Dermatology – TopicaL Therapy and Topical Corticosteroids – Flashcards
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restore normal skin function after an insult removes water, lipids, or protein from epidermis this alters integrity of skin barrier and compromises function restoration accomplished thru use of mild soaps, emollient creams and lotions Classically explained: "IF IT IS DRY, WET IT..IF IT IS WET, DRY IT"
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Purpose of Topical Therapy:
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Have lost water In most instances, have *lost epidermal lipids and proteins which help contain moisture* Corrected by replacing moisture with emollient creams and lotions
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Dry skin or dry cutaneous lesions
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Worse in dry winter months ("Winter itch") MC affects hands and lower legs Skin is rough, covered w/fine white scales, progresses to thicker tan or brown scales Severe: crisscrossed & fissured Itching (severe) or burning sensation *Txt: Emollients, 12% lactate lotion (Lac-Hydrin, AmLactin)*
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Severe Dry Skin (Xerosis)
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Emollients, 12% lactate lotion (Lac-Hydrin, AmLactin)
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Xerosis Txt
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Exudative inflammatory diseases pour out serum Leaches complex lipids and proteins from epidermis Managed with Wet Compresses -Suppresses inflammation -Debrides crust and serum -Repeated cycles of wetting and drying eventually dry the lesion -*Excessive use OVERDRIES causing severe drying and chapping* -Once wet phase is controlled, restore lipids and proteins with emollient creams and lotions - discontinue wet dressings!
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Topical Therapy - Wet Diseases
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Restore water & lipids to epidermis Added Urea (Carmol, Vanamide) and Lactic Acid (Lac-Hydrin, AmLactin) have special lubricating properties -very effective *Creams are thicker and more lubricating than lotions* Most effective when applied to *damp skin* After shower or bath, pat dry & immediately apply moisturizer Apply as frequently as necessary to keep skin soft Menthol and phenol can be added to reduce pruritus
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Topical Therapy - Emollient Creams & Lotions
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Poison ivy Bullous impetigo Eczematous skin with secondary infx Herpes simplex/zoster Insect bites Intertrigo Nummular eczema Stasis dermatitis/ulcers Sunburn (blistering) Tinea pedis—vesicular
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Topical Therapy - Wet Dressings Valuable aid in txt of exudative skin diseases
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Inflammation suppression - evaporative cooling = constriction of superficial vessels which decreases erythema and production of serum *Controls acute inflammatory processes faster than corticosteroids (topical or oral)* Wound debridement - macerates vesicle and crusts Drying effect Antibacterial action -- by adding aluminum acetate, acetic acid, or silver nitrate
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Topical Therapy - Wet Dressings Benefits
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Tap water doesn't need to be sterilized Poison ivy, sunburn, noninfected exudative process
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Topical Therapy - Wet Dressings Water
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Dissolve 1-3 packets in 16 oz water Mildly antiseptic; for acute inflammation, poison ivy, insect bites, athlete's foot
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Topical Therapy - Wet Dressings Burow's sol'n (aluminum acetate)
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Aqueous solution Stains skin Bactericidal; for exudative infected lesions (stasis ulcers/dermatitis)
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Topical Therapy - Wet Dressings Silver nitrate 0.5%
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Dilute vinegar (5%) Bactericidal: for some gram neg (pseudomonas)
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Topical Therapy - Wet Dressings Acetic acid (1-2.5%)
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Use 4-8 layers of clean, soft material (folded) Wet folded dressing in solution -Wring out until sopping wet Place on affected area *Leave in place 30-60 min* *Use 2-4x per day* Discontinue use when skin becomes dry What would be a sign of this?
