KULIAH REGULER

2016

DERMATOVENEREOLOGICAL
THERAPY

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 Dr. Muslimin, SpKK

Department of Dermatovenereology
Faculty of Medicine
Diponegoro University Semarang

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Dermatovenereological
therapy

 There are two parts of therapy in

dermatovenereology

 Dermatological therapy
 Venereological therapy

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Dermatological therapy

 Therapy used in treating skin diseases

consists:

 topical therapy
 systemic therapy
 physical modalities

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 Dermatological therapy (2)
 The objectives:  General principles:
 to heal/cure  Listen to what patient has to say.
 to improve/repair  Look at the whole person and not
only at her/his rash.
 to minimize disability
 Be realistic about what is possible.
 to prevent
 Make a diagnosis before
embarking on treatment.
 Explain to the patient what is
going on.
 Treatment of acute rashes.

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 Venereological therapy
 Therapy used in treating  Regimens must be efficacious, easily to
venereal disease administered, simple to administered,
consists: and preferably single dose, safe.
 topical therapy  Timely treatment is essensial to stop
transmission of disease.
 systemic therapy
 Inadequate or self treatment or
 surgical therapy
traditional treatment  resistence to
 General principles: antibiotics
 Based on clinical  Sex partner referral for diagnosis,
syndromes  laboratory councelling, and treatment to prevent
test to confirm the further transmission and reinfection.
diagnosis.

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 Topical therapy
 Appropiate topical  Assessment of skin’s
therapy requires: present condition:
 Accurate diagnosis.  History of disease
 Appreciation of the  acute/chronic, stage,
patient´s skin type. localize/generalize
 Assessment of skin’s
 Skin effloresense
present condition.
 intact/damage
 Choice of the correct
therapeutic agent.
 Use of the correct vehicle.

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 Topical therapy (2)

 Advantages of topical therapy:

 Direct delivery to target tissue.
 Reduced systemic side effects.
 The success or failure of therapy is observed
directly.

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 Topical therapy (3)
 Adverse side effects:
 Irritation.
 Sensitization.
 Akneiform folliculitis.
 Pigmentation.
 Photoallergy/phototoxi
city.
 Percutaneus
absorption:
 Penetration through
the stratum corneum
 Metabolism of drug
 Transdermal delivery
sistems
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 Topical therapy (4)

 Penetration through  Penetration

the stratum corneum enhancers:
interfered by:  urea
 skin temperature  salicylic acid
 hydration of stratum  dimethyl sulphoxide
corneum
 propylene glycol
 skin condition
 location
 age
 topical agent

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 Topical therapy (5)

 Elements of topical  Amount needed for

prescription: one application of
 Medication cream:
 Vehicle  face : 2g
 Concentration  arm : 3g
 Amount  leg : 4g
 How to apply  whole body : 30 g
Ointment (-10%), lotion (+50%)

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 Topical therapy (6)

 Topical agent  The functions of vehicle:

contains:  to transport
 Vehicle or the base  to stabilize the active
constituent
 The active ingredient  to transfer
 The additives:
 preservatives
 colourants
 fragrance
 emulsifyng agents &
stabilizers

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There are 3 building blocks for all preparation

Powder

Shake lotion
Ointment paste
Drying paste

Grease Creams Liquid

Ointment Cold cream Vanishing cream

w/o o/w 13
 Topical therapy (7)
Face
Site of lesions Hairy skin
Trunk/Extremities
Genitalia
Skin fold
The choice of Generalize
vehicle Powder/shake lotion
Cream
Tincture
Liquid
Ointment
The form of vehicle
Gel
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 Topical therapy (8)
The choice of topical vehicle

VEHICLE COMPOSITION EXAMPLE USES

Powder Solid Zinc oxide - Absorbent, protective

Talcum venetum & cooling
Calamine - Acute or subacute
Titanium dioxide inflamation
- Face, body & flexures
- CI: exudating areas
Liquid/solution Liquid Water - Medicated bath
Alcohol - Soak/wet dressings
Ether Tincture - Compress
Propylene glycol - Oily skin & hairy
areas
Shake lotion Liquid & solid Calamine lotion - Anti pruritic, anti
Burrow’s lotion eczematous & cooling
- Dry surfaces/mildly
oozing
- CI: exudating & hairy
areas
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 The choice of topical vehicle (2)

