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Medical Therapy in  Dermatology  5 th  year Lecture 1 By Dr Faraedon Kaftan Consultant Dermatologist College of Medicine U...
<ul><li>Medical therapy in Dermatology   </li></ul><ul><li>consists of: </li></ul><ul><li>I-  General aspects of treatment...
<ul><li>I. General aspects of treatment </li></ul><ul><li>General principles :  </li></ul><ul><li>Same as for other branch...
<ul><li>The dermatological consultation </li></ul><ul><li>2 types of dermatologists: </li></ul><ul><li>1. Dermatologists w...
<ul><li>The  depressed patient  has a (droop), slow in responses to questions  </li></ul><ul><li>The anxious patient  is m...
<ul><li>Patients consult dermatologists because they: </li></ul><ul><li>1. want help with their skin problems </li></ul><u...
<ul><li>Body image, self-esteem & leper complex: </li></ul><ul><li>Body image is largely cutaneous </li></ul><ul><li>Skin ...
<ul><li>Side effects:  especially should be considered in </li></ul><ul><li>1. Elderly: they are taking drugs prescribed, ...
<ul><li>Therapy:  General management </li></ul><ul><li>Explanation: </li></ul><ul><li>1. Chronicity or irreversible change...
<ul><li>Avoidance of aggravating factors: </li></ul><ul><li>Temperature </li></ul><ul><li>Humidity </li></ul><ul><li>Appro...
<ul><li>II-   Topical  Therapy  </li></ul><ul><li>is quite attractive & of advantage  because of:    </li></ul><ul><li>1. ...
<ul><li>Topical  Therapy  </li></ul><ul><li>A. Prescribing topical treatment: </li></ul><ul><li>1. Drug concentration:  </...
<ul><li>1. Drug concentration: 3 ways: </li></ul><ul><li>A. %: 1%  = 1 gm of drug in 100 g of the formulation e.g.: </li><...
<ul><li>2. Choice of vehicle:  </li></ul><ul><li>Topical medication must be applied to the skin in a suitable vehicle (act...
<ul><li>Vehicles  are:  </li></ul><ul><li>A. Cream  </li></ul><ul><li>B. Gel  </li></ul><ul><li>C. Lotion </li></ul><ul><l...
<ul><li>3. Frequency of application: </li></ul><ul><li>Active preparations  applied once or twice/day  </li></ul><ul><li>E...
<ul><li>4. Quantity to be pplied: </li></ul><ul><li>A useful guide is the fingertip unit (FTU) which equals ½ g.   </li></...
Fingertip unit (FTU): applied to the terminal phalynx of the index finger
<ul><li>5. Advice to patients: Explain: </li></ul><ul><li>-  Timing  of the application: After bathing in many cases e.g. ...
<ul><li>6. Hazards associated   with topical treatments: </li></ul><ul><li>- Irritant reactions </li></ul><ul><li>- Allerg...
B. Formulation of skin topical treatment <ul><li>Vehicle </li></ul><ul><li>must provide rapid delivery of the drug to the ...
Constituents of vehicles <ul><li>1. Lipids:   </li></ul><ul><li>2. Emulsifiers:   </li></ul><ul><li>3. Humectants:   </li>...
C. Topical treatments used in the management of skin disease <ul><li>1. Antiperspirants:  </li></ul><ul><li>2. Antibiotics...
<ul><li>3. Antifungal agents:  allylamines, imidazoles, morpholines, polyenes, ciclopirox olamine, tolnaftate, undecylenic...
<ul><li>6. Astringents: Topical Antiseptics   :  KMNO4, aluminium acetate, silver nitrate </li></ul><ul><li>For Skin sepsi...
<ul><li>Topical steroids </li></ul><ul><li>Have revolutionized the practice of dermatology since they were introduced in t...
<ul><li>Topical Cs Potencies: </li></ul><ul><li>1. Mild (Low) potency :  </li></ul><ul><li>e.g.: HC:   Hydrocortisone 0.5-...
<ul><li>3. High potency: e.g.:   (Betnosam)  </li></ul><ul><li>(I50-100 times as potent as HC)  </li></ul><ul><li>Betameth...
 
<ul><li>Skin absorption of topical steroids </li></ul><ul><li>Steroids are absorbed at different rates from different part...
<ul><li>SEs of topical steroids </li></ul><ul><li>I. Local Skin SEs: </li></ul><ul><li>1. Skin thinning (atrophy)  </li></...
