University Of Southern California Department Of .

Common DermatologicMedicationsMedical Student Rotation Lecture SeriesDepartment of DermatologyUniversity of Southern California

Medication Classes Topical Systemic– Papulosquamousdisorders (e.g. psoriasis.lichen planus)– Papulosquamousdisorders (e.g. psoriasis,lichen planus)– Atopic Dermatitis– Atopic Dermatitis– Acne/Rosacea– CTD (dermatomyositis,lupus,scleroderma/morphea)– Skin Cancer

Class 1BRAND NAMEGENERIC NAMECLASS 1 - SuperpotentClobex Lotion/Spray/Shampoo, 0.05%Clobetasol propionateCormax Cream/Solution, 0.05%Clobetasol propionateDiprolene Gel/Ointment, 0.05%Betamethasone dipropionateOlux Foam, 0.05%Clobetasol propionatePsorcon Ointment, 0.05%Diflorasone diacetateTemovate Cream/Ointment/Solution, 0.05%Clobetasol propionateUltravate Cream/Ointment, 0.05%Halobetasol propionateVanos Cream, 0.1%Fluocinonide

Class 2CLASS 2 - PotentCyclocort Ointment, 0.1%AmcinonideDiprolene Cream AF, 0.05%Betamethasone dipropionateDiprosone Ointment, 0.05%Betamethasone dipropionateElocon Ointment, 0.1%Mometasone furoateFlorone Ointment, 0.05%Diflorasone diacetateHalog Ointment/Cream, 0.1%HalcinonideLidex Cream/Gel/Ointment, 0.05%FluocinonideMaxiflor Ointment, 0.05%Diflorasone diacetateMaxivate Ointment, 0.05%Betamethasone dipropionatePsorcon Cream 0.05%Diflorasone diacetateTaclonex Ointment, .064%Betamethasone dipropionate and calcipotrieneTopicort Cream/Ointment, 0.25%DesoximetasoneTopicort Gel, 0.05%Desoximetasone

Class 3CLASS 3 - Upper Mid-StrengthAristocort A Ointment, 0.1%Triamcinolone acetonideCutivate Ointment, 0.005%Fluticasone propionateCyclocort Cream/Lotion, 0.1%AmcinonideDiprosone Cream, 0.05%Betamethasone dipropionateFlorone Cream, 0.05%Diflorasone diacetateLidex-E Cream, 0.05%FluocinonideLuxiq Foam, 0.12%Betamethasone valerateMaxiflor Cream, 0.05%Diflorasone diacetateMaxivate Cream/Lotion, 0.05%Betamethasone dipropionateTopicort Cream, 0.05%DesoximetasoneValisone Ointment, 0.1%Betamethasone valerate

Class 4CLASS 4 - Mid-StrengthAristocort Cream, 0.1%Triamcinolone acetonideCordran Ointment, 0.05%FlurandrenolideElocon Cream, 0.1%Mometasone furoateKenalog Cream/Ointment/Spray, 0.1%Triamcinolone acetonideSynalar Ointment, 0.025%Fluocinolone acetonideUticort Gel, 0.025%Betamethasone benzoateWestcort Ointment, 0.2%Hydrocortisone valerate

Class 5CLASS 5 - Lower Mid-StrengthCordran Cream/Lotion/Tape, 0.05%FlurandrenolideCutivate Cream, 0.05%Fluticasone propionateDermAtop Cream, 0.1%PrednicarbateDesOwen Ointment, 0.05%DesonideDiprosone Lotion, 0.05%Betamethasone dipropionateKenalog Lotion, 0.1%Triamcinolone acetonideLocoid Cream, 0.1%HydrocortisonePandel Cream 0.1%HydrocortisoneSynalar Cream, 0.025%Fluocinolone acetonideUticort Cream/Lotion, 0.025%Betamethasone benzoateValisone Cream/Ointment, 0.1%Betamethasone valerateWestcort Cream, 0.2%Hydrocortisone valerate

Class 6 & 7CLASS 6 - MildAclovate Cream/Ointment, 0.05%Alclometasone dipropionateDerma-Smoothe/FS Oil, 0.01%Fluocinolone acetonideDesOwen Cream, 0.05%DesonideSynalar Cream/Solution, 0.01%Fluocinolone acetonideTridesilon Cream, 0.05%DesonideValisone Lotion, 0.1%Betamethasone valerateCLASS 7 - Least PotentTopicals with hydrocortisone 1, 2.5%, dexamethasone, methylprednisolone and prednisolone

2 Components Active compound– The medicine (e.g. clobetasol, triamcinolone) Vehicle– Delivers the medicine– Determines rate of absorption

