KULIAH REGULER 2013 DERMATOVENEREOLOGICAL THERAPY

Dr. Muslimin, SpKK Department of Dermatovenereology Faculty of Medicine Diponegoro University Semarang
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Dermatovenereological therapy
There are two parts of therapy in dermatovenereology
Dermatological therapy Venereological therapy

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

Dermatological therapy (2)

The objectives:
to to to to heal/cure improve/repair minimize disability prevent

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. 4

Venereological therapy
Therapy used in treating venereal disease consists:
Regimens must be efficacious, easily to administered, simple to administered, and preferably single dose, safe. topical therapy Timely treatment is essensial to systemic therapy stop transmission of disease. surgical therapy Inadequate or self treatment or traditional treatment resistence General principles: to antibiotics Based on clinical Sex partner referral for diagnosis, syndromes councelling, and treatment to laboratory test to prevent further transmission and confirm the diagnosis. reinfection. 5

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/phototoxi city.

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%)

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Topical therapy (6)

Topical agent contains: The functions of vehicle:
to transport to stabilize to transfer the active constituent

Vehicle or the base The active ingredient The additives:

preservatives colourants fragrance emulsifyng agents & stabilizers

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There are 3 building blocks for all preparation

Powder

Ointment paste Drying paste

Shake lotion

Grease
Ointment Cold cream w/o

Creams
Vanishing cream o/w

Liquid

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Topical therapy (7)

Site of lesions
Face Hairy skin Trunk/Extremities Genitalia Skin fold Generalize Powder/shake lotion Cream Tincture Liquid Ointment Gel
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The choice of vehicle

The form of vehicle

Topical therapy (8)

The choice of topical vehicle
COMPOSITION Solid EXAMPLE Zinc oxide Talcum venetum Calamine Titanium dioxide Water Alcohol Tincture Ether Propylene glycol Calamine lotion Burrows lotion VEHICLE Powder USES - Absorbent, protective & cooling - Acute or subacute inflamation - Face, body & flexures - CI: exudating areas - Medicated bath - Soak/wet dressings - Compress - Oily skin & hairy areas - Anti pruritic, anti eczematous & cooling - Dry surfaces/mildly oozing - CI: exudating & hairy areas
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Liquid/solution

Liquid

Shake lotion

Liquid & solid

The choice of topical vehicle (2)

Vehicle Cream Composition Examples Uses to make the skin became dry not suitable for the dry skin used on acute/subacute inflammation, hairy & the flexure areas easier to apply than ointments, more greasier than the vanishing cream the best penetration & used in chronic inflammation CI: wet surfaces, hairy & flexure areas the best protection CI: exudating, hairy & flexure areas * sun block agent Solid or semisolid in the cold & become liquid on warming up As alternatives to lotions on hairy & oily skin 15

Oil in water (O/W) Vanishing cream ~ milk Aqueous cream

Ointment

Water in oil (W/O) Cold cream ~ butter Petroleum (vaselin) Lanolin Oil, little or no water Vaselin, paraffin, lanolin Oil & solid Zinc oxide paste Zinc oxide linament Titanium dioxide paste* Methylcellulose, agar/gelatin in a liquid

Paste

Gel

Semisolid

The active ingredients are used for topical therapy

The active ingredients 1. Boric acid 2. Benzoic acid 3. Salisilic acid The effects of therapy Anti septic, astringent Anti fungal, anti septic Keratoplasty 1-2% Keratolytic > 3% Anti bacterial, anti fungal Caustic Anti fungal, anti hyperhidrotic Anti pruritic Pediculoid Anti pruritic, anti eczema Anti bacterial, anti fungal, keratolytic, anti pruritic, anti eczema Uses 3% solution compress 10% ointment, powder, shake lotion 5-10% Whitfield ointment 2-4% ointment

4. TCA 5. Aluminium chloride 6. Anastesin 7. Gamexan, crotamiton, permethrin 8. Liquor carbonate detergent 9. Resorcinol

solution solution powder ointment, cream, lotion Emulsion, ointment ointment

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The active ingredients are used for topical therapy (2)

