Microsoft word - we-183 _marco_ .doc

(+)Catherine A. Marco, MD, FACEP
Professor, Director of Medical Ethics
Curriculum, University of Toledo College
of Medicine
If It's Dry, Wet It; If It's Wet,
Dry It: A Commonsense Guide
to Dermatologic Therapy

Pharmacologic management of dermatologic conditions isn’t
really that simple. This presentation well review classes of
dermatologic pharmacology, including not only emollients,
drying agents, and steroids, but also other treatments such as
antibiotics, antifungal agents, antivirals, chemotherapeutic
agents, immunomodulators, and other treatments for
common cutaneous conditions. Learn what to use and what
complications might develop.
• Review standard treatment regimens for common skin • Discuss recent advances in treatment of common • List common pharmaceutical agents used in therapy of • Identify patients in need of referral to a dermatologist. WE-183 Wednesday, October 29, 2008 10:00 AM - 10:50 AM McCormick Place - Lakeside Building (+)No significant financial relationships to disclose “If It’s Dry, Wet It: If It’s Wet, Dry It;
Otherwise, Use Steroids”…?
A Commonsense Guide to
Dermatologic Therapy”
Catherine A. Marco, MD, FACEP
Professor, Department of Surgery, Division of Emergency Medicine University of Toledo College of Medicine Review standard treatment regimens for common skin conditions. Discuss recent advances in treatment of common cutaneous conditions. List common pharmaceutical agents used in therapy of cutaneous conditions. Identify patients in need of dermatologic referral or consultation.
Introduction
Skin diseases constitute a significant fraction of health care economics in the United
States. Cutaneous complaints result in approximately 10% of outpatient medical visits
and $36 billion in health care annually, including $20 billion in ambulatory care costs and
$3 billion in prescription costs, and $2 billion in indirect costs (lost work days, etc.).
Rapidly advancing diagnostic and therapeutic technologies result in novel dermatologic
agents, and novel uses of traditional agents.
Is there truth to the old adage: “ If It’s Dry, Wet It; If It’s Wet, Dry It; Otherwise, Use
Steroids” ??? Indeed, there is some truth to the ancient advice that selection of vehicle
and formulation are important, and that steroids are frequently therapeutic for
inflammatory skin conditions. In addition to a review of vehicles, formulations, and
steroids, this lecture will address other commonly prescribed systemic and topical
medications used to treat dermatologic disorders.
There is an overwhelming amount of literature on the subject of skin therapies (66,411
published articles in the past 10 years!). This presentation will highlight a select group
of therapies for dermatologic complaints seen in emergency medicine. Continuing
medical education about new therapies represents an essential component of the effective
delivery of quality medical care. Dermatologic consultation should be sought when
appropriate. Pharmaceutical references should be used to assist in prescribing
appropriate dosages and routes of administration.
OVERVIEW: CATEGORIES OF DERMATOLOGIC THERAPEUTIC AGENTS
Systemic Topical Mucosal
Photodynamic
Intralesional agents
II. VEHICLES FOR TOPICAL DERMATOLOGIC AGENTS
Case 1:
A 35 year old man with longstanding psoriasis presents with an exacerbation of symptoms. He requests
“that new foam – it’s better than the cream, isn’t it?”

A.
Emollients
mineral oil, baby oil (Eucerin, Aquaphor, “moisturizers” (primarily water, fragrances) Retard water loss, occlude the treatment molecules, increase skin Ointments, creams and gels: emulsions of oil in water Increase even distribution and absorption Emulsifying
Create oil-in-water preparations (creams, lotions) Humectants
maintain appropriate water content for oil-in-water preparations; increase Emulsion stabilizers and viscosity builders
Thickening
Solvents
Increase potency by increasing absorption Preservatives and chemical stabilizers
Alcohols, parabens, propylene glycol, etc. CHOICE OF PREPARATION:
To treat dry conditions (eczema, psoriasis, etc.): Emollients (ointment > cream > lotion) To treat moist conditions (contact dermatitis, infections, etc.) Gels or solutions or powders, Burrow’s emulsion Emollients or solvents; apply under occlusion To aid in application (scalp, hirsute areas, difficult to reach areas): Patient preference and compliance linked more closely to outcomes than III. GENERIC
Generic drugs must meet FDA specifications as equivalent and are usually less expensive. However, vehicle variations are permissible and may affect clinical efficacy.
IV.
HOW MUCH IS ENOUGH?
1 FTU (fingertip unit) dispenses 0.5 grams (will cover 2 closed hand areas) Trunk, single application (either front or back): 3 g Entire body, single application: 20-30 g to cover one arm, bid for 1 week: 42 grams to cover entire body, bid for 1 week: 400-800 grams
V. STEROIDS: TOPICAL AND SYSTEMIC
Case 2:
A 25 yo female presents with chronic complaints of dry, itchy skin on her inner elbows and backs of her
knees. The rash is worse with stress.

