Transcript Dermatologic therapies - American Academy of Dermatology

Dermatologic Therapies
Basic Dermatology Curriculum
Last updated June 8, 2011
1
Module Instructions
 The following module contains a number
of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated guide to clinical dermatology
and dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
2
Goals and Objectives
 The purpose of this module is to help medical students gain
familiarity with common dermatologic treatments.
 By completing this module, the learner will be able to:
• Estimate the amount of topical medication needed for therapy
based on frequency of application and body surface area
involved
• Choose appropriate strengths of topical steroids based on age,
body location and severity of dermatitis
• List side effects of prolonged use of topical steroids
• Discuss the basic principles of medications used to treat acne
• Discuss the basic principles of topical antifungals, oral
antihistamines and topical psoriasis medications
3
Principles of Dermatologic Therapy
 The efficacy of any topical medication is
related to:
• The active ingredient (inherent strength)
• Anatomic location
• The vehicle (the mode in which it is
transported)
• The concentration of the medication
4
Vehicles
Foams
Gels
Creams
Sprays
Oils
Solutions
Ointments
5
Vehicles
 Ointments (e.g. Vaseline): lubricating, occlusive; greasy
• USE for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesions
• AVOID on hairy and intertriginous (when skin is in contact with skin,
e.g. armpits, groin, pannus) areas
 Creams (vanish when rubbed in): less greasy, drying
effects; not occlusive, can sting, more likely to cause
irritation (preservatives/fragrances)
• USE for acute exudative inflammation, intertriginous areas
 Lotion (pourable liquid): less greasy, less occlusive; may
contain alcohol (drying effect on oozing lesion); penetrate
easily, little residue
• USE for hairy areas
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Vehicles (cont.)
 Oils: less stinging than lotions or solutions
• USE for the scalp, especially for people with coarse or very curly
hair
 Gel (jelly-like): may contain alcohol, greaseless, least
occlusive; dry quickly
• USE for acne, exudative inflammation (e.g. acute contact
dermatitis); on scalp/hairy areas without matting
 Foams (cosmetically elegant): spread readily, easier to
apply; more expensive
• USE for hairy areas; inflammation
• Sprays: Aerosols (rarely used), pump sprays
7
Medication Costs
 Topical medications can be very expensive
 They are not all covered by insurance
 Over the counter (OTC) treatments are generally
cheaper than prescriptions
 Generics are less expensive than brand name
prescriptions
 It is helpful to know the costs of the medications
you prescribe and be able to tell the patient in
advance what they should expect to pay
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What goes into a topical
prescription?
9
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
10
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
• Generic name
11
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
• Generic name
• Vehicle
12
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
• Generic name
• Vehicle
• Concentration
13
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
• Generic name
• Vehicle
• Concentration
• Sig (directions)
14
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
• Generic name
• Vehicle
• Concentration
• Sig
• Amount
15
Topical prescriptions
 What goes into a prescription?
• Desonide cream 0.05% apply to affected area
(face) BID PRN for scaling #15 Grams RF3
• Generic name
• Vehicle
• Concentration
• Sig
• Amount
• Refills
16
Now Let’s Review Some
Common Types of Medications
Used by Dermatologists
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Topical Corticosteroids
 Topical steroids produce an antiinflammatory response in the skin
 They are effective for conditions that are
characterized by hyperproliferation,
inflammation, and immunologic involvement
 They can also provide symptomatic relief for
burning and pruritic lesions
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Topical Corticosteroids
 Corticosteroids are organized into classes based
on their strength (potency)
• Therefore, steroids within any class are
equivalent in strength
 Strength is inherent to the molecule, not the
concentration
 Know one steroid from each class that would be
available to the majority of your patients (the
generic in that class)
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Topical Steroid Strength
Potency
Class
Example Agent
Super high I
Clobetasol propionate 0.05%
High
II
Fluocinonide 0.05%
III – V
Triamcinolone acetonide ointment 0.1%
Triamcinolone acetonide cream 0.1%
Triamcinolone acetonide lotion 0.1%
VI – VII
Fluocinolone acetonide 0.01%
Desonide 0.05%
Hydrocortisone 1%
Medium
Low
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Topical Steroid Strength
 Remember to look at the
class not the percentage
• Note that clobetasol 0.05%
is stronger than
hydrocortisone 1%.
