Rational Use of Topical Corticosteroids-noppadol230555
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yCorticosteroids .. 2495y Hydrocortisone (eczematous dermatoses)
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Corticosteroidy y 4
(hexane 3 pentane 1 )
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Corticosteroidy (Ring structure) (Side chain)
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Corticosteroidy y yy
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Structure of CorticosteroidsTriamcinolone acetonide Betamethasone dipropionate
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7Mechanism of action
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Pharmacologyy (Anti-inflammatory effects)y (Immunosuppressive effects)y (Antiproliferative
effects) : fibroblasts (collagen and ground substances)
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Pharmacologyy (Vasoconstriction)
histamine, bradykinins & prostaglandins
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Pharmacologyy (Vasoconstriction)
Corticosteroids
vasoconstrictor assay vasoconstriction test
Corticosteroids 11
vasoconstrictor assayy 5 mg
9 12 y infrared reflection photometers /
thermal conductivity / laser doppler velocimetry
y metabolism 12
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y 7
( 1 7 )y 4 mild,
moderate, very potent, super potent
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Class 1 superpotent Betamethasone
dipropionate 0.05% Clobetasolpropionate 0.05%
Diprotopointment/gel/lotion Dermovate cream
Class 2 potent, upper mild strength
Desoximetasone0.25% Mometasonefuroate 0.1%
Topicort cream
Elomet ointment
Class 3 potent,upper mild strength
Betamethasonevalerate 0.1
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Class 4 mild strength Fluocinolone
acetonide 0.025% Mometasonefuroate 0.1% Prednicabate 0.1%
Synalar ointment
Elometcream/lotion Dermatop ointment
Class 5 lower mild strength
Triamcinoloneacetonide 0.1%
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Class 6 mild strength Triamcinolone
acetonide 0.02%Class 7 least strength
Hydrocortisone 0.5,1,2.5% Prednisolone 0.5%
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Corticosteroids (chemical characteristics)9Fluticasone propionate : local
adverse effect 9Mometasone furoate :
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Corticosteroids (vehicles)9corticosteroid 9
(ointment) (cream) (lotion)
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Corticosteroids (vehicles) : (ointment)9 (preservative) : 9 ( lichenification) 9
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Corticosteroids (vehicles) : (cream)9 (intertriginous area)
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Corticosteroids (vehicles) : (lotion) (gel) (solution)9 9 alcohol propylene
glycol / :
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Corticosteroids (potency)9class 6-7 or low potency 9 class 2-5
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Corticosteroids9 corticosteroids 99 1
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Corticosteroids9 atopic dermatitis 9 2 10
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Corticosteroids9 dyshidrosis lichen simplex chronicus 9 :
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Corticosteroids9 / 300 potency 9 potency
salicylic acid (occlusion)
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1. / 2.
3.
4. 5. / 6. /7. / 8. / 9. 10.
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0.1 % Triamcinolone acetonide cream
0.1 % Triamcinolone acetonide lotion
2
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0.1 % Triamcinolone acetonide cream
0.1 % Triamcinolone acetonide lotion
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0.1 % Betamethasone valerate cream
0.05 % Betamethasone dipropionate ointment
2
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0.1 % Betamethasone valerate cream
0.05 % Betamethasone dipropionate ointment
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PotencyyConcentrationy0.1 % Triamcinolone acetonideXy0.02 % Triamcinolone acetonide Y
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PotencyyDosage Form : yOintment is absorbed better than
cream or lotiony0.1 % Mometasone furoate ointment Xy0.1 % Mometasone furoate cream Y
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PotencyySalt of Drugy0.05 % Betamethasone dipropionate Xy0.1 % Betamethasone valerate Y
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yLow potencyyShort termy yRotational therapy
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Side Effecty
(local adverse effects)y (systemic reactions)
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Side Effect local adverse effects (atrophic changes)y . . 2506 Triamcinolone
acetonide y (epidermal atrophy) (alteration in
skin elasticity) 38
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Side Effect local adverse effects (atrophic changes)y / potency :
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Side Effect local adverse effects (atrophic changes) :
dermal atrophyy fibroblasts y collagen : 3 2
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Side Effect local adverse effects (atrophic changes) :
dermal atrophyy 0.1% Betamethasone valerate 3 9 159
(telangiectasia) (easy bruising) (purpura)
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telangiectasia
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purpura easy bruising
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Side Effect local adverse effects (hypopigmentation)y melanocyte : melanin
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Side Effect local adverse effectsy 16 43y (tinea versicolor) (tinea incognito) (onychomycosis) (herpes simplex infection) (molluscum contagiosum) (scabiasis)
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Side Effect local adverse effects (acneiform reactions)y 3 9steroid acne9 (perioral dermatitis)9steroid rosacea