<ul><li>SEs of Topical Cs Potencies: </li></ul>
<ul><li>*  The risk of these SEs depends on the </li></ul><ul><li>1. Strength of the steroid  </li></ul><ul><li>2. Length ...
<ul><li>Dermovate (Clobetasol propionate) or Dermodin  should never be used on the following areas: </li></ul><ul><li>1. F...
<ul><li>Skin thinning   </li></ul>
<ul><li>Stretch marks   </li></ul>
<ul><li>Bruising  </li></ul>
<ul><li>Prominent capillaries   </li></ul>
<ul><li>POD </li></ul>
<ul><li>8. Cytotoxic & antineoplastic agents:  bleomycin, 5-Fluorouracil, T4 endonuclease, mechlorethamine, imiquimod, dic...
<ul><li>11. Dithranol: Topical Dithranol:  Anti-proliferative for Psoriasis </li></ul><ul><li>12. Emollients: </li></ul><u...
<ul><li>16. Sunscreens : </li></ul><ul><li>17. Tars : wood tars, shale tars, coal tar </li></ul><ul><li>Topical Coal tar: ...
<ul><li>III-  Systemic   Therapy  </li></ul><ul><li>is for more serious condition & infections </li></ul><ul><li>Indicatio...
<ul><li>4. Systemic NSAI therapy: </li></ul><ul><li>5. Cytokines: </li></ul><ul><li>6. Interferons: </li></ul><ul><li>7. I...
<ul><li>10.  B.  Systemic Cytotoxics:   </li></ul><ul><li>a. Alkylating agents </li></ul><ul><li>b. Antimetabolites </li><...
<ul><li>11. PUVA: </li></ul><ul><li>12. Photopheresis: </li></ul><ul><li>13. Plasmapheresis: </li></ul><ul><li>14. Intrave...
<ul><li>22. Miscellaneous drugs: (used in special ways in dermatology) </li></ul><ul><li>A.  Antimalarials   Hydroxychloro...
<ul><li>IV-  Phototherapy  & Photochemotherapy </li></ul><ul><li>Phototherapy   Sunlight helps certain skin conditions, bo...
<ul><li>Photochemotherapy (PUVA) </li></ul><ul><li>UVA  is used in combination with photosensitizing  psoralens  given top...
<ul><li>PUVA  can be combined with acitretin (RePUVA) but not methotrexate.  </li></ul><ul><li>Bath PUVA , bath containing...
<ul><li>V-  Radiotherapy   & reactions to ionizing radiation </li></ul><ul><li>VI-  Physical therapies </li></ul><ul><li>1...
<ul><li>VII-  Laser therapies:  Laser (Light Amplification by Stimulated Emission of Radiation)  (Next lecture) </li></ul>...
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Dermatology 5th year, 1st lecture (Dr. Faraedon Kaftan)

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The lecture has been given on Feb. 27th, 2011 by Dr. Faraedon Kaftan.

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Transcript of "Dermatology 5th year, 1st lecture (Dr. Faraedon Kaftan)"

  1. 1. Medical Therapy in Dermatology 5 th year Lecture 1 By Dr Faraedon Kaftan Consultant Dermatologist College of Medicine University of Sulaimani 2011
  2. 2. <ul><li>Medical therapy in Dermatology </li></ul><ul><li>consists of: </li></ul><ul><li>I- General aspects of treatment </li></ul><ul><li>II- Topical Therapy </li></ul><ul><li>III- Systemic Therapy </li></ul><ul><li>IV- Phototherapy </li></ul><ul><li>V- Radiotherapy & reactions to ionizing radiation </li></ul><ul><li>VI- Physical therapies </li></ul><ul><li>VII- Laser therapies </li></ul><ul><li>VIII- Dermatological Surgical procedures </li></ul>
  3. 3. <ul><li>I. General aspects of treatment </li></ul><ul><li>General principles : </li></ul><ul><li>Same as for other branches in medicine in addition to particular topical therapy . </li></ul><ul><li>During history taking: many patients say they have had no treatment (only few ointments) </li></ul><ul><li>Patients may be unaware of the potential harm that can be done by topical therapy (self-administrated or iatrogenic) </li></ul><ul><li>Instruction on how to use any remedy is much more important than in other branches of medicine </li></ul><ul><li>Dermatologists are always available but Dermatologists still have to persuade many patients that no specific treatment is available for their problem </li></ul><ul><li>Consultation is central dermatological aspect which demands great skill in communication techniques thus Improving Dr.- patient communication is necessary </li></ul>
