Medications in Dermatology
Corticosteroids
- Potency: Ointment >creams- occlusive nature of an ointment enhances absorption of the corticosteroid.
- Creams
- more preservatives and excipients than ointments, and so are more likely to cause hypersensitivity or irritation.
- A cream base may be used for an acute weeping rash.
- gel or lotion
- hair-bearing areas
- Stubborn dermatoses
- benefit from occlusion, such as plastic wrap, occlusive dressings or gloves, applied overnight with appropriate securing in place.
- absorption
- greatest at thin skin of eyelids, genitals and skin creases: use a mild corticosteroid.
- least at thick skin of palms and soles: use apotent corticosteroid.
- the limbs and trunk: moderately potent corticosteroid
- For Candida infection
- (e.g. secondary infection of irritant napkin dermatitis)
- mix 1% hydrocortisone in equal quantities with an antifungal preparation such as nystatin.
| Generic name | Formulation |
| Group I Mild | |
| Desonide 0.5% | Lotion |
| Hydrocortisone 0.5%, 1% | Cream, ointment |
| Group II Moderately potent | |
| Betamethasone valerate 0.02% | Cream |
| Betamethasone valerate 0.05% | Cream, ointment |
| Clobetasone butyrate 0.05% | Cream |
| Triamcinolone acetonide 0.02%, 0.05% | Cream, ointment |
| Group III Potent | |
| Betamethasone valerate 0.1% | Cream, ointment |
| Betamethasone dipropionate 0.05% | Cream, ointment, lotion |
| Methylprednisolone aceponate 0.1% | Cream, ointment, fatty ointment, lotion |
| Mometasone furoate 0.1% | Cream, ointment, lotion, hydrogel |
| Group IV Very potent | |
| Betamethasone dipropionate 0.05% (in optimised vehicle) | Cream, ointment |
| Clobetasol propionate 0.05% | Cream*, ointment*, lotion*, shampoo |
Overall, the choice of potency will largely be guided by the following factors:
- patient: age (infant, child or adult) and lesion location
- lesion: type and severity of lesion (as described in Table 2)
- topical medication: molecular structure, percentage and formulation/vehicle
- method of application: occlusive dressing increases potency with better efficacy and effect, and wet dressing intensifies the effect by improved permeability of topical medication.
| Common skin conditions treatable with topical corticosteroid (TCS) agents | |
| Mild (low) potency TCS | Dermatitis (face, eyelids, napkin area)IntertrigoPerianal inflammation |
| Mild-to-moderate potency TCS | Atopic dermatitisAsteatotic eczemaContact dermatitisDry nummular eczemaPerianal inflammation (severe)Intertrigo (short term)Scabies (after scabicide)Seborrhoeic dermatitis |
| Moderate-to-potent/ultrapotent TCS | Atopic dermatitis (severe)Alopecia areataContact dermatitis (severe)Eczema of hyperkeratotic, exudative nummular, hand and feetGranulomatous skin disorders – Granuloma annulare, Necrobiosis lipoidica, and sarcoidosisLupus erythematosusLichen – simplex chronicus, planus and sclerosusPemphigus and pemphigoidPsoriasisStasis dermatitisVitiligo |
Topical corticosteroid application
- advice of applying TCS agents ‘sparsely’ is no longer applicable
- instead, ‘liberally’ is encouraged.
- Type
- ointment : is preferred for dry, scaly and mucocutaneous lesions
- (eg on the lips and genitals)
- Cream: wet/oozing lesions
- liquid (solution, lotion) for hairy areas (eg scalp), where cream or ointment is unable to reach the areas of affected skin
- ointment : is preferred for dry, scaly and mucocutaneous lesions
- moisturisers/emollients
- It is highly recommended to use adjunct moisturisers/emollients following application of TCS agents to affected areas.
- The moisturiser can be applied locally or to the whole body to ease pruritus and irritation by maintaining optimum skin moisture.
- The moisture alone is also useful as a steroid-sparing agent in trivial dermatitis.
