The zinc topped tables used for many years to prepare tar “spreads” in a teaching hospital dermatology department were recently thrown out a sign of the times and an indication of both the increasing use of systemic treatment and much more effective forms of phototherapy.
There is still an important place for topical treatment and “dressing clinics” to play a vital role in the treatment of skin diseases and enabling affected individuals to continue their daily lives as far as possible.
The link between hospital departments and community services has been greatly increased by the development of the role of “liaison nurses”.
These nurses, with experience and training in the treatment of skin disease, visit patients in their homes to supervise treatment in conjuction with the general practitioner and the practice nurse.
As they are based in the hospital they can call on any specialist opinion or treatment needed.
A great variety of preparations is available for the treatment of skin conditions, and those most commonly used are described.
There are numerous effective alternatives.
Topical treatment
General treatments
The epidermis is capable of absorbing both greasy and aqueous preparations or a mixture of the two.
The type of lesion influences which type is used.
• Dry, scaling skin greasy ointments.
• Crusted, weeping lesions creams which are an emulsion of greases in water.
• For occlusion or long action pastes which are powder (for example, zinc oxide) in an ointment.
• For the face and scalp gels Composition of bases
The consistency and properties of ointment and cream depend on the ratio of oil or grease to water (that is, whether they are oil in water or water in oil) and the emulsifying agents used.
For example, emulsifying ointment contains soft white paraffin, emulsifying ointment, and liquid paraffin.
The oils and greases range from mineral oil through soft paraffin to solid waxes.
Some are naturally occurring, such as lanolin and beeswax.
Creams or ointments may be used on their own as emollients or as vehicles for active ingredients.
Emollients
There are numerous preparations for softening dry scaling skin and it is largely a matter of personal preference as to which one is used.
Official preparations
• Soft white paraffin greasy; protects skin and is long lasting.
• Emulsifying ointment less greasy; mixes with water and can be used for washing.
• Aqueous cream oil in water emulsion; useful as a vehicle, as an emollient, and for washing.
• Liquid paraffin: white soft paraffin, equal parts spreads easily and is less greasy than white soft paraffin.
• Hydrophilic ointment contains propylene glycol; mixes with water and spreads easily.
• Lanolin (hydrous wool fat) the natural emollient from sheep; mixes with water and greases, softens the epidermis, but can also cause allergic reactions.
Proprietary preparations
Proprietary preparations are numerous, varied, and more expensive than the standard preparations.
They may also contain sensitisers lanolin and preservatives (hydroxybenzoate, chlorocresol, sorbic acid) and can cause allergies.
Some examples are E45 cream (Crookes), Oilatum cream (Stiefel), and Lacticare (Stiefel), Unguentum Merck (Merck), Aquadrate (Norwich Eaton), and Diprobase (Schering-Plough).
Bath additives
Bath additives comprise dispersible oils such as Oilatum (Westwood, United States), Aveeno (Bioglan), Balneum (Merck), Alpha Keri (Westwood, United States), Emulsiderm, and Dermol (Dermal).
Topical steroids
Topical steroids provide effective anti-inflammatory treatment but have the disadvantage of causing atrophy (due to decreased fibrin formation) and telangiectasis.
They are readily absorbed by thin skin around the eyes and in flexures.
On the face the halogenated steroids produce considerable telangiectasia, so nothing stronger than hydrocortisone should be used (except in lupus erythematosus).
They can cause hirsutism and folliculitis or acne.
Infection of the skin may be concealed (tinea incognita, for example) or made worse.
Side effects can be avoided by observing the following guidelines:
• Avoid long term use of strong steroids.
• Potent or very potent steroids should be applied sparingly and often for a short time, then a less potent preparation less often as the condition improves.
• Use only mildly potent steroids (that is, hydrocortisone) on the face.
• Use preparations combined with antibiotics or antifungals for the flexures.
Topical steroids come in various strengths and a wide variety of bases ointments, creams, oily creams, lotions, and gels which can be used according to the type of lesion being treated.
Their pharmacological activity varies and they are classified according to their potency, the synthetic halogenated steroids being much stronger than hydrocortisone:
• Very potent Dermovate (GSK). In Britain a full list showing relative potencies appears in MIMS.
