Transcript Topical Skin Therapies - UNC School of Medicine

Topical Therapeutics Update
Adam O. Goldstein, MD
Associate Professor
University of North Carolina
Department of Family Medicine
Chapel Hill, NC
[email protected]
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
Topical therapies







Acne
Antifungal *
Antibacterial
Anti-inflammatory *
Moisturizers
Sun protection
Hair






Psoriasis
Eczema
Aging
Debridement
Parasites
Warts
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)
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)
(http://www.dermnetnz.org/index.html)
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®)
(http://www.dermnetnz.org/index.html)
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)
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
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
Prescribing combination topical
fungal/corticosteroid preparations


Lotrisone (cream/lotion)
 Betamethasone
dipropionate/
clotrimazole
Mycolog II, Mytrex
(cream, ointment)
 Nystatin/
triamcinolone
acetonide
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)
Preparations









Creams
Lotions
Ointments
Gels
Pastes and Powders
Soaps
Shampoos, foams & mousse
Dressings
Other (e.g. astringents, collodions,
tinctures , emollients)
Creams
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)
Lotions
Lotions
Useful for scalp and
other hairy areas
 Spreads over wide
areas easily
 Cosmetically more
acceptable in these
areas

Ointments
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

Gels

Evaporate quickly
Cosmetically elegant
Useful for most skin conditions

Gels may be irritating d/t alcohol in base


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:
Soaps
Soaps and other cleansing bars are useful to
cover large areas of skin
 Ex. Acne

Sulfer soap, benzyl peroxide bars, salicylic acid bars
Shampoos and Foams

Shampoos and foams (mousse)
offer cosmetically elegant ($$)
formulations (increasing)

Examples:

betamethasone valerate
mousse, salicylic acid & tar
shampoos
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
Tube Sizes to prescribe(bid application for 10 days)
Face and Neck:
30g
 Trunk (Front and back): 60g
 One Arm:
30g
 One Leg:
60g
 One Hand:
15g
 One Foot:
30g

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

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

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

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)
? If Applied
for
Therapeutic
Purposes!
Potential Adverse Effects of Topical Steroids
Percutaneous absorption and general
suppression
 Skin atrophy or striae
 Papular or perioral dermatitis

Potent Topical Steroids to Face

prolonged (usually >6 weeks) application of
potent corticosteroids to the face



rosacea
perioral dermatitis
atrophy
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?
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
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.
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
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?
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

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):645-74.
Savin R. Diagnosis and treatment of tinea versicolor. J Family Pract
1996; 43(2): 127-32.
Coskey RJ. Contact dermatitis caused by diphenhydramine
hydrochloride. J Amer Acad Dermato 1983; 8(2): 204-6.
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,
1990-1994. 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): 59-62.
References






Volden G. Successful treatment of chronic skin diseases with
clobetasol propionate and a hydrocolloid occlusive dressing. Acta
Dermato-Vener 1992; 72(1): 69-71.
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):327-32.
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: 71-75.
THANK YOU!