 When several are listed,
they are listed in order of
strength
• Note that triamcinolone
ointment is stronger than
triamcinolone cream or
lotion because of the
nature of the vehicle
Potency
Class
Super
high
I
Clobetasol 0.05%
High
II
Fluocinonide 0.05%
III – V
Triamcinolone ointment 0.1%
Triamcinolone cream 0.1%
Triamcinolone lotion 0.1%
VI –
VII
Fluocinolone 0.01%
Desonide 0.05%
Hydrocortisone 1%
Medium
Low
Example Agent
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Corticosteroid Selection
 Super high potency (Class I) are used for severe
dermatoses over nonfacial and nonintertriginous areas
• Scalp, palms, soles, and thick plaques on extensor
surfaces
 Medium to high potency steroids (Classes II-V) are
appropriate for mild to moderate nonfacial and
nonintertriginous areas
• Okay to use on flexural surfaces for limited periods
 Low potency steroids (Classes VI, VII) can be used for
large areas and on thinner skin
• Face, eyelid, genital and intertriginous areas
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Local Side Effects of
Topical Steroids
 Local side effects of topical steroids include:
• Skin atrophy
• Telangiectasias
• Striae
• Acne
• Steroid Rosacea
• Hypopigmentation
 The higher the potency the more likely side
effects are to occur.
 To reduce risk, the least potent steroid should be
used for the shortest time, while still maintaining
effectiveness
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Local Corticosteroid Skin Side Effects
Skin Atrophy
Striae
24
Local Corticosteroid Skin Side Effects
Hypopigmentation
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Systemic Side Effects of
Topical Steroids
 Systemic side effects are rare due to low absorption
 They can include:
•
•
•
•
•
Glaucoma (when steroid applied to the eyelid)
Hypothalamic pituitary axis suppression
Cushing’s syndrome
Hypertension
Hyperglycemia
 The higher the potency the more likely side effects are to
occur
 To reduce risk, the least potent steroid should be used for
the shortest time, while still maintaining effectiveness
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Duration of Treatment
 Duration of treatment is limited by side effects
 In general:
• Super high potency: treat for <3 weeks
• High and Medium potency: <6-8 weeks
• Low potency: side effects are rare. Treat facial, intertriginous,
and genital dermatoses for 1-2 week intervals to avoid skin
atrophy, telangiectasia, and steroid-induced acne
 Stop treatment when skin condition resolves
• To avoid rebound/flares: taper with gradual reduction of both
potency and dosing frequency every 2 weeks
 If the patient does not respond to treatment within these
guidelines, consider referral to a dermatologist
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Prescribing topical steroids
The following slides will review how to
estimate the amount of medication to
prescribe according to the affected body
surface area (BSA)
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Estimating BSA:
Palm of Hand
1 Palm = 1% BSA
Use the size of the
patient’s palm, not
your own
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Estimating topicals:
Fingertip unit
 Quantity of topical
medication (dispensed
from a 5mm nozzle)
placed on pad of the
index finger from distal
tip to DIP joint
 Fingertip unit (FTU) =
500 mg = treats 2%
BSA
30
2 palms 2 times a day = 30 grams / mo
1 Palm = 1% BSA
1 Palm = 1% BSA
FTU = 0.5 G
Covers 2 % BSA
Covers 2 palms
2 palms = 2% BSA
2 palms 2 times per day
= 1 gram per day
SO…GIVE 30 GRAMS
FOR EVERY 2 PALMS
OF AREA TO COVER
(FOR 1 MONTH Rx)
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Practice Question 1
 Take a look at the following photograph and decide
how much BSA is affected. Then try to answer the
question on the following slide.
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Practice Question
 Which of the following prescriptions would you
recommend for BID dosing for 1 month duration?