Combinations with antiseptics and antifungals, are listed below:
Mildly potent
• Vioform HC (Zyma)
• Terra-Cortril ointment (Pfizer), containing oxytetracycline and hydrocortisone
• Fucidin H cream or ointment (Leo), containing fucidic acid and hydrocortisone
• Canesten HC (Baypharm)
• Daktacort cream (Janssen)
Moderately potent
• Betnovate N (betamethasone and neomycin) (GSK)
• Synalar N (neomycin; Zeneca)
• Trimovate cream (clobetasone butyrate, nystatin, and oxytetracyclin; GSK)
• Fucibet (betamethasone, fucidic acid; Leo)
Very potent
• Dermovate-NN (clobetasone, with neomycin and nystatin; GSK).
Antiseptics and cleaning lotions
Simple antiseptics are very useful for cleaning infected, weeping lesions and leg ulcers.
Potassium permanganate can be used by dropping four or five crystals in a litre of water or in an 0·1% solution that is diluted to 0·01% for use as a soak.
It will stain the skin temporarily and plastic containers permanently.
Silver nitrate 0·25% is a simple, safe antiseptic solution that, applied as a wet compress, is useful for cleaning ulcers.
Flamazine (Smith and Nephew) is silver sulfadiazine cream, used for leg ulcers, pressure sores, and burns.
Hydrogen peroxide (6%) helps remove slough but tends to be painful.
Hioxyl (Quinoderm) is a proprietary cream for desloughing.
Iodine (2·5%) is an old fashioned, effective preparation as a tincture in alcohol and Betadine (Napp) is a proprietary equivalent.
Ionil T (Galderma) has benzalkonium chloride and coal tar solution, and Betadine (SSL) contains povidone iodine.
Shampoos containing selenium sulphide (Selsun, Abbot) and ketokonazole (Nizoral, Janssen) can be used for seborrhoeic dermatitis and also for pityriasis versicolor of the skin.
There are numerous other antiseptic, cleansing, and desloughing agents such as cetrimide, chlorhexidine, benzalkonium chloride, benzoic acid, and enzyme preparations such as Varidase (Lederle), a streptokinase and streptodornase preparation.
Tar preparations
Tar has an anti-inflammatory effect and seems to suppress the epidermal turnover in lesions of psoriasis.
The various tar pastes are generally too messy to use at home and are most suitable for dermatology treatment centres.
Standard tar paste contains a strong solution of coal tar 7·5% in 25 g of zinc oxide, 25 g of starch, and 50 g of white soft paraffin.
There are numerous proprietary preparations that are less messy and do not stain but are not so effective.
They are useful for treating less severe psoriasis at home. Examples are: Alphosyl cream (Stafford-Miller), Pragmatar (Bioglan), Psoriderm (Dermal); alphosyl HC (Stafford-Miller) and Carbo-Cort (Lagap) contain hydrocortisone as well.
Dithranol can be used in a paste containing salicylic acid, zinc oxide starch, and soft white paraffin.
It has to be applied carefully avoiding contact with the surrounding skin, as it can cause severe irritation.
It is best to start with a low concentration.
For short contact treatment relatively clean preparations in a range of concentrations are available, such as Dithrocream (Dermal),
Anthranol (Stiefel), and Psoradrate cream (Stafford-Miller).
Ichthammol is a useful soothing extract of shale tar. It can be made up as a 1% paste in yellow soft paraffin with 15% zinc oxide.
Bath preparations are useful for dry skin and widespread psoriasis.
Coal tar solution (20%) can be used or Polytar Emollient (Stiefel) or Psoriderm.
Tar shampoos are useful for treating psoriasis of the scalp.
Polytar (Stiefel), T-Gel (Neutrogena), Capasal (Dermal), and Alphosyl (Stafford-Miller) are some examples.
Keratolytics
These can be used for hyperkeratotic lesions.
They soften and help remove excess keratin.
If used for extensive areas or in infants systemic absorption can occur.
A useful preparation is salicylic acid 2–4% in aqueous cream. Salicylic acid with betamethasone ointment (Diprosalic ointment, Schering- Plough) can be used for hyperkeratotic lesions where inflammation is present.
Antipruritics
Useful anti-pruritics for persistent itching include menthol (0·5%) or phenol 1% in aqueous cream, and calamine lotion, which contains arachis oil.
Barrier and protective preparations
These preparations protect against softening and maceration from moisture in flexures, for example the groins.
They also have an occlusive effect.
They are essentially bases with zinc oxide or silicone (as dimethicone).