Vehicle Composition Examples Uses

Cream  Oil in water (O/W) Vanishing cream  to make the skin became dry
~ milk Aqueous cream  not suitable for the dry skin
 used on acute/subacute
inflammation, hairy & the
flexure areas
 Water in oil (W/O) Cold cream  easier to apply than ointments,
~ butter Petroleum (vaselin) more greasier than the
Lanolin vanishing cream
Ointment Oil, little or no water Vaselin, paraffin,  the best penetration & used in
lanolin chronic inflammation
 CI: wet surfaces, hairy &
flexure areas
Paste Oil & solid Zinc oxide paste  the best protection
Zinc oxide linament  CI: exudating, hairy & flexure
Titanium dioxide areas
paste* * sun block agent
Gel Semisolid Methylcellulose,  Solid or semisolid in the cold &
agar/gelatin in a become liquid on warming up
liquid  As alternatives to lotions on
hairy & oily skin 16
 The active ingredients are used for topical therapy

The active ingredients The effects of therapy Uses

1. Boric acid Anti septic, astringent 3% solution  compress
10% ointment, powder, shake lotion
2. Benzoic acid Anti fungal, anti septic 5-10% Whitfield ointment
3. Salisilic acid Keratoplasty  1-2% 2-4% ointment
Keratolytic  > 3%
Anti bacterial, anti fungal
4. TCA solution
Caustic
5. Aluminium chloride solution
Anti fungal, anti hyperhidrotic
6. Anastesin powder
Anti pruritic
7. Gamexan, ointment, cream, lotion
Pediculoid
crotamiton,
permethrin
8. Liquor carbonate Emulsion, ointment
Anti pruritic, anti eczema
detergent
9. Resorcinol ointment
Anti bacterial, anti fungal,
keratolytic, anti pruritic, anti
eczema 17
 The active ingredients are used for topical therapy (2)

The active ingredients The effects of therapy Uses

10. Rivanol Anti septic, astringent Compress
11. Selenium sulfide Anti seborhoe, anti fungal Shampoo
12. Sulfur praecipitatum Anti pruritic, keratolytic, anti Ointment
bacterial
13. Sodium thiosulfide Anti fungal Solution
14. Talcum venetum Closer, Glider Powder
15. Zinc oxide Anti septic, tissue granulation Powder, compress
16. Eritromycin 2% Bacteriostatic  Acne Ointment, gel, lotion
Clindamycin 1% Bacteriostatic  Acne Ointment, gel, lotion
Gentamycin 0,1% Cream, ointemnt
Bactericyd
Mupirocyn 2% Ointment
Bactericyd, bacteriostatic
Bactericyd
Fucidic acid 2% Cream, ointment
 Rosacea
Metronidazol 1% Cream, gel
Silver sulfadiazine Bactericyd  burn Cream
17. Corticosteroids Anti inflammation, Ointment, cream, gel
immunosuppressant, anti
proliferation
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 Topical therapy (9)
Soaks/Compresses

 Materials
 Normal saline solution
 KMnO4 solution
 0.1% acetic acid solution
 3% boric acid solution
 0.1% rivanol solution

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 Methods for soaks
 Open soaks
 application of a water
compress without
occlusion
 cause cooling & drying by
evaporation
 effective for drying moist,
oozing, acute
inflammation skin
eruptions
 applied for 20’ 3x a day
 Close soaks
 employ occlusion over a
compress
 cause heat retention
 excellent for debridement of
wound & ulcer  maceration
 applied for 1-2 hours 2-3x a
day
 applied 24 hour 2-3 day, rewet
the dressing 4-5x for removing
thick crusts
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 The active ingredients are used for topical therapy (3)

