Dermatological pharmacology for the boards AND wards

General considerations for Topical Preparations

In any prescription for a topical preparation specify:

1. Base (ointment, creams, lotion)

2. Quantity to be supplied
3. Site and frequency of application

The patient should understand:

1. Where to apply the preparation

2. How much to use
3. Frequency of application
4. When to apply-particularly if using more than one application- both at once or should
applications be separated by a certain amount of time?
5. Adverse effects
6. Expected outcome of treatment
7. How long to continue treatment
8. For topical steroids - how to step up or step down strength of treatment

Emollients

Creams are less greasy than ointments.

Indication: dry skin, eczema, psoriasis
Mechanism: soothe dry itchy skin, but effects are soft-lived
Short-lived apply frequently and liberally to all the skins (Rx large tubs)
The best emollient is the one the patient likes (there is no difference) offer patient
selection
Apply soap substitute as well.

Light creams Aqueous cream, Dermol cream, Cetraben cream, Diprobase cream, Doublebase
Lotions Dermol 500
Greasy preps Hydromol ointment, Epaderm ointment, emulsifying ointment, 50% white soft
paraffin in liquid parraffin
*Dermol products contain benzalkonoium chloride and may be useful if secondary infection is
problem e.g. in atopic eczema.

S/E: uncommon
o Contact dermatitis transient irritant reactions to ingredients in creams are not
uncommon. Rarely patients may become allergic to one of ingredients in a cream.
Ointments are less likely to cause irritancy or allergy than creams (no preservatives)
o Fire hazard: emulsifying ointment of 50% liquid paraffin in white soft paraffin.
Ointment may be ignited by a naked flame. Risk is greater when these preps are
applied to large body areas, and clothes get soaked in them.

Soap substitutes

Useful in dry itchy skin conditions.

Aqueous cream is a satisfactory soap substitutes but not adequate as a leave on emollient.
Emulsifying oint, Hydromol oint, or Epaderm oint are greasier soap substitutes.
Dermatological pharmacology for the boards AND wards

Topical corticosteroids

Indications: inflammatory conditions e.g. insect bites, eczema, localised psoriasis (including
flexural & scalp psoriasis)
Potencies: Rx strong enough steroid to control problem. May need > 1 strength of
treatment. Ensure that the patient understand the potencies (give written info), and shows
how to step-up or step-down strength the Tx. It is acceptable to Rx brand names rather than
generic steroid names (as you need to know what else is in the prep vehicle, preservatives)

Mild Hydrocortisone 1-2.5%

Mild with antimicrobials e.g. canesten HC, Daktacort, Fucidin H
o Used for inflamed flexural rashes when secondary infection is
likely to complicate Rx with topical steroids
Moderate Betnovate-RD, Eumovate
Moderate with antimicrobials: Trimovate
Potent Betnovate, Elocon
Potent w antimicrobials: Betnovate-C, Fucibet
Potent with salicyclic acid: Diprosalic
Very potent Dermovate
Application: (1) no more frequently than BD; OD is usually sufficient; (2) spread thinly on
affected skin apply enough to glisten; (3) apply about 20-30 mins after emollient
S/E:
o Mild-moderately potent topical corticosteroids are associated w FEW S/Es
They are safe to use in children and on the thin skin of face and flexures
o For potent and very potent steroids; S/Es:
Spreading and worsening of unTx skin infection including fungal;
Thinning of skin which may be restored over a period after stopping Tx but
the original structure may never return;
Irreverisble straie atrophicae and telangiectasia may then occur;
Acne, or worsening of acne or rosacea
Hypopigmentation which may be reversible; but more often the loss of
colour is secondary to skin condition rather than Tx.
CANNOT use on face
UnderTx because of steroid-phobia is a common cause of Tx failure. Rarely prolonged topical
Tx w large quantities of very potent corticosteroid has been reported to cause adrenal
suppression or Cushings. Absorption is greatest where skin is thin and from intertriginous
areas = vulva, groin, axilla. Absorption is increased by occlusion.