There are many preparations; some of the most commonly used are:
• Conotrane (Yamanoouchi) and Siopel (Bioglan), contain dimeticone (dimethicone)
• Metanium (Roche), contains titanium dioxide
• Sudocrem (Forest) and Drapolene (Pfizer), contain lanolin.
Treatment for specific situations
Sunscreens
These give a degree of protection mainly to ultraviolet B but also to ultraviolet A.
They depend on their effect on a physical barrier (usually titanium dioxide) and chemicals that combine with epidermal cells, usually esters of PABA or oxybenzone.
Camouflage
Scars, congenital naevi and other blemishes that cannot be removed can be covered with suitable creams. Proprietary preparations are available.
Antiperspirants
Aluminium chloride for hyperhidrosis: aluminium chloride 20% (Driclor, Stiefel, or Anhydrol, Dermal Laboratories).
Depigmenting agents 2% hydroquinone cream is available without prescription as “fade-out”.
Preparations containing corticosteroids are also prescribed but not available as proprietary preparations.
Antimitotic agents
5-Flourouracil cream is useful for treating incipient malignancies that is, solar keratoses, but not actual carcinomas.
It is available as Efudix cream (Roche), which is applied daily for one to two weeks.
It produces a variable degree of inflammation that is allowed to subside before the treatment is repeated.
Infestations
(1) Scabies.
The correct procedure for treatment is more important than the preparation used.
Benzyl benzoate 25% application BP is still available and is cheap but tends to irritate the skin.
Malathion is available as Derbac (SSL), Prioderm (SSL), and Quellada M (Stafford-Miller), and Permethrin as Lyclear cream (Kestrel) preparations are more effective and less likely to irritate. 6% sulphur in white soft paraffin or permethrin are recommended for young children and pregnant or lactating women.
For resistant cases ivermectin (Mectizan, MSD) by mouth is available on a named patient basis.
(2) Pediculosis.
Preparations containing malathion, carbaryl, and permethrin are used either as shampoos or lotions.
Lotions are most effective and should be left on the skin for 12 hours before washing off.
The same preparations are available as for treating scabies, with the addition of 0·5% malathion lotion as Suleo-M (SSL).
Recently a lotion of phenothrin (Full Marks, SSL) has become available for treating head and pubic lice.
Preparations for the mouth
Steroids Adcortyl in Orabase (Squibb) or Corlan pellets (Evans). Both these preparations contain corticosteroids.
Corsoidyl (chlorhexidine, GSK), and Difflam (3m Riker) are useful mouthwashes.
Topical immunosuppressants
Tacrolimus (Protopic, Fujisawa) has recently become available as an ointment in two strengths, 0.03% and 0.1%.
It has not been evaluated in children under the age of two or in pregnant women.
It is recommended that it is only used by dermatologists or those with considerable experience in treating eczema.
Although the exact mode of action is unknown it does diminish T cell stimulation by Langerhan cells and diminishes the production of inflammatory mediators from mast cells.
It should be used in moderate to severe atopic eczema that has not responded to either treatment.
Skin irritation with burning, erythema, and pruritis are the most common side effects.
In view of its immunosuppressive activity any infection should be treated first and it should be used with caution if there is a risk of viral infection or if inoculations using attenuated or live organisms are being used.
Pimecrolimus (Elidel, Steeple Novartis) is a similar preparation recommended for intermittent treatment of eczema can also be used as an initial treatment for any flare up of eczema.
It diminishes cytokine activity long term relieving both the erythema and pruritis of eczema.
In common with topical steroids any immunosuppressive drug should be used with caution as viral infections are likely to be present or the patient is undergoing inoculation with live or attenuated organisms.
Systemic treatment
Antibiotics are probably the most commonly used systemic treatment.
Long term antibiotics are needed for acne and cellulitis.
Antifungal and antiviral drugs are indicated if topical treatment is ineffective, particularly in the immunosuppressed, and when the infection has been confirmed by laboratory tests. Immunosuppressant drugs have had a considerable impact on the treatment of autoimmune and connective tissue diseases and diminished the need for systemic steroids previously the only treatment available.
They are increasingly used for extensive and persistently inflamed dermatoses, particularly psoriasis and eczema.
Antibacterial drugs
All penicillins may cause allergic rashes, which may be severe, and the broad spectrum penicillins, amoxicillin, ampicillin, and co-amoxiclav, are particularly likely to cause an intense rash in patients with glandular fever.
