Dermatologic Therapies

Medical Student Core Curriculum

in Dermatology

Last updated June 8, 2011 1

Module Instructions

The following module contains a number

of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated guide to clinical dermatology
and dermatopathology.
We encourage the learner to read all the
hyperlinked information.

2
 Goals and Objectives
The purpose of this module is to help medical students gain
familiarity with common dermatologic treatments.
By completing this module, the learner will be able to:
Estimate the amount of topical medication needed for therapy
based on frequency of application and body surface area
involved
Choose appropriate strengths of topical steroids based on age,
body location and severity of dermatitis
List side effects of prolonged use of topical steroids
Discuss the basic principles of medications used to treat acne
Discuss the basic principles of topical antifungals, oral
antihistamines and topical psoriasis medications
3
Principles of Dermatologic Therapy

The efficacy of any topical medication is

related to:
The active ingredient (inherent strength)
Anatomic location
The vehicle (the mode in which it is
transported)
The concentration of the medication

4
 Vehicles

Foams
Creams
Gels

Sprays

Oils

Solutions
Ointments
5
 Vehicles
Ointments (e.g. Vaseline): lubricating, occlusive; greasy
USE for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesions
AVOID on hairy and intertriginous (when skin is in contact with skin,
e.g. armpits, groin, pannus) areas
Creams (vanish when rubbed in): less greasy, drying
effects; not occlusive, can sting, more likely to cause
irritation (preservatives/fragrances)
USE for acute exudative inflammation, intertriginous areas
Lotion (pourable liquid): less greasy, less occlusive; may
contain alcohol (drying effect on oozing lesion); penetrate
easily, little residue
USE for hairy areas
6
Vehicles (cont.)
Oils: less stinging than lotions or solutions
USE for the scalp, especially for people with coarse or very curly
hair
Gel (jelly-like): may contain alcohol, greaseless, least
occlusive; dry quickly
USE for acne, exudative inflammation (e.g. acute
contact dermatitis); on scalp/hairy areas without matting
Foams (cosmetically elegant): spread readily, easier to
apply; more expensive
USE for hairy areas; inflammation
Sprays: Aerosols (rarely used), pump sprays
7
Medication Costs
Topical medications can be very expensive
They are not all covered by insurance
Over the counter (OTC) treatments are
generally cheaper than prescriptions
Generics are less expensive than brand name
prescriptions
It is helpful to know the costs of the medications
you prescribe and be able to tell the patient in
advance what they should expect to pay
8
What goes into a topical
prescription?

9
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3

10
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
Generic name

11
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
Generic name
Vehicle

12
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
Generic name
Vehicle
Concentration

13
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
Generic name
Vehicle
Concentration
Sig (directions)

14
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected
area (face) BID PRN for scaling #15 Grams
RF3
Generic name
Vehicle
Concentration
Sig
Amount
15
Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area
(face) BID PRN for scaling #15 Grams RF3
Generic name
Vehicle
Concentration
Sig
Amount
Refills
16
Now Lets Review Some
Common Types of Medications
Used by Dermatologists

17
Topical Corticosteroids

Topical steroids produce an anti-

inflammatory response in the skin
They are effective for conditions that are
characterized by hyperproliferation,
inflammation, and immunologic involvement

They can also provide symptomatic relief

for burning and pruritic lesions
18
Topical Corticosteroids

Corticosteroids are organized into classes based

on their strength (potency)
Therefore, steroids within any class are
equivalent in strength
Strength is inherent to the molecule, not the
concentration
Know one steroid from each class that would be
available to the majority of your patients (the
generic in that class)

19
 Topical Steroid Strength

Potency Class Example Agent

Super high I Clobetasol propionate 0.05%
High II Fluocinonide 0.05%
Triamcinolone acetonide ointment 0.1%
Medium III V Triamcinolone acetonide cream 0.1%
Triamcinolone acetonide lotion 0.1%

