Systemic Antibiotics & Antibacterial agents: for: 1. Acne, 2. rosacea, 3. skin sepsis

18 Systemic Antifungals: Griseofulvin, Ketoconazole, Itraconazole, Terbinafine

19. Systemic Antivirals: Acyclovir, Famciclovir: for: 1. HS, 2. HZ

20. Antiparasitic agents:21. Drugs to improve peripheral circulation:

22. Miscellaneous drugs: (used in special ways in dermatology)

A. Antimalarials Hydroxychloroquine: for: 1. LE, 2. PCT B. Systemic Antileprotic Dapsone: for: 1. DH, 2. leprosy, 3. vasculitis & Sulfapyridine C. Clofazimine D. Sulfasalazine E. Thalidomide F. Colchicine G. Traditional chinese herbal medicine23. Transdermal delivery system:

IV- Phototherapy & Photochemotherapy• Phototherapy Sunlight helps certain skin conditions,

both UVB and UVA are employed.Ultraviolet B• UVB (290-320 nm) is given 3 times a week.  • The initial dose is determined from the patients skin type

or minimal erythema dose (MED).  • With each visit, the scheduled dosage is increased.  • Commonly, 10-30 treatments are the normal course.• UVB can be used in children and pregnant women.  • Used in psoriasis, mycosis fungoides, atopic eczema,

and pityriasis rosea.  • Side effects include acute sunburn and increase risk of

skin cancer.• A rotating mechanical head wounds the skin down to the

dermis.

Photochemotherapy (PUVA)• UVA is used in combination with photosensitizing

psoralens given topically or systemically.  • PUVA stand for Psoralens plus UltraViolet A.  • Commonly, oral 8-methoxypsoralens is taken 2

hours before UVA (320-400 nm).  • MOA: photoactivated psoralens results in DNA

cross-linking, inhibition of cell division, and suppression of cell-mediated immunity. 

• Like UVB, the initial dose of UVA is determined by MED or skin type; and dosage is increased a scheduled visits. 

• PUVA is usually given 2-3 times per week for 15-25 treatments. 

• PUVA can be combined with acitretin (RePUVA) but not methotrexate.

• Bath PUVA, bath containing a psoralen, is an alternative to systemic-side effects of oral psoralens. 

• Local PUVA, topical psoralen, may be effective in psoriasis and dermatitis involving the hands or feet. 

• Indications of PUVA : psoriasis, vitiligo, mycosis fungoides, atopic eczema or polymorphic light eruption 

• SEs:• Acute SEs: pruritus, nausea, & erythema • long-term SEs: premature skin ageing and skin cancer

(depend on the number and total dose of UVA)  • Cataracts are possible and UVA-opaque sunglasses must

be worn for 24 hours after taking psoralen.

V- Radiotherapy & reactions to ionizing radiation

VI- Physical therapies1. Cryosurgery2. Curettage: Benign lesions & Non-melanoma skin cancer

3. Electrosurgery: a. electrocautery b. electrosurgery c. electrolysis4. Infrared coagulation5. Caustics6. Chemical peeling7. Intralesional therapy: IL Triamcinolone8. Sclerotherapy9. Miscellaneous physical therapy: a. Keloid therapy b. Minor surgical procedures c. haemostasis

10. Soft-tissue augmentation & Facial line correction

VII- Laser therapies: Laser (Light Amplification by Stimulated Emission of Radiation) (Next lecture)

VIII- Dermatological Surgical proceduresBasic Dermatological Surgical procedures are:

• Excisional Biopsy• Incisional Biopsy• Punch Biopsy • Shave Biopsy • Curettage• Cautery• Cryotherapy• Mohs’ Surgery• Dermabrasion