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Commonly prescribed topicals:

Perils and pearls of using corticosteroids and antimicrobials in

skin conditions

MA R G A R E T A . B O B O N IC H, D N P , D C N P , F N P -C , F A A N P

ASS I S TAN T P ROF ESSOR, F RAN C ES P AY N E B OLTON SC HOOL OF N URS I N G

& C WRU SC HOOL OF M ED I C I N E

UN I V ERS I TY HOSP I TALS C ASE M ED I C AL C EN TER

M ARG ARET .B OB ON I C H@UHHOSP I TALS .ORG

National Conference for Nurse Practitioners

Chicago, IL

October 9, 2016

Disclosure

Lilly

AbbVie

©2016 Bobonich

Objectives

1. Describe the pharmacodynamics of topical

corticosteroids and antimicrobials.

2. Discuss important concepts in selecting

appropriate agents to optimize patient outcomes and minimize risks, side effects and

complications.

3. Review three case studies of dermatologic

conditions and selection of topical therapies.

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Topical Glucocorticosteroids (TCS)

Usually short-term tx for dermatoses

Salzberger & Witten (1952)

Effect vs side effects vs phobia

Indications (vague)

Anti-inflammatory

Anti-pruritic

Vasoconstriction

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TCS Indications

High potency (I to III)

Alopecia areata

Atopic dermatitis (resistant)

Discoid lupus

Lichen planks

Nummular eczema

Lichen sclerosis

Psoriasis

Hand dermatitis (severe)

Medium potency (IV and V)

Asteatotic eczema

Stasis dermatitis

Nummular eczema

Low potency (VI and VII)

Eyelid dermatitis

Diaper dermatitis

Perianal inflammation

Ference, J.D. & Last, A.R. (2009). Choosing Topical Corticosteroid. Am Family Physician, 79(2): 135-140. ©2016 Bobonich

TCS Mechanism of Action

Anti-inflammatory effects

epidermis

Anti-proliferative actions

epidermis & dermis

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Percutaneous absorption

Vehicle

Potency or concentration (vehicle can affect potency)

Frequency

Location

Duration

Occlusion

Quality of barrier

Hydration ↑

Temperature environment or body ↑

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Choice of TCS Vehicle

Foams

Gels

Lotions

Creams

Ointment

Most

alcohol

Least alcohol

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Selection of potency

Vasoconstriction assays & comparative clinical trials

Duration of inflammatory condition

Acute

Chronic

Location

Face, intertriginous and genitals- low (2wks)

Palms/soles- high/super high

Age- Infants & elderly

Condition

Quality of barrier

Exceptions

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Hypothalamic-pituitary adrenal axis

suppression (HPA)

Can occur with any TCS

Increases with steroid absorption

TCS under occlusion

Higher concentrations of TCS

Application over large surface areas

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Calcineurin inhibitors*

Pimecrolimus (Elidel)

Tacrolimus (Protopic)

ALTERNATIVE TO TCSs

Indications: Atopic dermatitis; eczema

Advantage: Do not cause atrophy.

Disadvantages- Not as effective, slower onset, $$$$

SE: burning, stinging, itching

*Black Box Warning: FDA 2006 skin malignancy and lymphoma with long-term use ©2016 Bobonich

So what do I prescribe?

How much?

Brand or generic?

Formulation or vehicle?

What potency?

How often?

Refills?

This is so confusing!

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Pearls for prescribing TCS

Control/monitor QUANTITY and REFILLS

Written instructions: how, when, and when to stop

Do NOT to share

Request the pharmacist label the TUBE not the box

Avoid combination products

Rotational therapy

If not responsive (2 weeks) RETHINK diagnosis

Contraindicated in skin with infection, patients with perioral dermatitis, acne or rosacea

