PHARMACEUTICAL CARE WHEN DISPENSING OTC MEDICATIONS FOR THE SYMPTOMATIC TREATMENT OF SKIN LESIONS

The skin, the largest body organ, is the interface between the internal and external environments. The skin is composed of the epidermis and dermis. Epidermal or epithelial cells begin in the basal layer of the epidermis and migrate outward, undergoing degenerative changes in each layer.

The outer layer, called the stratum corneum, is composed of dead cells and keratin. The dead cells are constantly being shed (desquamated) and replaced by newer cells.

Normally, approximately 1 month is required for cell formation, migration, and desquamation. When dead cells are discarded, keratin remains on the skin. Keratin is a tough protein substance that is insoluble in water, weak acids, and weak bases. Hair and nails, which are composed of keratin, are referred to as appendages of the skin.

Melanocytes are pigment-producing cells located at the junction of the epidermis and the dermis. These cells produce yellow, brown, or black skin coloring in response to genetic influences, melanocyte-stimulating hormone released from the anterior pituitary gland, and exposure to ultraviolet (UV) light (eg, sunlight).

The dermis is composed of elastic and fibrous connective tissue. Dermal structures include blood vessels, lymphatic channels, nerves and nerve endings, sweat glands, sebaceous glands, and hair follicles. The dermis is supported underneath by subcutaneous tissue, which is composed primarily of fat cells. The skin has numerous functions, most of which are protective, including the following:

• Serves as a physical barrier against loss of fluids and electrolytes and against entry of microorganisms, foreign bodies, and other potentially harmful substances

• Detects sensations of pain, pressure, touch, and temperature through sensory nerve endings

• Assists in regulating body temperature through production and elimination of sweat • Serves as a source of vitamin D when exposed to sunlight or other sources of UV light. Skin contains a precursor for vitamin D.

• Serves as an excretory organ. Water, sodium, chloride, lactate, and urea are excreted in sweat.

• Inhibits growth of many microorganisms by its acidic pH (4.5 to 6.5)

Mucous membranes are composed of a surface layer of epithelial cells, a basement membrane, and a layer of connective tissue. They line body cavities that communicate with the external environment (ie, mouth, vagina, anus). They receive an abundant blood supply because capillaries lie just beneath the epithelial cells.

Dermatologic disorders may be primary (ie, originate in the skin or mucous membranes) or secondary (ie, result from a systemic condition, such as measles or adverse drug reactions).

 

DISORDERS OF THE SKIN

Because the skin is constantly exposed to the external environment, it is susceptible to numerous disorders, including those described in the following sections.

Inflammatory Disorders

Dermatitis

Dermatitis is a general term denoting an inflammatory response of the skin to injuries from irritants, allergens, or trauma. Eczema is often used as a synonym for dermatitis.

Whatever the cause, dermatitis is usually characterized by erythema, pruritus, and skin lesions. It may be acute or chronic. • Atopic dermatitis is a common disorder characterized mainly by pruritus and lesions that vary according to the extent of inflammation, stages of healing, and scratching.

Scratching damages the skin and increases the risks of secondary infection. Acute lesions are reddened skin areas containing papules and vesicles; chronic lesions are often thick, fibrotic, and nodular.

The cause is uncertain but may involve allergic, hereditary, or psychological elements. Approximately 50% to 80% of clients have asthma or allergic rhinitis; some have a family history of these disorders. Thus, exposure to possible causes or exacerbating factors such as allergens, irritating chemicals, foods, and emotional stress should be considered. The condition may occur in all age groups but is more common in children.

• Contact dermatitis results from direct contact with irritants (eg, soaps, detergents) or allergens (eg, clothing materials or dyes, jewelry, cosmetics) that stimulate inflammation. Irritants cause tissue damage and dermatitis in anyone with sufficient contact or exposure. Allergens cause dermatitis only in sensitized or hypersensitive people. The location of the dermatitis may indicate the cause (eg, facial dermatitis may indicate an allergy to cosmetics).

• Seborrheic dermatitis is a disease of the sebaceous glands characterized by excessive production of sebum. It may occur on the scalp, face, or trunk. A simple form involving the scalp is dandruff, which is characterized by flaking and itching of the skin. More severe forms are characterized by greasy, yellow scales or crusts with variable amounts of erythema and itching.