Fluocinolone acetonide 0.01%

Low VI VII Desonide 0.05%
Hydrocortisone 1%
20
 Topical Steroid Strength
Remember to look at the
class not the percentage
Potency Class Example Agent
Note that clobetasol 0.05% is
stronger than hydrocortisone Super
I Clobetasol 0.05%
high
1%.
High II Fluocinonide 0.05%
When several are listed,
Triamcinolone ointment 0.1%
they are listed in order of
Medium III V Triamcinolone cream 0.1%
strength Triamcinolone lotion 0.1%
Note that triamcinolone
Fluocinolone 0.01%
ointment is stronger than Low
VI
Desonide 0.05%
triamcinolone cream or lotion VII
Hydrocortisone 1%
because of the nature of the
vehicle

21
 Corticosteroid Selection
Super high potency (Class I) are used for severe
dermatoses over nonfacial and nonintertriginous areas
Scalp, palms, soles, and thick plaques on extensor
surfaces
Medium to high potency steroids (Classes II-V) are
appropriate for mild to moderate nonfacial and
nonintertriginous areas
Okay to use on flexural surfaces for limited periods
Low potency steroids (Classes VI, VII) can be used for
large areas and on thinner skin
Face, eyelid, genital and intertriginous areas
22
Local Side Effects of
Topical Steroids
Local side effects of topical steroids include:
Skin atrophy Acne
Telangiectasias Steroid Rosacea
Striae Hypopigmentation
The higher the potency the more likely side
effects are to occur.
To reduce risk, the least potent steroid should be
used for the shortest time, while still maintaining
effectiveness

23
Local Corticosteroid Skin Side Effects

Skin Atrophy Striae

24
Local Corticosteroid Skin Side Effects

Hypopigmentation

25
Systemic Side Effects of
Topical Steroids
Systemic side effects are rare due to low absorption
They can include:
Glaucoma (when steroid applied to the eyelid)
Hypothalamic pituitary axis suppression
Cushings syndrome
Hypertension
Hyperglycemia
The higher the potency the more likely side effects are to
occur
To reduce risk, the least potent steroid should be used for
the shortest time, while still maintaining effectiveness

26
Duration of Treatment
Duration of treatment is limited by side effects
In general:
Super high potency: treat for <3 weeks
High and Medium potency: <6-8 weeks
Low potency: side effects are rare. Treat facial, intertriginous,
and genital dermatoses for 1-2 week intervals to avoid skin
atrophy, telangiectasia, and steroid-induced acne
Stop treatment when skin condition resolves
To avoid rebound/flares: taper with gradual reduction of both
potency and dosing frequency every 2 weeks
If the patient does not respond to treatment within these
guidelines, consider referral to a dermatologist
27
Prescribing topical steroids

The following slides will review how to

estimate the amount of medication to
prescribe according to the affected body
surface area (BSA)
28
Estimating BSA:
Palm of Hand

1 Palm = 1% BSA
Use the size of the
patients palm, not
your own

29
Estimating topicals:
Fingertip unit

Quantity of topical
medication (dispensed
from a 5mm nozzle)
placed on pad of the
index finger from distal
tip to DIP joint
Fingertip unit (FTU) =
500 mg = treats 2%
BSA
30
 2 palms 2 times a day = 30 grams / mo

1 Palm = 1% BSA 2 palms = 2% BSA

2 palms 2 times per day
= 1 gram per day
1 Palm = 1% BSA

SOGIVE 30 GRAMS
FTU = 0.5 G FOR EVERY 2 PALMS
Covers 2 % BSA OF AREA TO COVER
Covers 2 palms (FOR 1 MONTH Rx)
31
 Practice Question 1
Take a look at the following photograph and decide
how much BSA is affected. Then try to answer the
question on the following slide.

