Dermatological therapy (1)General principles:Listen to what patient has to say.Look at the whole person and not only at her/his rash.Be realistic about what is possible.Make a diagnosis before embarking on treatment.Explain to the patient what is going on.Treatment of acute rashes.

Dermatological therapy (2)The objectives:to heal/cureto improve/repairto minimize disabilityto prevent

Dermatological therapy (3)Therapy used in treating skin diseases consists:topical therapysystemic therapyphysical modalities

Topical therapyAppropiate topical therapy requires:Accurate diagnosis.Appreciation of the patients skin type.Assessment of skins present condition.Choice of the correct therapeutic agent.Use of the correct vehicle.Assessment of skins present condition:History of diseaseacute/chronic, stage, localize/generalizeSkin effloresenseintact/damage

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.

Topical therapy (3)Adverse side effects:Irritation.Sensitization.Akneiform folliculitis.Pigmentation.Photoallergy/phototoxicity.Percutaneus absorption:Penetration through the stratum corneumMetabolism of drugTransdermal delivery sistems

Topical therapy (4)Penetration through the stratum corneum interfered by:skin temperaturehydration of stratum corneumskin conditionlocationagetopical agentPenetration enhancers:ureasalicylic aciddimethyl sulphoxidepropylene glycol

Topical therapy (5)Elements of topical prescription:MedicationVehicleConcentrationAmountHow to applyAmount needed for one application of cream:face: 2 garm : 3 gleg : 4 gwhole body: 30 g Ointment (-10%), lotion (+50%)

Topical therapy (6)Topical agent contains:Vehicle or the baseThe active ingredientThe additives:preservativescolourantsfragranceemulsifyng agents & stabilizersThe functions of vehicle:to transportto stabilizeto transferthe active constituent

There are 3 building blocks for all preparationPowderGreaseLiquidDrying pasteOintment pasteShake lotionOintmentCreamsCold creamw/oVanishing creamo/w

Topical therapy (7)The choice of vehicleSite of lesionsThe form of vehicleFaceHairy skinTrunk/ExtremitiesGenitaliaSkin foldGeneralizePowder/shake lotionCream TinctureLiquidOintmentGel

Topical therapy (6) The choice of topical vehicle

VEHICLE

COMPOSITION

EXAMPLE

USES

Powder

Solid

Zinc oxide

Talcum venetum

Calamine

Titanium dioxide

Absorbent, protective & cooling

Acute or subacute inflamation

Face, body & flexures

CI: exudating areas

Liquid/solution

Liquid

Water

Alcohol

Ether

Propylene glycol

Medicated bath

Soak/wet dressings

Compress

Oily skin & hairy areas

Shake lotion

Liquid & solid

Calamine lotion

Burrows lotion

Anti pruritic, anti eczematous & cooling

Dry surfaces/mildly oozing

CI: exudating & hairy areas

Tincture

The choice of topical vehicle (2)

Vehicle

Composition

Examples

Uses

Cream

Oil in water (O/W)

~ milk

Water in oil (W/O)

~ butter

Vanishing cream

Aqueous cream

Cold cream

Petroleum (vaselin)