Acute

SHORT courses of HIGH potency

Chronic

Treat with LOW potency

Intermittent better than continuous

©2016 Bobonich

Topicals Corticosteroids

Class 1

Class 2

Super Potency

High Potency

Clobetasol 0.05%

Class 3

Class 4

Class 5

Upper Mid-Potency

Moderate Mid-Potency

Lower Mid-Potency

Fluocinonide 0.05%

Triamcinalone 0.1%

Class 6

Class 7

Mild Potency

Least Potency

Desonide 0.05%

Hydrocortisone 2.5%

Category Potency Examples

Desoximetasone 0.25% cr or 0.05% cr are free of propylene glycol **

MY FAVORITES

FOR

PRESCRIBING

©2016 Bobonich

Dispensing for BID dosing for 2 weeks

Location Adult Dosage

gms FTUs

Child tube size

(gm)

Infant Tube size

(gm)

Entire face &

neck

35 2.5 15 15

One entire hand 14 1 15 15

Entire foot (not both)

28 2 15 15

One entire arm 42 3 30 15

One leg 84 6 30 30

Entire body 30gm for one application

n/a n/a

Rule of thumb: Children = ½ adult amount; Infants (6-12 months) = ¼ adult amount Rule of hands: Area equal to 2 adult hands (palm & fingers) = 1 FTU

1 Finger tip unit (FTU) = 0.5 gm

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FDA approved TCS in children

Class Generic Name Age Group

SUPER Clobetasol propionate 0.05% foam > 12 years

HIGH Fluocinonide 0.1% cream > 12 years

MED Mometasone 0.1% cream/ointment > 2 years

Fluticasone 0.05% lotion/cream > 1 year

LOW Alclometasone 0.05% cream/ointment > 1 year

Prednicarbate 0.1% cream/ointment > 1 year

Fluocinolone acetonide 0.01% in peanut oil > 3 months

Desonide 0.05% hydrogel > 3 months

Hydrocortisone butyrate 0.1% cream > 3 months

http://nationaleczema.org/eczema/treatment/topical-corticosteroids/basics-of-topical-corticosteroids/ ©2016 Bobonich

Corticosteroids in pregnancy

Limited data on safety

Emollient therapy first

Topicals preferred over systemic

Mild to moderate potency

Potential risk: premature rupture of membranes,

interuterine growth restriction, gestational DM, osteoporosis, infection and pregnancy-induced hypertension

Avoid during first trimester if possible

©2016 Bobonich

Localized side effects

Atrophy

Bruising, purpura, skin fragility, striae, telangiectasia, pigment abnormality

Irritation

Infections (secondary)

Dermatitis

Delayed wound healing

Photosensitization

Steroid-induced acne & rosacea

Rebound phenomenon

Tachyphylaxis ©2016 Bobonich

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Systemic side effects*

Ocular

Endocrine Metabolic

Renal & cardiovascular Misc

*Usually seen in extended use of high potency. ©2016 Bobonich

Pearls to reduce steroid side effects

Use potent steroid to gain QUICK control of disease

THEN taper to less potent

Taper instead of abrupt cessation

Reduce frequency (alternate days, weekend, etc)

Use of topical immunomodulators

Caution on flexural surfaces, face, genitals and intertriginous

Avoid occlusion

Employ other topical agents (keratolytics, moisturizers, etc.)

Avoid combination products

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Successful use of topical corticosteroids depends on the

correct diagnosis

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Atopic Dermatitis

“Out of place” or strange

Atopic march

Most common type of eczema

“infantile eczema”, “atopic eczema”

60% cases 1st year, 95% before 4 yrs old

Must have three of the following:

1. Pruritus

2. Typical morphology and distribution

3. Chronically relapsing dermatitis

4. PMH or FHx atopic disease ©2016 Bobonich

Therapeutic approach

Control the Environment

Emollients (jars & tubes)

Moisturizers

Topical corticosteroids

Topical non-corticosteroids

Antihistamines

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Stasis dermatitis

Frequently in presence of venous insufficiency

Pruritus

Eczema

Hemosiderin staining

Ankle (medial) involvement

Varicosities

Edema

Stasis dermatitis:

Can develop into secondary infection, cellulitis, ulcers, etc

Most frequent cause for patients admitted unnecessarily w/misdiagnosis of cellulitis

Dav id CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.