32
Practice Question
Which of the following prescriptions would you
recommend for BID dosing for 1 month duration? Use
2% BSA.
a. Fluocinonide 0.05% ointment, apply to affected area
(knees) BID, # 30 grams
b. Fluocinonide 0.05% ointment, apply to affected area
(knees) BID, # 90 grams
c. Hydrocortisone 1% ointment, apply to affected area
(knees) BID, # 30 grams
d. Hydrocortisone 1% ointment, apply to affected area
(knees) BID, # 90 grams
33
 Practice Question
Which of the following prescriptions would you recommend
for BID dosing for 1 month duration? Use 2% BSA.
a. Fluocinonide 0.05% ointment, apply to affected area
(knees) BID, # 30 grams (2 palms = 2% BSA = 30 grams
for 1 mo BID)
b. Fluocinonide 0.05% ointment, apply to affected area (knees)
BID, # 90 grams (for a 3 month supply)
c. Hydrocortisone 1% ointment, apply to affected area (knees)
BID, # 30 grams (need a higher potency steroid for plaque
psoriasis on the knees)
d. Hydrocortisone 1% ointment, apply to affected area (knees)
BID, # 90 grams
34
 Estimating amounts
It takes ~30 grams to cover an average adult
body (for one application)
Here is a rough estimation of amounts to
prescribe for BID use for a month:
Face
30-45 grams
Extensor surfaces of both arms
120-150 grams
Widespread on trunk, legs, arms:
1-2 pounds (454 grams = 1 lb.)
35
 Estimating amounts:
re-assess of follow-up

The best way to assure you are giving the

right amount is to re-assess on follow-up
If your patient was given a 60-gram tube,
confirm they are using it according to
instructions, and ask how long that tube lasts
If a 60-gram tube only lasts them 2 weeks, they
need 2 of them to last a month

36
 Estimating BSA:
Rule of Nines
The rule of nines is a
good, quick way of
estimating the affected
BSA
Often used when
assessing burns
The body is divided into
areas of 9%
Less accurate in children Source: McPhee SJ, Papadakis MA: Current Medical
Diagnosis and Treatment 2010, 49th Edition:
http://www.accessmedicine.com. Copyright The
McGraw-Hill Companies, Inc.
37
 Pediatric Dosing

Children require adjusted dosage

Use a pediatric version of the rule of nines or the
patients palm to estimate BSA
Remember that children, especially infants have a
high body surface area to volume ratio, which puts
them at risk for systemic absorption of topically
applied medications

38
 Pediatric Dosing (cont.)
Low potency topical corticosteroids are safe when
used for short intervals
Can cause side effects when used for extended durations
High potency steroids must be used with caution
and vigilant clinical monitoring for side effects in
children
Potent steroids should be avoided in high risk areas
such as the face, folds, or occluded areas such as
under the diaper
39
Lets move on to some more types of
medications used by dermatologists