Diagnosis: ECZEMA

STEROIDS
Mechanisms of action of topical corticosteroids: reduction of capillary wall permeability Adverse effects: (incidence increased in pediatrics) HPA suppression from systemic absorption (med, high potency) Newer agents: Adequate anti-inflammatory effects with reduced adverse preparations for face, eyelids, axillae, groin No data to support use more frequently than qd Use occlusive therapy for inflamed, thickened skin TOPICAL STEROIDS*
Potency Agent
Strength
Super High
* This table contains selected topical steroids and is not exhaustive. # newer agents with lower atrophy and other adverse effects $ affordable agents (<$30 /30 g, generic) B. SYSTEMIC
STEROIDS
reduction of capillary wall permeability endocrine: suppression of hypothalamic-pituitary-adrenal axis striae, acne, rosacea, telangestasia, lanugo hyperlipidemia, inhibition of wound healing Relative: infection, pregnancy, DM, HTN, PUD, psychosis, renal Use once-daily therapy if appropriate, AM dose to reduce cortisol Treat for 1-3 weeks for most dermatologic conditions to prevent rebound VI. ANTI-INFECTIVE
ANTIBACTERIAL

Case 3:
An 18 year old male football player presents with redness and swelling of left forearm.
Diagnosis: METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)
A.
Invasive: Bacteremia, pneumonia, osteomyelitis, septic arthritis, Systemic Antibacterial agents commonly used to treat skin infections
Linezolid (IV, po, effective against MRSA) Topical antibacterial agents
Sodium sulfacetamide (Novacet, Sulfacet-R, etc.) Polymixin B (active against gram negative organisms, inc. Gentamicin (active against gram negative, Pseudomonas, strep, Combination agents (synergistic mechanism of action) Active against gram positive, gram negative, anaerobes, May cause skin discoloration (not used on face) ANTIVIRAL
Case 4:
A 21 year old woman presents with recurrent episodes of “cold sores” on lip, exacerbated during times of
stress or illness.
Diagnosis: Herpes simplex labialis

Systemic antiviral agents
HZV: 500 mg po tid (superior to acyclovir for reducing PHN and pain) HZV: 1 g po tid (superior to acyclovir for reducing PHN and pain) Topical antiviral agents
Acyclovir 5% (Zovirax) (Rx for initial herpes genitalis, herpes labialis) Vidarabine 3% ophth ointment (Vira – A) (Rx for herpes keratitis) trifluridine 1% ophth solution (Viroptic) (Rx for herpes keratitis) ANTIFUNGAL AGENTS: Systemic and topical agents
Polyenes: bind to fungal wall membrane, loss of membrane integrity
2. Azoles

a.
(sporanox): po or iv; does not cross blood-brain disturbances, hallucinations, rash, hepatic adverse effect profile (N/V, rash, hepatic 3. Echinocandins (inhibit cell wall synthesis)
Allylamines
Terbinafine
(Lamisil) : po or topical
Effective against dermatophytes, esp. onychomycosis 4 week treatment regimen for tinea capitis Griseofulvin: oral only
dermatophytes (e.g. Tinea capitis) (not yeast)
Table: Summary of Systemic Antifungal Drug Therapy

Infection Treatment Dose
Aspergillosis

Table: Summary of Topical Antifungal Drug Therapy

Infection Treatment
Dermatophytes Terbinafine
Yeasts Clotrimazole Econazole Miconazole 4. ANTIPARASITIC
pediculocide and scabicide; resistance developing in some areas Apply to entire body neck and below 8-14 hours, rinse Considered treatment of choice for pediculosis capitis 0.3% gel, 0.3% lotion, .33% mousse or shampoo Indicated for scabies failing topical therapy, strongyloidiasis, veterinary preparation only available in US 45-70% cure rate; some resistance developing Petrolatum, physostigmine ophthalmic ointment Effective for eyelashes pediculosis infestation OTHER THERAPEUTIC AGENTS
ANTIHISTAMINES
H1 antihistamines (indicated for acute urticaria, seasonal rhinitis, allergic diphenhydramine (po, cream, gel, lotion, spray) Drug of choice: dermatographism, cholinergic urticaria H2 antihistamines (indicated for peptic ulcer disease, or in combination B. ANTIPROLIFERATIVE
AND IMMUNOMODULATORY DRUGS

