Nonpharmacological Therapy

DRUGS USED IN SKIN DISORDERS Acne vulgaris: is an inflammatory disease of the skin, caused by changes in the pilosebaceous units (skin structures consisting of a hair follicle and its associated sebaceous gland). Acne lesions are commonly referred to as pimples, spots or zits. The primary factors involved in the formation of acne lesions are increased sebum production, sloughing of keratinocytes, bacterial growth and inflammation. Acne occurs when tiny holes on the surface of the skin called pores become clogged. Each pore is an opening to a canal called a follicle, which contains a hair and an oil gland. Normally, the oil glands help keep the skin lubricated and help remove old skin cells. When glands produce too much oil, the pores can become blocked, accumulating dirt, debris, and bacteria. The blockage is called a plug or comedone. Oil secretions are said to build up beneath the blocked pore, providing a perfect environment for the skin bacteria Propionibacterium acnes, a slow growing anaerobic gram positive bacterium which is a causative organism. The typical acne lesions are: comedones, papules, pustules, nodules and inflammatory cysts. These are the more inflamed form of pus-filled or reddish bumps, even boil-like tender swellings. If the follicular wall is damaged or ruptured, follicle contents may extrude into the dermis and present as a pustule. Comedones are small, flesh-colored, white, or dark bumps that give skin a rough texture. The bumps are found at the opening of a sebaceous follicle (pore). Whiteheads are white, raised bumps caused by collections of oil and skin in pores. Whiteheads are also known as closed comedones and pimples. Blackheads are tiny, dark spots caused by a small plug in the opening of a follicle (pore) on the skin. Blackheads are also called open comedones. Acne lesions typically occur on the face, back, upper chest and shoulders. Acne is not caused by food including, chocolate, coffee, fats, dry food and sea food. The goals of treatment are to prevent the formation of new acne lesions, heal existing lesions and prevent or minimize scarring. Nonpharmacological Therapy Clean your skin gently with a mild, non-drying soap (like Dove, Neutrogena, or Basics.) Remove all dirt or make-up. Wash once or twice a day, including after exercising. However, avoid excessive or repeated skin washing. Avoid tight headbands. Avoid touching your face with your hands or fingers. Try not to squeeze, scratch, pick, or rub the pimples. Although it might be tempting to do this, it can lead to scarring and skin infections. 1

Avoid greasy cosmetics or creams. Look for water-based or "non-comedogenic" formulas. Take make-up off at night. General Instructions for applying topical drugs Topical Before applying cream, gel or lotion, wash the affected area with nonmedicated soap and water or with a mild cleanser and then gently pat dry with a towel. Wait 15 to 30 minutes before applying topical medicine to make sure the skin is completely dry. Apply enough medicine to cover the affected areas, and rub in gently. Do not use this medicine in or around the eyes or lips, or inside the nose, or on sensitive areas of the neck. During the first 3 weeks, skin may become irritated. Also, acne may seem to get worse before it gets better. If skin problem has not improved within 6 to 8 weeks, check with your health care professional. Do not wash the areas of the skin treated with topical medicines for at least 1 hour after application. Avoid using any other topical medicine on the same area within 1 hour before or after using topical medicine. Start with lowest concentration with one topical preparation at a time and apply initially only QHS then increase BID if well tolerated. Do not use cream, gel or lotion on open wounds and scars. Pharmacological Therapy Name Dosage/Indication/Efficacy Side Effects & Interactions Benzoyl Peroxide It works as a peeling agent, increasing skin Dryness Gel, lotion, cream, turnover and clearing pores, thus reducing the Irritation soap bar bacterial count there as well as directly as an Allergic contact 2.5 % to 10 % antibacterial. dermatitis Available forms are from 2.5 % to 10 % and over Can bleach hair and 5% is Rx. fabric 10 % is not significantly more effective but may be more irritating. Gel formulations are usually more potent, whereas lotions, creams, and soaps have weaker potency. Alcohol based gel preparations cause more dryness and irritation. To limit the irritation and increase tolerability Monitoring/Contraindications/Precautions Burning and irritation goes away with time and use. Store gel at room temperature away from fire, flame and children. Avoid excessive sun exposure or sunlamps and use sun screen at least 30 minutes after applying benzoyl peroxide. Fair and moist skin is more sensitive, therefore apply to skin after 30 minutes of washing. 2