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Steroidacne
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steroid rosacea
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perioral dermatitis
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Side Effect local adverse effects (acneiform reactions)y perioral dermatitis & steroid rosacea99
(rebound phenomenon) 9
(tachyphylaxis) 50
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Side Effect local adverse effects (acneiform reactions)ysteroid acne9 (acne vulgaris) 9 9
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Side Effect local adverse effectsy corticosteroid (glaucoma)y (vision loss)y corticosteroid 300
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Tachyphylaxisy corticosteroids
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Steroid additiony corticosteroidsy high potenty y rosacea telangiectasis
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corticosteroidsy y 0.2 6y corticosteroid
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corticosteroids Parabens Isopropyl palmitatePropylene glycol Polysorbate 60Benzyl alcohol Stearyl alcoholChlorocresol CorticosteroidEthylenediamine HCl Antibiotics
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Side Effect Systemic effectsy corticosteroid :9High potency clobetasol propionate 0.05% 2 g/day 2 3 9Medium potency 7 g/day 2 weeks
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Side Effect Systemic effectsy 9 /9 : 9 9 potency of corticosteroids
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Side Effect Systemic effects y 9 9
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9 1 (fingertip
units) 9 1 fingertip units : male = 0.49 g female = 0.43 g
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1 fingertip units
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9 Rule of hand9 1 1 g9 1 2
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9 corticosteroids class 1 3 1 2 : 1 tachyphylaxis9corticosteroids class 4 7 2
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9 corticosteroids High potency : 2 weeks9corticosteroids Medium/Low potency : 3 months
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9 corticosteroids Low potency : 2 weeks9 1 side effects 2.5 3 & drug metabolism
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9Systemic side effects 9 9 Adrenal crisis9
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9 FDA USA .. 2530 25409 Betamethasone 79.4 ( 25.7 Betamethasone dipropionate + Clotrimazole)
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9 Conchrane database 9 //9 class 1
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9 C 9 pregnancy category C9 :
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y Tar: 3-10 % LCD
(Liguor Carbonis Detergents)y 3-5%CCT (Crude Coal Tar)
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(Topical therapy)1. Corticosteroids 2. Tar 3. Dithranol (Anthralin) 4. Calcipotriol 5. Salicylic acid
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CoalTar
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(Tars) y DNA y y
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Tar Shampooy20 %Coal Tar Shampooy Olive oily
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Scalp Lotiony0.02 % TA LotionyDesoximetasone yMometasone lotion
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Combination with Coal TaryTreatment PsoriasisyCoal Tar + corticosteroidy5 % LCD in 0.02 % TAy5 % LCD in 0.1 % Bet.
Valeratey5 % LCD in 0.05 % Bet.
valerate
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Tar + Corticosteroidy5 % LCD creamy5 % LCD in 0.02 % TAy 5 % LCD in 0.05 % Bet. Valeratey 5 % LCD in 0.1 % Bet. Valeratey //
(genital area) 77
EmollientyCream baseyLiquid paraffin
(Mineral oil)yPetroleum jelly
(Vaseline)
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Keratolytic agenty 3 - 10 % salicylic acidy 3 - 10 % urea creamy combind with
corticosteroid
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Combination with UreayTreatment for Dry skiny10 % Urea in 0.02 % TAy10 % Urea in 0.1 % Bet.
Valeratey20 % Urea ointmenty40 % Urea ointment
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Keratolytic agentSalicylic acid Urea
y 3 % SA in 0.02 % TAy 5 % SA in 0.02 % TAy 10 % SA in 0.02 % TAy 10 % SA ointmenty 20 % SA ointment
y10 , 20 % Urea y 10 % Urea in 0.02 % TAy 10 % Urea in 0.05 %
Bet.valeratey 10 % Urea in 0.1 %
Bet.valerate81
Combination with Antibiotic agentyClioquinol
(Iodochlorhydroxyquin)yantibiotic that works by
preventing the growth of fungus/bacteriay3 % Vioform in 0.02 %
TA82
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Calcipotriol y y differentiation y
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Calcipotriol y 3 , y 50 /
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VitamineD3Analogues
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Fucidicacid
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First line drug Second line drug
yMethotrexate 5-25 ./ 3 12 . (triple dose therapy) y Retinoid:- acitretin 0.25-1 ././
y Cyclosporin 3 5 ././ 1 - 2 / (2 divided dose)
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Methotrexate
2.5 . 88
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Methotrexatey Dihydrofolate reductase DNA y y y
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MethotrexateyPsoriatic erythroderma yPustular psoriasis yPsoriasis ySevere plaque type psoriasis yPsoriatic arthritis
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Methotrexatey 2.5-25 . y 3 12 y 2.5-5 . 1 2
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Methotrexate 2.5 mg take 1 : 1 : 1
Monday 08.00 AM 1 Tab
Monday 08.00 PM 1 Tab
Tuesday 08.00 AM 1 Tab
Begin on Monday morning
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Methotrexate 2.5 mg take 2 : 2 : 1
Wednesday 08.00 PM 2 Tab
Thursday 08.00 AM 2 Tab
Thursday 08.00 PM 1 Tab
Begin on Wednesday evening
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Methotrexate1.2.23.4.5.6.7. MTX
MTX 12 8.
