Clinical Workshop on Dermatology. 3 Nov 2005 & 10 Nov 2005

Transcription

1 Clinical Workshop on Dermatology 3 Nov 2005 & 10 Nov 2005

2 Clinical Workshop on Dermatology Eczema Acne Psoriasis Highlights on commonly used dermatological products

3 Eczema - Introduction The most common types: Atopic dermatitis Contact dermatitis Seborrhoeic dermatitis Goals: Decrease pruritus Suppress inflammation Lubricate the skin Reduce anxiety

4 Eczema - Introduction DON T Contact irritants or triggering factors Scratching Wear or contact wolly underclothes & toys Over-bathing, excessive heating, over-use of soaps DO Keep bathing time short Use lukewarm water Use non-irritant soap Pat dry Keep skin moist with frequent use of emollients

5 Eczema - Medication Case I: 53/F Rx Aqueous Cream BD Betamethasone valerate 0.1% cream BD prn,, to hands Daktacort cream BD, to groin Urea cream BD Chlortetracycline 3% ointment BD, to hands

6 Eczema - Medication Case II: 70/M Dx: Ecezema+ Tinea pedis Rx Aqueous Cream daily Emulsifying ointment, use as soap daily Fluocinolone acetonide cream % BD, apply to body, arms and legs Mometasone furoate 0.1% cream, daily to affected area Tioconzole 1% cream, BD for toe webs and feet / Castellani s s paint => stable on this medication and has been continued for years

7 Emollient Eczema - Patient counseling Examples: AQ, emulsifying ointment, urea cream Regular and frequent use can reduce the use of topical steroid by 10-20% Average amounts of cream needed to cover various parts of the body Single application 2g 3g 4g 30-60g Area (for each part listed) Both hands, head, face, genital, anal One arm, front or back of trunk One leg Whole body Amount needed for 7 days 45g 60g 90g 1-2.5kg *For same surface area, 5-10% less ointment is needed than cream

8 Eczema - Patient counseling Common mistakes of applying cream: Use too much or do not rub them in fully If the cream can be seen on the skin after application, the patient has made mistakes waste drugs / not getting full therapeutic benefits Use thinly and frequently, not thickly and occasionally Use emollient soon after bath the stratum corneum can absorb as much as six times its weight in water after being soaked for minutes. Application of emollient immediately after bathing will trap the water in the skin and reduce dryness

9 Eczema - Medication Case III: 24/M Dx: Rx Atopic Ecezema (AD over trunk and back of neck, skin not very dry) Acne Piriton 4mg TDS prn (03-04) 04) Atarax 25mg nocte prn(03 (03-04) 04) Aqueous Cream daily (03-04) 04) Olive oil, BD (04) Betamethasone valerate 0.1% cream BD, to seriously affected area (03-05) 05) Synalar % BD, to mildly affected area(03-05) 05) Adapalene 0.1% gel, to acne BD (04-05) 05)

10 Case IV: 29/F Dx: : Eczema (+/ PMH: Eczema - Medication (+/- pregnancy) 2000: Pregnancy, generalised itch over face, body and limbs piriton 2001: add Atarax 25mg nocte, prn 2002: still itchy, add coal tar solution, change antihistamine to t Polaramine 2mg TDS + Promethazine 25mg nocte itching improved 2003: No need of oral antihistamine Oct 03: Skin worsen, very dry. Just got pregnant off coal tar solution Piriton 2005:Skin get worsen. Eczema over bilateral flexural surface of elbow and neck with excoriation. Controlled by coal tar. Encourage to use emollient

11 Eczema - Medication Rx (Case IV) Aqueous Cream TDS prn Emulsifying ointment daily Alcomethasone diproprionate cream 0.05% BD to face Synalar % BD, mildly affected area Mometasone furoate 0.1% cream daily, seriously affected area Coal tar solution

12 Antihistamine Eczema - Patient counseling Local antihistamine: provide only a mild topical anesthetic effect.it is doubtful they exert a true antihistaminimic effect when administered topically Systemic: major beneficial effect may be due to sedation Clinical effectiveness of different antihistamines: Piriton 4mg Atarax 25mg Polaramine 2mg Promethazine 25mg > Diphehydramine 25mg Sedating vs non-sedating: sedative action of antihistamine helps patient sleeps and decrease the anxiety that is common with persistent pruritus. Non-sedating antihistamine may lack these benefits. However, it can be tried if sedative effect of antihistamine have to be avoided.