Tretinoins 0.01%, 0.025%, 0.05%, 0.1% Retin-A, Stieva A Vitamin A acid Retin A micro Gel, topical solution and cream Isotretinoin Isotrex 0.05% Gel Tazarotene Tazorac, Avage 0.05%, 0.1% Cream, gel start with low concentration daily or every other day and then concentration to BID PRN. The retinoids are a class of chemical compounds that are related chemically to vitamin A. First generation: which include retinol, tretinoin (Retin-A), isotretinoin and alitretinoin. Second generation: which include etretinate and its metabolite acitretin. Third generation: which include tazarotene and bexarotene. Retin A is a drug commonly used to treat acne vulgaris, treat fine wrinkles, dark spots, or rough skin on the face caused by damaging rays of the sun and keratosis pilaris. Cream, gel and solution apply HS Isotretinoin reduces the production of sebum and shrinks the sebaceous glands. It stabilizes keratinization and prevents comedones from forming. For severe cystic acne vulgaris Apply gel BID Synthetic acetylenic retinoid Approved for treatment of psoriasis, acne vulgaris, and sun damaged skin (photo damage). Apply HS after washing face. 3 Burning feeling Stinging feeling Redness of skin Lightening of skin of treated area. Erythema Sensitivity to cold and wind Not significant Worsening of acne, Dry skin Itchiness Redness and in some cases extreme drying and cracking of skin Retinoid Analog Lotion, cream, and gel apply HS Not significant To help tretinoin work properly, regularly use sunscreen or sunblocking lotions with a sun protection factor (SPF) of at least 15 is recommended. Also, wear protective clothing and hats. Vitamin A derivatives are teratogen and should not be used during pregnancy or seeking to become pregnant. In the morning, apply a moisturizing sunscreen with SPF 15 or greater. Wash your hands completely after using Tazarotene Cream. Use Tazarotene Cream with extreme caution in children younger than 17 years of age. Women of childbearing potential should use effective birth control methods (e.g., condoms, birth control pills, diaphragms) while using Tazarotene Cream. Do not breast-feed while taking Tazarotene Cream. Results take at least 12 weeks to see optimum improvement.

Adapalene, 0.1% Differin Cream, gel, lotion Erythromycin Solution, gel, lotion 1.5%, 2% Erysol, T- stat Clindamycin 1% Dalacin T, Cleocin T Neomycin /Methylprednisolone Lotion 0.25% Azelaic Acid Azelex 20% cream Systemic Therapy With or without zinc is effective against inflammatory acne. Decreases colonization of bacterium. Apply BID Efficacy in increased with benzoyl peroxide. Suppresses but does not cure. Apply BID Keep using this medicine for the full time of treatment, even if the symptoms begin to clear up after a few days. Apply BID Mild to moderate acne. Apply BID Useful for those who can t tolerate benzoyl peroxide. Not significant Dryness Scaliness Peeling of skin Not significant Dryness Temporary burning Itching After washing or shaving, it is best to wait 30 minutes before applying this medicine. The alcohol in it may irritate freshly washed or shaved skin. This medicine contains alcohol and is flammable. Do not use near heat, near open flame, or while smoking. It is important to use Azelex Cream for the full course of treatment. Failure to do so may decrease the effectiveness of Azelex Cream. Name Dosage/Indication/Efficacy Side Effects & Interactions Tetracycline Indicated for acne and rosacea. May azotemia Least expensive Fungal growth 500 mg BID initially for 1 month then 250 500 Photosensitivity mg/d maintenance. Minocycline Minocin Capsule For moderate to severe acne. More effective than tetracycline Expensive. 100 mg/day initially then 50 mg/d maintenance. Dizziness Vertigo Rarely hepatic dysfunction 4 Monitoring/Contraindications/Precautions Should be given 1 hour before or 2 hours after any medicine or food or dairy products and multi vitamins. Contraindicated in first trimester of pregnancy and children under 8 years. Take with full glass of water. Can be taken with or without food. Minocin Pellet-Filled Capsules works best if it is taken at the same time each day. Avoid sun light and tanning booths.

