DERMATOLOGIC THERAPY

HEAD LICE (Pediculosis capitis)
PERMETHRIN 1% LOTION (Elimite, generic)-apply lotion to hair after shampooing, let set at least 10 mins, rinse
REMOVE NITS! (Nit comb)
Lindane 1% cream/shampoo (Kwell)- lather into wet hair x4mins, rinse. Do not repeat! Contraindicated in pregnancy!
Also OTC Rx- Rid, others

PUBIC LICE (Pediculosis pubis)
Permethrin 1% lotion as with head lice
Massage into affected area, leave on 10+ mins., rinse
Don’t forget nits (Nit comb- metal if possible)
Abdominal hair
Eyelashes! (can use nit comb, petrolatum to suffocate)
Same alternative Rx as head lice

SCABIES
Permethrin 5% cream (Elimite)
Massage into skin from head to toe (don’t forget creases, fingerwebs & under nails)
Let set 12-14hrs., wash off
Wash sheets, bedclothes in hot water/ bleach or iron them
Treat all skin contacts
Repeat Rx in 2 weeks if necessary

SCABIES Rx- Alternatives
Ivermectin (stromectol)- 6-9mg po x1 dose repeat in 1 week if needed
Lindane 1% lotion- apply neck to toes and leave on 8-12 hrs, rinse. Do not retreat
Crotamiton 10% lotion,cream (Eurax)-apply neck to toes (leave on) repeat 24hrs
Pregnancy- 6% precipitated sulfur in hydrophilic petrolatum head to toe daily x3days- stinks to high heaven!

INSECT BITES
STRONG (Class 1) topical steroids- clobetasol proprionate, augmented betamethasone diproprionate, halobetasol proprionate, others
Cool/cold compresses
PO antihistamines- Diphenhydramine, hydroxyzine, others
Topical anesthetics- camphor, lidocaine
Severe- systemic steroids

TICK BITE PROPHYLAXIS
Doxycycline 100mg po bid x1-3days if recent (past 2-3wks)
Make sure it “goes down”
Watch for photosensitivity

FEVER BLISTERS/COLD SORES
Herpes simplex I & II
Valtrex (valcyclovir) 2 gm po bid x 1day at first Sx to prevent
Valtrex 500mg bid x5 days
Famvir 250mg bid x5 days
Acyclovir 400mg tid x5 days
Above doses for recurrent outbreaks- for initial infection use double dose since no immunity

CHICKEN POX/SHINGLES
VARICELLA/ZOSTER- Human Herpesvirus III
Valtrex 1gm po tid x 1wk
Famvir 500mg po tid x 1wk
Acyclovir 800mg po 5x/day x 1wk
Pain killers (Darvocet, Percocet, etc)
Burow’s solution
?Systemic steroids to prevent neuralgia
Varivax – 0.5ml SQ x2 doses 4-8 wks apart

TINEA CAPITIS
Must Rx orally!
Lamisil 250mg/day x4-8wks
Sporanox 200mg/day x4-8wks
Griseofulvin 250-500mg 2-4x/day
Ketoconazole 2% shampoo or selenium sulfide 2.5% shampoo helpful
Topical antifungals can help

TINEA CORPORIS/TINEA CRURIS
Topical antifungals
Dry with hair dryer
PO Rx if severe or 2 or more sites

ANTIFUNGALS
ALLYLAMINES
IMIDAZOLE DERIVATIVES
CICLOPIROX OLAMINE
OTHERS (Nystatin, tolnaftate, gentian violet, others)

ALLYLAMINES
TERBINAFINE (Lamisil), NAFTIFINE (Naftin), BUTENAFINE (Mentax)
FUNGICIDAL- very effective against dermatophytes
Ineffective against yeast!!
Not broad spectrum

IMIDAZOLE DERIVATIVES
KETOCONAZOLE (Nizoral)
FLUCONAZOLE (Diflucan)
CLOTRIMAZOLE (Lotromin, Mycelex)
ITRACONAZOLE (Sporanox)
ECONAZOLE (Spectazole)
MICONAZOLE (Monistat)
OXICONAZOLE (Oxistat)
EXELCONAZOLE (Exelderm)
OTHERS

IMIDAZOLE DERIVATIVES
BROAD SPECTRUM- Active against dermatophytes, yeast and some bacteria
FUNGISTATIC (not fungicidal like allylamines) against dermatophytes
ACTIVE AGAINST YEAST (unlike allylamines)
SOME ANTIBACTERIAL (econazole kills Staph)

CICLOPIROX OLAMINE
LOPROX
Active against yeast and dermatophyte
Gel and cream bases

OTHER TOPICAL ANTIFUNGALS
ANTI-YEAST- Nystatin
ANTI-DERMATOPHYTE- Tolnaftate
ACTIVE AGAINST BOTH- Gentian violet solution, topical phenol (Castellani’s paint), selenium sulfide 2.5% solution