Topical tacrolimus and pimecrolimus

Calcineurin inhibitors are licensed for topical use in moderate to severe atopic eczema. They are also
effective in facial psoriasis. Long-term safety still being evaluated. Should not usually be considered
first-line treatments unless a specific reason to avoid or reduce use of topical corticosteroids.

PO anti-histamines

Non-sedating = chronic urticaria e.g. fexofenadine, cetirizine

Dermatological pharmacology for the boards AND wards

Sedating for itching e.g. hydroxyzine, chlorphenamine, but also Tx any underlying skin
problem or systemic disease that is causing the itch.

Dermatophytoses

Topical preparations
Localised infections of body (tinea corporis), groin (tinea cruris), hand (tinea manuum), foot
(tinea pedis, athletes foot).
Imidazole antifungals e.g. clotrimazole, econazole, miconazole
Terbinafine cream - more effective but more expensive.
Apply BD. To prevent relapse, continue local antifungal for 12 weeks after the
disappearance of all signs of infection.

Systemic therapy (PO)

Systemic therapy - infections of scalp (tinea capitis) or nail (tinea unguium) or if fungal
infection is widespread, disseminated or intractable.
Examine skin scrapings if systemic therapy is being considered or where there is doubt about
the diagnosis.
Options - terbinafine (fungicidal and most effective), azoles or griseofulvin (fungistatic)

Pityriasis versicolor
Ketoconazole shampoo as a body wash (drying and can be irritating - may need an emollient
as well) plus topical imidazole antifungals
If infection is widespread, treat systemically with a triazole antifungal e.g itraconazole.
Relapse is common, especially in the immunocompromised.

Candidiasis
Topical imidazole antifungal e.g. clotrimazole or miconazole

Infestation: scabies

5% permethrin cream
MoDA: interferes w Na channel of nerve cell membrane disruption AP bug spasm
Adult apply whole body then wash off after 8-12 h
Child, elderly, or IC apply whole body including face, neck, scalp, and ears.
Repeat application after 7 days.
All members of affected household / sexual contacts, or other close contacts should be
treated simultaneously including those who are not itching.
The itch and inflammation takes several weeks to settle = treat with sedating anti-H,
emollient, and topical corticosteroids.
Dermatological pharmacology for the boards AND wards

Treatment of psoriasis

Topical Vitamin D analogues e.g. calcipotriol

Dovonex cream or Dovobet ointment = calcipotriol + betnovate

Indications: localised psoriasis
Apply OD or BD; max 100g weekly not suitable for widespread disease.
Local skin reactions = itching, erythema, burning, paraesthesia, dermatitis these are
common, but reduced if combined w topical corticosteroids.
Avoid in disorders of calcium metabolism

Coal tar preparations

Indication: chronic plaque psoriasis.

Exorex lotion = prepared coal tar 1% in an emollient basis
Clean extract of coal tar practicable for home use
Contact with normal skin is not harmful so can be used for widespread small lesions.
Apply 12 times daily.
Adverse effects unlikely: some people dislike the smell.
Crude coal tar concentrations of 1 to 5% with salicylic acid in a soft paraffin base, but few
outpatients tolerate the smell and mess. Reserved for in-patients.

Cocois Scalp ointment or Sebco scalp ointment

Coal tar solution & salicylic acid in coconut oil with applicator nozzle
Indications: Scaly scalps - psoriasis, eczema, seborrheic dermatitis
Apply to scalp once weekly (if severe use daily for first 37 days)
Leave on overnight and shampoo off next morning

Oral retinoid (vitamin A derivative): acitretin

MoDA: works by inducing keratinocyte differentiation and reduce epidermal hyperplasia = cell
turnover reduced. It is also immunomodulatory it reduces PMN chemotaxis, for example.

Only prescribed by, or under the supervision of, a consultant dermatologist

Indications: psoriasis, other disorders of keratinisation e.g. Darier dz, ichthyosis

The least toxic systemic Tx for psoriasis but NOT as effective as MTX
S/E: teratogenicity (stays in cells and remains a risk for 2 years after stopping), therefore
avoid in women who wish to conceive. Dry and cracking lips, dry skin and mucosal surfaces,
hair thinning.
Monitor: LFTs, and blood lipids (TG fast before test).