Lanolin

to make the skin became dry

not suitable for the dry skin

used on acute/subacute inflammation, hairy & the flexure areas

easier to apply than ointments, more greasier than the vanishing cream

Ointment

Oil, little or no water

Vaselin, paraffin, lanolin

the best penetration & used in chronic inflammation

CI: wet surfaces, hairy & flexure areas

Paste

Oil & solid

Zinc oxide paste

Zinc oxide linament

Titanium dioxide paste*

the best protection

CI: exudating, hairy & flexure areas

* sun block agent

Gel

Semisolid

Methylcellulose, agar/gelatin in a liquid

Solid or semisolid in the cold & become liquid on warming up

As alternatives to lotions on hairy & oily skin

The active ingredients are used for topical therapy

The active ingredients

The effects of therapy

Uses

1. Boric acid

2. Benzoic acid

3. Salisilic acid

4. TCA

5. Aluminium chloride

6. Anastesin

7. Gamexan, crotamiton, permethrin

8. Liquor carbonate detergent

9. Resorcinol

Anti septic, astringent

Anti fungal, anti septic

Keratoplasty 1-2%

Keratolytic > 3%

Anti bacterial, anti fungal

Caustic

Anti fungal, anti hyperhidrotic

Anti pruritic

Pediculoid

Anti pruritic, anti eczema

Anti bacterial, anti fungal, keratolytic, anti pruritic, anti eczema

3% solution compress

10% ointment, powder, shake lotion

5-10% Whitfield ointment

2-4% ointment

solution

solution

powder

ointment, cream, lotion

Emulsion, ointment

ointment

The active ingredients are used for topical therapy (2)

The active ingredients

The effects of therapy

Uses

10. Rivanol

11. Selenium sulfide

12. Sulfur praecipitatum

13. Sodium thiosulfide

14. Talcum venetum

15. Zinc oxide

16. Eritromycin 2%

Clindamycin 1%

Gentamycin 0,1%

Mupirocyn 2%

Fucidic acid 2%

Metronidazol 1%

Silver sulfadiazine

17. Corticosteroids

Anti septic, astringent

Anti seborhoe, anti fungal

Anti pruritic, keratolytic, anti bacterial

Anti fungal

Closer, Glider

Anti septic, tissue granulation

Bacteriostatic Acne

Bacteriostatic Acne

Bactericyd

Bactericyd, bacteriostatic

Bactericyd

Rosacea

Bactericyd burn

Anti inflammation, immunosuppressant, anti proliferation

Compress

Shampoo

Ointment

Solution

Powder

Powder, compress

Ointment, gel, lotion

Ointment, gel, lotion

Cream, ointemnt

Ointment

Cream, ointment

Cream, gel

Cream

Ointment, cream, gel

Topical therapy (7) Soaks/CompressesMaterialsNormal saline solutionKMnO4 solution0.1% acetic acid solution3% boric acid solution0.1% rivanol solution

Methods for soaksOpen soaksapplication of a water compress without occlusioncause cooling & drying by evaporationeffective for drying moist, oozing, acute inflammation skin eruptionsapplied for 20 3x a dayClose soaksemploy occlusion over a compresscause heat retentionexcellent for debridement of wound & ulcer macerationapplied for 1-2 hours 2-3x a dayapplied 24 hour 2-3 day, rewet the dressing 4-5x for removing thick crusts

The active ingredients are used for topical therapy (3)Corticosteroidschronic, extensive use of potent topical steroids even under occlusion

systemic side effects:adrenal suppressionCushings syndromegrowth retardationTopical side effects:striae & atrophyacneperioral dermatitisrosaceapurpura & teangiectasiamasking effectGlaucomaAllergic contact dermatitisHypopigmentationReduced wound healingHirsutism (face)Folliculitis & miliaria

The active ingredients are used for topical therapy (3) Regional Differences in Penetration of GlucocorticoidsMucous membraneScrotumEyelidsFaceChest & backUpper arms & legsLower arms & legsDorsa of hands and feetPalmar & plantar skinNailsLess penetration

