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D44 Dermatology
Miscellaneous Lesions
Toronto Notes 2019
Dermatologic Therapies
Table 26. Common Topical Therapies
Topical Vehicles
• Ointment (water in oil): hydrate, greasy
• Cream (oil in water): hydrate, variable
• Lotion (powder in water): drying, cosmesis
• Solutions (water, alcohol, propylene glycol)
• Gel (solution that melts on contact with
skin, alcohol): drying
• Foam is a newer vehicle and several
agents are now available in foam vehicles Examples include Olux-E (clobetasol), Verdesso (desonide), Luxiq (betamethasone), and Enstilar (betamethasone propionate and calcipotriol)
• Sprays: Lamisil (terbinafine) spray, Clobex spray (clobetasol)
• Laquers: Penlac (ciclopirox), Jublia (efinaconazole)
Dosing Schedule
0.005% cream, ointment, scalp solution, apply bid
For maintenance therapy apply OD
5% cream applied 3x/wk Apply at bedtime, leave on 6-10 h, then wash off with mild soap and water
Max duration 16 wk
1% or 5% cream, applied once overnight to all skin areas from neck down, repeated one week later
1% cream bid
Use for as long as lesions persist and discontinue upon resolution of symptoms
0.03% (children) or 0.1% (adults) ointment bid Continue for duration of disease PLUS 1 wk after clearing
Indications
Psoriasis
Genital warts Cutaneous warts AK
Superficial BCC
Scabies (Kwellada-P Lotion, Nix® Dermal Cream)
Pediculosis (Kwellada-P
Crème Rinse®, Nix Crème Rinse®)
AD (mild to moderate)
AD (mild to moderate)
Comments
Burning, itching, skin irritation, worsening of psoriasis Avoid face, mucous membranes, eyes; wash hands after application
Maximum weekly dosage of cream by age:
2-5 yr – 25 g/wk 6-10 yr – 50 g/wk 11-14 yr – 75 g/wk >14 yr – 100 g/wk
Inactivated by light (do not apply before phototherapy)
Avoid natural/artificial UV exposure
Local skin and application site reactions Erythema, ulceration, edema, flu-like symptoms Works best for warts on mucosal surfaces May induce inflammation and erosion
Do not use in children <2 yr
Hypersensitivity to drug, or known sensitivity to chrysanthemums
Local reactions only (resolve rapidly); including burning, pruritus
Low toxicity, excellent results
Consider second application after 7 d
Burning
Lacks adverse effects of steroids
May be used on all skin surfaces including head, neck, and intertriginous areas
Expensive
Burning
Lacks adverse effects of steroids
May be used on all skin surfaces including head, neck, and intertriginous areas
Expensive
Drug Name
Calcipotriol
(Dovonex®)
Imiquimod
(Aldara®)
Permethrin
(Kwellada® P Lotion and Nix® Dermal Cream)
Pimecrolimus
(Elidel®)
Tacrolimus Topical (Protopic®)
Indications
Severe psoriasis
Other disorders of hyperkeratinization (ichthyosis, Darier’s disease)
Chickenpox
Herpes zoster
Genital herpes
Acute and prophylactic to reduce transmission in infected patients Herpes labialis
Psoriasis
May also be effective in: Lichen planus
EM
Recalcitrant urticaria Recalcitrant AD
Dermatitis herpetiformis, neutrophilic dermatoses
Table 27. Common Oral Therapies
Drug Name
Acitretin
(Soriatane®)
Antivirals
Cyclosporine
(Neoral®)
Dapsone
Dosing Schedule
25-50 mg PO OD; maximum 75 mg/d
famciclovir (Famvir®)
250 mg PO tid x 7-10 d (for 1st episode of genital herpes)
125 mg PO bid x 5 d (for recurrent genital herpes)
valacyclovir (Valtrex®)
1000 mg PO bid x 7-10 d
(for 1st episode of genital herpes) 500 mg PO bid x 5 d
(for recurrent genital herpes)
2.5-4 mg/kg/d PO divided bid Max 4 mg/kg/d
After 4 wk may increase by 0.5 mg/kg/d q2wk
Concomitant dose of magnesium may protect the kidneys
50-100-150 mg PO OD tapering to 25-50 mg PO OD to as low as
50 mg 2x/wk
Comments
Monitoring strategies
Monitor lipids, LFTs at baseline and q1-2wk until stable
Contraindications
Women of childbearing potential unless strict contraceptive requirements are met Drug interactions
Other systemic retinoids, methotrexate, tetracyclines, certain contraceptives May be combined with PUVA phototherapy (known as re-PUVA)
Side effects
Headache, nausea, diarrhea, abdominal pain Reduce dose if impaired renal function
Side effects
Dizziness, depression, abdominal pain Reduce dose if impaired renal function Drug interactions
cimetidine
Monitoring strategies
Blood pressure, renal function
Contraindications
Abnormal renal function, uncontrolled hypertension, malignancy (except NMSC), uncontrolled infection, immunodeficiency (excluding autoimmune disease), hypersensitivity to drug
Long-term effects preclude use of cyclosporine for >2 yr; discontinue earlier if possible May consider rotating therapy with other drugs to minimize adverse effects of each drug
Monitoring strategies
Obtain G6PD levels before initiating; in the initial 2 wk obtain methemoglobin levels and follow the blood counts carefully for the first few months
Side effects
Neuropathy
Hemolysis (Vitamin C and E supplementation can help prevent this)
Drug interactions
Substrate of CYP2C8/9 (minor), 2C19 (minor), 2E1 (minor), 3A4 (major)
Often a dramatic response within hours