TINEA PEDIS/TINEA MANUM
Allylamines preferred since fungicidal (Lamisil, Naftin, Mentax)
“2 foot 1 hand” dis- po Lamisil
Powder or antiperspirants to feet to prevent recurrence

TINEA UNGUIUM (nail fungus)
TOENAILS- Lamisil 250mg/day x 3 months- drug stays in nails >1yr
Monitor LFT’s, CBC in immune defic.
Alternative- Lamisil 250mg/day x 1wk on, 3 wks off for three cycles
Sporanox 200mg bid x 1wk on, 3 wks off for three cycles

TINEA VERSICOLOR
MISNOMER- caused by yeast not dermatophyte
Ketoconazole 400mg (2 200mg tabs together) po qAM x 1-3days, no shower for 8 hrs after each dose
Alternative selenium sulfide 2.5% lotion/shampoo, other topical anti-yeast (not Lamisil)
Exfoliation (scrubbing) can be helpful

CANDIDA INTERTRIGO
Imidazole topical (Lotromin, Nizoral, Oxistat, others)
Nystatin (Mycostatin) powder
Loprox gel/cream
Combination- Mycolog II cream (nystatin w/ triamcinolone acetonide)
Dry with hair dryer
Oral (Diflucan, Nizoral) for severe

CELLULITIS
Must Rx PO
Cephalexin (Keflex) 500mg 3-4x/day x at least 2-4 wks
Amoxicillin/clavulinic acid (Augmentin) 875-2gm po bid x 2-4wks minimum
Fluoroquinolones- Levaquin 500-750mg/day or Avelox 400mg bid or Cipro 500-750mg bid for at least 2-4wks

IMPETIGO
Mupirocin 2% cream/ointment (Bactroban) tid Retapamulin 1% ointment (Altabax) bid
Other topicals such as Neomycin, Bacitracin not as effective
PO antibiotics (Keflex, Augmentin, etc for severe cases
.

ACNE TREATMENT
TOPICAL
ORAL ANTIBIOTICS
ACCUTANE (Isotretinoin)
HORMONAL (BCP’s, spironolactone)

COMEDONAL ACNE
No need for PO or topical antibiotics
Tretinoin (Retin-A) cream/gel/solution
Adapalene (Differin) cream/gel 0.1 & 0.3%
Azelex (azelaic acid)
Salicylic acid 2% or 3%
Sodium sulfacetamide 10% solution +/- sulfur

INFLAMMATORY ACNE
Need GERMKILLERS!
Topical benzoyl peroxide 5% or 10%
Topical clindamycin gel/cream/lotion/foam
Topical erythromycin gel/cream/lotion

INFLAMMATORY ACNE
COMBINATION THERAPY
Benzoyl peroxide/erythromycin (Benzamycin)
Benzoyl peroxide/clindamycin (Benzaclin gel, Duac gel)

ROSACEA
Topical metronidazole 1% gel/cream (Metrogel, Noritate)
Sodium sulfacetamide/sulfur cream/gel/cleanser (Rosac, Avar, Plexion)
Azaleic acid 15% (Finacea)
PO antibiotics (TCN, erythromycin, cephalexin all low dose)

TOPICAL BASES
OINTMENTS- ,most moisturizing, most powerful and most greasy

CREAMS-
next most powerful and moisturizing; not as greasy

LOTIONS-
even less powerful and moisturizing but more spreadable

SOLUTIONS-
least powerful, more drying and most spreadable

GELS-
very powerful and very drying; often sting open or sensitive areas

ORAL ANTIBIOTICS FOR ACNE
Tetracycline 250-500mg 2-4x/day
Erythromycin 250-500mg 2-4x/day
Minocycline 50-100mg 1-2x/day
Doxycycline 50-100mg 1-2x/day
Cephalexin 250-500mg 2-4x/day
Trimethoprim/sulfamethoxazole DS 1-2x/day

ISOTRETINOIN
Accutane/Sotret/Amnesteem/Others
Unique action- shrinks oil glands removing germ’s food source
Derivative of Vitamin A
Works on both inflammatory lesions AND comedones (oral form of tretinoin)
Monitor CBC, LFT’s, Lipids
Pregnancy Cat X : very difficult to get for females of childbearing age & getting harder

HORMONAL TREATMENT
ORAL CONTRACEPTIVES- to help control oil and menstrual flareups

SPIRONOLACTONE (Aldactone)-
for women with hyperandrogenism

SEBORRHEIC DERMATITIS
Sodium sulfacetamide 10% lotion (Klaron,others)
Topical Imidazoloes (Nizoral 2% shampoo/ cream, Mycelex, others)
Ciclopirox olamine (Loprox 1% shampoo/cream/gel/lotion)
OTC hydrocortisone 1% cream works fastest but only treats symptoms

CONTACT DERMATITIS
STRONG (ClassI) topical steroids
COOL COMPRESSES
PO ANTIHISTAMINES
SYSTEMIC STEROIDS (if severe)
AVOIDANCE (Patch testing to try to find cause)