  4. 4. <ul><li>The dermatological consultation </li></ul><ul><li>2 types of dermatologists: </li></ul><ul><li>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 </li></ul><ul><li>2. Dermatologists who like to see their patients dressed: </li></ul><ul><li>the patient’s dress provides </li></ul><ul><li>a. Psychosocial information </li></ul><ul><li>b. The gait of the patient into consulting room gives useful information </li></ul>
  5. 5. <ul><li>The depressed patient has a (droop), slow in responses to questions </li></ul><ul><li>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 </li></ul><ul><li>The language of description: burning sensation in photosensitivity eruptions as porphyria </li></ul><ul><li>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 </li></ul><ul><li>In dermatitis artefacta ; taking good history is necessary </li></ul><ul><li>Little matchboxes & plastic bags containing detritus are very characteristic of patient with delusions of parasitosis </li></ul>
  6. 6. <ul><li>Patients consult dermatologists because they: </li></ul><ul><li>1. want help with their skin problems </li></ul><ul><li>2. require information </li></ul><ul><li>3. require medical treatment </li></ul><ul><li>4. require explanation </li></ul><ul><li>5. require understanding and emotional support </li></ul><ul><li>Patients need to know the answers to 3 basic questions: 1. why me? 2. why now? </li></ul><ul><li>3. why this particular disease? </li></ul><ul><li>The patients values a doctor who listens </li></ul><ul><li>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. </li></ul>
  7. 7. <ul><li>Body image, self-esteem & leper complex: </li></ul><ul><li>Body image is largely cutaneous </li></ul><ul><li>Skin disease affecting any part of the body surface may produce depression in body image, self-esteem, confidence & 2ndary depression </li></ul><ul><li>Sites: scalp, hair, face, hands and genital area </li></ul><ul><li>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 </li></ul>
  8. 8. <ul><li>Side effects: especially should be considered in </li></ul><ul><li>1. Elderly: they are taking drugs prescribed, OTC (by hands) & herbal medicine </li></ul><ul><li>2. New drugs </li></ul><ul><li>3. If major SEs are not explained </li></ul><ul><li>4. Pregnancy </li></ul><ul><li>5. Lactation </li></ul><ul><li>6. Children & Neonates: because of immature renal and liver function </li></ul><ul><li>7. Poor renal function leads to the accumulation of drug & metabolite(s) in the body increasing the risk of SEs </li></ul><ul><li>8. In liver disease: </li></ul><ul><li>- The reduction (↓) in 1 st -pass metabolism may lead to toxic drug levels </li></ul><ul><li>- Reduced (↓) protein binding may lead to increased bioavailability & SEs </li></ul>
  9. 9. <ul><li>Therapy: General management </li></ul><ul><li>Explanation: </li></ul><ul><li>1. Chronicity or irreversible changes </li></ul><ul><li>2. In autoimmune diseases or atopic dermatitis: it is Not easy to explain the etiology </li></ul><ul><li>3. patient’s questions should be answered </li></ul><ul><li>4. In CD or Urticaria: one should listen to patient’s Explanation </li></ul><ul><li>5. The patient’s memory of drug or topical medicaments given is usually defective, especially if self-administered </li></ul>
  10. 10. <ul><li>Avoidance of aggravating factors: </li></ul><ul><li>Temperature </li></ul><ul><li>Humidity </li></ul><ul><li>Appropriate clothing: </li></ul><ul><li>should not be too constricting, too hot or too harsh </li></ul><ul><li>Irritants should be avoided </li></ul><ul><li>Sensitizers should be avoided </li></ul><ul><li>Man patients believe that skin disease is a manifestation of dirt or germs to be removed with vigour or exorcized with soap and water </li></ul><ul><li>Germicides in inappropriate concentrations </li></ul><ul><li>Advice to stop scratching & give treatment to stop itching </li></ul>
