TOPICAL THERAPY IN
DERMATOLOGY
Treatment in dermatology
- is very specific, unlike in other medical specialties we intensively treat with
topical preparations and also have a wide array of possible treatment options
Drugs
• Topical
• Systemic
Dermatosurgery
Physical therapy
• phototherapy
• cryotherapy
• laser
• electrotherapy
Balneotherapy, thalassotherapy
POWDER
LIQUID
SUSPENSION
EMULSION
PASTE
TOPICAL THERAPY TRIANGLE
FAT/OIL
EXPLANATION
We have 3 basic substances: ointment bases (fat/oil), powders and liquid
substances. We can mix them and create different preparations.
Powder + liquid base = suspension
- we have to shake it, so the particles are dispersed evenly
Ointment + liquid base = emulsion
- creams (w/o – oleo cream, o/w – hydro (water) cream
- lotions
- emulsifiers help to keep the correct texture
Powder + ointment = paste
- powder makes at least 20% of the mixtur
TOPICAL THERAPY TRIANGLE
BASIC TREATMENT RULES
For the therapy to work, we must have the correct diagnosis, know the stage
of the disease and think of the particular body area we are going to treat.
1. First of all, we must have the correct diagnosis, for example:
Tinea incognita - when we use anti-inflammatory creams for infectious
diseases, the lesions fade a bit, but do not heal, they ignite rapidly again after
the treatment stops. We have to use antimycotics to treat it.
Eczema herpeticum – there is an endogenous immune disorder in patients with
eczema, microbes readily multiply there – e.g. Staphylococcus aureus, Herpes
simplex. Most often, when a person with eczema has herpes labialis, the virus
can be introduced from the viral lesion onto the eczematous skin, where the
virus spreads easily, thousands of new lesions can appear + also some systemic
symptoms such as raised temperature, lethargy arise - we must not use local
steroids!!!
2. Another criterion for successful therapy is to know the stage of the disease,for
example:
Acute eczema:
Exudes fluid, blisters form, we use a topical preparation that dries the lesions, we
must not close it with an ointment. We use solutions, foams, lotions, gels.
Subacute eczema:
Is dominated by inflammation and redness. We use hydrophilic creams and lotions
(gels and solutions would dry too much in this phase).
Chronic eczema:
is characterized by excoriations, hyperkeratosis, dryness. We use fatty ointments
generously. Patients with atopic dermatitis sometimes have to be treated every 2
hours if the dryness is too severe.
BASIC TREATMENT RULES
3. Lastly, we must think about the location of the skin problem:
Face: it is a photosensitive zone, do not apply photosensitizers (tetracycline paste,
retinoids - be careful, apply at night, SPF during the day is important).
Palms, soles: e.g. keratoderma, palmoplantar pustulosis. The skin is hard and thick, we
often find painful cracks and fissures, we use strong ointment bases.
Scalp: we use easily removable products - lotions, solutions, gels, foams, shampoos. To
remove scale deposits, we use ointments (classic lard works as well), which loosen the
scales, that can later be combed out. Be careful with staining preparation (tar
products) because they can change hair color (for example turn blonde hair into dark
or violet)
Intertriginous localization: there is increased friction, heat and occlusion. Beware of
substances that are readily absorbed under occlusion – e.g. strong corticoids can cause
stretch marks, increase the growth of microflora. In this area, we tend to use
preparations with an antimicrobial component.
BASIC TREATMENT RULES
TOPICAL THERAPY TYPES
ANTIBIOTICS
- most often, we use fusidic acid (brand names Fucidin, Fucicort, FucidinH)
- mupirocin (Bactroban)
- tetracycline, chloramphenicol (must be compounded)
- used for impetigo, bacterial superinfections…
- antibiotics can sensitize + lose their effectiveness, we use them sparingly and only
for a limited amount of time
VIROSTATICS
- Acyclovir - indicated for herpes simplex, not relevant for herpes zoster. It makes
sense for the first 24 hours, when it should be applied every 4 hours. For herpes
simplex, we rather use healing gels that calm the skin and prevent skin cracking.
NOTE: With all the before and after mentioned preparations, there are often outages in distribution, so there is little
value in learning company names of products, it often changes.
ANTIMYCOTICS
- fungal infections are very common - onychomycosis, interdigital mycosis, pityriasis
versicolor…
- there are many products available - clotrimazole for yeasts and G + microbes
(Canesten), ciclopirox-olamin (Batrafen), naftifin (Exoderil), terbinafin (Lamisil)….
ANTIPARASITICS
- Permethrin - for scabies, a relatively safe insecticide, not toxic to humans, can also
be used in children and pregnant women. Lindane (Scabicide) has been used in the
past and banned by the EU 10 years ago for toxicity.