13 Topical steroids Corticosteroids Indicated for inflammatory aspect of AD Case I II III IV Steroids used Betamethasone valerate 0.1% cream BD prn,, to hands Daktacort cream BD, to groin Fluocinolone acetonide cream % BD, apply to body, arms and legs Mometasone furoate 0.1% cream, daily to affected area Betamethasone valerate 0.1% cream BD, to severe area Synalar % BD, to mildly affected area Alcomethasone diproprionate cream 0.05% BD to face Synalar % BD, mildly affected area Mometasone furoate 0.1% cream daily, seriously affected area

14 Choices of Corticosteroids Strength and base depend on stage and location of eczema, as well as the age of patient Principle: weakest but adequate strength for disease Potent steroid will be used short-term term to obtain initial control, then change to a weaker one as maintenance

15 Absorption of Hydrocortisone to various parts of body Plantar surface of foot 0.14% Forearm 1% Scalp 4% Forehead 7% Cheeks 13% Scrotum 36% Low potency for groin, axillae and face High potency for area with poor penetration: elbows, knees, palms, soles Adding urea doubles potency of hydrocortisone Increase concentration will increase potency, but not in a linear fashion. E.g. increase HC by 10-fold will increase potency by a factor of four only

16 Eczema - Patient counseling Chronic eczema: generally with BD dosage Preparations should be rubbed in thoroughly When possible, apply while the skin is moist e.g. after bathing to enhance the effect For chronic disease like AD, best to discontinue therapy gradually to reduce chances of rebound flares of topical lesion Acute weeping eczema: KMnO4 then Steroid cream or lotion Contraindications: acne vulgaris,, ulcers, scabies, warts, fungal infection, etc S/E: epidermal and dermal atropy,, localized find hair growth, hypopigmentation

17 Wet-Wrap Wrap Wet-wrap for severe recalcitrant AD = topical steroid under occlusion of wet tube gauze ADV: increase hydration, maintain moisture, prevent scratch, increase potency of corticosteriod (10x) Indication: for chronic, dry, thickened and scaly AD Procedures: After bath emollient to whole body diluted steroid to lesion 1st gauze 2nd gauze left overnight remove in morning apply emollient and steroid DISADV: sweat retention, increased risk of infection Advice: keep for a short period ~12 hr. Apply to cool lesion Use after bath to increase hydration of skin and clinical effectiveness of medication

18 Allergy to corticosteroid Patient complains burning sensation / itching after apply corticosteroid, is he allergic reaction to topical corticosteroid? Cortisol is endogenously secreted by the adrenal gland and is essential to life and so, allergy to it is rare. The occurrence of allergic symptoms are usually not due to corticosteroid, but the preservative (e.g. paraben) ) or other ingredients or the base (e.g.lanolin). May change to another preparation with different formulation. If reaction continues, need to further assess by patch test

19 Other drug therapies for AD Systemic corticosteroid: for severe eczematous flare, a short course will be used Immuno-modulatory modulatory agents: Azathioprine, cyclosporin Because of adverse effects, they will only be considered for chronic severe AD with poor response to the usual treatment New agents: IVIG, Interferon, Tacrolimus(topical), MMF

20 Dandruff: Seborrhoeic dermatitis ear is the most common site of involvement and may lead to otitis externa in severe case Tx: Ketoconzole shampoo / shampoo containing selenium sulphide,, tar or zinc For thick scalp scale and crust, SSE (sulphur( salicylic emulsion) can be applied two hours before shampooing. Apply steroid lotion BD to provide symptomatic relief. Lesion on chest/ trunk Cradle cap: Tx: : Olive oil, wash off few hours later with shampoo e.g. 5% cetrimide

21 Acne - Introduction NO known cure exists, but treatment can reduce its severity Goals: Relieve discomfort Improve skin appearance Prevent pitting and scarring Alleviate psychological distress and social rejection

22 Acne - Introduction Mechanism of drug therapy: Normalize follicular keratinization e.g. retinoids, azelaic acid, benzoyl peroxide Decrease sebum production e.g Isotretinoin, hormone manipulation Suppress bacterial flora (P. acnes) e.g. antiobiotics, benzoyl peroxide, azelaic acid, isotretinoin Prevent an inflammatory response e.g. antibiotics, retinoids

23 Acne Counseling Slow improvement, take over several weeks to months Counseling should include natural history of acne, proper drug administration or application technique, e.g. apply Benzoyl peroxide routinely over the entire susceptible areas, instead of infrequently to existing lesions only, to obtain long- term control potential adverse effects

24 Acne - Medication Case I: 24/F Dx: : Acne Rx Benzoyl peroxide 4% cream daily Clindamycin 1% lotion daily Tretinoin 0.05% cream, apply at night prn