Keller EC, Tomecki KJ, Chadi Alraies M. Distinguishing cellulitis from its mimics. Cleve Clin J Med. Aug 2012;79(8):547-52. ©2016 Bobonich

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Stasis Dermatitis

Assess underlying etiology

Topical CCS (Una boot if wet)

Assess for infection or ulceration

Compression and elevation

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Beyond topical steroids

Large body surface areas

Underlying systemic disease

Recalcitrant or severe disease

Thick lesions

Significant impact QOL

Consider comorbidities

Oral, intramuscular, intralesional

intravenous

Steroid sparing agents & therapies ©2014 Bobonich

No clear superior efficacy comparing IM to oral

Advantages vs disadvantages

Clinical preference on individual basis

ORAL INTRAMUSCULAR

ABSORPTION Predictable Variable

COMPLIANCE Relies on patient Total dose administered

DURATION Any time period Select short, intermediate or long-acting

PATIENT HEALTH Req. functional GI tract Not affected by N/V

PATEINT’S ROLE Active control/participation No role or control

CLINICIAN’S ROLE Prescribe and monitor Assured of delivery from IM

DIURNAL VARIATION Some with AM dosing No diurnal variation

Tapering Precise Based on metabolism

Comparison of Oral and Intramuscular Corticosteroids

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Case

Study

©2014 Bobonich ©2016 Bobonich

To treat…........ or not to treat?

Aka: cradle cap, dandruff (misdiagnosis of acne in

adolescence)

Unknown etiology but suspect Pityrosporum (M. furfur)

Inflammation and scale

Clinical presentation varies with age

Distribution of sebaceous glands

Flares

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Seborrheic dermatitis (Seb derm)

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Seb Derm

Treatment

Alternating therapies: anti-yeast shampoos, antifungal topicals, TCS, and calcineurin inhibitors

Cochran Review (2014)

Only minor differences in treatment outcomes and no

clear differences between the agents

Kastarinen, H., Oksanen, T., Okokon, E.O. et al. (2014). Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp.

Cochrane Database Syst. Rev . 5:CD009446.

©2016 Bobonich

Antifungals (superficial fungal infections)

©2016 Bobonich

Topical agents for

superficial fungal infections

Yeast vs dermatophytes

Selection based on organism

Location (skin , hair and nails)

Vehicle

Fungistatic vs fungicidal

Other properties: antimicrobial and anti-inflammatory

Recurrence

Prevention

Systemics

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Tinea

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Tinea Corporis

“Ringworm”

Very contagious

T. rubrum

Topical or systemic

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Differential Diagnosis

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Tinea Pedis

T. Rubrum, T. mentagrophytes

Several types

Check other body sites

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Tinea cruris

+/- mixed candida &

dermatophytes

Not common kids

Tx with topical azoles 2-4 wks

Oral griseofulvin, if severe

Always check feet

DDX: intertrigo, contact derm, candidiasis, erythasma,

bacterial infection

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DDX Tinea cruris

• Unilateral, half-moon

• Spreads peripherally • Not usually scrotum

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“Diaper” candidiasis

C. albicans 80%

Marginal scaling

Beefy red confluent plaques & erosions

Satellite papules/pustules (hallmark)

Includes skin folds, concave surfaces

No improvement with barrier creams (zinc oxide, A&D, petrolatum, triple paste)

KOH preparation or fungal culture ???

Check oral mucosa and mother breasts/nipples

if breast feeding

Dx of yeast is not always a SLAM DUNK! ©2016 Bobonich

Diaper candidiasis therapies

• Nystatin cream is DOC

Imidazoles- not as effective, irritating

Allylamines- not as effective

• If severe inflammation- okay to uses hydrocortisone 1% ointment for a couple days (LIMITED TIME)

• May need tx oral nystatin for oral thrush (mother’s nipples)

• Refer if severe and not responsive to tx. Reconsider Dx

• Never use combination products

• Clotrimazole/betamethasone diproprionate (Lotrisone)

• Nystatin/triamcinolone acetonide (Mycolog)