Use 2% BSA.
a. Fluocinonide 0.05% ointment, apply to affected area
(knees) BID, # 30 grams
b. Fluocinonide 0.05% ointment, apply to affected area
(knees) BID, # 90 grams
c. Hydrocortisone 1% ointment, apply to affected area
(knees) BID, # 30 grams
d. Hydrocortisone 1% ointment, apply to affected area
(knees) BID, # 90 grams
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Practice Question
 Which of the following prescriptions would you recommend
for BID dosing for 1 month duration? Use 2% BSA.
a. Fluocinonide 0.05% ointment, apply to affected area
(knees) BID, # 30 grams (2 palms = 2% BSA = 30 grams
for 1 mo BID)
b. Fluocinonide 0.05% ointment, apply to affected area (knees)
BID, # 90 grams (for a 3 month supply)
c. Hydrocortisone 1% ointment, apply to affected area (knees)
BID, # 30 grams (need a higher potency steroid for plaque
psoriasis on the knees)
d. Hydrocortisone 1% ointment, apply to affected area (knees)
BID, # 90 grams
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Estimating amounts
 It takes ~30 grams to cover an average adult
body (for one application)
 Here is a rough estimation of amounts to
prescribe for BID use for a month:
• Face
• 30-45 grams
• Extensor surfaces of both arms
• 120-150 grams
• Widespread on trunk, legs, arms:
• 1-2 pounds (454 grams = 1 lb.)
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Estimating amounts:
re-assess of follow-up
 The best way to assure you are giving the
right amount is to re-assess on follow-up
• If your patient was given a 60-gram tube,
confirm they are using it according to
instructions, and ask how long that tube lasts
• If a 60-gram tube only lasts them 2 weeks, they
need 2 of them to last a month
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Estimating BSA:
Rule of Nines
 The “rule of nines” is a
good, quick way of
estimating the affected
BSA
 Often used when
assessing burns
 The body is divided into
areas of 9%
 Less accurate in children
Source: McPhee SJ, Papadakis MA: Current Medical
Diagnosis and Treatment 2010, 49th Edition:
http://www.accessmedicine.com. Copyright © The
McGraw-Hill Companies, Inc.
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Pediatric Dosing
 Children require adjusted dosage
 Use a pediatric version of the rule of nines or the
patient’s palm to estimate BSA
 Remember that children, especially infants have a
high body surface area to volume ratio, which puts
them at risk for systemic absorption of topically
applied medications
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Pediatric Dosing (cont.)
 Low potency topical corticosteroids are safe when
used for short intervals
• Can cause side effects when used for extended
durations
 High potency steroids must be used with caution
and vigilant clinical monitoring for side effects in
children
 Potent steroids should be avoided in high risk
areas such as the face, folds, or occluded areas
such as under the diaper
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Let’s move on to some more
types of medications used by
dermatologists
Medications commonly used to treat
Acne vulgaris
40
Benzoyl peroxide
 Benzoyl peroxide is a topical medication with both
antibacterial and comedolytic (breaks up
comedones) properties
 Available as a prescription and over-the-counter,
as well as in combinations with topical antibiotics
 Patients should be warned of common adverse
effects:
• Bleaching of hair, colored fabric, or carpet
• May irritate skin; discontinue if severe
 Available as a cream, lotion, gel, or wash
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Topical Antibiotics
 Used to reduce the number of P. acnes and
reduce inflammation in inflammatory acne
 Do not use as monotherapy (often used with
benzoyl peroxide to prevent the development of
antibiotic resistance in the treatment of mild-tomoderate acne and rosacea)
• Erythromycin 2% (solution, gel)
• Clindamycin 1% (lotion, solution, gel, foam)
 Metronidazole 0.75%, 1% (cream, gel) is used in
the treatment of rosacea
42
Topical Retinoids
(tretinoin, all trans retinoic acid)
 Topical retinoids are vitamin A derivatives
 Used for acne vulgaris; photodamaged skin; fine
wrinkles, hyperpigmentation
 Patients should be warned of common adverse
effects:
• Dryness, pruritus, erythema, scaling
• Photosensitivity
 Available as a cream or gel
 Do not apply at the same time as benzoyl peroxide
because benzoyl peroxide oxidizes tretinoin
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Topical Acne Treatment:
Side Effects
 Topical acne treatments are often irritating and can
cause dry skin
• When using retinoids or benzoyl peroxide, consider
beginning on alternate days. Use a moisturizer to reduce
their irritancy.