The active ingredients 10. Rivanol 11. Selenium sulfide 12. Sulfur praecipitatum 13. Sodium thiosulfide 14. Talcum venetum 15. Zinc oxide 16. Eritromycin 2% Clindamycin 1% Gentamycin 0,1% Mupirocyn 2% Fucidic acid 2% Metronidazol 1% Silver sulfadiazine 17. Corticosteroids The effects of therapy Anti septic, astringent Anti seborhoe, anti fungal Anti pruritic, keratolytic, anti bacterial Anti fungal Closer, Glider Anti septic, tissue granulation Bacteriostatic Acne Bacteriostatic Acne Bactericyd Bactericyd, bacteriostatic Bactericyd Rosacea Bactericyd burn Anti inflammation, immunosuppressant, anti proliferation Compress Shampoo Ointment Solution Powder Powder, compress Ointment, gel, lotion Ointment, gel, lotion Cream, ointemnt Ointment Cream, ointment Cream, gel Cream Ointment, cream, gel Uses

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Topical therapy (9) Soaks/Compresses

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

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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 19

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) Folliculitis & miliaria 20

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

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The active ingredients are used for topical therapy (4) Classification of topical steroids
Group 1 Mildly potent Alclometasone dipropionate 0.05% Fluocinolone acetonide 0.0025% Hydrocortisone 0.5-2.5% Group 2 Moderately potent Betamethasone valerate 0.025% Clobetasone butyrate 0.05% Desoxymethaso ne 0.05% Fluocinolone acetonide 0.00625% Flurandrenolone 0.0125% Group 3 Potent Group 4 Very potent Clobetasol propionate 0.05% Diflucortolone valerate 0.3% Halcinonide 0.1%

Beclomethasone dipoprionate 0.025% Betamethasone dipoprionate 0.05% Betamethasone valerate 0.1% Desoxymethasone 0.25% Diflucortolone valerate 0.1% Fluocinolone acetonide 0.025% Fluocinonide 0.05% Hydrocortisone 17-butyrate 0.1% Mometasone furoate 0.1% Triamcinolone acetonide 0.1%

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Systemic therapy
CLASSIFICATION EXAMPLES 1. Antibacterial Penicilline V Aqueous penicillin G Penicillin G procaine Penicillin G benzathine Ampicillin Amoxicillin Ampicillin + clavulanic acid Eritromisin A: C: A: C: A: C: A: C: C: A: C: A: C: A: C: A: C: DOSES 250-500 mg (400,000-800,000units)/6-8 hours 15-50 mg/kg/d in 3 or 4 divided doses 5 million units or more 50,000-100,000 unit/kg/g 600,000-1 million unit or more daily 25,000-50,000 units/kg/d every 12 hours 1.2 million units 27 kg 900,000 units < 27 kg 300,000-600,000 units 250-500 mg/6 hours < 20 kg 50 mg/kg/d every 6 hours 0.5 g/8 hours < 20 kg 50 mg/kg/d every 8 hours 250 500 mg/8 hours 20 mg/kg/d every 8 hours 250-500 mg/6 hours 30-50 mg/kg/d every 6 hours
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Systemic therapy (2)

1. Antibacterial 1st generation sephalosporins Sefalexin Sefadroxil Clindamycin Tetracycline Doxycycline Minocycline A: 1-4 g/d 4 divided doses C: 25-50 mg/kg/d 4 divided doses A: 1-2 g/d 2 divided doses C: 30 mg/kg/d 2 divided doses A: 150-300 mg/d C: 8-16 mg/kg every 6 hours A: 1-2 g/d 2 or 4 divided doses C: < 8 years 25-50 mg/kg/d A: 1st d 100 mg/12 hours 100 mg/d C: > 8 years 2 mg/lb/d every 12 hours A: 1st d 100 mg/12 hours 100 mg/d C: > 8 years 1st d 4mg/kg/d every 12 hours 2 mg/kg/d every 12 hours A: 160/80 every 12 hours C: T 8 mg/kg/d, S 40 mg/kg/d every 12 hours A: 1st dose 50 mg/d 100-300 mg/d 24 C: 1st dose 0.5 mg/kg/d

TrimethoprimSulfamethoxazole Dapson

Systemic therapy (3)

2. Anti fungal Griseofulvin Ketokonazol Itraconazol (Kandidosis vaginalis) A: C: A: C: A: 500-1000 mg/d > 2 years 10-12 kg/d 200-400 mg/d 3.3 mg/kg/d 2 x 200 mg/d (1d) 2 x 100 mg/d (3ds)