  11. 11. <ul><li>II- Topical Therapy </li></ul><ul><li>is quite attractive & of advantage because of:   </li></ul><ul><li>1. direct delivery and </li></ul><ul><li>2. reduced systemic toxicity </li></ul><ul><li>There is a vehicle which contains an active ingredient </li></ul>
  12. 12. <ul><li>Topical Therapy </li></ul><ul><li>A. Prescribing topical treatment: </li></ul><ul><li>1. Drug concentration: </li></ul><ul><li>2. Choice of vehicle: </li></ul><ul><li>3. Frequency of application: </li></ul><ul><li>4. Quantity to be pplied: </li></ul><ul><li>5. Advice to patients: </li></ul><ul><li>6. Hazards associated with topical treatments </li></ul><ul><li>B. Formulation of skin topical treatment </li></ul><ul><li>C. Topical treatments (Drugs) used in the </li></ul><ul><li>management of skin disease </li></ul>
  13. 13. <ul><li>1. Drug concentration: 3 ways: </li></ul><ul><li>A. %: 1% = 1 gm of drug in 100 g of the formulation e.g.: </li></ul><ul><li>- 60% Salicylic acid ointment in plantar warts or </li></ul><ul><li>corns </li></ul><ul><li>- 0.003% calcitriol in psoriasis= 3 µ/g </li></ul><ul><li>B. For liquid preparations: </li></ul><ul><li>- 1% solution contains 1 g of drug in 100 ml of </li></ul><ul><li>the formulation: </li></ul><ul><li>- w/w= (weight in weight) </li></ul><ul><li>- w/v= (weight in volume) </li></ul><ul><li>C. Solution in parts: </li></ul><ul><li>- 1 part in 1000 KMNO4 contains 1 g in 1 L of </li></ul><ul><li>solution = 0.1% (w/v) </li></ul>
  14. 14. <ul><li>2. Choice of vehicle: </li></ul><ul><li>Topical medication must be applied to the skin in a suitable vehicle (active agent in the formulation) </li></ul><ul><li>The choice of vehicle depends on: </li></ul><ul><li>1. The anatomical site to be treated </li></ul><ul><li>2. The condition of the skin </li></ul><ul><li>Rules: </li></ul><ul><li>1. Bland preparations (least likely to irritate) in acutely inflamed skin </li></ul><ul><li>2. Wet medications (lotions or creams) in moist or exudative skin eruptions </li></ul><ul><li>3. Occlusive Ointments in dry skin lesions </li></ul><ul><li>4. Shampoos, lotions, gels or mousses in hair-bearing skin </li></ul><ul><li>5. Cosmetic properties of the vehicle when treating the face: </li></ul><ul><li>Lotions in oily skin in acne </li></ul><ul><li>Emollient cream in rosacea </li></ul>
  15. 15. <ul><li>Vehicles are: </li></ul><ul><li>A. Cream </li></ul><ul><li>B. Gel </li></ul><ul><li>C. Lotion </li></ul><ul><li>D. Ointment </li></ul><ul><li>E. Paste </li></ul><ul><li>F. Powders </li></ul><ul><li>G. Paints </li></ul><ul><li>H. Collodions </li></ul><ul><li>I. Microspoges </li></ul><ul><li>J. Liposomes </li></ul>
  16. 16. <ul><li>3. Frequency of application: </li></ul><ul><li>Active preparations applied once or twice/day </li></ul><ul><li>Excessive frequency of application: causes </li></ul><ul><li>- SEs </li></ul><ul><li>- Unnecessary systemic exposure to the drug </li></ul><ul><li>Emollients should be applied frequently enough to maintain their physical effect (several applications daily) </li></ul>
  17. 17. <ul><li>4. Quantity to be pplied: </li></ul><ul><li>A useful guide is the fingertip unit (FTU) which equals ½ g.  </li></ul><ul><li>One FTU is the amount of topical agent that can be applied to the terminal phalynx of the index finger. </li></ul><ul><li>The whole body requires 20-30 g of ointment/single dose  </li></ul><ul><li>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 </li></ul><ul><li>Emollients </li></ul><ul><li>are useful in dry-skin disorders due to their ability to re-establish the surface lipid layer and enhancing rehydration of the epidermis.  </li></ul><ul><li>There are several emollient ointments, creams and oils added to baths. </li></ul>