 Topical agents take 2-3 months to see effect
 Patients will often stop their topical treatment too early
from “red, flakey” skin without improvement in their
acne
 Patient education is a crucial component to acne
treatment
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Oral Antibiotics
 Tetracycline, doxycycline, minocycline
 Use for moderate to severe inflammatory acne
 Often combined with benzoyl peroxide to prevent
antibiotic resistance
 If the patient has not responded after 3 months of
therapy with an oral antibiotic, consider:
• Increasing the dose,
• Changing the treatment, or
• Referring to a dermatologist
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Oral Treatment: Side Effects
 Tetracyclines (tetracycline, doxycycline,
minocycline):
• Are contraindicated in pregnancy and children age
<8 years
• May cause GI upset (epigastric burning, nausea,
vomiting and diarrhea can occur)
• Can cause photosensitivity (patients may burn
easier, which can be easily managed with better
sun protection). Recommend sun block with UVA
coverage for all acne patients on tetracyclines
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Oral Tetracyclines:
Patient Counseling
 Major side effects:
• Tetracycline: GI upset, photosensitivity
• Doxycycline: GI upset, photosensitivity
• Minocycline: GI upset, vertigo, hyperpigmentation
 Patients need clear instructions
• If taking for acne, it is okay to take them with food and
dairy products for tolerability of GI side effects
• Take with full glass of water; avoids esophageal erosions
• Tetracyclines do NOT interfere with birth control pills
• It takes 2-3 months to see improvement
47
Oral Isotretinoin
 Oral isotretinoin, a retinoic acid derivative, is indicated in
severe, nodulocystic acne failing other therapies
 Should be prescribed by physicians with experience
using this medication
 Typically given in a single 5-6 month course
 Isotretinoin is teratogenic and therefore absolutely
contraindicated in pregnancy
• Female patients must be enrolled in a FDA-mandated
prescribing program in order to use this medication
• Two forms of contraception must be used during isotretinoin
therapy and for one month after treatment has ended
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Isotretinoin Side Effects
 Common side effects of isotretinoin include:
•
•
•
•
Xerosis (dry skin)
Cheilitis (chapped lips)
Elevated liver enzymes
Hypertriglyceridemia
 Individuals with severe acne may suffer mood
changes and depression and should be monitored
 Severe headache can be a manifestation of the
uncommon side effect pseudotumor cerebri
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Topical Antifungals
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Topical Antifungals
 There are several classes of topical antifungal
medications
 Some classes are fungistatic (stop fungi from
growing), others are fungicidal (they kill the
fungi)
 Not all conditions are treatable with topical
antifungals (specifically, hair infections and nail
infections do not respond to topical treatment and
require systemic treatment)
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Topical Antifungals
 The following are some examples of topical
antifungals:
• Imidazoles (fungistatic): Ketoconazole (Rx & OTC),
Econazole, Oxiconazole, Sulconazole, Clotrimazole (Rx
& OTC), Miconazole (OTC)
– Useful to treat candida and dermatophytes
• Allylamines and benzylamines (fungicidal): Naftifine,
Terbinafine (OTC), Butenafine
– Better for dermatophytes, but not candida
• Polyenes (fungistatic in low concentrations): Nystatin
– Better for candida, but not dermatophytes
52
Advantages of Topical Antifungals
 Topical antifungals are preferred for most
superficial fungal infections of limited extent.