Working mechanism: Inhibiting the synthesis of Ergosterol and 14- demethylase enzym

3. Anti histamine

Sedation CTM Oxatomide Cyproheptadine Non sedation Terfenadin Astemizol Loratadine

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

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Systemic therapy (3)

4. Corticosteroids Prednisone Methylprednisolone Triamcinolone Dexamethason Starting dose varies widely, depending on the condition being treated

Working mechanism: Anti proliferative

Anti Inflamation
Immunosuppressant

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Systemic therapy (4)

5. Anti virus Acyclovir 5 mg/kg/8 hour IV HS: 5 x 200 mg 10 ds HZ: 5 x 800 mg 7 10 ds

1. 2. 3. 4. 5. 6. 7. 8. 9.

Kapsomers kapsid Asam nukleat Nukleokapsid Peplomer Envelop Matriks protein Kapsomers kapsid Asam nukleat Nukleokapsid
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Systemic therapy (5)

6. Anti leprosy 7. Immune therapy Rifampycin Dapson Lamprene Immune modulator Isoprenosin Immune suppression Methotrexate Cyclophosphamide Azathioprine Cyclosphorine 600 mg/m (15 mg/kg/m) 100 mg/d (1-2 mg/kg/d) 300 mg/m50 mg/d 50 mg/kg/d 3-4 divided doses 10-25 mg/w, 2.5-7.5/12 hours 3 ds 100-200 mg/d MD 100 mg/d 50-150 mg/d (1-2 mg/kg/d) 3-5 mg/kg/d

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Terapi sistemik (5) Antihistamin

Cara kerja: dengan menghambat reseptor H1 and H2 pada sel target. Interaksi histamin & reseptor jaringan H1:
Permeabilitas vena meningkat Kontraksi otot polos Resistensi jalan nafas meningkat Kemotaksis eosinofil & netrofil meningkat Stimulasi mukosa hidung
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Antihistamin (2)
Interaksi histamin & reseptor jaringan H2:
Permeabilitas vena meningkat Cardiac rate meningkat Kontraksi otot jantung meningkat Sekresi asam lambung meningkat Stimulasi CD8 & limfosit Peningkatan produksi mukosa jalan nafas Inhibisi kemotaksis netrofil & eosinofil
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Antihistamin (3)
Antihistamin H1
Antihistamin tradisional/klasik/tipe H1 generasi I Antihistamin tipe H1 generasi II/sedasi rendah

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Antihistamin tradisional/klasik/tipe H1 generasi I

Efek:
antihistamin sedasi antikolinergik aktivitas antiemetik efek anti motion sickness

Klasifikasi:
Alkilamine = chlorpheniramine maleate/chlortrimethone maleate Aminoalkyl ether = diphenhidramine HCl Ethylenediamine = Tripelennamine HCl Phenotiazine = Prometazine HCl Piperidine = Siproheptadine HCl 32 Piperazine = Hydroxyzine HCl

Antihistamin tipe H1 generasi II/sedasi rendah

Efek sedasi & antikolinergik lebih rendah Macam:
Terfenadine Astemizole Cetirizine Loratadine Acrivastine Oxatomide Fexofenadine Desloratadine
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Antihistamin (4)
Antihistamine H2
kurang lipofilik efek terhadap susunan saraf pusat lebih rendah jenis:
cimetidine Ranitidine Famotidine Nizatadine
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Obat lain dengan aktivitas antihistamin:

antidepresan trisiklik ketotifen

Perbandingan potensi

Kortikosteroid
Obat

Kortison Kortisol Prednison/predinosolon Metil prednisolon/triamsinolon Betametason Deksametason

Dosis setara 25 20 5 4 0,60 0,75

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Kortikosteroid (2)
Indikasi
mutlak: pemfigus, lupus eritematosus sistemik, nekrolisis epidermal toksik, sindrom Steven Johnson relatif: pemfigoid bulosa, eritema nodusum, lupus eritematosus diskoid, eritroderma, eritema multiforme

Kontrindikasi:
absolut: herpes simpleks, TBC tidak diterapi relatif: ulkus peptikum, infeksi, DM, hipertensi, kehamilan