25 Acne - Medication Case II: 21/M Dx: : Acne Rx 2003: Acne over face, with few whiteheads. No pustules, no scaring 2005:Not much improved over years. Intolerant of Erythromycin GI S/E, try minocycline Benzoyl peroxide 5%,BD (03-05) 05) Adapalene 0.1% gel, apply at night (04-05) 05) Erythromycin 250mg BD for 20 weeks (4/04), then changed to Minocycline 100mg daily for 20 weeks

26 Acne - Medication Benzoyl peroxide May cause transient warmth or stinging, significant drying, skin irritation, how to reduce them? Mild skin redness or drying is acceptable and indicates proper dosage and optimal therapeutic response If excessive skin dryness or peeling occur: Decrease frequency of application NO countertreating will moisturizers or emollients Change to lower strength, or Change to a less drying formulation Contact time / drying effect of lotion < cream < gel

27 Retinoids Acne - Medication e.g. Retin-A, Stieva-A, Adapalene Very effective as it affects all the 4 known pathogenic factors Use in mild to moderate cases who fails to respond benzoyl peroxide or topical antibiotics Oral Isotretinoin will be used for extensive and severe acnes, with dosage of 20mg-40mg BD (0.5-1mg/kg), cumulative dose 120mg/kg (usually take 3-77 months) In practice, 90% cure rate with 1mg/kg dosage for 4 months

28 General: Retinoid - Counseling avoid avoid during pregnancy; Use contraception during therapy and continued for at least 1 month after drug discontinuation ( delayed elimination) Apply Apply sunscreen (SPF 15 or higher) to sun-exposed area, or wear protective clothing because sun exposure intensifies skin irritation

29 TopicalTopical Retinoid - Counseling Mild Mild skin redness and drying are expected during the initial phase of treatment Acne Acne may appear worsen within the first week because preclinical lesion become visible

30 OralOral Retinoid - Counseling Limit alcohol intake (because of enhanced Isotretinoin-induced induced hypertriglyceridemia and hepatoxicity which may cause acute pancreatitis in extreme cases Expected skin and mucous membrane dryness e.g.dry mouth, dry eyes emollient, lip balm, artifical eyedrop or eye ointment as required Muscle pain is possible (~5%) Depression?!

31 Acne - Medication Antibiotics: NO single agent is superior Choice of antibiotic mainly based on cost, response to previous treatment, pregnancy status, adverse effect, etc

32 Choices of Antibiotics Tetracycline: most extensively studied and the least expensive Minocycline: once daily dosage, less interaction with dairy products but more expensive and with additional toxicities e.g. hepatoxicity, arthralgia,, arthritis, intracranial hypertension, discoloration or hyperpigmentation of skin #Usually use Tetracyline with dosage 1g/day in divided doses for 2 months, and reassessed If < 20% improve, may substitute with minocycline.

33 Choices of Antibiotics Erythromycin: as effective as tetracycline but resistance develops rapidly Safe in pregnancy Septrin: 1-22 tabs BD is effective for patients refractory to conventional therapy Recommend for short period (6 months or less) because of side effects) Topical metronidazole mainly reserved for rosacea

34 Antibiotics Patient counseling Combination therapy e.g. oral antibiotic + topical retinoid apply topical agent only to face because chest and back application is difficult and expensive Tetracycline / Minocycline Taken on empty stomach to increase absorption i.e. 1 hr prior or 2 hr after meals To minimise the chelation with aluminium and magnesium cations,, take at least hr prior, or 4 hours after antacid / milk Contraindicated in pregnancy

35 Hormonal therapy Acne - Medication For acne with androgen excess like hirsutium and androgenic alopecia Diane 35 <cyproterone (estrogen)> Others cyproterone (anti-androgen) androgen) + ethinyl estradiol Cyproterone is teratogenic and is contraindicated in pregnancy Indicate for women who desire contraception 5% sulphur in calamine lotion As keratolytic and mild antiseptic Advise patient to apply a minute quantity once at night before bed and wash off in the morning Skin dryness, redness and desquamation is expected. Stop if the reaction is severe.