They tend to accumulate in patients with renal failure and may reduce the excretion of methotrexate which is used in the treatment of psoriasis.
Phenoxymethylpenicillin (penicillin V) is useful in Gram positive infections and erysipelas.
Flucloxacillin is used to treat infections due to penicillinase producing organisms.
It is used in impetigo and cellulitis.
Amoxicillin and ampicillin are broad spectrum antibiotics but are destroyed by penicillinase.
Co-amoxiclav is a combination of amoxacillin and clavullinic acid.
It is effective against a wide range of organisms and beta lactamase producing staphylococci as well.
Cephalosporins are not affected by penicillinase and are effective against both Gram positive and Gram negative infections.
Ciprofloxacin is used for infections with both Gram positive and Gram negative organisms such as pseudomonas.
Erythromycin is used for the treatment of acne and is useful in Gram positive infections.
Resistant strains of staphylococcus are appearing.
Metronidazole is useful for treating anaerobic infections and trichomonas infections.
It is useful for rosacea that is not responding to conventional treatment.
Antifungal drugs
Topical treatment is usually effective but for fungal infection of the nails and intractable infections of the skin systemic treatment may be required.
Griseofulvin (500 mg daily) is a well established treatment for fungal infections of the skin, hair, and nails.
Although it should not be used in pregnancy, it can be used in children.
It can cause lupus erythematosus to flare up.
Terbinafine (250 mg daily) is an effective systemic antifungal drug that does not affect the liver.
It is used for both nail and skin infections.
Imidazole and triazole drugs include itraconazole and ketoconazole, which are effective for dermatophyte infections of the skin and pityriasis versicolor.
Antiviral drugs
Discovery of drugs that inhibit viral DNA polymerase and inhibit their proliferation in vivo means that effective treatment for herpes simplex and zoster is now possible.
They are effective at the early stages of infection and should be started as soon as symptoms appear.
Aciclovir (Zovirax, GSK) is available as a cream. Aciclovir is effective against both herpes simplex and zoster.
The standard dose is 200mgfive times daily for five days.
In varicella infections and herpes zoster 800 mg is given five times daily for seven days.
It can also be given by intravenous infusion, and should be applied as soon as symptoms appear.
In addition, it can be used for prophylaxis, particularly in the immunocompromised patients and atopics who are liable to fulminating infection.
Famciclovir and valaciclovir are similar and are recommended for treating herpes zoster.
Antihistamines
These drugs are used in urticaria and acute allergic (type I immediate hypersensitivity) reactions.
The newer long acting and non-sedating antihistamines are useful for treatment during the day and can be combined with one of the sedating type at night if pruritus is preventing sleep.
Non-sedating antihistamines only cross the blood–brain barrier to a slight extent.
They may cause arrhythmias, particularly terfenadine.
• Acrivastine (Semprex, GSK) 8mgthree times daily
• Cetirizine (Zirtek, UCB Pharma) 10 mg once daily
• Fexofenadine (Telfast, Hoechst) 120 or 180 mg once daily
• Loratadine (Clarityn, Schering-Plough) 10 mg once daily.
Sedating antihistamines
There are many available and which is used is largely a matter of personal preference.
The sedating effect, which is enhanced by alcohol, means that they are best taken at night.
They also potentiate CNS depressants and anticholinergic drugs. They tend to have anticholinergic effects, causing dry mouth, blurred vision, tachycardia, and urinary retention. Those commonly used are:
• Cyproheptadine (Periactin (MSD) 4 mg up to four times daily)
• Hydroxyzine (Atarax (Pfizer) 10–25 mg at night; can be used during the day if drowsiness is not a problem)
• Promethazine (10 or 25 mg at night or twice daily)
• Trimeprazine (Vallergan (Castlemead) 10 mg two to three times daily).
Corticosteroids
In addition to topical preparations, systemic steroids may be required for the treatment of severe inflammatory skin conditions such as erythroderma developing from psoriasis or eczema.
They are also used in vasculitis and erythema multiforme as well as connective tissue diseases.
They are often required for the treatment of pemphigoid and pemphigus together with immunosuppressant drugs.
The side effects must be borne in mind, particularly for any long term treatment.
Most important are given below.
Water and electrolytes
Sodium and water retention with loss of potassium.
Musculoskeletal
Osteoporosis, aseptic necrosis of the femoral head, growth retardation in children, and muscle wasting.
