Topical Treatments

Goals and Objectives

• By completing this module, you should be able to:

1. Estimate the amount of topical medication needed for therapy based on frequency of application and body surface area involved
2. Choose appropriate strengths of topical steroids based on age, body location and severity of dermatitis
3. List side effects of prolonged use of topical steroids
4. Discuss the basic principles of medications used to treat acne
5. Discuss the basic principles of topical antifungals, oral antihistamines and topical psoriasis medications

Principles of Dermatologic Therapy

• The efficacy of any topical medication is related to:

1. The active ingredient (inherent strength)
2. Anatomic site
3. The vehicle (the mode in which it is transported)
4. The concentration of the medication

1- Ointments

• occlusive; greasy has lubricant effects (e.g. Vaseline):

• USE for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesions
• AVOID on hairy and intertriginous areas as armpits, groin, pannus)

2- Creams

• Vanish when rubbed in:
• Less greasy than ointment, has drying effects; not occlusive, can sting, more likely to cause irritation
• USE for acute exudative inflammation & intertriginous areas

3- Lotion (pourable liquid): less greasy, less

• occlusive; may contain alcohol (drying effect on
• oozing lesion); penetrate easily, little residue

• USE for hairy areas

4- Foams (cosmetically elegant):

• spread readily, easier to apply; more expensive

• USE for hairy areas; inflammation

5- Sprays: Aerosols (rarely used), pump sprays

6- Oils:

• less stinging than lotions or solutions

• USE for the scalp, especially for people with coarse or very curly hair

7- 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

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

Topical Prescriptions

What goes into a topical prescription?

• 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

Common Types of Dermatologic Medications

Topical Corticosteroids

• Topical steroids produce an anti-inflammatory response in the skin
• They are effective for conditions that are characterized by:

1. Hyperproliferation? psoriases
2. Inflammation? eczema, psoriases
3. Immunologic involvement? psoriases, bullous phemegoid
4. provide symptomatic relief for burning and pruritic lesions? itching without cause

• Corticosteroids are organized into classes based on their strength (potency)
• Therefore, steroids within any class are equivalent in strength
• Strength is depends on 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)

Topical Steroid Strength

Potency	Class	Example Agent	Prescribed for
Super high	I	Clobetasol propionate 0.05%	potency (Class I) are used for severe dermatoses over nonfacial and nonintertriginous areas * Scalp, palms, soles, and thick plaques on extensor surfaces
High	II	Fluocinonide 0.05%	potency steroids (Classes II-V) are appropriate for mild to moderate nonfacial and nonintertriginous areas * Okay to use on flexural surfaces for limited periods
Medium	III – V		same as above
		Triamcinolone acetonide ointment 0.1%
		Triamcinolone acetonide cream 0.1%
		Triamcinolone acetonide lotion 0.1%
Low	VI – VII		steroids (Classes VI, VII) can be used for large areas and on thinner skin * Face, eyelid, genital and intertriginous areas
		Fluocinolone acetonide 0.01%
		Desonide 0.05%
		Hydrocortisone 1%

Topical Steroid Strength

• Remember to look at the class not the percentage
  • Note that clobetasol 0.05% is stronger than hydrocortisone 1%.
• When several are listed, they are listed in order of strength
  • Note that triamcinolone ointment is stronger than triamcinolone cream or lotion because of the nature of the vehicle

Local Side Effects of Topical Steroids

• 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

Local Side Effects of Topical Steroids

1. Skin atrophy -side effects can be used for keloids treatment
2. Telangiectasias
3. Striae
4. Acne
5. Steroid Rosacea
6. Hypopigmentation - may also treat hyperpigmentation

Local Side Effects of Topical Steroids

• Striae

• Skin Atrophy

Local Side Effects of Topical Steroids

Hypopigmentation

Systemic Side Effects of Topical Steroids

Systemic side effects are rare due to low absorption - They can include:

1. Glaucoma (when steroid applied to the eyelid)
2. Hypothalamic pituitary axis suppression
3. Cushing’s syndrome
4. Hypertension
5. 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

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