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

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

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  • 1. Medical Therapy in Dermatology 5 th year Lecture 1 By Dr Faraedon Kaftan Consultant Dermatologist College of Medicine University of Sulaimani 2011
  • 2.
    • Medical 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
  • 3.
    • 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
  • 4.
    • The dermatological consultation
    • 2 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
  • 5.
    • 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
  • 6.
    • Patients consult dermatologists because they:
    • 1. want help with their skin problems
    • 2. require information
    • 3. require medical treatment
    • 4. 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.
  • 7.
    • 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
  • 8.
    • Side effects: especially should be considered in
    • 1. Elderly: they are taking drugs prescribed, OTC (by hands) & herbal medicine
    • 2. New drugs
    • 3. If major SEs are not explained
    • 4. Pregnancy
    • 5. Lactation
    • 6. Children & Neonates: because of immature renal and liver function
    • 7. 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 1 st -pass metabolism may lead to toxic drug levels
    • - Reduced (↓) protein binding may lead to increased bioavailability & SEs
  • 9.
    • 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
  • 10.
    • Avoidance of aggravating factors:
    • Temperature
    • Humidity
    • Appropriate clothing:
    • should not be too constricting, too hot or too harsh
    • Irritants 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 concentrations
    • Advice to stop scratching & give treatment to stop itching
  • 11.
    • 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
  • 12.
    • 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 treatments
    • B. Formulation of skin topical treatment
    • C. Topical treatments (Drugs) used in the
    • management of skin disease
  • 13.
    • 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/g
    • B. 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)
  • 14.
    • 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 skin
    • 2. Wet medications (lotions or creams) in moist or exudative skin eruptions
    • 3. Occlusive Ointments in dry skin lesions
    • 4. Shampoos, lotions, gels or mousses in hair-bearing skin
    • 5. Cosmetic properties of the vehicle when treating the face:
    • Lotions in oily skin in acne
    • Emollient cream in rosacea
  • 15.
    • Vehicles are:
    • A. Cream
    • B. Gel
    • C. Lotion
    • D. Ointment
    • E. Paste
    • F. Powders
    • G. Paints
    • H. Collodions
    • I. Microspoges
    • J. Liposomes
  • 16.
    • 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)
  • 17.
    • 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.
  • 18. Fingertip unit (FTU): applied to the terminal phalynx of the index finger
  • 19.
    • 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
  • 20.
    • 6. Hazards associated with topical treatments:
    • - Irritant reactions
    • - Allergic reactions
    • - Systemic SEs (rare)
  • 21. 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
  • 22. Constituents of vehicles
    • 1. Lipids:
    • 2. Emulsifiers:
    • 3. Humectants:
    • 4. Penetration enhancers:
    • 5. Preservaties:
    • 6. Solvents:
  • 23. C. Topical treatments used in the management of 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  
  • 24.
    • 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
  • 25.
    • 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.
  • 26.
    • 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.
  • 27.
    • 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)
  • 28.
    • 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)
  • 29.  
  • 30.
    • 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%
  • 31.
    • SEs of topical steroids
    • I. 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
  • 32.
    • SEs of Topical Cs Potencies:
  • 33.
    • * 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!)
  • 34.
    • Dermovate (Clobetasol propionate) or Dermodin should never be used on the following areas:
    • 1. Face
    • 2. Axillae
    • 3. Groin
  • 35.
    • Skin thinning
  • 36.
    • Stretch marks
  • 37.
    • Bruising
  • 38.
    • Prominent capillaries
  • 39.
    • POD
  • 40.
    • 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:
  • 41.
    • 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 :
  • 42.
    • 16. Sunscreens :
    • 17. Tars : wood tars, shale tars, coal tar
    • Topical Coal tar: Presumed anti-inflammatory and anti-proliferative effects. 1. Eczema 2. Psoriasis
    • 18. 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, menthol
    • 20. Miscellaneous agents : capsaicin, minoxidil, nicotinamide
  • 43.
    • III- Systemic Therapy
    • is for more serious condition & infections
    • Indications:
    • 1. Systemic Cs therapy: Prednisolone: for:
    • 1. Bullous disorders, 2. CT disease, 3. vasculitis
    • 2. Sex hormones & related compounds: Systemic Antiandrogens: Cyproterone: for: Acne (only in ♀s)
    • 3. Systemic Antihistamines H1Blockers: for: 1. Eczema, 2. Urticaria
    • & other antiallergic drugs :
  • 44.
    • 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
  • 45.
    • 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
  • 46.
    • 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:
  • 47.
    • 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 medicine
    • 23. Transdermal delivery system:
  • 48.
    • 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.
  • 49.
    • Photochemotherapy (PUVA)
    • UVA is used in combination with photosensitizing psoralens given topically or systemically. 
    • PUVA stand for P soralens plus U ltra V iolet 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. 
  • 50.
    • 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.
  • 51.
    • V- Radiotherapy & reactions to ionizing radiation
    • VI- Physical therapies
    • 1. Cryosurgery
    • 2. Curettage: Benign lesions & Non-melanoma skin cancer
    • 3. Electrosurgery: a. electrocautery b. electrosurgery
    • c. electrolysis
    • 4. Infrared coagulation
    • 5. Caustics
    • 6. Chemical peeling
    • 7. Intralesional therapy: IL Triamcinolone
    • 8. Sclerotherapy
    • 9. Miscellaneous physical therapy:
    • a. Keloid therapy b. Minor surgical procedures c. haemostasis
    • 10. Soft-tissue augmentation &
    • Facial line correction
  • 52.
    • VII- Laser therapies: Laser (Light Amplification by Stimulated Emission of Radiation) (Next lecture)
    • VIII- Dermatological Surgical procedures
    • Basic Dermatological Surgical procedures are:
    • Excisional Biopsy
    • Incisional Biopsy
    • Punch Biopsy
    • Shave Biopsy
    • Curettage
    • Cautery
    • Cryotherapy
    • Mohs’ Surgery
    • Dermabrasion