Medications commonly used to treat

Acne vulgaris

40
Benzoyl peroxide
Benzoyl peroxide is a topical medication with both
antibacterial and comedolytic (breaks up
comedones) properties
Available as a prescription and over-the-counter,
as well as in combinations with topical antibiotics
Patients should be warned of common adverse
effects:
Bleaching of hair, colored fabric, or carpet
May irritate skin; discontinue if severe
Available as a cream, lotion, gel, or wash
41
 Topical Antibiotics
Used to reduce the number of P. acnes and reduce
inflammation in inflammatory acne
Do not use as monotherapy (often used with benzoyl
peroxide to prevent the development of antibiotic
resistance in the treatment of mild-to-moderate acne
and rosacea)
Erythromycin 2% (solution, gel)
Clindamycin 1% (lotion, solution, gel, foam)
Metronidazole 0.75%, 1% (cream, gel) is used in the
treatment of rosacea 42
Topical Retinoids
(tretinoin, all trans retinoic acid)
Topical retinoids are vitamin A derivatives
Used for acne vulgaris; photodamaged skin; fine
wrinkles, hyperpigmentation
Patients should be warned of common adverse
effects:
Dryness, pruritus, erythema, scaling
Photosensitivity
Available as a cream or gel
Do not apply at the same time as benzoyl peroxide
because benzoyl peroxide oxidizes tretinoin
43
 Topical Acne Treatment:
Side Effects
Topical acne treatments are often irritating and can
cause dry skin
When using retinoids or benzoyl peroxide, consider
beginning on alternate days. Use a moisturizer to reduce
their irritancy.
Topical agents take 2-3 months to see effect
Patients will often stop their topical treatment too early
from red, flakey skin without improvement in their
acne
Patient education is a crucial component to acne
treatment
44
 Oral Antibiotics
Tetracycline, doxycycline, minocycline
Use for moderate to severe inflammatory acne
Often combined with benzoyl peroxide to prevent
antibiotic resistance
If the patient has not responded after 3 months of
therapy with an oral antibiotic, consider:
Increasing the dose,
Changing the treatment, or
Referring to a dermatologist
45
 Oral Treatment: Side Effects
Tetracyclines (tetracycline, doxycycline,
minocycline):
Are contraindicated in pregnancy and children age
<8 years
May cause GI upset (epigastric burning, nausea,
vomiting and diarrhea can occur)
Can cause photosensitivity (patients may burn
easier, which can be easily managed with better
sun protection). Recommend sun block with UVA
coverage for all acne patients on tetracyclines
46
 Oral Tetracyclines:
Patient Counseling
Major side effects:
Tetracycline: GI upset, photosensitivity
Doxycycline: GI upset, photosensitivity
Minocycline: GI upset, vertigo, hyperpigmentation
Patients need clear instructions
If taking for acne, it is okay to take them with food and
dairy products for tolerability of GI side effects
Take with full glass of water; avoids esophageal erosions
Tetracyclines do NOT interfere with birth control pills
It takes 2-3 months to see improvement
47
 Oral Isotretinoin
Oral isotretinoin, a retinoic acid derivative, is indicated in
severe, nodulocystic acne failing other therapies
Should be prescribed by physicians with experience using
this medication
Typically given in a single 5-6 month course
Isotretinoin is teratogenic and therefore absolutely
contraindicated in pregnancy
Female patients must be enrolled in a FDA-mandated
prescribing program in order to use this medication
Two forms of contraception must be used during isotretinoin
therapy and for one month after treatment has ended 48
 Isotretinoin Side Effects
Common side effects of isotretinoin include:
Xerosis (dry skin)
Cheilitis (chapped lips)
Elevated liver enzymes
Hypertriglyceridemia
Individuals with severe acne may suffer mood
changes and depression and should be monitored
Severe headache can be a manifestation of the
uncommon side effect pseudotumor cerebri
49
Topical Antifungals

50
Topical Antifungals

There are several classes of topical antifungal

medications
Some classes are fungistatic (stop fungi from
growing), others are fungicidal (they kill the
fungi)
Not all conditions are treatable with topical
antifungals (specifically, hair infections and nail
infections do not respond to topical treatment and
require systemic treatment)
51
 Topical Antifungals
The following are some examples of topical
antifungals:
Imidazoles (fungistatic): Ketoconazole (Rx & OTC),
Econazole, Oxiconazole, Sulconazole, Clotrimazole (Rx &
OTC), Miconazole (OTC)
Useful to treat candida and dermatophytes
Allylamines and benzylamines (fungicidal): Naftifine,
Terbinafine (OTC), Butenafine
Better for dermatophytes, but not candida
Polyenes (fungistatic in low concentrations): Nystatin
Better for candida, but not dermatophytes 52
Advantages of Topical Antifungals
Topical antifungals are preferred for most
superficial fungal infections of limited extent.
Advantages include:
Relatively low cost
Acceptable efficacy
Ease of use
Low potential for side effects, complications,
or drug interactions

53
Oral Antihistamines

54
 Antihistamines
Antihistamines are the most widely used agents for
pruritus and chronic urticaria
1st Generation H1 antagonists are sedating
Anticholinergic side effects (e.g. memory impairment,
confusion, dry mouth, blurred vision) are dose-limiting
Use as a sleep aid at night for patients with pruritus
Use with caution in elderly due to increased fall risk, CNS
and anticholinergic effects
2nd Generation H1 antagonists are minimally sedating
and require less frequent dosing than 1st generation H1
antihistamines 55
Antihistamines
The following are examples of H1 antihistamines:
1st Generation 2nd Generation
Diphenhydramine (OTC) Cetirizine (OTC)
Hydroxyzine (Rx, generic) Loratadine (OTC)
Chlorpheniramine (OTC) Fexofenadine (OTC)
For most pruritic dermatoses that are not
urticaria, 1st generation H1 antihistamines
primarily work through their sedative effect rather
than their anti-histaminic properties
56
Medications used in Psoriasis