 Corticosteroids  Topical side effects:

 striae & atrophy
 chronic, extensive use
 acne
of potent topical  perioral dermatitis
steroids even under  rosacea
occlusion  purpura & teangiectasia
 “masking” effect
 Glaucoma
 systemic side effects:  Allergic contact dermatitis
 adrenal suppression  Hypopigmentation
 Cushing’s syndrome  Reduced wound healing
 Hirsutism (face)
 growth retardation
 Folliculitis & miliaria

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 The active ingredients are used for topical therapy (3)
Regional Differences in Penetration of
Glucocorticoids

 Mucous membrane  Upper arms & legs

 Scrotum  Lower arms & legs
 Eyelids  Dorsa of hands and feet
 Face  Palmar & plantar skin
 Chest & back  Nails

Less penetration

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 The active ingredients are used for topical therapy (4)
Classification of topical steroids

Group 1 Mildly Group 2 Group 3 Potent Group 4 Very

potent Moderately potent
potent
Alclometasone Betamethasone Beclomethasone dipoprionate Clobetasol
dipropionate valerate 0.025% propionate
0.05% 0.025% Betamethasone dipoprionate 0.05%
Fluocinolone Clobetasone 0.05% Diflucortolone
acetonide butyrate 0.05% Betamethasone valerate 0.1% valerate 0.3%
0.0025% Desoxymethaso Desoxymethasone 0.25% Halcinonide
Hydrocortisone ne 0.05% Diflucortolone valerate 0.1% 0.1%
0.5-2.5% Fluocinolone Fluocinolone acetonide 0.025%
acetonide Fluocinonide 0.05%
0.00625% Hydrocortisone 17-butyrate
Flurandrenolone 0.1%
0.0125% Mometasone furoate 0.1%
Triamcinolone acetonide 0.1%
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 Systemic therapy
CLASSIFICATION EXAMPLES DOSES
1. Antibacterial Penicilline V A: 250-500 mg (400,000-800,000units)/6-8 hours
C: 15-50 mg/kg/d in 3 or 4 divided doses
Aqueous penicillin G A: 5 million units or more
C: 50,000-100,000 unit/kg/g
Penicillin G procaine A: 600,000-1 million unit or more daily
C: 25,000-50,000 units/kg/d every 12 hours
Penicillin G benzathine A: 1.2 million units
C:  27 kg 900,000 units
C: < 27 kg 300,000-600,000 units
Ampicillin A: 250-500 mg/6 hours
C: < 20 kg 50 mg/kg/d every 6 hours
Amoxicillin A: 0.5 g/8 hours
C: < 20 kg 50 mg/kg/d every 8 hours
Ampicillin + clavulanic A: 250 –500 mg/8 hours
acid C: 20 mg/kg/d every 8 hours
Eritromisin A: 250-500 mg/6 hours
C: 30-50 mg/kg/d every 6 hours
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 Systemic therapy (2)
1. Antibacterial 1st generation
sephalosporins
 Sefalexin A: 1-4 g/d 4 divided doses
C: 25-50 mg/kg/d 4 divided doses
 Sefadroxil A: 1-2 g/d 2 divided doses
C: 30 mg/kg/d 2 divided doses
Clindamycin A: 150-300 mg/d
C: 8-16 mg/kg every 6 hours
Tetracycline A: 1-2 g/d 2 or 4 divided doses
C: < 8 years 25-50 mg/kg/d
Doxycycline
A: 1st d 100 mg/12 hours  100 mg/d
Minocycline C: > 8 years 2 mg/lb/d every 12 hours
A: 1st d 100 mg/12 hours  100 mg/d
C: > 8 years 1st d 4mg/kg/d every 12
hours  2 mg/kg/d every 12 hours
Trimethoprim-
A: 160/80 every 12 hours
Sulfamethoxazole
C: T 8 mg/kg/d, S 40 mg/kg/d every
Dapson 12 hours
A: 1st dose 50 mg/d  100-30025mg/d
C: 1st dose 0.5 mg/kg/d
 Systemic therapy (3)

3. Anti histamine Sedation

 CTM
 Oxatomide 3 x 4-12 mg/d
 Cyproheptadine
Non sedation
 Terfenadin 2 x 60 mg/d
 Astemizol 10 mg/d
 Loratadine 10 mg/d