MTX

Only prescribed once weekly for psoriasis that is uncontrolled (e.g. Sx onycholysis).
Other indications: psoriatic arthritis, RA, Crohns
Dose: 10- 25 m/wk. Adjust to response.
Co-Rx with folic acid 5 mg/d on at least one day of week to reduce S/Es (regimens vary and
folic acid is sometimes given daily).
Counsel patient about limiting or avoiding EtOH
S/E:
Dermatological pharmacology for the boards AND wards

oAnorexia, N - common on day of Tx

oLow WBC advised to report all SiSx esp. sore throat
oHepatitis, liver Fb, rarely cirrhosis
oInterstitial pneumonitis/pulmonary fibrosis (seen in RA, not psoriasis) SOB, cough,
fever
o Teratogenic BOTH men & women should avoid conception for at least 3 months
after stopping.
Monitoring: check FBCs + renal (U&Es) + LFTs before starting Tx.
o Repeat weekly until Tx stabilised, thereafter monitor monthly.

Ciclosporin

Immunosuppressant used in severe atopic dermatitis and severe psoriasis

Nephrotoxic monitor BP and renal function
Long term use = increased risk of skin cancer, particularly in patient who have had previous
phototherapy.

Treatment of acne

Benzoyl peroxide (2.5 %, 5%, 10%)

Effective in mild to moderate acne. Comedones and inflamed lesions respond.

Apply to all face not just spots. Start with low concentration and increase contact time
gradually. Gel is more drying and irritant than cream.
Takes 2-3 months to have a maximal effect.
Adverse effects: skin irritation, bleaches clothing / towels

Topical antibacterial

Topical erythromycin and clindamycin effective for mild inflammatory acne.

Use for 4- 6 months for maximal efficacy
Use in combination with benzoyl peroxide to reduce likelihood of resistance.
Adverse effects: uncommon but may cause mild irritation of the skin

Adapalene

A retinoid-like drug licensed for mild to moderate acne.

Less irritant than retin-A. It is the most effective treatment for comedonal acne.
Local reactions include burning, erythema, stinging, pruritus, dry or peeling skin build up
contact time gradually.

Oral ABx

Oxytetracycline or tetracycline or doxycycline - 500 mg twice daily. - milk reduces the

absorption. Take on empty stomach (30m before food or 2h after food)
Lymecycline 408 mg daily.
Erythromycin 500 mg twice daily - an alternative to a tetracycline; may be used in children
Maximum improvement occurs after 4 to 6 months. It controls rather than cures and there
is often recurrence after stopping treatment.
Dermatological pharmacology for the boards AND wards

Adverse effects: Deposition of tetracyclines in growing bone and teeth (by binding to
calcium) causes staining and occasionally dental hypoplasia - should not be given to children
under 12 years or in pregnancy.

OCP

Dianette - mix of cyproterone acetate and ethinylestradiol

Indications: severe acne in women refractory to prolonged oral antibacterial therapy
Avoid if personal history of venous or arterial thrombosis, severe or multiple risk factors for
arterial disease (smoking, diabetes, obesity etc.) or severe migraine.

Oral retinoids (vitamin A derivatives): isotretinoin

Only prescribed by, or under the supervision of, a consultant dermatologist

Indicated: severe acne, refractory acne, acne causing psychological disturbance

Given for at least 16 weeks; repeat courses are NOT normally required.

S/Es:

Dryness of skin + mucous membranes

Nose bleeds, joint pains.
Drug is teratogenic dont give to women of CBA unless practise effective contraception.
Written consent form.
Continue contraception 1 month after stopping Tx.
Reports of depression and suicide (acne also causes depression).
A causal link between isotretinoin and psychiatric changes (including suicidal ideation) has
not been established, but not a C/I. Discuss possibility before initiating Tx.