- Diluting the topical steroid with moisturiser does not change the potency of the medicine.
- Timing
- Application is usually encouraged in the evening/night after bathing to avoid incidental removal of the medication as a result of day-to-day activities.
- In terms of frequency, a once-daily regimen is generally recommended for better compliance.
- Twice-daily application may be considered for the initial week(s) for certain severe lesions, reducing to daily or alternate-day application depending on the response.
- occlusive dressing
- An occlusive dressing with appropriate cover, such as a tubular bandage or plastic wrap, is favourable for severe and thick/keratotic/lichenified lesions.
- Occlusion with a non-irritant glove or sock can also be used for lesions of the hand or foot, respectively.
- duration
- The duration of treatment depends on the type and intensity of the lesion
- Amount
- The required dose (amount) is guided by location and extent of the lesion.
- The fingertip unit (FTU) is a useful general guide for the amount of topical agent
- A child aged six years with face and neck involvement requires 2 FTU (1 g) daily, and a 15 g tube of topical corticosteroid (TCS) would last two weeks.
- An adult with one leg and foot involvement requires 8 FTU (4 g) daily, and two tubes of 15 g TCS or one tube of 30 g would last one week.
- General Rule that
- 30 g
- – will cover the adult body once
- – will cover hands twice daily for 2 weeks
- – will cover a patchy rash twice daily for 1 week
- that 200 g will cover a quite severe rash twice daily for 2 weeks
- 30 g
Adverse effects
- Topical steroids have
- anti-inflammatory effects
- immunosuppressive effects
- antiproliferative effects
- Adverse effects
- skin thinning (atrophy)
- stretch marks (striae) in armpits or groin area
- enlarged or broken capillaries (telangiectasia)
- easy bruising and tearing of the skin
- localised increased hair thickness and length (hypertrichosis)
- acne-like changes
- colour change of the skin
- periorificial dermatitis
- steroid rosacea
- pustular psoriasis
- contact dermatitis
- pigment alteration
- Red Skin syndrome
- ‘topical corticosteroid withdrawal’
- rare adverse reaction resulting from inappropriate topical corticosteroid use in some conditions (eg periorificial dermatitis, rosacea, some psoriasis conditions) and when treating certain areas of the body (eg genital area).
- can also be associated with an exacerbation of the original skin condition
- Symptoms include
- papulopustular rashes
- red burning skin
- hypothalamic–pituitary–adrenal axis suppression is extremely rare, Nevertheless, it is necessary to be mindful of systemic absorption
- iatrogenic Cushing’s syndrome
- growth retardation
- cataract
- glaucoma
- susceptible individuals :
- young children and elderly patients with thin skin, higher-potency TCS agents
- Adverse events are generally reversible by cessation of medication
- methylprednisolone aceponate and mometasone furoate are associated with lesser local and systemic adverse effects than older formulations of TCS because of their lipophilic structure and pharmacokinetics.
- Mild-to-moderate-potency steroids and short-term use of potent topical steroids are safe in pregnancy and lactation according to a systematic review
Keratolytic agents
- are acids that disrupt the adhesions between the keratinocytes thus causing shedding of these layers.
- used for exfoliative procedures/ keratolytic peels
- used in acne, roughness and mild dyspigmentation
- Clinical results take time and repeated treatments to become apparent.
- ex:
- Urea
- Salicylic acid
- range from 0.5% up to 30%
- Salicylic acid 2-3% _ Betamethasone 0.05% (Diprosalic®) = Psoriasis, Hyperkeratotic eczema
- Salicylic acid 15-27% (Duofilm®) = Viral warts, Corns
- Salicylic acid 2%, Coal tar solution 12%, Sulphur 4% (Coco-Scalp) = Seborrhoeic dermatitis Dandruff, Scalp psoriasis
- Salicylic acid 0.5% oil-free acne wash (Neutrogena®) = Acne
- Lactic acid
- Fruit acids (alpha hydroxy acids)
- Propylene glycol
- Jessner’s solution – 14% each of resorcinol, salicylic acid, and lactic acid, mixed in ethanol.
side effects
- Moderate or severe skin irritation (particularly if not present before use of this medicine)
- Flushing
- warm skin and reddening of skin.