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1. complete blood count2. BUN3. creatinine4. liver function test
yy y 1-3
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y HIV Immunosuppression y y 1.52 g liver biopsy liver biopsy liver biopsy 1 . y 3
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SideEffectofMTXy y y y y
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SideEffectofMTXy (nephropathy) y y y (reactivation of sunburn response)
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DrugInteractionofMTXy methotrexate alcohol, salicylates, cotrimoxazole, trimethoprim, probenecid, phenytoin, retinoids, pyrimethamine furosemide
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Acitretin25mg
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y y differentiation y CMI HMI y
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1. Pustular psoriasis 2. Extensive plaque type psoriasis
3. Erythrodermic psoriasis
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yAcitretin 0.5 - 1 ././ 0.25 - 0.5 ././ 3
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y () y complete blood count,
liver function test, cholesterol, Triglyceride, HDL yPregnancy test
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y liver function test 1 - 3 y triglyceride
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SideEffectyCheilitis (100%), , ,
(20-50%), (100%), , (bruising), , (20%), ,
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SideEffecty y y y (teratogenicity) 3
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y y ( 3 ) y
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y liver function test y y tetracycline ( intracranial hypertension) phenytoin (competition of plasma-protein binding)
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H1receptorantagonistsShortActing LongActing
yChlorpheniramineyHydroxyzine
yCetirizineyLoratadiney DesloratadineyLevocetirizine
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H1-receptor antagonistsCPM Details
yShort ActingySedative side effectyMost common use 1
tab hs
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H1-receptor antagonistsHydroxyzine 10 mg Details
yShort ActingySedative side effectyMost common use 1
tab hs
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H1-receptor antagonistsyCetirizineyLoratadineyLong Actingy1 tab OD
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Topical Retinoids Retinol, Retinoic acid, Isotretinoin, Adapalene
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Topical Retinoids* * * Glycosaminoglycan *
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Topical Retinoids *
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Topical Retinoids* * * *
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Topical Retinoids* Oral Retinoids * Topical Retinoids * , 120
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* Carboxylic acid hydroxy alpha * AHA
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* * * * * *
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* AHA 4-30% ( AHA 3-10%) * AHA 50%
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Salicylic acid
AHA BHA
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* AHA * Salicylic acid 128
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* alpha-helical peptide chains 3 *
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* *
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1. (melanocytes)2. 3. tyrosinase
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4. melanosome malpighian cell phacocytosis melanocytic dendrite
5. melanosome oxidized form () reduced form ()
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1. (opacifying or covering agent) 2. (depigmentating agent) tyrosinase
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3. (sunscreen agent) UV
4. (oxidizing agent)
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- alpha hydroxy acid (AHA) -
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Hydroquinone
- 3 - 5 % Hydroquinone- -
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Azelaic acid- - tyrosinase 137
Azelaicacid
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Arbutin- hydroquinone glycoside Bergenia crassifolia Arctostaphylos uvaursi - tyrosinase hydroquinone
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- magnesium ascorbyl phosphate , sodium ascorbyl phosphate sodium ascorbyl sulfate - ascorbyl dipalmitate , ascorbyl glucosamine - gamma-ascorbic acid phosphatase 140
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Lactic acid - Lactic acid tyrosinase - 5 20 % -
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(UV)y UV- A
y UV - B sunburn
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y 10.00 - 15.00 . y
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y y UV UV UVA
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y ySPF SunProtectionFactor UVB SPF15,30
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SPF15 y 30 y SPF 15 15 30 7
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???
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y 1y 2 y
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SunProtectionProduct
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