36 Acne Case III: 33/F Dx: : Dermatitis, Acne, androgenic alopecia, Tinea pedis Rx: Adapalene 0.1% gel, daily Clindamycin 1% lotion, BD Cyproterone 50mg daily Diane 1 tablet daily Ketoconazole shampoo, 2x/week Nerisone C cream, to hand daily Travocort cream, BD Paraffin soft white, daily Urea cream 10%, BD Pimecrolimus 1% cream, daily Zyrtec 10mg daily prn Soap spirit shampoo, BD

37 General Psoriasis - Introduction characterized by chronic recurrent exacerbations and remissions, but Psoriasis is not fatal or contagious, and it can be controlled Optimism and encouragement to patients will make it easier for them to apply sometimes awkward and messy topical agents, or take potentially toxic medications. Avoid alcohol Positive correlation between psoriasis and alcohol intake Sunlight?? Goal of therapy Complete clearance of psoriatic lesions

38 Psoriasis - Introduction Treatment approach Mild topical steroid (BD) along with tar ointment (nocte), or sequential treatment with Calcipotriol If ineffective add Calcipotriol e.g. BD for 8 weeks; stop steroid if the conditions under control Moderate topical therapy +/- Acitretin and narrow band UVB / PUVA

39 Case I: M/74 Dx: : Psoriasis Rx: Psoriasis - Medication Aqueous cream, BD Diprosalic ointment, OM for seriously affected area Synalar % cream, BD to trunk and limbs < change to Travocort in 9/05> Calcipotriol 0.005% ointment, nocte Atarax 25mg, nocte prn Coal tar solution, as bathing Polytar liquid, as shampoo 242, BD <stopped in 9/05>

40 Psoriasis - Medication Case II: M/49 Dx: : Rheumatoid arthritis, Psoriasis PMH: 98: psoriatic arthropathy,, on methotrexate 02: MTX toxicity 03: skin stable, thin plaques over elbows and trunk, minor scalp lesions with dandruffs 04: with dandruff, disease control fluctuate 05: elbow region improved. Repeat medications

41 Psoriasis - Medication Rx: Emulsifying ointment, BD (00-05) 05) Betamethasone scalp lotion, nocte (00-05) 05) Synalar 0.025% BD (00-05) 05) Diprosalic ointment, OM to seriously affected area (00-05) Calcipotriol 0.005% ointment, nocte to seriously affected area (00-05) 05) Coal tar solution, for bathing (00-05) 05) Salicylic acid 2%+Coal tar 4%+Sulphur 2% ointment, BD (00-05) 05) Salicylic acid + sulphur cream, twice weekly (02-05) 05) Polytar shampoo, twice weekly (02-05) 05) Soap spirit shampoo (00-01) 01)

42 Psoriasis - Medication Case III: M/41 Dx: : Psoriasis Rx: Acitretin 25mg daily Calcipotriol 0.005% ointment, to arm daily Synalar % cream, to body, arms & legs BD Polytar liquid, as shampoo once weekly Paraffin soft white, BD Urea cream 10%, BD < switch with 242>

43 Psoriasis - Counseling Shampoo Scalp psoriasis may be treated with steroid preparations in gels or lotion, but coal tar shampoo is more effective for scaling and pruritus Lather into the scalp for minutes then rinse out Bathing Polytar: : cupfuls for 8 inch bath Coal tar: 15ml for 8 inch bath Soak for minutes, then pat dry

44 Coal tar Psoriasis - Counseling Can be applied at bedtime to overcome some of the negative cosmetic bias Wash off with liquid paraffin or olive oil Avoid use on face, flexures and genitalia because of tar s irritant properties Increased risk of carcinoma?? no evidence Sulphur+salicylic acid Keratolytic agent for scalp psoriasis Apply 2hr before shampooing 242 For chronic plaque psoriasis Tar with salicylic acid is useful in reducing scaling For patient sensitive to tar component, equal proportion of steroid can be mixed with it

45 Psoriasis - Counseling Emollient Decrease fissure, cracking and scaling Ointment vehicles are favored because it helps to moisturize the plaques (cream may dry the plaque further) Calcipotriol May affect bone and calcium metabolism Limit to 100g/week(adult) and monitor Adverse effects: burning, stinging, pruritus, erythema and scaling With comparable effectiveness as corticosteroids and with less adverse effect e.g. tachyphylaxis.. But slower in onset and associated with more dermal irritation

46 Psoriasis - Counseling Topical corticosteroid Provide prompt relief More potent preparations are required as psoriasis is generally corticosteroid-resistant; resistant; less potent agents are appropriate in intertriginous area e.g. face Corticosteroid + salicylic acid Enhance penetration of corticosteroid & improve clinical efficacy Adverse effect: atrophy, telangiectasia, striae, tachylaxis,etc Sequential use of Calcipotriol on weekdays with steroid in weekends

