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Pharm Ex 2 (a) - Topical Steroids

Pharm Ex 2 - Topical Steroids
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What type of drugs are used for dermatologic conditions?
Primarily topical but can also include other routes
Topicals - Types
Topical corticosteroids, NSAIDS, Anti infectives, Acne preparations, Burn prep, Keratolytics, tars, scabicides/pediculocides, local anesthetics
Topical agents - factors that affect absorption
Vehicle used affects absorption
Broken or inflamed skin = increase absorption
Thinner skin = increase abpt
Children absorb abt 3X the amt that adults do
Pregn & lactating pt needs to be esp careful abt topical
Why do children require a lower dose, and potency?
They absorb about 3X the amount that adults do
What topical agents may be harmful to fetus
tretinoin, lindane and podophyllin
T/F Mucous membranes absorb in high concentrations?
True, because of increased vascularity
T/F - All topically applied medications can be absorbed systemically
True, all topicals can be absorbed systemically
Which is has slower absorption and is incomplete- topical or oral agents?
Absorption of topical agents is slow and incomplete when compared to oral agents
T/F - Patient instructions for topicals should include to apply a thin layer and agents are for external use only - avoiding the eyes
True, PA needs to be clear that its for external use only
Vehicles for topical absorption - CREAMS (advantage)
White, most freq base used,
cosmetically more acceptable
Can be used on most body areas
Esp good in intertriginous areas
Can be drying with prolonged use
Good for exfoliative dermatitis
What are the disadvantages of using Creams?
Can be drying with prolonged use
Ointments
Translucent
Has petroleum jelly in it which incr its occlusiveness and potency
Which is more potent - Ointment or Cream?
Ointment is more potent than cream
Which component of ointments increases it potency and occlusiveness?
Petroleum jelly - it creates a barrier betw med and skin and doesn't allow h2O to penetrate
Gels
Clear with gelatinous consistency, can feel sticky, alcohol gels feel cool and are drying
Good for exudative inflammation.
Nonalcoholic gels are drying as well & good for scalp lesions
Which is the best vehicle for exudative inflammation?
Gels are best for exudative inflammation
Which is the best vehicle for exfoliative dermatitis?
Creams are best for exfoliative dermatitis
Which is best for the scalp, hair areas?
-Gels are best because they won't mat the hair
- Solutions & Lotions
-Aerosols
Solutions and Lotions
Clear or milky, useful for scalp because it penetrates the hair shaft
Can be drying when used in intertriginous areas
Effect of solutions & lotions on intertriginous areas?
They are drying and irritating when used in intertriginous areas
Why are solutions and lotions good for scalp?
Because they penetrate the hair shaft
Aerosols
-Suspended in a base & delivered via propellant, ---useful for scalp,
-convenient for pts who lack mobility,
-useful for moist lesions
Which is best for moist lesions?
Aerosols are useful for moist lesions
What are the main indications for topical steroids?
Inflammatory and pruritic dermatoses that are responsive to corticosteroids
-Psoriasis, Eczema, contact dermatitis
Common side eff of topical corticosteroids?
Atrophy (if used chronically or in high doses)
Striae, telangiectasia, purpura, acne, perioral dematitis and steroid rosacea
Cataracts and glaucoma if used for long period around eye
What increases the risk for side effects of corticosteroids?
Prolonged use
Used under occlusion
On face and on intertriginous areas
What is the action of corticosteroids?
Inhibition of migration of macrophages & Leukocytes into area by reversing dilation & permeability of small vessels
What is the most important variable when choosing a topical steroid?
Potency - it needs to be potent enough to achieve response and low enough to reduce side effects
Where its located -large area-->use something else
When would we use low potency?
On kids
-Large areas
-Mild conditions
-On areas prone to steroid damage (face, scrotum, axilla, flexures and skin folds)
When would we use high potency?
-Areas resistant to milder agents
-more sever conditions
-Small areas
Which is higher in potency - Group I or IV?
Group I is more potent/very high
Group II = High
Group III = Medium
Group IV = Low
Freq & Course for topical corticosteroids
Use sparingly 2-4X/day
-Adequate results with --> 2-6 weeks
-Do not discontinue abruptly after prolonged use
-Do not abruptly discontinue a potent agent = rebound
What are the precautions with High potency steroids?
- Do NOT use fluorinated/high potency on FACE
-Treatment should be short
-Short term intermittent therapy with high potency may cause fewer side eff than long term med or low therapy
What should be done instead of abruptly discontinuing?
Reduce freq or switch to a milder agent
Titrate off slowly (prevents flair ups)
If not responding to a topical corticosteroid?
Stop therapy for 4-7 days and resume with a diff agent
Group I: Megapotent
Amt applied daily MUST be closely monitored
-NO more than 50g of cream or ointment per week
-2 wks MAXIMUM course length
-Week off before grp I agent can be used again
-Refills should be limited
-Watch for renal suppression, atrophy
-If occluded --> NO more than 12 hr/day
What is pulse dosing and when is it mostly used?
When we take a week ''off'' from dosing and its mostly used in grp I topical corticosteroids
Can occlussive dressing be used with Betamethasone dipropionate (Diprolene)
NO, but it can be used with Florone
Group II
High potency but less side effects than group I
Group IV
Usually OTC
-Good for covering large areas
Which groups is most commonly indicated for skin condt. requiring Rx strength topical steroids?
Group III
Monitoring topical steroids
Reevaluate in 10dy
-Watch for superinfection
-With high potency --> monitor serum & urinary free cortisol & ACTH stimulation testing
Who is most susceptible to superinfections?
Geriatric, HIV, chemo, babies, Immuncomp, diabetic patients most susceptible
What preg class are topical steroids
Group C
Contraindications for Topical steroids
Allergy to any component of product
-Primarily bacterial infections: impetigo, acne, erysipelas, cellulites, rosacea or perioral dermatitis
Precautions with topical steroids
-High potency should NOT be used on face, axilla or groin
-Care with eyes
-Local irritation may develop - If so discontinue
-Atrophy common with high potency agents
-Do NOT use as a lone agent in widespread plaque psoriasis
-Weakens skin infections --> don't use if pt has bacterial infection
Should topical steroids be used on a bacterial infection?
NO - if pt has a bacterial infection avoid steroids as topical steroids worsen skin infections
Adverse effects - LOCAL
Itching, burning, erythema, folliculitis, perioral dermatitis, acne, dryness of skin
secondary infection, contact dermatitis
When discon high potency ->Plaque psoriasis may develop into pustular psoriasis
Adverse effects - SYSTEMIC (high potency)
Suppression of Hypothalamus -> Pituitary-> Adrenal axis that is reversible
May develop symptoms of Cushing's syndrome
Hyperglycemia and Glycosuria may develop
Patient education on burning after application
Remind them that everything put on skin has potential to burn, ask if it goes away after a few min