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Kortikosteroid (3)
Komplikasi:
Hipertensi Perubahan mood, psikosis, pseudotumor Supresi aksis hipotalamus-pituitariadrenal, hirsutism, menstruasi ireguler, kegemukan, moon face, buffalo hamp ulkus peptikum, pankreatitis DM limfositopenia, monositopenia, netrofilia infeksi oportunistik osteoporosis, nekrosis aseptik kepala femur & humerus, miopati glaukoma & katarak retensi Na & cairan, hipokalemia alkalosis
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Terapi nutrisi
Tujuan: memberi keseimbangan anabolisme-katabolisme tergantung kondisi seseorang Komponen:
protein karbohidrat lemak vitamin & mineral

Defisiensi vitamin:
kheilitis, dermatitis seboroik (vit B2=riboflavin) stomatitis angularis (vit B6=piridoksin) pelagra (niasin) 4D: dermatitis, diare, dimensia, death

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Terapi nutrisi (2)

Defisiensi mineral:
akrodermatitis enteropatika (Zn)
dermatitis diare alopesia

Bentuk:
diet biasa diet padat, lunak, saring, bubur diet cair diet khusus: TKTP, rendah garam, bebas lemak, bebas gluten total parenteral nutrisi (TPT)
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Karsinoma Sel Basal (Se)

Physical methods of therapy

Environmental climate therapy

Dead sea psoriasis
Sea coast atopics Cutting

Surgical

Electrosurgery

Cryotherapy

Wave

Phototerapy
UVA UVB

Ionizing radiation (X ray)

Skin kancers Benign conditions (rarely & great caution) Acne Keloids Hemangiomas
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PUVA for psoriasis

Psoriasis
Nummular dermatitis Parapsoriasis Pityriasis rosea

Kaposis sarcoma
Lymphoma

Acne

Cutaneous surgery
Cold steel surgery: Cryosurgery elliptic excission, skin Chemical peel graft, flap, biopsy, Liposuction MOHS, blepharoplasty, LASER scalp reduction & hair transplantation Soft tissue Electrosurgery augmentation Dermabrasion Curettage
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Bedah kulit (2)

Bedah listrik/electrosurgery
suatu tindakan bedah dengan menggunakan alat listrik yang membangkitkan aliran listrik terkontrol destruksi jaringan yang selektif macam: elektrodesikasi, elektrofulgurasi, elektrokoagulasi, elektroseksi, elektrolisis

Bedah kimia (chemical peeling)

suatu tindakan bedah dengan mengoleskan bahan kimia perubahan anatomi; makro/mikro lesi pada epidermis/dermis macam:
superfisial: TCA 10%, as. Retinoat, AHA medium: TCA 35-50%, AHA deep: TCA 70%, fenol jenuh 42 88%

Bedah kulit (3)

Bedah beku (cryosurgery)
suatu tindakan bedah dengan menggunakan bahan kriogen membekukan jaringan nekrosis macam:
nitrogen cair (-1960C) N2O (-89,50C) CO2 (-78,50C) Freon 22, 12 (-410C, -600C)

Dermabrasi
suatu tindakan bedah untuk mengelupaskan kulit selapis demi selapis dengan menggunakan alat dermabrader macam:
sikat kawat diamond fraise

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Bedah kulit (4)

Laser: Light Amplification by Stimulating Emission of Radiation
Prinsip: amplifikasi cahaya Tujuan:
memotong koagulasi neovaskularisasi proliferasi fibroblas epitelisasi

Sifat:
monokromatis, kolomasi, koheren spektrum optik (gelombang kasat mata-infra merah)

Respon jaringan:
refleksikan dibiaskan ditransmisikan diserap

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Laser (2)
Macam:
Kontinu (CW)
Argon: adenoma sebasea, telangiektasis, lesi jinak berpigmen, granuloma piogenikum CW Nd YAG: CW CO2: veruka vulgaris, kondiloma akuminata, keloid, moluskum kontagiosum, tumor apendik kulit, psoriasis, tato, nevus epidermal Laser Copper Vapox Laser KTP

Berpulsa dengan energi tinggi

Laser Dye: nevus araneus, rosasea Laser Ruby: lesi jinak berpigmen Laser Q-Switched Ruby: tato Laser Q-Switched Alexandrite Laser Q-Switched Nd YAG

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A view of Marburg, Germany

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