- True allergy to topical salicylic acid is rare, however serious reactions including anaphylaxis have been reported.
Precautions
- do not use any of the following preparations on the affected area
- Alcohol containing preparations
- Any other medicated topical agents, e.g. benzoyl peroxide, topical retinoids, calcipotriol
- Abrasive soaps and cleansers
- Cosmetics or soaps that dry the skin or are designed to peel/exfoliate
Coal tar
- It appears to have antimicrobial, antipruritic (reduce itching) and keratoplastic (normalise keratin growth in the skin and reduce scaling) effects.
- used for treat the scaling, itching and inflammation of
- Scalp psoriasis
- Palmoplantar pustulosis
- Plaque psoriasis
- Atopic dermatitis
- Products:
- Coconut Oil Compound Ointment (Coco-Scalp™) for scalp psoriasis
- Egopsoryl TA Gel™ to apply to psoriasis plaques
- Polytar Emollient and Liquid for bathing
- Shampoos such as Polytar™, Sebitar™, Ionil T™ and Fongitar™
- The use of coal tar is declining as newer compounds effective against the different forms of psoriasis are replacing it.
- However, it still has the advantages of being low cost and causing less systemic toxicity as compared with more modern therapies.
- general tips for using coal tar products.
- Apply it at bedtime if possible to avoid the daytime inconvenience of the smell and staining
- Leave on skin for at least 2 hours unless otherwise directed by your doctor
- If treating the scalp, apply with a downward stroke in the same direction as hair growth
- Cover or wrap with bandages to help the preparation stay in place and prevent staining. Do not use plastic wrap as this may cause irritation and infection
- Do not apply to infected, blistered, raw or oozing areas of the skin
- After applying coal tar preparations, protect the treated area from direct sunlight and do not use a sunlamp unless otherwise directed by your doctor.
Vitamin A
is also called retinol. Natural and synthetic compounds derived from retinol are known as retinoids and include:
- First generation
- Isotretinoin, Retinol, Retinal, Tretinoin, Alitretinoin are modifications of natural retinoids which do not act selectively
- Second generation
- Acitretin is an oral retinoid in which a benzene ring is replaced by a cyclohexane ring
- Third generation
- Adapalene, tazarotene, and bexarotene are polyaromatic retinoids with selective activity for the retinoid receptors
- Fourth generation
- Trifarotene is highly specific for the skin retinoid (RAR-γ) receptor
Topical retinoids
- Types and uses
- adapalene, isotretinoin, tretinoin, trifarotene
- Mild – moderate Acne vulgaris and its complications
- Applied to the face once daily at bedtime
- effective first-line treatment for comedonal and inflammatory acne
- not recommended as monotherapy for severe acne (pustules,deep nodules, cysts)
- It may take 12 weeks or longer before improvement is seen.
- useful to treat post-inflammatory hyperpigmentation as they inhibit melanosome transfer and facilitate melanin dispersal.
- They are particularly recommended for the treatment of acne in skin of colour.
- Photodamage and photoageing
- If used longterm (>6 months) topical tretinoin can reduce freckling, solar lentigines, fine wrinkling, solar comedones, sun-induced skin fragility, and actinic keratoses
- Melasma
- active ingredient in skin bleaching cream to treat melasma.
- Darier disease
- Mild – moderate Acne vulgaris and its complications
- Alitretinoin
- Kaposi sarcoma
- Bexarotene
- Cutaneous T-cell lymphoma
- Tazarotene
- Facial acne
- Postinflammatory hyperpigmentation in dark skin
- Chronic plaque psoriasis
- Photodamage
- adapalene, isotretinoin, tretinoin, trifarotene
- Contraindications
- Hypersensitivity or allergy to retinoids or excipients
- Some topical retinoids are contraindicated for use in pregnancy
- Precautions
- Topical retinoids can make eczema worse because of their drying effect – (erythema, peeling, dry skin)
- Topical retinoids can cause photosensitivity
- women of childbearing age must use effective contraception due to the teratogenic effects of retinoids.