Doxycycline Vibra - Tabs Isotretinoin Accutane Capsule Hormonal Therapy 100 mg/day initially then maintenance. More effective on empty stomach. Retinoid es sebum production, changes sebum composition, inhibits P. acnes growth within follicles, and inhibits inflammation. Severe nodular cyst form of acne in patients who are unresponsive to other therapies. Dosing guidelines range from 0.5 1 mg/kg/day. Cumulative dose is 120 150 mg/kg. A 6 months course is sufficient for most patients. Adverse effects are dose related. Capsule can be taken once daily with full glass of water. If relapse occurs, wait 8 weeks after completion of the first course before reinstituting therapy. Photosensitivity Diarrhea Drying of mouth, nose, and eyes Cheilitis Transient in TGs and serum cholesterol Photosensitivity Skin desquamation To prevent pregnancy, use an extra form of birth control (e.g., condoms). Not indicated in pregnancy. With or without food. Take with full glass of water. Take 1 hour before or 2 hours after dairy product and multivitamins. Avoid sun light and tanning booths. Avoid in pregnancy. Do not use Accutane if you are a woman who is pregnant, planning to become pregnant, or breastfeeding. Serious birth defects can occur in pregnant women who use Accutane. Completely abstain from sexual intercourse or practice 2 forms of birth control beginning 1 month before, during, and for 3 month after use of Accutane. Must have 2 negative urine or blood pregnancy tests before you may begin taking Accutane. Take with food. Patients should be screened for depression. Worsening of acne may occur during the first part of therapy but do not stop therapy. Avoid sun light and tanning booths. LFTs periodically. Capsule can be sprinkle on applesauce or ice cream. Name Dosage/Indication/Efficacy Side Effects & Interactions Diane 35 Take one tab daily for 21 days, off for 7 days and Thromboembolism then repeat cycle. Break through bleeding EE 0.035mg / cyprotene 2mg N/V Weight gain 5 Monitoring/Contraindications/Precautions May be taken with food or bed time. Improvement can be seen after 6 to 8 weeks. Avoid in pregnancy. Cervical examination annually.

Alesse Tricyclen EE 0.02 mg / levonorgestrel 0.1 mg Take one tab daily for 21 days, off for 7 days and then repeat cycle. The triphasic product contains a fixed amount of ethinyl estradiol of 0.035 mg and increasing dosing of norgestimate, 0.215 and 0.250 mg. Take one tab daily for 21 days, off for 7 days and then repeat cycle. Bloating Chloasma Breasts tenderness Depression Headache (migraine) Antibiotics concentration of hormones. Same as above Same as above Same as above Same as above Psoriasis is a chronic inflammatory papulosquamous erythematous skin disease. It is marked by the presence of silvery scales on top and pink to red beneath with sharply delineated edges. Scales may be found anywhere on the body but more likely on scalp, sacral area, extensor surfaces of knees and elbows. Psoriasis usually begins as 1 or 2 limited lesions on elbows or scalp. Months or years later it starts to involve the limbs and trunk. Lesions are usually localized but can gradually grow to cover large areas. It can have significant physiological and psychological effects. 98% cases are of Caucasian race. It has early age of onset, family history and increased frequency of human lymphocyte antigen. Can develop in later stage of life with no family history. Hyperproliferative skin condition resulting from skin cell turnover rate of approximately 10 20 times normal. Skin cells of psoriatic plaque reach the outermost layer in 3 4 days. Genetic predisposition, factors such as stressful incidents and infection are strong risk factors. Cytokines, particularly pro-inflammatory cytokines, T cells, macrophages and vascular endothelial growth factor are heavily involved in pathogenesis. Tumor necrosis factor-alpha (TNF α), in particular, has been a target of biological therapy. TNF-alpha is high in serum, synovium and psoriatic plaques. Chronic condition varies from mild forms of the disease to very severe with such extensive coverage that it hinders social and work life. 6