©2016 Bobonich

Class & Indications Generic name Dermatophyte Yeast Gram + Gram - Anti-inflammatory

Polyenes (fungistatic)

Candidiasis Nystatin 0 ++++

Azoles (fungistatic)

Tinea

Pityriasis/tinea versicolor

Candidiasis

Seborrheic dermatitis

Miconazole + +++

Clotrimazole + +++

Ketoconazole + +++ ++ ++

Oxiconazole + +++

Econazole + +++ + + +

Sertaconazole + +++ ++

Allylamines/ Benzylamine (fungicidal)

Tinea

Pityriasis/tinea versicolor

Naftifine + + +++

Terbinafine +++ + +++

Butenafine ++++ ++ +++

Other Agents

Tinea; Onychomycosis; Candidiasis

Pityriasis/tinea versicolor; Seborrheic

dermatitis

Ciclopirox ++ ++++

C. Albicans

+++ +++ +++

Pityriasis/tinea versicolor

Seborrheic dermatitis

Selenium sulfide

(RX & OTC)

+++

Pityrosporum

Bobonich& Nolen (2015)

Indications and Effectiveness of Topical Antifungals

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Betamethasone

dipropionate/clotrimazole (Lotrisone)

Indications: Tinea cruris or corporis- twice daily for 1 week

Tinea pedis- twice daily for 2 weeks.

Not recommended for children under

17 years old or diaper dermatitis

High potency topical corticosteroid

Railan, D., Wilson, J.K, Feldman, S.R. & Fleischer, A. B. (2002). Pediatricians who prescribe clotrimazole-betamethasone diproprionate (Lotrisone)

often utilize it inappropriate settings regardless of their knowledge of the drug’s potency. Dermatology Online Journal, 8(2):3. ©2016 Bobonich

Case

Study

Tinea

Capitis

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Tinea capitis

T. tonsurans 90 to 95%

School children and adolescents

Alopecia, papules, pustules, inflammation, scale

May have: boggy scalp, secondary infections, and lymphadenopathy.

“Kerion”

TOC: systemics

Griseofulvin 5-10 mg/kg/day (higher off-label)

Prevent further transmission ! ©2016 Bobonich

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Clinical pearls treating superficial fungal

Remember high rate of reinfection

Maybe secondary infections

? systemics for extensive involvement & comorbidities

Examine entire body (esp. hands, feet & groin)

Hair and nails require longer treatment- 6 to 12 wks

Fungistatic and fungicidal

Social history is very important for dx and tx

Environmental control is essential

If not responsive, RETHINK diagnosis

©2016 Bobonich

Tinea Versicolor

Pityrosporum

More often in adolescents and young adults

Hypopigmented, oval, sometimes scaly lesions

Involving mostly trunk, neck, upper extremities

Selenium sulfide or ketoconazole shampoos

NO LONGER use oral antifungal (ketoconazole)

BLACK BOX WARNING !

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Clinical presentations of tinea versicolor

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Antibacterials for superficial

wounds

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Antibacterial agents

High local concentrations of drug

Minimal systemic absorption>> reduced risk and side effects

Minor or superficial wounds

Usually NOT for burns and deep wounds

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Factors influencing route of administration

Size and location

Depth and underlying structure

Mechanism of injury or etiology

Comorbidities

Suspected organism

Allergies and sensitivities of causative organism

Circulation

Socioeconomic

Time

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Name Bactericidal against

MOA COMMENTS

Bacitracin Gram + and Neisseria sp.