- not recommended for use by young children
- Not suitable to treat large areas of the body such as extensive acne over the back or chest
- Can be irritating if applied close to the eyes or lips. Adapalene is the least irritating topical retinoid, and tretinoin the most
Oral retinoids
- Acitretin
- Alitretinoin
- Bexarotene (a rexinoid)
- Isotretinoin
- Vitamin A (retinol)
In acne, isotretinoin:
- Reduces sebum production
- Shrinks the sebaceous glands
- Reduces follicular occlusion
- Inhibits the growth of bacteria
- Has anti-inflammatory properties.
Used for:
- for the treatment
- acne
- severe follicular conditions
- Rosacea. Seborrhoea, hidradenitis suppurativa, scalp folliculitis.
- acute promyelocytic leukaemia
- severe psoriasis (pustular psoriasis, erythrodermic psoriasis, and palmoplantar psoriasis) palmoplantar keratoderma
- pityriasis rubra pilaris
- Darier disease
- lichen planus
- lichen
- cutaneous lupus erythematosus.
Acne dose: Isotretinoin
- 0.1 to over 1 mg/kg body weight OR lower dosages, unrelated to body weight (eg, 10 mg/day)
- side effects of isotretinoin are dose dependent; at 1 mg/kg/day, nearly all patients will have some side effects, whereas, at 0.1 mg/kg/day, most patients will not
- Some patients may only need a small dose once or twice a week
- treatment may be completed in a few months or continue for several years.
- courses have often been restricted to 16–30 weeks (4–7 months) to minimise the risk of teratogenicity
Adverse effects
- teratogenicity (category X)
- malformations include craniofacial, central nervous system, cardiovascular, and thymic
- Blood donation by males and females on isotretinoin is not allowed in case the blood is used for a pregnant woman.
- Mucocutaneous effects:
- cheilitis, dryness of the oral mucosa, epistaxis, xerophthalmia, xerosis, fingertip fissuring, hair loss, nail fragility, periungual granuloma, paronychia
- Musculoskeletal effects:
- myalgia, arthralgia, bone pain, premature fusion of the epiphyses, skeletal hyperostosis, calcification of tendons and ligaments
- Neurological effects:
- headaches, raised intracranial pressure
- Ophthalmologic effects:
- nyctalopia (loss of night vision)
- Gastrointestinal/metabolic effects:
- nausea, abdominal pain, diarrhoea, elevated liver enzymes and lipids (triglycerides and cholesterol).
- Psychiatric effects:
- depression, irritability/aggression, suicidality, and sleep disturbances. Retinoid-associated depression and suicidality are debatable due to the lack of valid/scientific study
- Commercial pilots may be subject to flying restrictions if they take isotretinoin
- High dose isotretinoin in very young children has been associated with
- premature epiphyseal closure, leading to shorter stature (this is not seen in the low dose used for the treatment of acne)
Calcipotriol
- Calcipotriol is a vitamin-D derivative
- 1% as powerful as the natural hormone calcitriol (also known as 1,25 dihydroxycholecalciferol).
- Calcipotriol is also available in combination with betamethasone propionate as a
- gel or ointment (Daivobet)
- foam (Enstilar).
- used for
- used mainly for psoriasis
- moderately or very effective for about 80% of patients
- patches become less scaly and thick, but red patches often persist despite continued treatment.
- Plaques of severe psoriasis before and after six weeks use of calcipotriol ointment:
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- Also used in
- Morphoea
- Palmoplantar pustulosis
- Ichthyosis
- Palmoplantar keratoderma
- Grover disease
- Disseminated superficial porokeratosis and linear porokeratosis
- Benign familial pemphigus
- Pityriasis rubra pilaris
- Acanthosis nigricans
- Epidermal naevus.