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/cure
to improve/repair
to minimize disability
to prevent

Dermatological therapy (3)

Therapy used in treating skin diseases
consists:
topical therapy
systemic therapy
physical modalities

Topical therapy
Appropiate 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 disease
acute/chronic, stage,
localize/generalize

Skin effloresense
intact/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/phototoxic
ity.

Percutaneus
absorption:
Penetration through the
stratum corneum
Metabolism of drug
Transdermal delivery
sistems

Topical therapy (4)

Penetration through
the stratum corneum
interfered by:
skin temperature
hydration of stratum
corneum
skin condition
location
age
topical agent

Penetration
enhancers:
urea
salicylic acid
dimethyl sulphoxide
propylene glycol

Topical therapy (5)

Elements of topical
prescription:
Medication
Vehicle
Concentration
Amount
How to apply

Amount needed for

one application of
cream:
face
arm
leg
whole body

:2g
:3g
:4g
: 30 g

Ointment (-10%), lotion (+50%)

Topical therapy (6)

Topical agent
contains:

The functions of vehicle:

Vehicle or the base

The active ingredient
The additives:
preservatives
colourants
fragrance
emulsifyng agents &
stabilizers

to transport
to stabilize
to transfer

the active
constituent

There are 3 building blocks for all preparation

Powder

Shake lotion

Ointment paste
Drying paste

Grease
Ointment

Liquid

Creams
Cold cream

Vanishing cream

w/o

o/w

Topical therapy (7)

Site of lesions

The choice of
vehicle

The form of vehicle

Face
Hairy skin
Trunk/Extremities
Genitalia
Skin fold
Generalize
Powder/shake lotion
Cream
Tincture
Liquid
Ointment
Gel

Topical therapy (6)

The choice of topical vehicle

The choice of topical vehicle (2)

The active ingredients are used for topical therapy

The active ingredients are used for topical therapy (2)

Topical therapy (7)

Soaks/Compresses
Materials
Normal saline solution
KMnO4 solution
0.1% acetic acid solution
3% boric acid solution
0.1% rivanol solution

Methods for soaks

Open soaks
application of a water
compress without
occlusion
cause cooling & drying
by evaporation
effective for drying
moist, oozing, acute
inflammation skin
eruptions
applied for 20 3x a day

Close soaks
employ occlusion over a
compress
cause heat retention
excellent for debridement of
wound & ulcer maceration
applied for 1-2 hours 2-3x a
day
applied 24 hour 2-3 day,
rewet the dressing 4-5x for
removing thick crusts

The active ingredients are used for topical therapy (3)

Corticosteroids
chronic, extensive use
of potent topical
steroids even under
occlusion
systemic side effects:
adrenal suppression
Cushings syndrome
growth retardation

Topical side effects:

striae & atrophy
acne
perioral dermatitis
rosacea
purpura & teangiectasia
masking effect
Glaucoma
Allergic contact
dermatitis
Hypopigmentation
Reduced wound healing
Hirsutism (face)

The active ingredients are used for topical therapy (3)

Regional Differences in Penetration of Glucocorticoids

Mucous membrane
Scrotum
Eyelids
Face
Chest & back

Upper arms & legs

Lower arms & legs
Dorsa of hands and feet
Palmar & plantar skin
Nails

Less penetration

The active ingredients are used for topical therapy (4)

Classification of topical steroids

Systemic therapy

Systemic therapy (2)

Systemic therapy (3)

3. Anti histamine

Sedation
CTM
Oxatomide
Cyproheptadine
Non sedation
Terfenadin
Astemizol
Loratadine
Cetirizine
Fexofenadine
Desloratadine
Levocetirizine

3 x 4-12 mg/d
2 x 60 mg/d
10 mg/d
10 mg/d
10 mg/d

Systemic therapy (4)

Working mechanism: Anti proliferative

Anti Inflamation
Immunosuppressant

Systemic therapy (5)

Systemic therapy (6)

Antihistamine
Mechanism of action: by inhibiting H1 and H2
receptor on target cells
Interaction of histamine & H1 receptor:
Increased vein permeability
Smooth muscle contraction
Increased airway resistance
Increased neutrophyl and eosinophyl chemotaxis
Nasal mucosa stimulation

Antihistamine (2)
Interaction of histamine & H2 receptor:
Increased vein permeability
Increased cardiac rate
Increased myocardial contraction
Increased gastric acid secretion
Stimulation of CD8 & lymphocyte
Increased airway mucosa secretion
Inhibition of neutrophyl and eosinophyl chemotaxis

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

Traditional/classic type H1 antihistamine,

1st generation
Effects:
antihistamine
sedation
anticholinergic
Antiemetic activity
Anti motion sickness
effect

Classification:
Alkylamine = chlorpheniramine
maleate/chlortrimethone maleate
Aminoalkyl ether =
diphenhidramine HCl
Ethylenediamine =
Tripelennamine HCl
Phenotiazine = Prometazine HCl
Piperidine = Siproheptadine HCl
Piperazine = Hydroxyzine HCl

Low sedating type H1 Antihistamine, 2nd

generation
Weaker sedating and
anticholinergic effect

Examples:
Terfenadine
Astemizole
Cetirizine
Loratadine
Acrivastine
Oxatomide
Fexofenadine
Desloratadine