Interferes bacterial wall synthesis

Common sensitizer; rare but serious anaphylaxis w/application

to ulcer bed

Polymyxin B Gram – and P. aeruginosa

Increases permeability bacterial cell

membrane

Usually combined with bacitracin or neomycin for broad spectrum

Topical antibacterial agents- OTC

©2016 Bobonich

Name Bactericidal against

MOA COMMENTS

Neomycin

Gram + and –

S. aureus

Aminoglycoside;

inhibits protein

synthesis

Common sensitizer; Optimum coverage

combined w/bacitracin & polymyxin B

(Neosporin); risk ototoxicity and

nephrotoxicity if systemic absorption

Mupirocin MSSA, +/- MRSA,

Streptococci

Inhibits RNA and

protein synthesis

Rare sensitization; Less effective is incr.

serum or exudate or weeping wounds

(highly protein bound); used for

eradicating nasal staph carriage

Retapamulin Gram +/MRSA Inhibits protein

synthesis

Shorter tx time BID for 5days

Broader spectrum than mupirocin

Gentamycin Gram + and -; esp

P. aeruginosa; not

good against

strains of Strep or

Neisserias

Aminoglycoside;

inhibits protein

synthesis

Stinging common SE; uncommon

sensitization but common cross-

reactivity with neomycin sensitivity

patients; risk ototoxicity and

nephrotoxicity if systemic absorption

Topical antibacterial agents- Prescribed

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Impetigo

Treatment

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Topical Antivirals

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Topical agents for herpes simplex (HSV)

Most are FDA approved for ≥ 12 year

Usually in combination with systemic

Suppression vs episodic

Newer agents/formulations

Most not FDA Indicated for genital HSV

Combination products

Consider comorbidities

©2016 Bobonich

Acyclovir 5% (Zovirax)

Herpes Labialis (cream)

Adults (≥12 years) – For “cold sores” apply 5 times daily for 4

days. Cover lesions and symptomatic area (tingling). Start at the earliest sign or symptom (prodrome).

Genital Herpes (Ointment)

Apply ointment to all of the affected areas/lesions, 6 times daily for 7 days.

Pregnancy Category B; Lactation- unknown

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Acyclovir

Combination

acyclovir 5%/hydrocortisone 1% (Xerese) for herpes labialis

Buccal mucosa tablets

acyclovir (Sitavig) for herpes labialis

©2016 Bobonich

Penciclovir 1% (Denavir)

Inhibits replication within the cell d/t inhibits viral

DNA polymerase

Maintains higher cellular concentration for longer

time within cell (compared to acyclovir)

Indication Recurrent herpes labialis (≥12 years old)

Dosage- every 2 hours for 4 days

©2016 Bobonich

Docosanol (Abreva)

Prevents replication by inhibiting fusion of virus

and host

Shortens healing time and reduces symptoms

Pediatrics- ≥12 years old

Indications- herpes labialis ; not genital herpes

Dosage- 5 times daily till gone (max 10 days)

SE- minimal

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Take home message

Consider topical therapy for inflammatory

conditions and infections

Treatment must be individualized

Compare topicals vs systemics

Cultures are an important diagnostic tool

Rethink diagnosis if not responsive in 2 weeks

Consider differential diagnoses

©2016 Bobonich

“The eyes see only what the mind knows”

Resources

Berth-Jones, J. (Ed.). (2010). Chapter 73 Topical therapy. Rook’s Textbook of Dermatology (8th ed., pp. 73.1-73.52). Chichester, West Sussex UK: Wiley-Blackwell. Bobonich, M.E. & Nolen, M.N (2015). Dermatology for Advanced Practice Clinicians. Philadelphia, PA: Lippincott. Chi, C., Wang, S., Mayon-White, R., & Wojnarowska, F. (2013, September 4, 2013). Pregnancy Outcomes AfterMaternal Expsosureto Topical Corticosteroids; A UK Population-Based Cohort Study. Journal of the American Medical Association, E 1-7. Gupta, R., High, W.A, Butler, D., & Murase, J.E. (2013) Medicolegal aspects of prescribing dermatologic medications during pregnancy. Seminars in Cutaneous Medical Surgery, 32(4), 209-216. Habif, T. P. (2010). Topical Therapy and Topical Corticosteroids. In Clinical Dermatology. A color guide to diagnosis and therapy. (5th ed., pp. 75-90). China: Elsevier. Wolverton, S. (2013). Comprehensive Dermatologic Drug Therapy, 3rd Ed. London: Elsevier.

©2016 Bobonich