47 Psoriasis - Counseling Systemic corticosteroids have no place in therapy because of the increase in likelihood of rebound and patients are often worse after systemic steroid Photochemotherapy PUVA: Psoralen e.g. methoxsalen + UVA 8-methoxypsoralen (8-MOP): mg/kg, 0.8mg/kg, take 2hr before exposure to UVA light

48 Psoriasis - Counseling after PUVA therapy: Immediately 8hr after PUVA therapy, avoid direct and indirect sunlight If it can t t be avoided, then wear protective clothing (long sleeves, high neck-line) Use sunscreens that filter both UVA and UVB Wear wraparound sunglasses that block UVA for 24 hours to prevent cataract and acute eye photosensitivity

49 Psoriasis Systemic therapies Cyclosporine Lower dosage for psoriasis than for prevention of organ transplant rejection : 3-5mg/kg3 Rapid improvement, but most patients relapse months after stopping the therapy NO concurrent UVB or PUVA treatment should be received during cyclosporine therapy Acitretin (Neotigason ) For recalcitrant psoriatic disease Tetratogenic.. Absolute contraception must be practiced and continued for two years after cessation Dose: 0.5-1mg/kg/day Reduce the dose if it is used in combination with phototherapy or photochemotherapy

50 Psoriasis Systemic therapies Hydroxyurea Dose: mg daily Not as potent as MTX, but with less hepatotoxicity with continuous use Systemic steroids Withdrawal effect rarely used for psoriasis MTX (refer to notes of class I) Precautions e.g. Drug-induced psoriasis Chloroquine hydroxychloroquine is preferred for prophylaxis of malaria

51 Psoriasis - Medication Case IV Rx: Acitretin 12/1999: 40mg 2/2000: 35mg 6/2000: 30mg 9/2000:25mg Methotrexate 2/2003: 5mg once weekly 3/2003:7.5mg 7/2003: 10mg 9/2003: 12.5mg 12/2003: 10mg 1/2004: 7.5mg + folic acid 5mg daily

52 Hydroxyurea 5/2/2004: 500mg daily Cyclosporin 12/2/2004: 100mg BD 26/2/2004: 100mg daily 4/2004: 75mg BD (+ folic acid since 7/04) 8/2004: 50mg BD 10/2004: 25mg BD + Acitretin 25mg daily Acitretin 11/2004: 35mg daily (stopped cyclosporin) 12/2004: 30mg daily 3/ now: 20mg daily

53 Biological therapies for psoriasis Biologic agents are proteins that are extracted from animal tissues or synthesized through recombinant DNA techniques. It usually aims at blocking molecular activation in one of the cellular pathways in immune activation Examples:Efalizumab (Raptiva ), Alefacept (Amevive ), Infliximab(Remicade ), Etancercept (Enbrel ) Except Infliximab,, all the other three are approved by FDA for treatment of moderate to severe plaque psoriasis. Long-term or rare but serious adverse effect?? Cost?

54 Highlights on dermatological products Soap spirit shampoo / cetrimide 5% shampoo Both contain detergents that help to remove debris and scals Useful in pityriasis captitis,, scalp psorasis and soborrhoeic dermatitis Lather left on scalp for 5 minutes before getting rinsed off KMnO4 Astringent and antibacterial Proper dilution e.g. 5ml 4% to 2L (purplish pink) Lukewarm solution is helpful in acute weeping and blistering conditions (acute eczema / fungal infection) Soaked for minutes then mopped dry

55 Highlights on dermatological products Aluminium chloride 70% in ethanol As antiperspirant for treatment of hyperhidrosis Application: wash affected area with soap and water mopped dry apply thin layer of solution wash off on next morning with soap and water The frequency of use can be reduced according to response It may cause irritation, esp apply to damp area because of formation of HCl.

56 Salicylic acid Highlights on dermatological products Possess keratolytic,, antifungal and antimicrobial properties 3% ointment for treatment of hyperkeratotic and scaling skin conditions like dandruff and psoriasis 3% salicyclic acid in spirit Antifungal, for pityriasis versicolor 10% /20% For treatment of warts can callositis Castellani s paint Disinfectant for Gm +ve+ bacteria and some fungi Commonly for superficial fungal infection of skin and nail Mild irritant (Resorcinol)

57 Highlights on dermatological products Podophyllin paint A strong irritant for anogenital warts Usual dosage: times/ week Paint the solution on the lesion and allow to stay for 4 hours and then wash off Perilesional skin must be covered by soft paraffin as protection Avoid applying it to a large number of warts at one time as severe toxicity may be resulted Tetratogeinc.. Avoid in pregnancy and uses in treatment of cervical and urethral warts

58 Thank you