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 Systemic therapy (3)

Working mechanism: Anti proliferative

Anti Inflamation
Immunosuppressant

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Systemic therapy (4)

1. Kapsomers – kapsid
2. Asam nukleat
3. Nukleokapsid
4. Peplomer
5. Envelop
6. Matriks protein
7. Kapsomers – kapsid
8. Asam nukleat
9. Nukleokapsid
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Systemic therapy (5)

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 Terapi sistemik (5)
Antihistamin

 Cara kerja: dengan menghambat reseptor

H1 and H2 pada sel target.
 Interaksi histamin & reseptor jaringan H1:
 Permeabilitas vena meningkat
 Kontraksi otot polos
 Resistensi jalan nafas meningkat
 Kemotaksis eosinofil & netrofil meningkat
 Stimulasi mukosa hidung
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 Antihistamin (2)

 Interaksi histamin & reseptor jaringan H2:

 Permeabilitas vena meningkat
 Cardiac rate meningkat
 Kontraksi otot jantung meningkat
 Sekresi asam lambung meningkat
 Stimulasi CD8 & limfosit
 Peningkatan produksi mukosa jalan nafas
 Inhibisi kemotaksis netrofil & eosinofil
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 Antihistamin (3)

 Antihistamin H1
 Antihistamin tradisional/klasik/tipe H1
generasi I
 Antihistamin tipe H1 generasi II/sedasi
rendah

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 Antihistamin tradisional/klasik/tipe
H1 generasi I

 Efek:  Klasifikasi:
 antihistamin
 sedasi
 antikolinergik
 aktivitas antiemetik
 efek anti motion
sickness
 Alkilamine = chlorpheniramine
maleate/chlortrimethone maleate
 Aminoalkyl ether =
diphenhidramine HCl
 Ethylenediamine =
Tripelennamine HCl
 Phenotiazine = Prometazine HCl
 Piperidine = Siproheptadine HCl
 Piperazine = Hydroxyzine HCl

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Antihistamin tipe H1 generasi II/sedasi
rendah

 Efek sedasi &  Macam:

antikolinergik lebih  Terfenadine
rendah  Astemizole
 Cetirizine
 Loratadine
 Acrivastine
 Oxatomide
 Fexofenadine
 Desloratadine

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 Antihistamin (4)

 Antihistamine H2  Obat lain dengan

 kurang lipofilik aktivitas antihistamin:
 efek terhadap susunan  antidepresan trisiklik
saraf pusat lebih  ketotifen
rendah
 jenis:
 cimetidine
 Ranitidine
 Famotidine
 Nizatadine

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 Kortikosteroid
Perbandingan potensi

Obat Dosis
setara
Kortison 25
Kortisol 20
Prednison/predinosolon 5
Metil prednisolon/triamsinolon 4
Betametason 0,60
Deksametason 0,75

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 Kortikosteroid (2)
 Indikasi
 mutlak: pemfigus, lupus
eritematosus sistemik,
nekrolisis epidermal toksik,
sindrom Steven Johnson
 relatif: pemfigoid bulosa,
eritema nodusum, lupus
eritematosus diskoid,
eritroderma, eritema
multiforme
 Kontrindikasi:
 absolut: herpes
simpleks, TBC tidak
diterapi
 relatif: ulkus
peptikum, infeksi, DM,
hipertensi, kehamilan
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 Kortikosteroid (3)
 Komplikasi:
 Hipertensi
 Perubahan mood, psikosis,
pseudotumor
 Supresi aksis hipotalamus-
pituitari-adrenal, hirsutism,
menstruasi ireguler,
kegemukan, moon face,
buffalo hamp
 ulkus peptikum, pankreatitis
 DM
 limfositopenia,
monositopenia, netrofilia
 infeksi oportunistik
 osteoporosis, nekrosis
aseptik kepala femur &
humerus, miopati
 glaukoma & katarak
 retensi Na & cairan,
hipokalemia alkalosis
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 Terapi nutrisi
 Tujuan: memberi  Defisiensi vitamin:
keseimbangan anabolisme-  kheilitis, dermatitis
katabolisme tergantung seboroik (vit
kondisi seseorang B2=riboflavin)
 Komponen:  stomatitis angularis
 protein (vit B6=piridoksin)
 karbohidrat  pelagra (niasin) 4D:
 lemak dermatitis, diare,
 vitamin & mineral dimensia, death