  18. 18. Fingertip unit (FTU): applied to the terminal phalynx of the index finger
  19. 19. <ul><li>5. Advice to patients: Explain: </li></ul><ul><li>- Timing of the application: After bathing in many cases e.g. scabies </li></ul><ul><li>- Irritation: tretinoin, 5-FU </li></ul><ul><li>- Occlusion , bandaging or other dressing </li></ul><ul><li>* Occlusion increases the level of penetration of a drug into the skin </li></ul><ul><li>* Polythene gloves on the hands </li></ul><ul><li>* Clingfilm on the feet or limbs </li></ul><ul><li>* Self-adhesive hydrocolloid dressings on the limbs or trunk </li></ul><ul><li>* Wet wrap bandaging in Rx of AD </li></ul><ul><li>* Paste bandages to ↑ penetration & prevent scratching </li></ul>
  20. 20. <ul><li>6. Hazards associated with topical treatments: </li></ul><ul><li>- Irritant reactions </li></ul><ul><li>- Allergic reactions </li></ul><ul><li>- Systemic SEs (rare) </li></ul>
  21. 21. B. Formulation of skin topical treatment <ul><li>Vehicle </li></ul><ul><li>must provide rapid delivery of the drug to the SC & into the viable layers of the skin </li></ul><ul><li>Must be soothing </li></ul><ul><li>Comfortable to use </li></ul><ul><li>Cosmetically acceptable </li></ul><ul><li>Must provide a chemical environment in which the drug remains sufficiently stable prior to use to have a practical shelf life </li></ul>
  22. 22. Constituents of vehicles <ul><li>1. Lipids: </li></ul><ul><li>2. Emulsifiers: </li></ul><ul><li>3. Humectants: </li></ul><ul><li>4. Penetration enhancers: </li></ul><ul><li>5. Preservaties: </li></ul><ul><li>6. Solvents: </li></ul>
  23. 23. C. Topical treatments used in the management of skin disease <ul><li>1. Antiperspirants: </li></ul><ul><li>2. Antibiotics: Bacitracin, clindamycin, erythromycin, fusidic acid, gentamycin sulphate, Metronidazole, mupirocin, neomycin & framycetin, polymixin B, silver sulfadiazine, tetracyclines </li></ul><ul><li>Resistance and sensitization are potential problems. </li></ul><ul><li>Topical Metronidazole is used for 1. rosacea </li></ul><ul><li>2. Acne 3. folliculitis 4. impetigo 5. infected eczema   </li></ul>
  24. 24. <ul><li>3. Antifungal agents: allylamines, imidazoles, morpholines, polyenes, ciclopirox olamine, tolnaftate, undecylenic acid, other antifungal agents </li></ul><ul><li>For fungal infection of the skin & Candidiasis </li></ul><ul><li>4. Antiparasitic agents: Topical Parasiticidals : pyrethroids, malathion, Permethrin, Benzyl benzoate, Lindane. for Scabies & pediculosis </li></ul><ul><li>5. Antiviral agents: acyclovir & penciclovir, idoxuridine </li></ul><ul><li>For HS & HZ </li></ul>
  25. 25. <ul><li>6. Astringents: Topical Antiseptics : KMNO4, aluminium acetate, silver nitrate </li></ul><ul><li>For Skin sepsis & leg ulcers </li></ul><ul><li>7. Topical Corticosteroids (Cs) : </li></ul><ul><li>Anti-inflammatory, anti-proliferative, vasoconstrictive; different strengths available. For: 1. Eczema 2. DLE 3. LP </li></ul><ul><li>3. lichen sclerosus, 4. mycosis fungoides, </li></ul><ul><li>5. photodermatoses, 6. pityriasis rosea, </li></ul><ul><li>7. psoriasis. </li></ul>
  26. 26. <ul><li>Topical steroids </li></ul><ul><li>Have revolutionized the practice of dermatology since they were introduced in the late 1950s. </li></ul><ul><li>are associated with potential (SEs) especially if they are used incorrectly. </li></ul><ul><li>are 4 groups according to their strength. </li></ul><ul><li>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. </li></ul>