Percutaneous Absorption

Active Compound - PotencyIncreasingStrength Clobetasol 0.05% (I)Fluocinonide 0.05% (II)Triamcinolone 0.1% (IV)Westcort 0.1% (V) – not fluorinatedHydrocortisone 2.5% (VII)Hydrocortisone 1% - OTCConcentration has nothing to do withpotency

Active Compound Rules Use the least potent topical steroid necessary for theshortest duration possible Use a ladder approach All BID dosing– Can step-down to Qday dosing at patient improves Consider area of treatment– Never use anything stronger than class IV on the face/groin/axilla– Percutaneous absorption: Nail palm/sole trunk/extremities face/scalp scrotum Should never be used more than 3 weeks continuously– Use steroid-sparing agents

Vehicle Solution – alcohol– Most useful on hair-bearing areas Gel – cellulose with alcohol/acetoneDrying– Greaseless Lotion – oil in water Cream – oil in water emulsion– Have preservatives irritating Ointment – water in oil emulsion– Greasy– Many are preservative free Others: Foam, spray, oil, shampoo, paste, tape

Vehicle Rules If wet use a drying vehicle If dry use a moisturizing vehicle– ***Give the patient something that they willactually use Can occlude the medicine with saran wrap toincrease the absorption and potency Ointments are inherently occlusive– More potent than corresponding creams

How Much to Use FTU ointmentfrom 5mm-diameternozzle thatstretches from distalcrease to tip offinger 0.5 g Approx 20g forentire body 250g/week if used BID 1 lb 454 g 0.25g ½ FTU 1flat palm 1% BSA 1 FTU 2% BSA

How Much to Use

Children Lower potency topical CS recommended Cutivate Fluticasone propionate (V)– Safe in 3 months of age for 4 weeks Avoid Group I/II in pre-pubertal children Use only group VI/VII in diaper area for 3-10days Monitor growth parameters in children onchronic topical steroids

Adverse Effects Used for 30 years with excellent safety record Common––––Skin atrophy, striae, telangiectasiasRosacea/Perioral dermatitis/Acne/FolliculitisTachyphylaxis, ReboundHypopigmenation Less common–––––Allergic contact dermatitisImpaired wound healingTinea/scabies incognitoGlaucoma, cataractsHypertrichosis Systemic absorption HPA axis suppression– 1/3 of psoriatic w/ 30% BSA involvement– 1/3 of atopics w/ 20% BSA involvement: decreased barrier function

Topical Calcineurin Inhibitors Tacrolimus 0.1% or 0.03% ointment (Protopic);0.03% is used in pediatric population Pimecrolimus 1% cream (Elidel) Indications: atopic dermatitis, psoriasis, vitiligo,seb derm, perioral dermatitis Steroid-sparing agents– Avoid atrophy, striae, dyspigmentation– Used on face frequently Adverse effects: burning, stinging uponapplication Ointment occlusive than cream

Topical Vitamin D Analogues Calcipotriene (Dovonex)– 0.005% cream, ointment– Qday to BID Indication: psoriasis, vitili go, morphea Anti-inflammatory/anti-proliferative Inactivated by acidic pH– Don’t use with ammonium lactate 12% lotion Degraded by UV light– Do not apply before phototherapy

Topical RetinoidsDrug eAcne, hyperpigmentation, photo-agingQday0.1, 0.3% crm, gelQHS0.025, 0.05. 0.1% crmQHS0.05, 0.1% crm, gelLabs/MonitoringNone; monitor for compliance and A/E discussed belowAdverse EffectsDryness, redness, peeling, flaking, photosensitivityApplication notes:LeastModerateGreatest- Apply 10-15 minutes after washing face- Apply pea-sized amount to entire face (not spot treatment)- When starting or increasing strength titrate dose: use Q3nights x 1week, Q2nights x 1 week, then Qnight- Use AM moisturizer with SPF 30 - May use PM moisturizer 10-15mins after applying

Topical Antibiotics Topical Clindamycin 1%––––Gel, lotion, solution, pledgets Qday - BIDIndications: Acne, folliculitis, HSResistance may develoop, prevent with concomitant use of BPA/E: dryness, sensitivity, gram-negative folliculitis Topical Benzoyl peroxide 2.5-10% (OTC)– Cream, gel, foam, wash, lotion, pads Qday - BID– Indications: Acne, folliculitis, HS Washes are good for chest/back acne– A/E: dryness, irritation, esp when used with topical retinoid Careful will BLEACH hair, linens, and clothing