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

Group 1 Mildly potent

Group 2 Moderately potent

Group 3 Potent

Group 4 Very potent

Alclometasone dipropionate 0.05%

Fluocinolone acetonide 0.0025%

Hydrocortisone 0.5-2.5%

Betamethasone valerate 0.025%

Clobetasone butyrate 0.05%

Desoxymethasone 0.05%

Fluocinolone acetonide 0.00625%

Flurandrenolone 0.0125%

Beclomethasone dipoprionate 0.025%

Betamethasone dipoprionate 0.05%

Betamethasone valerate 0.1%

Desoxymethasone 0.25%

Diflucortolone valerate 0.1%

Fluocinolone acetonide 0.025%

Fluocinonide 0.05%

Hydrocortisone 17-butyrate 0.1%

Mometasone furoate 0.1%

Triamcinolone acetonide 0.1%

Clobetasol propionate 0.05%

Diflucortolone valerate 0.3%

Halcinonide 0.1%

Systemic therapy

CLASSIFICATION

EXAMPLES

DOSES

1. Antibacterial

Penicilline

Aqueous penicillin G

Penicillin G procaine

Penicillin G benzathine

Ampicillin

Amoxicillin

Ampicillin + clavulanic acid

Eritromisin

A: 250-500 mg (400,000-800,000units)/6-8 hours

C: 15-50 mg/kg/d in 3 or 4 divided doses

A: 5 million units or more

C: 50,000-100,000 unit/kg/g

A: 600,000-1 million unit or more daily

C: 25,000-50,000 units/kg/d every 12 hours

A: 1.2 million units

C: > 27 kg 900,000 units

C: < 27 kg 300,000-600,000 units

A: 250-500 mg/6 hours

C: < 20 kg 50 mg/kg/d every 6 hours

A: 0.5 g/8 hours

C: < 20 kg 50 mg/kg/d every 8 hours

A: 250 500 mg/8 hours

C: 20 mg/kg/d every 8 hours

A: 250-500 mg/6 hours

C: 30-50 mg/kg/d every 6 hours

Systemic therapy (2)

1. Antibacterial

1st generation sephalosporins

Sefalexin

Sefadroxil

Clindamycin

Tetracycline

Doxycycline

Minocycline

Trimethoprim-Sulfamethoxazole

Dapson

A: 1-4 g/d 4 divided doses

C: 25-50 mg/kg/d 4 divided doses

A: 1-2 g/d 2 divided doses

C: 30 mg/kg/d 2 divided doses

A: 150-300 mg/d

C: 8-16 mg/kg every 6 hours

A: 1-2 g/d 2 or 4 divided doses

C: < 8 years 25-50 mg/kg/d

A: 1st d 100 mg/12 hours 2nd 100 mg/d

C: > 8 years 2 mg/lb/d every 12 hours

A: 1st d 100 mg/12 hours 2nd 100 mg/d

C: > 8 years 1st d 4mg/kg/d every 12 hours 2nd 2 mg/kg/d every 12 hours

A: 160/80 every 12 hours

C: T 8 mg/kg/d, S 40 mg/kg/d every 12 hours

A: 1st dose 50 mg/d 2nd 100-300 mg/d

C: 1st dose 0.5 mg/kg/d

Systemic therapy (3)

3. Anti histamineSedation CTMOxatomideCyproheptadineNon sedationTerfenadinAstemizolLoratadineCetirizineFexofenadineDesloratadineLevocetirizine

3 x 4-12 mg/d

2 x 60 mg/d10 mg/d10 mg/d10 mg/d

2. Anti fungal

Griseofulvin

Ketokonazol

Itraconazol (Kandidosis vaginalis)

A: 500-1000 mg/d

C: > 2 years 10-12 kg/d

A: 200-400 mg/d

C: 3.3 mg/kg/d

A: 2 x 200 mg/d (1d)

2 x 100 mg/d (3ds)

Working mechanism: Inhibiting the synthesis of Ergosterol and 14- demethylase enzym

Systemic therapy (4)Working mechanism: Anti proliferativeAnti InflamationImmunosuppressant

4. Corticosteroids

Prednisone

Methylprednisolone

Triamcinolone

Dexamethason

Starting dose varies widely, depending on the condition being treated

5. Anti viral

Acyclovir

Valsiclovir

Famsiclovir

5 mg/kg/8 hour IV

HS: 5 x 200 mg ( 10 ds

HZ: 5 x 800 mg ( 7 10 ds

Systemic therapy (5)

6. Anti leprosy

7. Immune therapy

Rifampycin

Dapson

Lamprene

Immune modulator

Isoprenosin

Immune suppression

Methotrexate

Cyclophosphamide

Azathioprine

Cyclosphorine

600 mg/m (15 mg/kg/m)

100 mg/d (1-2 mg/kg/d)