  27. 27. <ul><li>Topical Cs Potencies: </li></ul><ul><li>1. Mild (Low) potency : </li></ul><ul><li>e.g.: HC: Hydrocortisone 0.5-2.5% (Cream/Ointment) </li></ul><ul><li>2. Moderate (Mid) potency: e.g.: (Cream/Ointment) </li></ul><ul><li>(2-25 times as potent as HC) </li></ul><ul><li>Clobetasone butyrate (Eumovate Cream) </li></ul><ul><li>Triamcinolone acetonide (Aristocort Cream/Ointment, Viaderm Cream/Ointment, Kenacomb Ointment) </li></ul>
  28. 28. <ul><li>3. High potency: e.g.: (Betnosam) </li></ul><ul><li>(I50-100 times as potent as HC) </li></ul><ul><li>Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Daivobet 50/500 Ointment, Fucicort) </li></ul><ul><li>Betamethasone dipropionate (Diprosone Cream/Ointment) </li></ul><ul><li>Diflucortolone valerate (Nerisone C/Cream/Fatty Ointment/Ointment) </li></ul><ul><li>Hydrocortisone 17-butyrate (Locoid C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion) </li></ul><ul><li>Mometasone furoate (Elocon Cream/Lotion/Ointment) </li></ul><ul><li>Methylprednisolone aceponate (Advantan Cream/Ointment) </li></ul><ul><li>4. Super High potency: e.g.: Clobetasol (Dermovate) Cream/Ointment </li></ul><ul><li>(up to 600 times as potent as HC) </li></ul><ul><li>Betamethasone dipropionate (Diprosone) Cream/Ointment) </li></ul>
  29. 30. <ul><li>Skin absorption of topical steroids </li></ul><ul><li>Steroids are absorbed at different rates from different parts of the body. </li></ul><ul><li>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: </li></ul><ul><li>Eyelids and genitals absorb 30% </li></ul><ul><li>Face absorbs 7% </li></ul><ul><li>Armpit absorbs 4% </li></ul><ul><li>Forearm absorbs 1% </li></ul><ul><li>Palm absorbs 0.1% </li></ul><ul><li>Sole absorbs 0.05% </li></ul>
  30. 31. <ul><li>SEs of topical steroids </li></ul><ul><li>I. Local Skin SEs: </li></ul><ul><li>1. Skin thinning (atrophy) </li></ul><ul><li>2. Striae: stretch marks </li></ul><ul><li>3. Easy bruising and tearing of the skin. </li></ul><ul><li>4. Perioral dermatitis: POD (rash around the mouth) </li></ul><ul><li>5. Telangiectasia: Enlarged blood vessels </li></ul><ul><li>6. Susceptibility to skin infections. </li></ul><ul><li>7. Tinea incognito: Disguising infection </li></ul><ul><li>8. Acneform eruption: No comedones </li></ul><ul><li>9. Allergy to the steroid cream. </li></ul><ul><li>II. Internal SEs </li></ul><ul><li>Adrenal gland suppression </li></ul><ul><li>Cushing's syndrome </li></ul>
  31. 32. <ul><li>SEs of Topical Cs Potencies: </li></ul>
  32. 33. <ul><li>* The risk of these SEs depends on the </li></ul><ul><li>1. Strength of the steroid </li></ul><ul><li>2. Length of application </li></ul><ul><li>3. Site treated </li></ul><ul><li>4. Nature of the skin problem. </li></ul><ul><li>* If you use a potent steroid cream on your face as a moisturiser, you will develop the SEs within a few weeks. </li></ul><ul><li>* 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!) </li></ul>
  33. 34. <ul><li>Dermovate (Clobetasol propionate) or Dermodin should never be used on the following areas: </li></ul><ul><li>1. Face </li></ul><ul><li>2. Axillae </li></ul><ul><li>3. Groin </li></ul>
  34. 35. <ul><li>Skin thinning </li></ul>
  35. 36. <ul><li>Stretch marks </li></ul>
  36. 37. <ul><li>Bruising </li></ul>
  37. 38. <ul><li>Prominent capillaries </li></ul>
  38. 39. <ul><li>POD </li></ul>
  39. 40. <ul><li>8. Cytotoxic & antineoplastic agents: bleomycin, 5-Fluorouracil, T4 endonuclease, mechlorethamine, imiquimod, diclofenac, podophyllin & podophyllotoxin </li></ul><ul><li>9. Depigmenting agents: Hydroquinone, Monobenzyl ether of Hydroquinone, additional phenol derivatives, retinoic acid, Kligman cream, azelaic acid, Kojic acid, liquiritin </li></ul><ul><li>10. Depilatories: </li></ul>