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 Terapi nutrisi (2)

 Defisiensi mineral:  Bentuk:

 akrodermatitis  diet biasa
enteropatika (Zn)  diet padat, lunak,
 dermatitis saring, bubur
 diare  diet cair
 alopesia
 diet khusus: TKTP,
 Karsinoma Sel Basal rendah garam, bebas
(Se) lemak, bebas gluten
 total parenteral nutrisi
(TPT)

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 Physical methods of therapy

Surgical
Environmental climate
therapy
Dead sea  psoriasis
Sea coast  atopics Cutting Electrosurgery Cryotherapy

Wave

Phototerapy Ionizing radiation (X ray)

UVA UVB Skin kancers Benign conditions

(rarely & great caution)
PUVA for psoriasis Psoriasis Kaposi’s sarcoma
• Acne
Nummular dermatitis Lymphoma
• Keloids
Parapsoriasis
• Hemangiomas
Pityriasis rosea
Acne 41
 Cutaneous surgery

 Cold steel surgery:  Cryosurgery

 elliptic excission, skin  Chemical peel
graft, flap, biopsy,
MOHS, blepharoplasty,
 Liposuction
scalp reduction & hair  LASER
transplantation  Soft tissue
 Electrosurgery augmentation
 Dermabrasion
 Curettage

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 Bedah kulit (2)
 Bedah listrik/electrosurgery  Bedah kimia (chemical peeling)
 suatu tindakan bedah
dengan menggunakan alat
listrik yang membangkitkan
aliran listrik terkontrol 
destruksi jaringan yang
selektif
 macam: elektrodesikasi,
elektrofulgurasi,
elektrokoagulasi,
elektroseksi, elektrolisis
 suatu tindakan bedah dengan
mengoleskan bahan kimia 
perubahan anatomi;
makro/mikro lesi pada
epidermis/dermis
 macam:
 superfisial: TCA 10%, as. Retinoat,
AHA
 medium: TCA 35-50%, AHA
 deep: TCA 70%, fenol jenuh 88%
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 Bedah kulit (3)
 Bedah beku (cryosurgery)  Dermabrasi
 suatu tindakan bedah  suatu tindakan bedah
dengan menggunakan untuk mengelupaskan
bahan kriogen  kulit selapis demi
membekukan jaringan  selapis dengan
nekrosis menggunakan alat
 macam: dermabrader
 nitrogen cair (-1960C)
 macam:
 N2O (-89,50C)
 sikat kawat
 CO2 (-78,50C)
 diamond fraise
 Freon 22, 12 (-410C, -600C)

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 Bedah kulit (4)
 Laser: Light Amplification
by Stimulating Emission
of Radiation
 Prinsip: amplifikasi cahaya
 Tujuan:
 memotong
 koagulasi
 neovaskularisasi
 proliferasi fibroblas
 epitelisasi
 Sifat:
 monokromatis,
kolomasi, koheren
 spektrum optik
(gelombang kasat
mata-infra merah)
 Respon jaringan:
 refleksikan
 dibiaskan
 ditransmisikan
 diserap

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 Laser (2)
 Macam:  Berpulsa dengan energi tinggi
 Kontinu (CW)  Laser Dye: nevus araneus,
 Argon: adenoma sebasea, rosasea
telangiektasis, lesi jinak
berpigmen, granuloma piogenikum  Laser Ruby: lesi jinak berpigmen
 CW Nd YAG:  Laser Q-Switched Ruby: tato
 CW CO2: veruka vulgaris,  Laser Q-Switched Alexandrite
kondiloma akuminata, keloid,
moluskum kontagiosum, tumor
 Laser Q-Switched Nd YAG
apendik kulit, psoriasis, tato,
nevus epidermal
 Laser Copper Vapox
 Laser KTP

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A view of Marburg, Germany 47