Topical Treatment Flashcards
intertriginous areas
-inguinal folds
-antecubital space
-maximum absorption-
preserving integrity of skin
-barrier
-anything removes water, lipids, proteins, from skin compromises function
-we treat to restore
topical therapies
-use of medicine directly on skin or mucosal surface
-stratum corneum is the rate limited barrier to “percutaneous drug delivery”
-drug penetration is inversely proportional to thickness of stratum cornea
-absorption is maximal over mucous membranes (eyelids scrotum intertriginous areas)
factors affecting absorption
-drug concentration
-thickness of skin and thickness of vehicle
-surface area
-occlusion
-hair follicles
-cutaneous circulation
composition of vehicles
-ointments- water in oil emulsion
-creams (aqueous creams)- oil in water emulsion
-gels- semisolid emulsion in alcohol base
-lotion/solutions- powder in water (some oil water)
topical therapies
-anti-microbials- dial soap, antibiotics, bleach baths
-anti-inflammatory agents- steroids and NSAIDs (voltarin)
-cleansers- cetaphil, cerave, dove soap…NOT IVORY SOAP
-moisturizers- cetaphil, lubriderm
-useful when there is need to target treatment area while avoiding systemic side effects
creams, lotion, ointments, and gels and solution
-restore water and lipids
-creams are generally thicker than lotions
-ointments are dense and oily
-best applied to damp skin (not wet)
-efficacy not necessarily dictated by cost
-gels are usually more drying and are used when emollients are not necessary
-solutions are best for hairy areas
vehicle: sequence of potency
-max -> min
-ointment
-cream
-lotion
-gel
-spray
-foam
ointment advantage
-best occlusive
-used in chronic, dry, brittle, lichenified dermatoses
-most potent effect
-fewer preservatives- less water, so micro-organisms cannot grow
ointment disadvantage
-difficult to spread and wash
-adherent to skin
-decreased evaporation/heat loss -> never put ointment on burn
-should not be used on weeping (exudates) lesions and intertriginous areas
-sticky and cosmetically unacceptable
lotions
-combination of liquids and powders
-less acute dermatoses
-can be drying
-should not be used on exudative lesions
creams
-semi solid emulsions containing lipids and water
-falls somewhere between an ointment and a lotion
-most people prefer consistency- less sticky less runny
-most prescribed
-contain preservatives
-if cream made reaction worse- think about allergy to preservatives
gels
-thickened lotion
-semi-solid clear base
-jelly like consistency
-tend to dry out when left on skin
-used to treat scalp and other hairy areas
-used on exudative inflammation (PI)
-can use on weeping lesions
-poison ivy
pros and cones of vehicles
-ointment- enhances penetration very well BUT greasy and hard to spread
-cream- easier to spread BUT may sting and acutely inflame skin
-solution- easy to use in hair BUT may sting in acutely inflamed skin, runny
-gel- easy to use in hair and mouth and penetration enhancer BUT alcohol base will sting inflamed skin and can dry skin
topical therapies powders
-cooling
-prevents friction
-absorbs moisture
-most useful in intertriginous areas
-do not use on oozing skin -> curst formation
-use for jock itch
topical therapies- baths
-whole or part of body is immersed in liquid
-widespread exudative leisons
-cleansing baths
-medicated baths
-duration limited to no more than 30 minutes
-temp 95-100 degrees
-use clorox for bad ezcema / infection
steroids-inflamatory cascade
-immunosuppressive
-anti-inflammatory
-lipocortins- steroid induced inhibitor of arachidonic acid -> mediates anti-inflammatory action of steroids
-stops inflammatory cascade
-anti-proliferative
-factors to consider- disease location, amount and duration of steroid
groups of steroids
-group 1-7 (weakest)
group 1 steroids
-group 1- treat difficult inflammatory diseases -> plaque, psoriasis, hand eczema
-BID-TID for 2 weeks -> 1 week rest
groups 2-7
-BID-TID and limited to 2-6 weeks
-careful when treating areas like face, intertriginous areas, scrotum -> absorption is much higher in these areas
-palms and soles are difficult to treat and require higher potency steroid -> usually 1 or 2
occulsion
-can be helped to enhance absorption
-sweater through skin and now covering it -> softens stratum corneum
-creates moisture to soften stratum corneum
-children skin is more receptive to steroids and care should be taken to use lower potency creams and lotions
-diapers form occlusion
-only group 6-7 agents should be used in diapers are no more than 10 days
-avoid group 1 in pre pubertal children all together
downside of steroids
-topical steroids have excellent safety record however some adverse reactions can occur
-potential side effects should be discussed with pt before prescribing:
-burning, itching, irritation, dryness, cause by vehicle
-hypertrichosis of face- hair growth
-hypo/hyper pigmentation
-milia/folliculitis after occlusion
-ocular hypertension/cataracts
-acne induced steroid use
steroids continued
-rebound phenomenon- once you stop using it comes back
-skin atrophy- thinning
-striae- lines that look like stretch marks, red
-systemic absorption
-tinea incognito- makes fungal infections worse
-skin blanching from acute vasocontriction
-nonhealing leg ulcers (steroids retard the healing process) WHY??? -> steroids stop inflammatory cascade -> slows healing
-YOU CANT use steroids on areas of infection
-steroid rosecea
-perioral dermatitis
-thins skin - can see the vasculature
class 1
-clobetasol 0.05%
-Cheetahs are Faster Than Humans
class 2
fluocinonide 0.05%c
class 4
triamcinolone 0.1%
class 7
hydrocortisone 2.5%
perioral dermatitis
-are you using retinae in the last 6 months?
-itchy
-can be caused by steroids
-tx- discontinue irritating agent
when do we use steroids
-inflammatory and puritic conditions
inflammatory cascade- pathogenesis and clinical findings
-immunocomplex at the site
-mast cells release histamine -> increase vessel permeability, vasodilation
-pro-inflammatory cytokines release -> chemotaxis (immune cells migrate to injury)
-disrupted endothelial cells release leukocytosis induced factors (b and t cells) -> increase WBC
cardinal signs of the inflammatory response
-redness (rubor)
-heat (calor)
-pain (dolor)
-swelling (tumor)
liquid nitrogen
-irritates the area and triggers the cascade
-triggers brain to send WBC to area
-creates inflammatory cascade to heal it
-body clears virus/warts on its own
-never give steroids for this -> blocks the cascade!!!
steroids
-modify the function of epidermal, dermal cells, and leukocytes that are involved in inflammatory skin diseases
-after passing through cell membrane, they react with receptor proteins within the cell to form steroid receptor complex
mechanisms of action for anti-inflammatory steroids
-suppress t-cell activation and cytokine production
-suppress mast cell degranulation
-decrease capillary permeability indirectly by inhibiting mast cells and basophils
-reduce expression of cyclooxygenase 2 and prostaglandin synthesis
-reduce prostaglandins, leukotriene and platelet activating factor levels by altering phospholipase A2 activity
corticosteroids
-decrease number of eosinophil (apoptosis)
-decrease cytokines produced by t lymphocytes
-decrease number of mast cells
-decrease cytokines produced by macrophages
-decrease number of dendritic cells
sunscreen
-chemical and physical blocker
-chemical sunscreens can be endocrine disrupters
-chemical sunscreens- degrade with heat
-physical- do not degrade