  40. 41. <ul><li>11. Dithranol: Topical Dithranol: Anti-proliferative for Psoriasis </li></ul><ul><li>12. Emollients: </li></ul><ul><li>13. Immunomodulators : (syn. Calcineurin inhibitors): Tacrolimus (Talimus), pimecrolimus, ciclosporin (cyclosporin) </li></ul><ul><li>14. Retinoids : Retinol (syn. Vitamin A), Retinoic acid, adapalene, bexarotene, tazarotene </li></ul><ul><li>Topical Keratolytics: 1. benzoyl peroxide & tretinoin for Acne, 2. Salicylic acid for scaly eczemas and warts </li></ul><ul><li>15. Sensitizing agents : </li></ul>
  41. 42. <ul><li>16. Sunscreens : </li></ul><ul><li>17. Tars : wood tars, shale tars, coal tar </li></ul><ul><li>Topical Coal tar: Presumed anti-inflammatory and anti-proliferative effects. 1. Eczema 2. Psoriasis </li></ul><ul><li>18. Vitamin D analogues : (deltanoids, secosteroids): </li></ul><ul><li>Tacalcitol (1,24 dihydroxycholecalciferol), calcipotriol, (calcipotriene,MC 903), Maxacalcitol (22-oxa-calcitriol) </li></ul><ul><li>Topical Vitamin D analogues: Inhibit keratinocyte proliferation and promote differentiation. for Psoriasis. </li></ul><ul><li>19. Traditional remedies : camphor, dyes, menthol </li></ul><ul><li>20. Miscellaneous agents : capsaicin, minoxidil, nicotinamide </li></ul>
  42. 43. <ul><li>III- Systemic Therapy </li></ul><ul><li>is for more serious condition & infections </li></ul><ul><li>Indications: </li></ul><ul><li>1. Systemic Cs therapy: Prednisolone: for: </li></ul><ul><li>1. Bullous disorders, 2. CT disease, 3. vasculitis </li></ul><ul><li>2. Sex hormones & related compounds: Systemic Antiandrogens: Cyproterone: for: Acne (only in ♀s) </li></ul><ul><li>3. Systemic Antihistamines H1Blockers: for: 1. Eczema, 2. Urticaria </li></ul><ul><li>& other antiallergic drugs : </li></ul>
  43. 44. <ul><li>4. Systemic NSAI therapy: </li></ul><ul><li>5. Cytokines: </li></ul><ul><li>6. Interferons: </li></ul><ul><li>7. ILs: Interleukinns: </li></ul><ul><li>8. Essential fatty acid: </li></ul><ul><li>9. Systemic Retinoids: Acitretin, Isotretinoin: (13-cis retinoic acid: Retane), for: </li></ul><ul><li>A. Keratinization disorders B. Acne </li></ul><ul><li>10. A. Systemic Immunosuppressants: Cyclosporin, Gold: for: 1. Psoriasis 2. Atopic eczema 3. Bullous disorders 4. LE </li></ul>
  44. 45. <ul><li>10. B. Systemic Cytotoxics: </li></ul><ul><li>a. Alkylating agents </li></ul><ul><li>b. Antimetabolites </li></ul><ul><li>c. Ciclosporin (Cyclosporin): </li></ul><ul><li>d. Fumaric acid esters (fumarates) </li></ul><ul><li>Methotrexate , Hydroxyurea, Azathioprine: for: </li></ul><ul><li>1. Psoriasis , </li></ul><ul><li>2. Sarcoidosis, </li></ul><ul><li>3. Bullous disorders, </li></ul><ul><li>4. Chronic actinic (solar) dermatitis </li></ul><ul><li>Methotrexate : 3 tab./week, each tab=2.5 mg </li></ul><ul><li>Total dose of MTX should not exceed 1 gm in the </li></ul><ul><li>patient’s life </li></ul>
  45. 46. <ul><li>11. PUVA: </li></ul><ul><li>12. Photopheresis: </li></ul><ul><li>13. Plasmapheresis: </li></ul><ul><li>14. Intravenous Igs: </li></ul><ul><li>15. Gold (Na thiomalate) </li></ul><ul><li>16. Chelating agents: </li></ul><ul><li>17. Systemic Antibiotics & Antibacterial </li></ul><ul><li>agents : for: 1. Acne, 2. rosacea, 3. skin sepsis </li></ul><ul><li>18 Systemic Antifungals : Griseofulvin, Ketoconazole, Itraconazole, Terbinafine </li></ul><ul><li>19. Systemic Antivirals: Acyclovir, Famciclovir: for: 1. HS, 2. HZ </li></ul><ul><li>20. Antiparasitic agents: </li></ul><ul><li>21. Drugs to improve peripheral circulation: </li></ul>
  46. 47. <ul><li>22. Miscellaneous drugs: (used in special ways in dermatology) </li></ul><ul><li>A. Antimalarials Hydroxychloroquine: </li></ul><ul><li>for: 1. LE, 2. PCT </li></ul><ul><li>B. Systemic Antileprotic Dapsone: for: 1. DH, 2. </li></ul><ul><li>leprosy, 3. vasculitis </li></ul><ul><li>& Sulfapyridine </li></ul><ul><li>C. Clofazimine </li></ul><ul><li>D. Sulfasalazine </li></ul><ul><li>E. Thalidomide </li></ul><ul><li>F. Colchicine </li></ul><ul><li>G. Traditional chinese herbal medicine </li></ul><ul><li>23. Transdermal delivery system: </li></ul>