- Sulfur ointment - for scabies, application for at least 5 days
- Dimethicone - suffocates lice
RETINOIDS - vitamin A derivatives – adapalene, tretinoin
- have keratolytic effect, normalize the keratinization process,
lower sebum production, stimulate immunity
- used for acne, psoriasis, ichthyosis, actinic keratosis….generally
said, conditions where excessive keratinization plays a role
- beware of their teratogenicity!!!, the use must be discontinued
when a woman gets pregnant or is actively trying to get pregnant
- they tend to dry out skin and make it more sensitive to sun, it is
generally better to apply them at night and wear high SPF on
treated areas during the day
DELTOIDS - vitamin D derivatives - tacalcitol, calcipotriol
- developed for the treatment of psoriasis
- they have anti-inflammatory effects like corticosteroids, but
they do not have their side effects, they act against atrophy
- therefore they are often combined with local steroids (Daivobet
gel)
- they can be overdosed – e.g. if a psoriatic patient uses too many
tubes per week on large areas of the body
IMMUNOMODULATORS
Imiquimod (Aldara)
- modulator of the immune response at the site of application, increases the
production of cytokines and activates T-lymphocyte, it has antiviral and
antitumor effect
- condyloma acuminata (HPV infection) responds well to this treatment, but
there is a strong local reaction – exudation and redness
- can be used for skin tumors - actinic keratoses, basal cell carcinomas - for
example, after an surgical incomplete excision in difficult localities - face,
around the nose
Ingenol-Mebutat (Picato)
- used until recently for actinic keratoses, but he European drug commission
has banned it for an increased incidence of squamous cell carcinoma
CYTOSTATICS
Podophyllotoxin
- derived from plants, useful for viral warts, in paste form for mycosis fungoides, a
significant inflammatory reaction occurs after application, the lesions hurt, ooz
liquid, peel, the patient needs to be warned about it, it is a standard reaction
Fluorouracil
- used for actinic keratoses, not available here, available in Austria
EMOLLIENTS
Emollients are externally applied substances that help to restore and maintain the
epidermal barrier. They are commonly referred to as moisturizers; their name is
derived from the Latin emollire, to soften. They lubricate and hydrate the skin.
ANTISEPTICS
- we prefer them to antibiotics, because resistance to them rarely develops
- povidone iodine - beware of iodine allergy, always ask the patient before
application!!!
- chlorhexidine, hypermanganese solution (light pink color is desirable - 1 grain per
bath, higher concentrations stain and burn), polyhexanide (Prontosan), octenidine
(Octenisept), bleach (sodium hypochlorite)
ASTRIGENTS
They generally cause constriction or contraction of tissues, therefore reduce discharge.
Externally applied astringents cause mild coagulation of skin proteins, dry, harden and
protect the skin, they can relieve minor skin irritations – cuts, insect bites and fungal
infections such as athlete’s foot.
- black tea - tannin has astringent effects
- Burrow's solution (aluminum triacetate) – insect bites, poison ivy rash…
- witch hazel - for oily skin and acne
KERATOLYTICS
- urea (15-20% concentration is keratoplastic, 40% keratolytic - for nails)
- salicylic acid (1, 2, 5% max.)
COAL TAR
- has excellent anti-inflammatory and antiproliferative effects - excellent for psoriasis
- but has a series of side effects – it’s phototoxic and carcinogenic with prolonged use
ANTIMICROBIAL SUBSTANCES
- chloroxine (Endiaron), often added to corticoids
IMMUNOSUPRESSANTS – tacrolimus (Protopic), pimecrolimus (Elidel)
- similar to cyclosporine, they are calcineurin inhibitors, used for severe atopic
dermatitis
- advantage: they do not cause skin atrophy
- disadvantage: danger of superinfection, herpes, higher risk of cancer in the future increased
possibility of systemic lymphomas and local tumors – spinalioma
CORTICOSTEROIDS
…. mentioned later in the lecture
• solutions, baths (in healing oils), wet dressings
• tinctures - contain alcohol, dry and cool the skin
• shampoos - for psoriasis, seborrheic dermatitis
• sprays - for larger areas, in between fingers for mycoses
• powders - for intertriginous areas, when we powder an applied cream (e.g. with
zinc oxide) one application a day is enough
• lotions- into a box
• gels – less accessible, not many on the market – e.g. Heparoid, Lioton gel (antiinflammatory,
local heparin)
• pastes - ointment saturated with powder
• oils - great for taking off pastes - patients often try to scrape them from the skin,
which causes further damage to the skin
• fatty ointments, creams
TOPICAL TREATMENT FORMULATIOS
OTHER:
- antiperspirants, depilatory creams
- protective UV factors
1) mineral filters - inert, usually create a white cast on the skin, suitable for children
2) chemical filters - often sensitize
- depigmenting agents, camouflage preparations, antifungal nail polishes
Worms - used in wound healing
to eliminate necrotic coating
OTHER:
Special cotton overalls made for
small atopic children so that they
do not scratch.
External wound dressing - silicone grids
Healing mud from the Dead Sea
- anti-inflammatory effect
- vasoconstrictive effect - disappears over
time – tachyphylaxis
- antiedematous effect - excellent for acute
allergic reactions
- antiproliferative effect - psoriasis, bullous
diseases...
- itch reduction
- anti-scarring effect – intralesional
application into keloids
LOCAL CORTICOSTEROIDS
According to their strength, we divide them into 4 classes:
I. mild – hydrocortisone acetate (Hydrocortison, Pimafucort )
II. moderate – triamcinolone acetonide (Triamcinolon-E)
III. potent – hydrocortisone butyrate (Locoid), momethasone furoate (Elocom),
methylprednisolone aceponate (Advantan), betamethasone dipropionate
(Beloderm)
IV. very potent - clobetasol propionate (Dermovate)
According to chemical structure:
- non-halogenated (hydrocortisone)
- halogenated (dexamethasone, betamethasone)
- contain a halogen atom (chlorine, fluorine), enhance the efficacy of
corticosteroids but often increase side effects, such as skin atrophy, adrenal
suppression, and telangiectasia
- they should not be used on the face – risk o perioral dermatitis
SIDE EFFECTS:
- tachyphylaxis - sudden decrease in response to a
drug after its administration
- rebound phenomenon – occurs when a therapy
with a strong corticoid is abruptly stopped, we
must discontinue the use gradually by
lengthening the application intervals (e.g. from
once a day to 3 times a week) or switching to
weaker corticoids
- atrophy, stretch marks
- slower wound healing
- when vasoconstriction is depleted, telangiectasia
is formed
- hypertrichosis
- perioral rosacea like dermatitis
- immunosuppression
THANK YOU FOR YOUR
ATTENTION :)