Case 5:
A 19 year old man presents with severe facial acne.

a.
increased turnover of follicular epithelium, interference of P. acnes ANALGESIC/ANTIPRURITIC AGENTS
SUNSCREENS
SPF: Dose of UVR required to produce one MED (minimal mg/cm2, divided by the UVR required to produce one MED on UVA blockers (meradimate, parsol 1789, etc.) 20-90 minutes, should be worn year-round. E. TOPICAL
ANESTHETICS
Eutectic mixture of local anesthetics (EMLA): lidocaine, prilocaine Lidocaine HCl (cream, gel, ointment, jelly, patch, solution, jelly)
VIII. COMPLEMENTARY AND ALTERNATIVE THERAPIES
Estimated over 600 million alternative medicine visits annually (exceeds 50% of the population uses some form of alternative medicine Many patients do not share this information with physicians Often used after failure of conventional therapies or seeking fewer side Efficacy: largely based on case reports and case series; Herbal Therapy: reports exist of success in treating: Adverse effects: hepatotoxicity, cardiotoxicity, respiratory distress, Aloe Vera: reports exist of success in treating: Capsaicin: reports exist of success in treating: Biofeedback (useful to diseases with ANS component) : Cognitive-behavioral therapy (useful in diseases with behavioral components) : Hypnotherapy: reports exist of success in treating: Homeopathy (high dilutions of drugs that induce symptoms): reports exist of success in treating:
CASE STUDIES IN DERMATOLOGIC THERAPEUTICS
1.
“ITCHY AND SCRATCHY”
A 25-year-old woman presents with itchy rash, after running through a field. Dermatologic or primary care follow-up within 48 hours
2. “RASH
DECISIONS”
A 35-year-old man presents with rash on his torso and arms. Dermatologic or primary care follow-up within 48 hours
3. “SEEING
A 45-year-old woman presents with target lesions on arms after taking sulfa antibiotics. “THE BIG TOP”
A 12-year-old boy presents with patchy hair loss, scalp inflammation and broken hairs. Dermatologic or primary care follow-up within 2 weeks “CHEAPER BY THE DOZEN”
A 21-year-old man presents with longstanding intermittent rash on back, arms, and legs. Clinical Features: chronic condition with sharply demarcated erythematous plaques with silvery scales on extensor surfaces Systemic therapies: steroids, retinoids, methotrexate “GROWING LIKE A WEED”
A 72-year-old man presents with scaling and irritation of his forehead and scalp. References