  47. 48. <ul><li>IV- Phototherapy & Photochemotherapy </li></ul><ul><li>Phototherapy Sunlight helps certain skin conditions, both UVB and UVA are employed. </li></ul><ul><li>Ultraviolet B </li></ul><ul><li>UVB (290-320 nm) is given 3 times a week.  </li></ul><ul><li>The initial dose is determined from the patients skin type or minimal erythema dose (MED).  </li></ul><ul><li>With each visit, the scheduled dosage is increased.  </li></ul><ul><li>Commonly, 10-30 treatments are the normal course. </li></ul><ul><li>UVB can be used in children and pregnant women.  </li></ul><ul><li>Used in psoriasis, mycosis fungoides, atopic eczema, and pityriasis rosea.  </li></ul><ul><li>Side effects include acute sunburn and increase risk of skin cancer. </li></ul><ul><li>A rotating mechanical head wounds the skin down to the dermis. </li></ul>
  48. 49. <ul><li>Photochemotherapy (PUVA) </li></ul><ul><li>UVA is used in combination with photosensitizing psoralens given topically or systemically.  </li></ul><ul><li>PUVA stand for P soralens plus U ltra V iolet A .  </li></ul><ul><li>Commonly, oral 8-methoxypsoralens is taken 2 hours before UVA (320-400 nm).  </li></ul><ul><li>MOA: photoactivated psoralens results in DNA cross-linking , inhibition of cell division , and suppression of cell-mediated immunity .  </li></ul><ul><li>Like UVB, the initial dose of UVA is determined by MED or skin type; and dosage is increased a scheduled visits.  </li></ul><ul><li>PUVA is usually given 2-3 times per week for 15-25 treatments.  </li></ul>
  49. 50. <ul><li>PUVA can be combined with acitretin (RePUVA) but not methotrexate. </li></ul><ul><li>Bath PUVA , bath containing a psoralen, is an alternative to systemic-side effects of oral psoralens.  </li></ul><ul><li>Local PUVA , topical psoralen, may be effective in psoriasis and dermatitis involving the hands or feet.  </li></ul><ul><li>Indications of PUVA : psoriasis, vitiligo, mycosis fungoides, atopic eczema or polymorphic light eruption   </li></ul><ul><li>SEs: </li></ul><ul><li>Acute SEs: pruritus , nausea , & erythema </li></ul><ul><li>long-term SEs: premature skin ageing and skin cancer (depend on the number and total dose of UVA)  </li></ul><ul><li>Cataracts are possible and UVA-opaque sunglasses must be worn for 24 hours after taking psoralen. </li></ul>
  50. 51. <ul><li>V- Radiotherapy & reactions to ionizing radiation </li></ul><ul><li>VI- Physical therapies </li></ul><ul><li>1. Cryosurgery </li></ul><ul><li>2. Curettage: Benign lesions & Non-melanoma skin cancer </li></ul><ul><li>3. Electrosurgery: a. electrocautery b. electrosurgery </li></ul><ul><li>c. electrolysis </li></ul><ul><li>4. Infrared coagulation </li></ul><ul><li>5. Caustics </li></ul><ul><li>6. Chemical peeling </li></ul><ul><li>7. Intralesional therapy: IL Triamcinolone </li></ul><ul><li>8. Sclerotherapy </li></ul><ul><li>9. Miscellaneous physical therapy: </li></ul><ul><li>a. Keloid therapy b. Minor surgical procedures c. haemostasis </li></ul><ul><li>10. Soft-tissue augmentation & </li></ul><ul><li>Facial line correction </li></ul>
  51. 52. <ul><li>VII- Laser therapies: Laser (Light Amplification by Stimulated Emission of Radiation) (Next lecture) </li></ul><ul><li>VIII- Dermatological Surgical procedures </li></ul><ul><li>Basic Dermatological Surgical procedures are: </li></ul><ul><li>Excisional Biopsy </li></ul><ul><li>Incisional Biopsy </li></ul><ul><li>Punch Biopsy </li></ul><ul><li>Shave Biopsy </li></ul><ul><li>Curettage </li></ul><ul><li>Cautery </li></ul><ul><li>Cryotherapy </li></ul><ul><li>Mohs’ Surgery </li></ul><ul><li>Dermabrasion </li></ul>
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