2 - Topical Therapy Flashcards
Purpose of topical therapy?
Restore normal skin function after an insult removes water, lipids, or protein from epidermis
This alters integrity of skin barrier and compromise function
How is restoration of normal skin function accomplished?
Through the use of mild soaps, emollient creams and lotions
If you’ve got a patient with dry cutaneous lesions or dry skin, they’ve lost:
Water
In most instances, they’ve lost epidermal lipids and proteins which help contain moisture
Replace moisture with emollient creams and lotions
What is xerosis?
Severe dry skin
When is xerosis worse?
In the dry winter months (“winter itch)
MC’ly affects the hands and lower legs
Describe xerosis
Skin is rough, covered with fine white scales, progresses to thicker tan or brown scales
If severe, criss-crossed and fissured
Itching, burning sensation can happen if more severe form
Txt of xerosis?
Emolloients
12% lactate lotion (Lac-Hydrin, AmLactin)
Describe wet diseases
Exudative inflammatory diseases pour out serum
Leaches complex lipids and proteins from epidermis
How are wet diseases managed?
Wet compresses
Suppresses inflammation
Debrides crust and serum
Repeated cycles of wet and dry eventually dry the lesion
Once wet phase is controlled, restore lipids and proteins with emollient creams and lotions - DISCONTINUE WET DRESSINGS
Why use emollient creams with urea and lactic acid?
Special lubricating properties - very effective
Creams
Are thicker and more lubricating than lotions
Emollient creams and lotions are most effective when applied to:
Damp skin
After shower, pat dry and immediately apply moisturizer
Apply as frequently as necessary to keep skin soft
What can be added to emollients to reduce pruritis?
Menthol and phenol
Wet dressing good for:
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
Benefits of wet dressings?
Inflammation suppression and evaporative cooling -> constriction of superficial vessels which decreases erythema and production of serum (works faster than topical or oral steroids)
You can get an antibacterial action with wet dressings by adding:
Aluminum acetate, acetic acid, or silver nitrate
Types of wet dressings
- Water - doesn’t need to be sterile - poison ivy, sunburn, non-infective process
- Burow’s Sol’n (aluminum acetate) - 1-3 packets in 16oz water - mildly antiseptic - acute inflammation, poison ivy, insect bites, athletes foot
- Silver nitrate 0.5% - stains skin - bactericidal; for exudative infected lesions (stasis ulcers / dermatitis)
- Acetic acid - dilute vinegar - bactericidal, good for some gram neg (pseudomonas)
Technique for wet dressings:
4-8 layers of clean, soft material
Soak in solution then wring out
Place on skin
Leave in place 30-60 mins
Use 2 to 4x per day
D/C once skin is dried out
Effects of topical steroids:
Anti-inflammatory
Vasoconstriction
Anti-mitotic (decreased proliferation of cells)
Which groups of meds should we (PA’s) be using?
Groups V through VII
The lower numbers are really in derm’s wheelhouse
What is the vehicle?
AKA the base
The substance in which the active ingredient is dispersed and determines RATE of absorption
Ex. creams, ointments, gels, solutions and lotions, foams
Cream
Mix of organic chemicals/oils, water and preservative
- White color, slightly greasy texture
- Can use almost anywhere
- cosmetically acceptable
- drying effect with prolonged use (best for acute exudative inflammation)
- most useful for intertriginous areas
Ointments
Primarily grease with little to no water
- usually preservative-free
- translucent, greasy feeling on skin
- most LIPOPHILIC, moisturizing, and occlusive
- greater penetration -> increased potency
TOO OCCLUSIVE for acute exudative eczematous inflammation or intertriginous areas
Gels
Mix of propylene glycol and water, sometimes alcohol
Greaseless, clear, jelly-like consistency
Good for acute exudative inflammation (i.e. poison ivy) due to drying effect
Useful in the scalp (does not mat the hair)
Solutions and lotions
Clear or milky
LEAST lipophilic - can be very drying
Solutions (alcohol) and lotions (water) most useful in scalp
Stinging and drying may result when applied to intertriginous areas
Foams
Good for scalp dermatoses, acute eczematous inflammation (i.e. poison ivy, plaque psoriasis)
High potency preparations: do not use for more than 2 weeks - suppresses HPA - do not use in kids under 12yrs
Things that can decrease absorption of topical steroid?
Thick scale
Lichenification
Use on soles / palms (thicker skin)
Things that can increase absorption of topical steroids?
Abrasion
Cracking
Fissuring
Atrophy
Keratolytic agents
propylene glycol can irritate already inflamed skin
Occlusion
Can increase steroids potency up to 100x
Can happen naturally (i.e. skin folds) or we can do it intentionally
Want better absorption?
Apply right after you get out of the shower (only lightly pat to dry off, then apply medicine)
Areas to watch out for that have thin stratum corneum and increased blood flow?
Face/eyelids
Local side effects of topical steroids:
Burning and itching • Hypopigmentation • Atrophy • Easy bruising • Striae • Hypertrichosis (face) • Steroid acne/folliculitis • Steroid rosacea • Dryness of skin - creams, lotions • Worsening infection • Rebound phenomenon
How will local allergic reaction commonly present?
Chronic dermatitis that is not exacerbated by, but “fails to respond to” corticosteroid therapy…..they’re allergic to the corticosteroid itself
Occasionally exanthem, purpura, or urticaria
If suspected, need skin test *patch testing
Systemic side effects of topical steroid therapy
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)
Intralesional?
Injected steroid (typically triamcinolone)
Injected into the lesions, not surrounding skin
IM steroids?
Longer lasting
Easier than topical and oral
Local atrophy at the site possible
Diabetic and topical steroids?
Can cause their sugars to go up
Pregnancy and topical steroids?
Avoid in 1st tri
Use only when benefit outweighs risk
Top 5 common mistakes in topical steroid therapy
- Steroid too weak for process and area
- Not enough rx given (tube size)
- Failure to follow up on txt
- Too strong used on kids
- Too strong used on face
What is a finger tip unit?
5mm diameter nozzle
1 FTU = 0.5gm
How much steroids for how much body area?
Slides 48 to 51
Smiling gives you wrinkles
Resting bitch face keeps you flawless