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Topical Therapy - Wet Dressings Technique
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Accurate diagnosis Proper strength Best vehicle Sufficient quantity Appropriate treatment duration Follow-up
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Topical Corticosteroid Therapy Keys to appropriate use
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Anti-inflammatory effect Vasoconstriction Anti-mitotic Decreased proliferation of cells
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Topical Corticosteroid Therapy Effects of topical steroids
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Triamcinolone was talked about the most Know one or two from each category
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Know strength of topical corticosteroids by class Some are in multiple classes because of concentration
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Groups I (strongest)- VII (weakest) Learn at least one from each group
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Topical Steroids - Strength Potency
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(limited # of org. compounds, primarily grease with little/no water) Typically preservative free Translucent w/ greasy feeling on skin *Most lipophilic, moisturizing, and occlusive.* *Greater penetration -> increased potency* *Too occlusive for acute (exudative) eczematous inflammation or intertriginous areas*
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Ointments
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(mix of propylene glycol & water, sometimes alcohol) Greaseless, clear, jelly-like consistency Useful for acute exudative inflammation Poison ivy *Useful in scalp* does not mat the hair
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Gels
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thick scale lichenification thicker skin areas (soles and palms)
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Topical Steroid Therapy--Barriers Increased barrier (decreases absorption)
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abrasion cracking fissuring atrophy keratolytic agents propylene glycol increase potency - can irritate already inflamed skin
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Topical Steroid Therapy--Barriers Decreased barrier (increases absorption)
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Choosing the right strength Nice Table in Habif (2-2) *Best results when right strength + right duration* *No response in 1-4 weeks - reevaluate!*
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Topical Steroids - Strength
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(aka base) the substance in which the active ingredient is dispersed & determines rate of absorption Creams Ointments Gels Solutions & Lotions Foams Some bases may cause irritation/allergy
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Vehicle -
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(mix of organic chemicals/oils, water & preservative) White color & slight greasy texture May cause irritation, stinging, allergy High versatility (use almost anywhere) Cosmetically acceptable Drying effect with long use -*best for acute exudative inflammation* *Most useful for intertriginous areas groin, rectal and axillary*
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Topical Steroids - Vehicle Cream
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(mix of water, etoh, & other chemicals) Clear or milky Least lipophilic can be very drying Solutions (alcohol) and lotions (water) *Most useful in scalp - penetrate easily through hair, leaves no residue* *Stinging and drying may result when applied to intertriginous areas*
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Solutions & Lotions
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Useful for *scalp dermatoses* Useful in areas of acute eczematous inflammation -*poison ivy and plaque psoriasis* High Potency Preparations (Olux - Clobetasol propionate - super potent) *Do Not Use > 2 weeks* Suppression of Hypothalamic-Pituitary-Adrenal (HPA) Axis *Do not use if age < 12 yrs*
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Foams
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Waterproof cover enhances absorption Unavoidable natural occlusion -axilla, inguinal folds, redundant skin folds (obesity) and diaper area Minimize side effects by choosing right agent *Occlusion can increase a steroid's potency by 100x* Remember: *Even hydrocortisone under diaper can cause adrenal suppression in an infant*
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Topical Steroid Therapy--Occlusion
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Stretches intracellular connections, increases absorption 4-5x Steroid application after bathing increases absorption Moist wraps over steroid and under occlusion added affect
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Topical Steroid Therapy Hydration
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Thin stratum corneum and increased blood flow increase absorption Face/Eyelids Decreased absorption due to thicker stratum corneum Soles/Palms
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Topical Steroid Therapy Regional Differences
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Burning and itching *Hypopigmentation* *Atrophy* Easy bruising Striae Hypertrichosis (face) Steroid acne/folliculitis Steroid rosacea Dryness of skin - creams, lotions Worsening infection Rebound phenomenon
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Topical Steroid Therapy Side-effects Local
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Preservative Coloring Steroid itself - commonly presents as chronic dermatitis that is not exacerbated by, but "fails to respond to", corticosteroid therapy Produces a nonspecific, self-supporting eczematous condition Occasionally exanthem, purpura or urticaria *If suspected need to skin test (patch testing)*
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Topical Steroids Local Effects--allergy Contact allergy to:
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Adrenal axis suppression -children ;2 -teens in active puberty Cushing Syndrome -unmonitored chronic use of high potency steroid or occlusion -Use of mid potency in large areas Failure to thrive Stunted growth Cataracts Glaucoma (if used near eyes)
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Topical Steroids Side effects --systemic
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Intralesional (typically triamcinolone) -inject lesion, not surrounding skin -dilute available strength to appropriate strengths IM -long lasting -easier than topical and oral -suppression less than oral, but can't stop the medications if it happens -local atrophy at site
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Other methods to give steroids
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needle is too short
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IM corticosteroids can cause local atrophy especially if
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Diabetes - Topicals can elevate blood sugar Pregnancy -Avoid in first trimester -Use only when benefits out weight the risks Cost
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Topical Steroid Therapy (Other considerations)
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#1 = Steroid too weak for process and area Not enough medication given -Tube size Failure to follow up on treatment -right diagnosis -refills for flares Too strong used on kids Too strong used on face
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Topical Steroid Therapy 5 most common mistakes
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Finger tip units (FTU) - 5mm diameter nozzle 1 FTU = 0.5gm "Rule Of Hand" - 0.5 FTU = one hand area or 0.25gm of ointment
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HOW MUCH DO I USE?!?
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No more than 45-60 grams of Group I agent per week Apply Group I agents QD-BID...pulse therapy (2 wks on, then 1 week off) Apply Group II - VI agents BID x 2-6 wks
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Topical Steroid Therapy Dosing In General...
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Tinea Incognito
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What results when you treat Tinea Cruris inappropriately with topical steroids?