Abramovits W, Goldstein AM, Stevenson LC: Changing paradigms in dermatology: topical immunomodulators
within a permutational paradign for the treatment of atopic and eczematous dermatitis. Clin Dermatol 2003;
21:383-91.
Abramowitz M, ed: Antifungal drugs. Treatment Guidelines from The Medical Letter. 2005; 3:7-14.
Arndt KA, Hsu JTS: Manual of Dermatologic Therapeutics. 2007; Philadelphia: Lippincott Williams &
Wilkins.
Ashcrost DM, Dimmock P, Garside R et al: Efficacy and tolerability of topical pimecrolimus and tacrolimus
treatment of atopic dermatitis: meta-analysis of randomized controlled trials. BMJ 2005; 330:516.
Berger TG et al: The use of topical calcineurin inhibitors in dermatology: safety concerns. J Am Acad
Dermatol 2006; 818-23.
Brazzini B, Pimpinelli N: New and established topical corticosteroids in dermatology. Am J Clin Dermatol
2002; 3:47-58.
Del Rossa J, Friedlander SF: Corticosteroids: options in the era of steroid-sparing therapy. J Am Acad
Dermatol 2005; 53:S50-8.
Dourmishev AL et al: Ivermectin : pharmacology and application in dermatology. Int J Dermatology 2005;
44:981-8.
Drugs for non-HIV viral infections. The Medical Letter 2007; 5:59-70.
Fleischer AB, Jr., Feldman SR, McConnell CF et al: Emergency Dermatology: A Rapid Treatment Guide. New
York: The McGraw-Hill Companies, 2002.
Frazee BW, Lynn J, Charlebois ED et al: High prevalence of methicillin-resistant Staphylococcus aureus in
emergency department skin and soft tissue infections. Ann Emerg Med 2005; 45:311-20.
Fridkin SK, Hageman JC, Morrison M et al: Methicillin-resistant staphylococcus aureus disease in three
communities. N Engl J Med 2005; 352:1436-44.
Goldsmith LA, Bolognia JL, Callen JP et al: American Academy of Dermatology consensus conference on the
safe and optimal use of isotretinoin: summary and recommendations. Am Acad Dermatol 2004; 50:900-6.
Gupta AK, Chow M: Prednicarbate (Dermatop): profile of a corticosteroid. J Cutan Med Surg 2004; 244-247.
Hengge UR, Ruzicka T, Schwartz RA et al: Adverse effects of topical glucocorticosteroids. J Am Acad
Dermatol 2006; 54:1-15.
Huang X, Tanojo H, Lenn J: A novel foam vehicle for delivery of topical corticosteroids. J Am Acad Dermatol
2005: 53:S26-38.
Jackson S, Gilchrist H, Nesbitt LT: Update on the dermatologic use of systemic glucocorticosteroids. Derm
Therapy 2007; 20:187-205.
James WD: Acne. N Engl J Med 2005; 352:1463-72. Joly P, Fontaine J, Roujeau JC: The role of topical corticosteroids in bullous pemphigoid in the elderly. Drugs Aging 2005; 22:571-6. Katsambas AD, Stratigos AJ: Dermatologic therapy in the new millennium. Clinics Dermatol 2001; 19:65-67. Khumalo N, Kirtschig G, Middleton P et al: Interventions for bullous pemphigoid. Cochrane Database Syst Rev 2005; CD002292. Lebwohl M, Clark L, Levitt J: Therapy for head lice based on life cycle, resistance, and safety considerations. Pediatr 2007; 119:965-74. The Medical Letter: Imiquimod (Aldara) for actinic keratosis. The Medical Letter 2004; 46:42-43. The Medical Letter: Clobetasol Propionate Spray for psoriasis. The Medical Letter 2006; 48:27-29. Nakagawa H: Comparison of the efficacy and safety of 0.1% tacrolimus ointment with topical corticosteroids in adult patients with atopic dermatitis. Clin Drug Investig 2006; 26: 235-46. Nally JB, Berson DS: Topical therapies for rosacea. J Drugs Dermatol 2006; 5:23-6. Nestor MS et al: The use of photodynamic therapy in dermatology: results of a consensus conference. J Drugs Dermatol 2006; 5:140-54. Norris DA: Mechanisms of action of topical therapies and the rationale for combination therapy. J Am Acad Dermatol 2005: 53:S17-25. Pelle MT, Crawford GH, James WD: Rosacea : II. Therapy. J Am Acad Dermatol 2004; 51:499-512. Powell FC: Rosacea. N Engl J Med 2005; 352:793-803. Roeder A, Schaller M, Schafer-Korting M et al: Safety and efficacy of fluticasone propionate in the topical treatment of skin diseases. Skin Pharmacol Physiol 2005; 18:3-11. Ruzicka T: Methylprednisolone aceponate in eczema and other inflammatory skin disorders – a clinical update. Int J Clin Pract 2006; 60:85-92. Scheinfeld N: A comparison of available and investigational antibiotics for complicated skin infections and treatment resistant Staphylococcus aureus and enterococcus. J Drugs Dermatol 2007; 6:97-103. Schon MP, Boehncke WH: Psoriasis. N Engl J Med 2005; 352:1899-912. Skinner R: Role of topical therapies in the management of cutaneous disease. J Cutan Med Surg 2005; 22-31. Smith V, Sharpe G: Key developments in dermatology. The Practitioner 2005; 239:399-407. Stein L: Clinical studies of a new vehicle formulation for topical corticosteroids in the treatment of psoriasis. J Am Acad Dermatol 2005; 53:S39-49. Wiedersberg S et al: Bioavailability and bioequivalence of topical glucocorticoids. Eur J Pharm Biopharm 2008; 68:453-66. Wolverton SE: Comprehensive Dermatologic Drug Therapy. 2007; Elsevier Inc. Wong VK, Fuchs B, Lebwohl M: Overview on desonide 0.05%: a clinical safety profile. J Drugs Dermatol 2004; 3:393-7.

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