57
 Skin Kinetics
Some dermatoses are associated with a higher
rate of epidermal turnover
For example, the epidermis of psoriasis replicates too
quickly
Topical therapies that inhibit keratinocyte
proliferation are used in the treatment of psoriasis
They include:
Vitamin D analogs
Coal tar
Tazarotene
58
 Psoriasis Treatment:
Topical Vitamin D Analogs
Calcipotriene (calcipotriol)
Inhibits keratinocyte proliferation
Most common side effect is skin irritation
Calcitriol
Inhibits keratinocyte proliferation
Stimulates keratinocyte differentiation
Inhibits T-cell proliferation
On more sensitive areas, less skin irritation than
calcipotriol
59
Psoriasis Treatment
Tar 2-5%
Antiproliferative effect
Disadvantages: stain clothing/hair/skin; messy; increases
photosensitivity
Can be combined with salicylic acid to penetrate thick
plaques
Tazarotene 0.05% and 0.1%
Topical retinoid used for acne, rosacea, psoriasis
Disadvantages: skin irritation; teratogenic; increases
photosensitivity
Can be combined with a Class II corticosteroid to reduce
irritation
60
 Take Home Points
The efficacy of any topical medication is related to the strength,
location, vehicle, and concentration
Topical medications can be very expensive
When writing a prescription for a topical medication, include:
generic name, vehicle, concentration, directions, amount, # of
refills
Corticosteroids are organized into classes based on their strength
(potency)
Skin atrophy, acne, striae, and telangiectasias are potential local
side effects of corticosteroid use
It takes ~30 grams to cover an average adult body (for one
application)
61
 Take Home Points
Use benzoyl peroxide with topical antibiotics to prevent the
development of antibiotic resistance in acne treatment
Lack of adherence is the most common cause of treatment failure
in acne patients; patient education is crucial
Topical antifungals are preferred for most superficial fungal
infections of limited extent
Antihistamines are the most widely used agents for pruritus and
chronic urticaria
2nd Generation H1 antihistamines are less sedating that 1st
generation H1 antihistamines
Many of the topical medications used in psoriasis inhibit
keratinocyte proliferation
62
Acknowledgements
This module was developed by the American
Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.
Primary authors: Alina Markova, Sarah D. Cipriano,
MD, MPH; Timothy G. Berger, MD, FAAD; Patrick
McCleskey, MD, FAAD.
Peer reviewers: Peter A. Lio, MD, FAAD; Ron
Birnbaum, MD.
Revisions: Sarah D. Cipriano, MD, MPH. Last revised
June, 2011.
63
 References
Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-
Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL;
2007. Available from: www.mededportal.org/publication/462.
Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for the
use of topical glucocorticosteroids. American Academy of Dermatology.
J Am Acad Dermatol 1996; 35:615.
Ference J, Last A. Choosing Topical Corticosteroids. Am Fam
Physician 2009;79 (2):135-140.
Goldstein B, Goldstein A. General principles of dermatologic therapy
and topical corticosteroid use. In: UpToDate, Basow, DS (Ed),
UpToDate, Waltham, MA, 2011.
Hettiaratchy S, Papini R. ABC of burns. Initial management of a major
burn: II assessment and resuscitation. BMJ. 2004;329:101-103. 64
 References
High Whitney A, Fitzpatrick James E, "Chapter 219. Topical Antifungal
Agents" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller
AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2969866.
Limb Susan L, Wood Robert A, "Chapter 230. Antihistamines" (Chapter).
Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ:
Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=3003116.
Nelson A, Miller A, Fleischer A, Balkrishnan R, Feldman S. How much of
a topical agent should be prescribed for children of different sizes? J
Derm Treat 2006; 17:224-228.
Weller R, Hunter J, Dahl M. Clinical Dermatology. 2008; 55.
Wolff K, Johnson R. Fitzpatricks Atlas of & Synopsis of Clinical
Dermatology. 2009; Sixth Ed.
65