300 mg/m( 50 mg/d

50 mg/kg/d 3-4 divided doses

10-25 mg/w, 2.5-7.5/12 hours 3 ds

100-200 mg/d ( MD 100 mg/d

50-150 mg/d (1-2 mg/kg/d)

3-5 mg/kg/d

Systemic therapy (6)AntihistamineMechanism of action: by inhibiting H1 and H2 receptor on target cells Interaction of histamine & H1 receptor:Increased vein permeabilitySmooth muscle contractionIncreased airway resistance Increased neutrophyl and eosinophyl chemotaxisNasal mucosa stimulation

Antihistamine (2)Interaction of histamine & H2 receptor:Increased vein permeabilityIncreased cardiac rateIncreased myocardial contractionIncreased gastric acid secretionStimulation of CD8 & lymphocyteIncreased airway mucosa secretionInhibition of neutrophyl and eosinophyl chemotaxis

Antihistamine (3)H1 antihistamineTraditional/classic type H1 antihistamine, 1st generationLow sedating type H1 Antihistamine, 2nd generation

Traditional/classic type H1 antihistamine, 1st generationEffects:antihistaminesedationanticholinergicAntiemetic activityAnti motion sickness effectClassification:Alkylamine = chlorpheniramine maleate/chlortrimethone maleateAminoalkyl ether = diphenhidramine HClEthylenediamine = Tripelennamine HClPhenotiazine = Prometazine HClPiperidine = Siproheptadine HClPiperazine = Hydroxyzine HCl

Low sedating type H1 Antihistamine, 2nd generation

Weaker sedating and anticholinergic effectExamples:TerfenadineAstemizoleCetirizineLoratadineAcrivastineOxatomideFexofenadineDesloratadine

Antihistamine (4)H2 AntihistamineLess lypophilicWeaker central nervous system effectexamples:cimetidineRanitidineFamotidineNizatadineOther drugs with antihistamine activity:Tricyclic antidepressantketotifen

Corticosteroid Potensial equivalent

Drug

Equivalent dose

Cortison

Cortisol

Prednison/predinosolon

Metil prednisolon/triamcinolon

Betamethason

Dexamethason

25

20

5

4

0,60

0,75

Corticosteroid (2)Indicationsabsolute: pemphigus, systemic lupus erythematosus, toxic epidermal necrolysis, Stevens-Johnson syndromerelative: bullous pemphygoid, erythema nodusum, discoid lupus erythematosus, erythroderma, erythema multiformeContraindications:absolute: herpes simplex, untreated TBRelative: peptic ulcer, infection, DM, hypertension, pregnancy

Corticosteroid (3)Complications:HypertensionMood disturbance, psychosis, pseudotumorHypothalamus-pituitary-adrenal axis supression, hirsutism, menstrual irregularity, obesity, moon face, buffalo humpPeptic ulcer, pancreatitisDMLymphocytopenia, monocytopenia, neutrophylia Opportunistic infectionosteoporosis, aseptic necrosis of femoral head & humerus, myopathy glaucoma & cataractSodium & fluid retention, hypokalemia, alkalosis

Physical methods of therapyEnvironmental climate therapyDead sea psoriasisSea coast atopicsSurgicalCryotherapyElectrosurgeryCuttingWavePhototerapy (1)UVAPUVA for psoriasisUVBPsoriasisNummular dermatitisParapsoriasisPityriasis roseaAcne Ionizing radiation (X ray)Skin cancersKaposis sarcomaLymphomaBenign conditions (rarely & great caution) Acne Keloid Hemangioma

KetrampilanTingkat kemampuan 1 : Mengetahui dan menjelaskanTingkat kemampuan 2 : Pernah melihat atau pernah didemonstrasikanTingkat kemampuan 3 : Pernah melakukan atau pernah menerapkan di bawah supervisiTingkat kemampuan 4 : Mampu melakukan secara mandiriKompetensiPunch biopsy (2)Incision/drainage of abscess (3)Excision of tumours (2)Cryotherapy on tumours (1)Wart, cryotherapy (3)Wound care (4)To apply a dressing (4)Varicose veins, compressive sclerotherapy (1)Varicose veins, ambulant compresive therapy on venouus leg ulcer (2)Phototherapy (1)