 Advantages include:
•
•
•
•
Relatively low cost
Acceptable efficacy
Ease of use
Low potential for side effects, complications,
or drug interactions
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Oral Antihistamines
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Antihistamines
 Antihistamines are the most widely used agents for
pruritus and chronic urticaria
 1st Generation H1 antagonists are sedating
• Anticholinergic side effects (e.g. memory impairment,
confusion, dry mouth, blurred vision) are dose-limiting
• Use as a sleep aid at night for patients with pruritus
• Use with caution in elderly due to increased fall risk, CNS
and anticholinergic effects
 2nd Generation H1 antagonists are minimally sedating
and require less frequent dosing than 1st generation H1
antihistamines
55
Antihistamines
 The following are examples of H1 antihistamines:
• 1st Generation
• 2nd Generation
• Diphenhydramine (OTC)
• Cetirizine (OTC)
• Hydroxyzine (Rx, generic) • Loratadine (OTC)
• Chlorpheniramine (OTC)
• Fexofenadine (OTC)
 For most pruritic dermatoses that are not
urticaria, 1st generation H1 antihistamines
primarily work through their sedative effect
rather than their anti-histaminic properties
56
Medications used in Psoriasis
57
Skin Kinetics
 Some dermatoses are associated with a higher
rate of epidermal turnover
• For example, the epidermis of psoriasis replicates too
quickly
 Topical therapies that inhibit keratinocyte
proliferation are used in the treatment of psoriasis
 They include:
• Vitamin D analogs
• Coal tar
• Tazarotene
58
Psoriasis Treatment:
Topical Vitamin D Analogs
 Calcipotriene (calcipotriol)
• Inhibits keratinocyte proliferation
• Most common side effect is skin irritation
 Calcitriol
• Inhibits keratinocyte proliferation
• Stimulates keratinocyte differentiation
• Inhibits T-cell proliferation
• On more sensitive areas, less skin irritation than
calcipotriol
59
Psoriasis Treatment
 Tar 2-5%
• Antiproliferative effect
• Disadvantages: stain clothing/hair/skin; messy; increases
photosensitivity
• Can be combined with salicylic acid to penetrate thick
plaques
 Tazarotene 0.05% and 0.1%
•
•
•
Topical retinoid used for acne, rosacea, psoriasis
Disadvantages: skin irritation; teratogenic; increases
photosensitivity
Can be combined with a Class II corticosteroid to reduce
irritation
60
Take Home Points
 The efficacy of any topical medication is related to the strength,
location, vehicle, and concentration
 Topical medications can be very expensive
 When writing a prescription for a topical medication, include:
generic name, vehicle, concentration, directions, amount, # of
refills
 Corticosteroids are organized into classes based on their strength
(potency)
 Skin atrophy, acne, striae, and telangiectasias are potential local
side effects of corticosteroid use
 It takes ~30 grams to cover an average adult body (for one
application)
61
Take Home Points
 Use benzoyl peroxide with topical antibiotics to prevent the
development of antibiotic resistance in acne treatment
 Lack of adherence is the most common cause of treatment failure
in acne patients; patient education is crucial
 Topical antifungals are preferred for most superficial fungal
infections of limited extent
 Antihistamines are the most widely used agents for pruritus and
chronic urticaria
 2nd Generation H1 antihistamines are less sedating that 1st
generation H1 antihistamines
 Many of the topical medications used in psoriasis inhibit
keratinocyte proliferation
62
Acknowledgements
 This module was developed by the American
Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.
 Primary authors: Alina Markova, Sarah D. Cipriano,
MD, MPH; Timothy G. Berger, MD, FAAD; Patrick
McCleskey, MD, FAAD.
 Peer reviewers: Peter A. Lio, MD, FAAD; Ron
Birnbaum, MD.
 Revisions: Sarah D. Cipriano, MD, MPH. Last revised
June, 2011.
63
References
 Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The WebBased Illustrated Clinical Dermatology Glossary. MedEdPORTAL;
2007. Available from: www.mededportal.org/publication/462.
 Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for the
use of topical glucocorticosteroids. American Academy of Dermatology.
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 Ference J, Last A. Choosing Topical Corticosteroids. Am Fam
Physician 2009;79 (2):135-140.
 Goldstein B, Goldstein A. General principles of dermatologic therapy
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UpToDate, Waltham, MA, 2011.
 Hettiaratchy S, Papini R. ABC of burns. Initial management of a major
burn: II – assessment and resuscitation. BMJ. 2004;329:101-103.
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References
 High Whitney A, Fitzpatrick James E, "Chapter 219. Topical Antifungal
Agents" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller
AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2969866.
 Limb Susan L, Wood Robert A, "Chapter 230. Antihistamines" (Chapter).
Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ:
Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=3003116.
 Nelson A, Miller A, Fleischer A, Balkrishnan R, Feldman S. How much of
a topical agent should be prescribed for children of different sizes? J
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 Weller R, Hunter J, Dahl M. Clinical Dermatology. 2008; 55.
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