Topical Anti-NeoplasticsDrug NameImiquimod 5% cream(Aldara)5-Fluorauracial 5% cream(Efudex)Indication(s)Genital warts, superficial BCC,AK, common warts, SCCis,molluscumDosingVaries; most common M,W,F PM Qday - BID; length varies withapplication, wash off in AM x 16 diagnosis; frequently used qDweeksfor 4 weeks, BID for 2 weeksdepending on patientpreferenceInitial LabsNoneMonitoringAdverse EffectsAK, actinic chelitis, SCCis,superficial BCC, common andgenital warts, porokeratosesNoneNo specific monitoringCheck for appropriate response to treatment while minimizingA/EErythema, pruritus, pain,burning, irritation, scaling,erosion/ulceration, flu-likesymptoms in 1-2%Erythema, pain, burning,irritation, scaling,erosion/ulceration,photosensitivity;

Systemic )Indication(s)Acne, rosacea, hidradenitis suppurtiva,pityriasis rubra pilaris, Darier’s diseasePsoriasis, pityriasis rubra pilaris,hidradenitis suppurativaDosing0.5-1.0mg/kg/day div BID or QdayGoal dose: 120-150mg/kgOral 10-25mg PO Qday, can titrateupLabs/MonitoringCBC, CMP, FLP QmonthCBC, CMP, FLP QmonthFemales: 2 negative urine/serum preg test,1 month apart*requires iPledge enrollmentAdverse EffectsXerosis, cheilitis, nasal dryness, dry eye,arthralgia/myalgia, HLD, hyperostosis,transaminitis, headache, pseudotumor,IBD?, depression?Xerosis, cheilitis, hair loss, dry-eye,photosensitivity, eption 1 month after d/cCaution: IBD, psych, HLD, bone diseasePregnancyContraception 3 years after d/cSevere renal/hepatic dx, or HLD

TNFa-Inhibitors

Other BiologicsDrugNameUstekinumab(Stelara)IL 12/23 xent)IL-4/13 inhibitorIndication(s)Psoriasis, psoriatic arthritisPsoriasis, psoriatic arthritis; superior toStelara and Etanercept in PASI 75scoresAtopic dermatitis; approved for adultsand ndication45 or 90mg SQ (weight based dosing) on Loading dose of 300 mg and 150 mgday 1; repeat in 4 weeks; then Q3every 4 weeksmonthsInjection given during clinic visitCBC, CMP Q6-12mo, Hep B/C panelPPD/quant gold QyearCBC, CMP Q6-12mo, Hep B/C panelPPD/quant gold QyearCommon: Injection site reactionNasopharyngitis, injection site reactions,Uncommon: infection, malignancy,headaches, candidiasis and HSVreversible posterior leukoencephalopathysyndromeActive infection (i.e. TB)Chronic/recurrent infectionActive infection (i.e. TB)Chronic/recurrent infectionInitial dose of 600 mg then 300 mg Q2weeksNoneKeratoconunctivitis, increased risk ofHSV infectionNone

verse atogenGI, transaminitisMany isease, vasculitis,- Oral; inhibits DNA CTD, AD,synthesisphoto-dermatosesTPMT levelCBC, CMPPPD/quant goldHep B/CCyclosporinePsoriasis, AD,- Oral; calcineurin pyodermainhibitor inhibits gangrenosumT-cellsBP, CBC, CMP, FLP, Renal dysfunctionU/A, MgHTN, HyperKPPD/quant gold, HLD, NMSCHep B/CMTXPsoriasis, sezary 5mg test dose,Stomatitis, LFTs,- Oral; Inhibits folic syndrome, atopic check CBC; then alopecia, N/D,acid pathway derm, bullous dx 5-25mg PO Qwk, anemia, BUN/Cr,interferes withCBC, CMP, Hep B/C, lymphoma,DNA synthesisPPD/quant, HIV; pneumonitis,folic acid QDinfectionMycophenolatePsoriasis, AD,Mofetil (Cellcept) bullous, CTD,- Oral; InhibitsvasculitisCBC, CMP,PPD/quant, HepB/C2-5mg/kg QdayMax 3-6 mosMANY druginteractionsLiver bx after1-1.5gm to evalfor hepaticfibrosisNO alcoholDiarrhea, GU,T and B cellsinfection, cytopenia, preferentiallymalignancyeffected

lous, CTD, vasculitis, papulosquamous, contact dermatitis, etc.Varies; 1mg/kg daily tapered over 3-4 weeks, but largely varies based ondiagnosis No taper needed if 2 weeksPPx: Ca/Vit D, PPI/H2 blocker, alendronateLabs/MonitoringBaseline PPD/quant, fasting glucose, TG, K, BP, weight, eye exam (cataracts)DEXA/Ophtho exam QyearAdverse EffectsEndocrine (adrenal, DM, Cushing syndrome), GI (ulcer), MSK (osteoporosis),Psych (depression, anxiety, psychosis), ID (infection), cardiac (HTN), ocular(cataract, glaucoma)Contraindications Active systemic infection (fungal, HSV keratitis), others are relativecontraindications