Cutaneous surgeryCold steel surgery:elliptic excission, skin graft, flap, biopsy (2), MOHS, blepharoplasty, scalp reduction & hair transplantationElectrosurgeryDermabrasionCurettage

Cryosurgery(1)Chemical peelLiposuctionLASERSoft tissue augmentation

Skin biopsyA skin biopsy is the removal a piece of skin to diagnose or rule out an illness.Biopsy TechniquesShave BiopsyPunch Biopsy (2)Fusiform/excisional Biopsy

Punch Biopsy-1More often used for deeper skin lesionsSmall cylinder of the skin is removed with a sharp, hollowed instrumen (2-6 mm).Large sample may be closed with stitches.

Punch Biopsy-2

Incision/drainage of abscess (3)

Open the cutaneous roof with fine scissors / an inverted # 11/ # 15 blade, grasp an edge & excise the overlying surface. Clean with saline & cover it with povidone iodine and a dressingAn abscess cavity is uncertain, aspirate it with a # 18 gauge needle after prepping with povidone-iodine. It cannot be located, antibiotics & intermittent warm compresses, check it in 24 hours

Anesthetize with regional field block 1% lidocain 1 cm from the border, inject into the roof of the abscess Incision should be large & directed RSTLThe cavity may be irrigated with saline & loosely packed with iodoform/plaine gauze. Leave this gauze and remove after 48 hoursUse intermittent warm water soaks after packing is removed

Cutaneous surgery (2)ElectrosurgeryA form of surgery using electrical equipment which generates controlled electric current to produce selective tissue destruction types: electrodesiccation, electrofulguration, electrocoagulation, electrosection, electrolysisChemical peelingA form of surgery by application of chemical agents to cause anatomical changes; for macro/micro lesions on epidermis/dermis Types: superficial: TCA 10%, retinoic acid, AHAmedium: TCA 35-50%, AHAdeep: TCA 70%, saturated phenol 88%

Cutaneous surgery (3)CryosurgeryA form of surgery by using cryogents tissue freezing necrosis Types: Liquid nitrogen (-1960C)N2O (-89,50C)CO2 (-78,50C)Freon 22, 12 (-410C, -600C)DermabrationA form of surgery to peel the skin layer by layer with dermabraderTypes:Wire brushDiamond fraise

Some conditions suitable for cryosurgeryPrecancerous lesions (1)Actinic keratosis, leukoplakia, Bowens disease, lentigo malignaEpithelial benign lesionsSeborrhoeic keratosis, HPV lesions (3), epidermal hamartoma, sebaceous hamartomaVascular benign lesions (1)Venous lake, angiokeratomas, lymphangiomaDermal tumours (1)Dermatofibroma, keloid, myxoid cystInflammatory dermal tumours (1)Prurigo nodularis, granuloma faciale

Cutaneous surgery (4)Laser: Light Amplification by Stimulating Emission of RadiationPrinciple: light amplificationObjectives:cuttingcoagulatingneovascularizationFibroblast proliferationepithelizationProperties:monochromatic, colimation, coherentOptical spectrum (infra-red,visible light)Tissue response:reflectingrefractingtransmittingabsorbing

Laser (2)Types:Continuous wave (CW)Argon: sebaceous adenoma, teleangiectasis, pigmented benign lesion, pyogenic granulomaCW Nd YAG:CW CO2: common warts, condyloma accuminatum, keloid, molluscum contagiosum, skin appendages tumor, psoriasis, tattoo, epidermal nevus Laser Copper VapoxLaser KTP

Pulsed with high energyDye laser: nevus araneus, rosaseaRuby laser: pigmented benign lesionQ-Switched Ruby laser: tattooQ-Switched AlexandriteQ-Switched Nd YAG