Goals of therapy are to improve physical signs of psoriasis, patient s quality of life and provide psoriasis control for the longest periods possible. Hydrocortisone 2.5% topical Pharmacotherapy MILD TO MODERATE CASES Name Dosage/Efficacy/Indication Side effects Monitoring/Counselling/Interactions Apply once daily to twice daily. Avoid thick plaques. Effective in mild cases. Shake bottle well before applying. Indicated for face and folds. Betamethasone 0.05% topical (Betaderm) Coal tar 1% topical Anthralin topical 1% (Anthranol) Vitamin D 3 topical derivatives UV light Apply once daily to twice daily. Effective in mild cases Indicated for body. Apply once daily. Indicated for plaques. Very effective and longer emission Apply once daily. Indicated for plaques Very effective and longer emission. Calcipotrol (Dovonex) is applied BID to affected area thinly and rub gently. Dovobet is applied as a thin layer once daily. Psoriasis plaques. Monotherapy with narrow-band ultraviolet B (UVB) has a lower risk of skin cancer compared with UVA. Skin thinning Striae Telangiectasis urpura Acne Local atrophy Dermatitis Folliculitis Photosensitivity Irritating Irritation Burning Rash Phototoxicity SEVERE CASES Avoid face and folds. Shake bottle well before applying. Avoid folds. Stains clothes, skin and hair and very messy. Can be combined with UVB. Contraindicated to folds. Can be combined with UVB. It should not be used by patients with demonstrated hypercalcemia or evidence of vitamin D toxicity. Dovonex cream should not be used on the face. Avoid sunlight exposure. Do not use calcipotriene topical on sunburned, wind burned, dry, chapped, or irritated skin or on an open wound. Avoid face and folds. Retinoids PO and topical Acitretin (Soriatane) 25 75 mg/day orally. Tazarotene (tazorac) apply thinly once daily to Skin irritation Arthralgia 7 Avoid face and folds. Acitretin is contraindicated in pregnancy, MTX and

Cr, gel, Tabs Methotrexate Tabs Psoralens with UVA Methoxsalen Oxsoralen Alefacept (Amevive) Inj. Efalizumab (Raptiva) Inj. affected areas (body). Acitretin is indicated for hands and feet. A cytotoxic that competitively inhibits dihydrofolic acid reductase and thereby inhibits DNA synthesis and cellular replication. 7.5 25 mg/d PO. Bath: 100 mg/75 L bath Water: soak in aqueous solution for 10 minutes before UVA exposure. Oral: 0.5 0.8 mg/kg 2 h before UVA exposure 3 times per week. Myalgia Alopecia Dry lips Bone marrow suppression Hepatotoxicity GI effects Blood dyscrasias Photosensitivity Pruritus Sun burn. UNRESPONSIVE SEVERE CASES: BIOLOGIC RESPONSE MODIFIERS 15 mg IM weekly for 12 weeks. Infection Dose dependent reduction of CD4 + Binds to CD11 leukocyte surface antigen, decreasing adhesion to other cell types and reducing T cell activation and function (monoclonal antibody) Start: 0.7 mg/kg SC x1; Max: 200 mg/dose Malignancy Infection Anemia Thrombocytopenia tetracycline. Women should abstain from alcohol during treatment and for 2 months after stopping acitretin because it converts to etretinate. In patients with psoriasis or rheumatoid arthritis, MTX is contraindicated in pregnancy, alcoholism, alcoholic liver disease, and chronic liver disease. Use with folic acid. Periodically monitor for toxicity, including CBC with differential and platelet counts and liver and renal function. Avoid Minipill with MTX Longest remission. Use only three times per week. Increased risk of cancer with long term use. Avoid in live vaccines and small pox vaccines. Monitor CD4 + at baseline and then q 2 weeks. Avoid in live vaccines and small pox vaccines. Monitor platelet at baseline then every month during initial treatment, then q3mo thereafter. Etanercept (Enbrel) Start: 50 mg SC 2x/wk for 3mo, then decrease to maintenance dose 50 mg SC q wk. Injection site reaction Worsening HF Avoid with live vaccines and small vaccines. Increased risk of serious infection. 8