Antihistamine (4)
H2 Antihistamine
Less lypophilic
Weaker central nervous
system effect
examples:
cimetidine
Ranitidine
Famotidine
Nizatadine

Other drugs with

antihistamine activity:
Tricyclic antidepressant
ketotifen

Corticosteroid
Potensial equivalent

Corticosteroid (2)
Indications
absolute: pemphigus,
systemic lupus
erythematosus, toxic
epidermal necrolysis,
Stevens-Johnson syndrome
relative: bullous pemphygoid,
erythema nodusum, discoid
lupus erythematosus,
erythroderma, erythema
multiforme

Contraindications:
absolute: herpes
simplex, untreated TB
Relative: peptic ulcer,
infection, DM,
hypertension,
pregnancy

Corticosteroid (3)
Complications:
Hypertension
Mood disturbance,
psychosis, pseudotumor
Hypothalamus-pituitaryadrenal axis supression,
hirsutism, menstrual
irregularity, obesity, moon
face, buffalo hump
Peptic ulcer, pancreatitis

DM
Lymphocytopenia,
monocytopenia, neutrophylia
Opportunistic infection
osteoporosis, aseptic
necrosis of femoral head &
humerus, myopathy
glaucoma & cataract
Sodium & fluid retention,
hypokalemia, alkalosis

Physical methods of therapy

Surgical

Environmental climate
therapy
Dead sea psoriasis
Cutting

Sea coast atopics

Electrosurgery

Cryotherapy

Wave

Phototerapy (1)
UVA
PUVA for psoriasis

Ionizing radiation (X ray)

UVB

Skin cancers

Psoriasis

Kaposis sarcoma

Nummular dermatitis

Lymphoma

Parapsoriasis
Pityriasis rosea
Acne

Benign conditions
(rarely & great caution)
Acne
Keloid
Hemangioma

Kompetensi
1.Punch biopsy (2)
2.Incision/drainage of abscess (3)
3.Excision of tumours (2)
4.Cryotherapy on tumours (1)
5.Wart, cryotherapy (3)
6.Wound care (4)
7.To apply a dressing (4)
8.Varicose veins, compressive sclerotherapy (1)
9.Varicose veins, ambulant compresive therapy on venouus leg ulcer (2)
10.Phototherapy (1)

Ketrampilan
Tingkat kemampuan 1 : Mengetahui dan menjelaskan
Tingkat kemampuan 2 : Pernah melihat atau pernah
didemonstrasikan
Tingkat kemampuan 3 : Pernah melakukan atau pernah menerapkan
di bawah supervisi
Tingkat kemampuan 4 : Mampu melakukan secara mandiri

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

Electrosurgery
Dermabrasion
Curettage

Cryosurgery(1)
Chemical peel
Liposuction
LASER
Soft tissue
augmentation

Skin biopsy
A skin biopsy is the removal a piece of
skin to diagnose or rule out an illness.
Biopsy Techniques
Shave Biopsy
Punch Biopsy (2)
Fusiform/excisional Biopsy

Punch Biopsy-1
More often used for deeper skin lesions
Small 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
dressing
An 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 RSTL
The cavity may be irrigated
with saline & loosely packed
with iodoform/plaine gauze.
Leave this gauze and remove
after 48 hours
Use intermittent warm water
soaks after packing is removed

Cutaneous surgery (2)

Electrosurgery
A form of surgery using
electrical equipment which
generates controlled
electric current to produce
selective tissue destruction
types: electrodesiccation,
electrofulguration,
electrocoagulation,
electrosection, electrolysis

Chemical peeling
A 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, AHA
medium: TCA 35-50%, AHA
deep: TCA 70%, saturated phenol
88%

Cutaneous surgery (3)

Cryosurgery
A form of surgery by using
cryogents tissue
freezing necrosis
Types:
Liquid nitrogen (-1960C)
N2O
(-89,50C)
CO2
(-78,50C)
Freon 22, 12 (-410C,
-600C)

Dermabration
A form of surgery to
peel the skin layer by
layer with dermabrader
Types:
Wire brush
Diamond fraise

Some conditions suitable for

cryosurgery
Precancerous lesions
(1)

Vascular benign lesions (1)

Venous lake,
angiokeratomas,
lymphangioma

Actinic keratosis,
leukoplakia, Bowens
disease, lentigo maligna Dermal tumours (1)

Epithelial benign lesions

Seborrhoeic keratosis,
HPV lesions (3),
epidermal hamartoma,
sebaceous hamartoma

Dermatofibroma, keloid,
myxoid cyst

Inflammatory dermal
tumours (1)
Prurigo nodularis, granuloma
faciale

Cutaneous surgery (4)

Laser: Light Amplification
by Stimulating Emission
of Radiation
Principle: light amplification
Objectives:
cutting
coagulating
neovascularization
Fibroblast proliferation
epithelization

Properties:
monochromatic,
colimation, coherent
Optical spectrum
(infra-red,visible light)

Tissue response:
reflecting
refracting
transmitting
absorbing

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

Pulsed with high energy

Dye laser: nevus araneus,
rosasea
Ruby laser: pigmented benign
lesion
Q-Switched Ruby laser: tattoo
Q-Switched Alexandrite
Q-Switched Nd YAG