Ophthalmic effect
Cataract formation and increased tendency to glaucoma.
Other effects
Increase in blood pressure, peptic ulceration and fat redistribution, and impaired glucose intolerance.
Retinoids
These vitamin A derivatives have proved very effective in the treatment of psoriasis and acne but are not without risk of side effects.
The most serious is that they are teratogenic and must be discontinued for at least three months after stopping treatment in the case of isotretinoin and five years after taking acitretin.
All patients should be warned of possible side effects and women of childbearing age must be using an effective form of contraception, which must have been used for at least a month before treatment has started as well as having a pregnancy test carried out.
Liver function tests and fasting cholesterol and triglycerides should be carried out on all patients.
After prolonged treatment in adolescence, radiological tests should be carried out to ensure that there is no extraosseous calcification.
The most important side effects are:
• Abnormal liver function tests
• An increase in cholesterol and triglycerides
• Occasional increases in electron spin resonance and lowered white count.
Clinical side effects
Drying and roughening of the skin and mucous membranes, particularly the lips, can occur.
There may also be thinning of the hair and nails. Photosensitivity eruptions can develop.
Occasionally muscle and joint pains occur.
Acitretin
This drug is used for severe psoriasis including pustulosis of the hands and feet.
It has also been used in other forms of keratosis such as Darier’s disease and pityriasis rubra pilaris.
Isotretinoin
This drug is used for severe acne vulgaris that has not responded to antibiotics or other treatments.
It is therefore often used in adolescence and it is important to be aware of the musculoskeletal effects and possible mood changes.
Immunosuppressants
Methotrexate This drug is useful in severe psoriasis that is not responding to topical treatment.
The main disadvantage is its adverse effect on the liver, which precludes its use in those who have alcoholic liver disease but who are often those most needing systemic treatments.
Idiopathic immunosuppression can occur so a test dose must always be given and a full blood count carried out 48 hours later before treatment has started.
There may be gastrointestinal upsets and osteometitis as well.
Methotrexate interacts with anti-inflammatory and antiepileptic drugs.
A full list of drug interactions should be consulted before treatment is started.
After a 2·5 mg test dose and full blood count 48 hours later, the regular dose is 5–15 mg by mouth once a week.
Full blood count and liver function tests should be carried out once a week for the first six weeks and thereafter once a month during treatment.
Folinic acid should be given at the same time, as this prevents bone marrow depression.
In many centres a liver biopsy is considered mandatory before treatment is started since blood tests will remain normal for some time during the development of hepatic fibrosis.
Azathioprine
This drug is used for systemic lupus erythematosus, pemphigus, and bullous pemphigoid.
It enables the dosage of systemic steroids to be reduced.
The most serious side effect is bone marrow suppression.
This may occur quite rapidly, particularly in those with diminished ability to metabolise the drug.
This is carried out by thiopurine methyl transferase (TMT).
The level of this enzyme should therefore be determined before treatment is started and those at low levels given a lower dosage.
Those who inherit high activity may require higher doses.
Other side effects include gastrointestinal upset, liver toxicity, and an increased tendency to infection.
Ciclosporin
This drug has proved helpful in severe psoriasis within inflammatory lesions and, secondly, in the treatment of severe atopic dermatitis.
There are a number of drug interactions and it is important to check renal function and monitor both blood urea and serum creatinine.
Other drugs
Dapsone
This drug was originally developed for treating leprosy but was proved very effective in dermatitis pityformis and some other conditions, such as pyoderma gangrenosum.
It may cause haemolytic anaemia, and other side effects include bone marrow suppression, hepatitis, and peripheral neuropathy. Regular blood checks are essential.
Hydroxychloroquine
This drug is used in both systemic and discoid lupus erythematosus as well polymorphic light eruption and porphyria cutanea tarda.
The most serious side effect is retinopathy but this does not occur if the dose does not exceed 6·5 mg/kg lean body weight.
Psoralens
These drugs are used in conjunction with long wavelength ultraviolet light as psoralen with ultraviolet A (PUVA) therapy.
It is used for the treatment of severe psoriasis.
It has also proved effective in some cases of atopic eczema, T cell lymphoma of the skin, and occasionally in lichen planus.
There is a risk of cataract formation, and a full blood count as well as antinuclear factor tests should be carried out.
Preparations for treating acne and varicose ulcers are described in the appropriate sections.
