Drugs Applied for Skin Conditions

Topical Agents

• topical= applied to skin or mucous membranes

• absorption usually slow (or none)

• Many forms: spray, cream, ointments, lotions, powders

• action may be local and systemic:

  • Local: topical steroids, local pain creams

  • Systemic: patches, nitroglycerin paste

• Some patches contain metal

• AE- usually local – irritation, stinging, burning, dermatitis.  If given inappropriately and/or excessively can absorb systemically or cause toxicity.

• Caution with applying heat – can alter absorption & release

• Some shouldn’t be occluded- stopped – increase absorption and risk of side effects

Topical Agents application

• Assess for allergies and assess baseline skin

• Ensure proper administration for best therapeutic effect

• Apply sparingly- small amounts, not over open wounds or broken skin, avoid contact with eyes or mucous membranes, do not use with occlusive dressings

• Monitor skin throughout therapy

• Wash hands after application

Emollients (ointments, creams, lotion)

• moisturizers used to protect, moisturize, and lubricate the skin

• Soften the moisturizer by rubbing it between your hands. Apply it to affected areas using your palm, in a downward stroke.

• Use a thick layer; the skin will absorb excess

Ointments

• Contain the most oil, seal in moisture (mineral oil, petroleum jelly, coconut oil).

• Thick, greasy but they work. May apply & wrap.

Creams

• Less oil, feel less greasy, spread easily.

• Eczema creams.

Lotions

• more water than oil, don’t seal in moisture as well.

• Be cautious if it contains fragrances and preservatives.

The “Soak and Seal” Method for Eczema

• Soak – take warm (not HOT) bath/shower, 10-15 minutes. Focus on clear water or gentle, fragrance-free, sulfate-free cleaner

• Pat dry gently (don’t rub)

• Seal – Apply moisturizer immediately while still wet to seal in. Prefer oil-containing. Apply prescription creams first if also have those.

Topical Corticosteroids (-sone)

Hydrocortisone, betamethasone, dexamethasone

• are often the first line of treatment for eczema.

• Steroids reduce itch, inflammation, dryness, prevent flairs

• Also used for other rashes, skin irritations, psoriasis, insect bites, even diaper rash (NOT fungal)

• Available as creams, solutions, foams and ointments.

• Differing strengths: Low potency doses available OTC.

• Often used in combinations in other drugs with oral corticosteroids (ex: ciprofloxacin/dexamethasone, acyclovir/hydrocortisone)cause thinning of skin.

• Not for prolonged use can cause withdrawal if don’t take breaks.

• Do not apply on face or near eyes or genitals or broken skin.

• use the cream for a few days after the area has healed

Topical Steroid Withdrawal Symptoms

• Severe itching, Peeling, Redness, Wrinkling, Pus oozing, Hair loss

• Most common in women

Topical calcineurin inhibitors - -limus

tacrolimus and pimecrolimus ointment 

• Alternative to steroids, if skin is damaged or steroids overused

• Approved for children 2+, used 2-4 times weekly

• Box warning for increasing risk of skin cancer and lymphoma

• Avoid sun after use, wear sunscreen.

• May cause skin pain/burning

Topical Phosphodiesterase 4 (PDE4) Inhibitors - crisaborole

• Targets PDE4 enzymes deep within the skin to reduce inflammation, swelling

• For mild to moderate eczema, apply thin layer twice daily. CAN be applied to any area (including on face).

• Can reduce to once daily once flairs have improved

• Cause mild topical issues/stinging

• “Why is eucrista so painful”

Topical Antiseptics- helps to prevent infection and removes bacteria

Chlorhexidine gluconate (CHG)

• Used as a surgical scrub, hand antiseptic, pre-op skin prep, wound care and cleaning (ChloraPrep)

• Liquid, bio-patch, dressing, external solution, pre-made swabs, etc.

• Read label for dry time; hairy areas may increase; allow to airdry

• Some solutions contain alcohol – avoid open flame and ignition sources

• Avoid eyes, ears, mouth

• Wipes are “below the jawline” only

• May cause staining of fabrics to brown

• Can cause burns in very low birthweight neonates

Iodine and provodine-iodine

• External antiseptic, oral antiseptic,

• or vaginal irritation (often surgical scrub)

• Available as aerosol powder, cream, gel, solution, ointment, pad, swab sticks, scrubs, mouth gargle, pads… etc.

• Iodine alone can be toxic; providone-iodine causes less irritation and toxicity

• Avoid occlusive dressings with iodine

• Can stain skin, clothing

• Iodine allergy is very common

Topical antivirals – acyclovir

• Applied for genital or mucocutaneous herpes (herpes simplex cold sores and fever blisters)

• Available as cream, ointment, buccal tablet (PO version also available)

• Apply prescribed amount (0.5-inch ribbon) to affected area six times per day for 7 days; apply at first sign of sores

• Local pain common (30% of ointment); Can cause irritation and contact sensitization.

• Avoid physical contact where lesions are present

Topical Antifungals – clotrimazole, ketoconazole, nystatin*

• Available as cream, foam, gel, shampoo (ketoconazole = Nizoral), powder (nystatin)

• Nystatin & ketoconazole for external use only. Apply liberally to clean and dry skin. For foot infection, apply to feet and also dust in all footwear.

• Cause itching, stinging, application site reaction

Clotrimazole

for vulvovaginal candidiasis aka (yeast infection), tinea infections

Ketoconazole

for cutaneous candidiasis, dandruff, seborrheic dermatitis, tinea infections

Nystatin

for diaper dermatitis, candida skin infections

Topical Antibiotics

Mupirocin, bacitracin

• Most minor scratches do not require an antibiotic – just good hygiene like cleaning and covering will do

• Most skin infections will use oral as first-line, topicals may be used for second-line management

Bacitracin

• ointment used to prevent skin/wound infections.

• Hypersensitivity reaction possible

Mupirocin

• treats skin infections (like impetigo or folliculitis) caused by staphylococcus; MRSA decolonization

• Can cause itching, rash, local burning, pain

Topical pain medications

Capsaicin

• Available as cream, lotion, patch, stick

• Alleviates pain from arthritis, neuralgias and neuropathies, other mild muscle aches and joint pain

• Apply no more than 3-4 times per day

• Application site burning is common (14%), also swelling, pain.

• Some formulations contain menthol. Do not use on damaged or broken skin. Can reduce sensory function in local area (burn risk)

• Excess or inappropriate use can cause serious burns).

• Avoid contact with eyes (wash hands after).

Calamine lotion

• for rashes like poison ivy, insect bites.

• Use 3-4 times per day. Be aware if formulation contains other meds.

Witch hazel

• for vaginal irritation, hemorrhoids.

• Available as pads, solution, wipes, use up to 6 times per day

Silver sulfadiazine

• cream applied to burned skin to prevent bacterial infection

• fungal infections & hematologic effects are possible

Topical phenylephrine with hydrocortisone, AKA Preparation H

• for hemorrhoids

• available as wipes, creams, suppositories