CLASS I TOPICAL STEROIDS
Clobetasol proprionate .05%- Temovate,Clobex, Olux, Embeline, others
Halobetasol proprionate .05%- Ultravate, others
Augmented betamethasone diproprionate .05% (Diprolene)
Diflorasone diacetate .05% (Psorcon)
Fluocinonide 0.1% (Vanos)

TOPICAL STEROIDS—CLASSII
Fluocinonide .05% (Lidex)
Amcinonide 0.1% (Cyclocort)
Mometasone 0.1% (Elocon)
Betamethasone diproprionate .05%, non-augmented (Diprosone)
Halcinonide 0.1% (Halog)
Desoximetasone 0.1% (Topicort)

CLASS III TOPICAL STEROIDS
MEDIUM POTENCY
Triamcinolone acetonide 0.1% (Kenalog,Aristocort, others)
Hydrocortisone valerate 0.2% (Westcort)
Fluocinolone acetonide .025% (Synalar)
Fluradrenolide .025% (Cordran)
LOW POTENCY TOPICAL STEROIDS,
Desonide .05% (Desowen, Lokara)
Aclometasone .05% (Aclovate)
Triamcinolone acetonide .025% (Aristocort A)
Fluocinolone acetonide .01%
Triamcinolone acetonide .025%

SYSTEMIC STEROIDS
PREDNISONE- 60mg/day x5 days, 40mg/day x 5 days, 20mg/day x 5 days
METHYLPREDNISOLONE (medrol dosepak)- 4mg tabs 6/day x1, 5/day x1 etc x 6 day course
IM dexamethasone (Decadron)- powerful, quick-acting but short duration
IM triamcinolone acetonide (Kenalog)

STEROIDS- CAVEATS
Intertriginous areas/body creases, facial skin and breast/buttocks susceptible to skin thinning and striae
Large body surfaces treated at risk for systemic absorption
Infants/children at higher risk
Occlusion (with Saran wrap, tape etc) can greatly increase potency and toxicity
Watch for striae (stretch marks) and skin thinning

HPA AXIS SUPPRESSION
Cushingoid- buffalo hump, moon facies, wt gain
Usually with prolonged (>1-2months) high dose (>20mg/day) systemic steroid Rx
Very rare with topical steroids- would need to go through at least 60mg/wk of class I steroid for at least 3 wks
Check fasting AM cortisol- will be low

STEROID ALTERNATIVES-IMMUNE MODULATORS
Pimecrolimus (Elidel) 1% cream
Tacrolimus (Protopic) .03%/0.1% ointment
Both of above anti inflammatory yet do not show steroid side effects
Recent FDA concern about theoretical increase cancer risk- only theoretical

IMIQUIMOD (ALDARA)
Immune modulator/stimulant
Induces production of at least 5 interleukins including those causing programmed cell death
First marketed for venereal warts
Active against skin cancers, all types of warts and probably molluscum

EMOLLIENTS/MOISTURIZERS
Hydrophilic petrolatum (Vaseline) is best!
Mineral oil/Baby oil is next best
OTC creams and lotions are more “cosmetically elegant” and more expensive
Best to apply WITHIN 3 MINS. after bathing
Bar soaps and bubble bath are drying due to alkaline pH (pH of skin is slightly acidic)
Body washes (neutral pH) are better

HYPERHIDROSIS
Antiperspirants OTC
Aluminum chloride in water (Certain Dri) OTC
Aluminum chloride in anhydrous alcohol (6.7%-Xerac AC, 20%-Drysol) STAINS!
Drionic device (Iontophoresis)
Botulin (Botox)
Sympathectomy

COMMON SENSE
“WHEN IT’S WET, DRY IT. WHEN IT’S DRY, WET IT. AND WHEN ALL ELSE FAILS: USE STEROIDS”
Change bases with the seasons- gels and solutions in summer, creams and ointments in winter.
Change bases with body areas
Tailor bases to rash (e.g. don’t use greasy ointment on weeping eczema)

BODY LICE (Pediculosis humanus corporis)
Only need to treat clothing
Wash or destroy clothing
Do permethrin 1% lotion (or 5% cream) as with head lice if desired
Nits live in clothing

ORAL CANDIDIASIS
Mycelex 10mg Troche- 1 tab dissolved slowly in mouth 5x/day for 2 wks
Oral Nystatin 1 tsp (=5ml=500,000units) let dwell in mouth as long as possible qid at least 2 days after clinical clearing
Fluconazole 200mg x 1 dose then 100mg/day x 1-3wks
Gentian violet 1% or 2% solution

STAPH NASAL CARRIAGE
Mupirocin cream/oint tid x 5days
Apply a dab inside each nostril
Pinch nostrils between fingers and “milk ” them back and forth to distribute cream
Do this 3 times a day for 5 days
Up to 80% clearance rate for at least 2-3 months
Oral Rx Rifampin (Rifadin) 300mg bid + Dicloxacillin or Augmentin x 2wks

Discontinuation of therapy

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