Corticosteroid therapy

1. Topical corticosteroids are the most widely used treatment for psoriasis. Corticosteroids have anti-inflammatory, immunosuppressive and antiproliferative properties.

2. Mid-potency corticosteroids are used for lesions on the torso and extremities, while low-potency corticosteroids are used for areas with delicate skin, such as that on the face, genitals or flexures. These delicate areas are at increased risk for cutaneous atrophy. High-potency corticosteroids are usually reserved for use on recalcitrant plaques or lesions on the palms of the hands and soles of the feet. They should not be used for more than two weeks.

Generic name

Trade name and strength

Superpotent

Betamethasone dipropionate

Diprolene gel/ointment, 0.05% [45 g]

Diflorasone diacetate

Psorcon ointment, 0.05% [45 g]

Clobetasol propionate

Temovate cream/ointment, 0.05% [45

g]

Halobetasol propionate

Ultravate cream/ointment, 0.05% [45 g]

Potent

Amcinonide

Cyclocort ointment, 0.1% [60 g]

Generic name

Trade name and strength

Betamethasone dipropionate

Diprosone ointment, 0.05% [45 g]

Desoximetasone

Topicort cream/ointment, 0.25%; gel 0.05% [45 g]

Diflorasone diacetate

Florone ointment, 0.05%; Maxiflor ointment, 0.05% [45 g]

Fluocinonide

Lidex cream/ointment, 0.05% [60 g]

Halcinonide

Halog cream, 0.1% [45 g]

Upper mid-strength

Betamethasone dipropionate

Diprosone cream, 0.05% [45 g]

Betamethasone valerate

Valisone ointment, 0.1% [45 g]

Diflorasone diacetate

Florone, Maxiflor creams, 0.05%

Mometasone furoate

Elocon ointment, 0.1% [45 g]

Triamcinolone acetonide

Aristocort cream, 0.5% [45 g]

Mid-strength

Desoximetasone

Topicort LP cream, 0.05% [60 g]

Fluocinolone acetonide

Synalar-HP cream, 0.2%; Synalar ointment, 0.025% [60 g]

Flurandrenolide

Cordran ointment, 0.05% [60 g]

Triamcinolone acetonide

Aristocort, Kenalog ointments, 0.1% [60 g]

Lower mid-strength

Betamethasone dipropionate

Diprosone lotion, 0.05% [60 g]

Betamethasone valerate

Valisone cream/lotion, 0.1% [45 g]

Fluocinolone acetonide

Synalar cream, 0.025% [45 g]

Flurandrenolide

Cordran cream, 0.05% [45 g]

Hydrocortisone butyrate

Locoid cream, 0.1% [45 g]

Hydrocortisone valerate

Westcort cream, 0.2% [45 g]

Prednicarbate

Dermatop emollient cream, 0.1%

Generic name

Trade name and strength

Triamcinolone acetonide

Kenalog cream/lotion, 0.1% [60 g]

Mild

Alclometasone dipropionate

Aclovate cream/ointment, 0.05% [60 g]

Triamcinolone acetonide

Aristocort cream, 0.1% [60 g]

Desonide

DesOwen cream, 0.05% [60 g]

Fluocinolone acetonide

Synalar cream/solution, 0.01% [60 g]

Betamethasone valerate

Valisone lotion, 0.1% [45 g]

3. Ointments are best for dry, scaly, hyperkeratotic plaques. Lotions and gels are best suited for the scalp; creams can be used on all areas.

4. Corticosteroid therapy may cause tachyphylaxis, leading to decreased efficacy with continued use and culminating in an acute flare-up when therapy is terminated. Tachyphylaxis can be minimized by switching to less potent corticosteroids and having them apply the medication less frequently once the lesions have improved. Local side effects include acne and localized hypertrichosis.

5. Skin atrophy can also occur and may lead to striae, telangiectasia and purpura. The use of very potent corticosteroids or weaker ones under occlusion may lead to suppression of the pituitary-adrenal axis. Systemic absorption can minimize by limiting use to <40-50 g/week of a potent corticosteroid and not more than 90-100 g/week of a moderately potent corticosteroid.

Topical Agents for Psoriasis

Drug

Advantages

Disadvantages

Comment

Corticosteroids

Easy to use, rapid onset

Tachyphylaxis, atrophy, telangiectasia and adrenal suppression possible

Can be used in combination with calcipotriene (Dovonex) or tazaro-tene (Tazorac)

Calcipotriene (Dovonex)

Well-tolerated

Expensive, may cause skin irritation

Potential for hypercalcemia with excessive use

Anthralin (Anthra-Derm)

Once-daily administration, well-tolerated

May stain and/or cause skin irritation

Microencapsulated form may be less staining and irritating

Tars

Effective with UV light therapy

May cause skin staining, folliculitis, contact allergy; malodorous

Commonly used for psoriasis of the scalp

Drug

Advantages

Disadvantages

Comment

Tazarotene (Tazorac)

Expensive, may be teratogenic; irritating to unin-volved skin

First topical retinoid indicated by the FDA for treatment of psoriasis

B. Keratolytics assist in removing scale or hyperkeratosis. Salicylic acid is usually prescribed in concentrations between 2 and 10 percent and should not be applied extensively on the body because salicylism (tinnitus, nausea, vomiting) may result.

C. Coal tar has antiproliferative and anti-inflammatory actions. It is beneficial when used alone in mild to moderate psoriasis, and is useful in combination with ultraviolet B radiation. The use of coal tar is limited by its unpleasant odor; it can also stain clothing and bedding.

D. Vitamin D analogs

1. Calcipotriene (Dovonex), a topical vitamin D analog, is as effective as betamethasone valerate ointment. The short-term response to calcipotriene can be maintained for up to 12 months.

2. Calcipotriene, applied twice daily, is well tolerated, although the face and groin areas should be avoided since it may cause irritant dermatitis. To avoid hypercalcemia, use should not exceed 100 g/week.

E. Retinoids

1. Retinoids mediate cell differentiation and proliferation. Tazarotene (Tazorac) use may lead to an extended response, providing long-term improvement and maintenance therapy.

2. Local skin irritation and pruritus are frequent side effects. Since tazarotene may be teratogenic; women of child-bearing age should use adequate birth-control measures. A negative pregnancy test should be confirmed within two weeks of initiating treatment.

F. Phototherapy and systemic therapy

1. Patients with psoriatic involvement of greater than 10%% of body surface area or with severe, incapacitating, or disfiguring psoriasis are candidates for photochemotherapy or systemic therapy.

2. UV light therapy is effective for psoriatic lesions. Phototherapy with ultraviolet A light and psoralens (PUVA) is effective widespread lesions. Daily sunlight exposure can benefit most patients; however, overexposure can exacerbate the disease.

3. Systemic therapies include methotrexate, etretinate (Tegison), cyclosporine, and hydroxyurea, and these therapies have better than an 80% response rate.

References: See page 195.

How To Deal With Rosacea and Eczema

How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

Get My Free Ebook


Post a comment