• Urticaria (“hives”) is an inflammatory response characterized by a skin lesion called a wheal, a raised edematous area with a pale center and red border, which itches intensely. Histamine is the most common mediator of urticaria and it causes vasodilation, increased vascular permeability, and pruritus.

Histamine is released from mast cells and basophils by both allergic (eg, insect bites, foods, drugs) and nonallergic (eg, radiocontrast media, opiates, and some antibiotics as well as heat, cold, pressure, UV light) stimuli. An important difference between allergic and nonallergic reactions is that many allergic reactions require prior exposure to the stimulus, whereas nonallergic reactions can occur with the first exposure.

• Drug-induced skin reactions can occur with virtually any drug and can resemble the signs and symptoms of virtually any skin disorder. Topical drugs usually cause a localized, contact dermatitis type of reaction and systemic drugs cause generalized skin lesions. Skin manifestations of serious drug reactions include erythema, facial edema, pain, blisters, necrosis, and urticaria. Systemic manifestations may include fever, enlarged lymph nodes, joint pain or inflammation, shortness of breath, hypotension, and leukocytosis. Drug-related reactions usually occur within the first or second week of drug administration and subside when the drug is discontinued.

Psoriasis

Psoriasis is a chronic skin disorder characterized by erythematous, dry, scaling lesions. The lesions may occur anywhere on the body but commonly involve the skin covering bony prominences, such as the elbows and knees. The disease is characterized by remissions and exacerbations. Exacerbating factors include infections, winter weather, some drugs (eg, beta blockers, lithium) and possibly stress, obesity, and alcoholism. The cause of psoriasis is thought to be an inflammatory process. The pathophysiology involves excessively rapid turnover of epidermal cells. Instead of 30 days from formation to elimination of normal epidermal cells, epidermal cells involved in psoriasis are abnormal in structure and have a lifespan of about 4 days.

Skin lesions may be tender, but they do not usually cause severe pain or itching. However, the lesions are unsightly and usually cause embarrassment and mental distress.

Rosacea

Rosacea is characterized by erythema, flushing, telangiectases (fine, red, superficial blood vessels) and acne-like lesions of facial skin. Hyperplasia of the nose (rhinophyma) eventually develops. Rosacea is a chronic disease of unknown etiology that usually occurs in middle-aged and older people, more often in men than women.

Dermatologic Infections

Bacterial Infections

Bacterial infections of the skin are common; they are most often caused by streptococci or staphylococci.

• Cellulitis is characterized by erythema, tenderness, and edema, which may spread to subcutaneous tissue. Generalized malaise, chills, and fever may occur.

• Folliculitis is an infection of the hair follicles that most often occurs on the scalp or bearded areas of the face.

• Furuncles and carbuncles are infections usually caused by staphylococci. Furuncles (boils) may result from folliculitis. They usually occur in the neck, face, axillae, buttocks, thighs, and perineum. Furuncles tend to recur. Carbuncles involve many hair follicles and include multiple pustules. Carbuncles may cause fever, malaise, leukocytosis, and bacteremia. Healing of carbuncles often produces scar tissue.

• Impetigo is a superficial skin infection caused by streptococci or staphylococci. An especially contagious form is caused by group A beta-hemolytic streptococci. This form occurs most often in children.

Fungal Infections

Fungal infections of the skin and mucous membranes are most often caused by Candida albicans.

• Oral candidiasis (thrush) involves mucous membranes of the mouth. It often occurs as a superinfection after the use of broad-spectrum systemic antibiotics.

• Candidiasis of the vagina and vulva occurs with systemic antibiotic therapy and in women with diabetes mellitus.

• Intertrigo involves skin folds or areas where two skin surfaces are in contact (eg, groin, pendulous breasts).

• Tinea infections (ringworm) are caused by fungi (dermatophytes). These infections may involve the scalp (tinea capitis), the body (tinea corporis), the foot (tinea pedis), and other areas of the body. Tinea pedis, commonly called athlete’s foot, is the most common type of ringworm infection.

Viral Infections

Viral infections of the skin include verrucal (warts) and herpes infections. There are two types of herpes simplex infections. Type 1 usually involves the face or neck (eg, fever blisters or cold sores on the lips), and type 2 involves the genitalia.

Other herpes infections include varicella (chickenpox) and herpes zoster (shingles).

Trauma

Trauma refers to a physical injury that disrupts the skin. When the skin is broken, it may not be able to function properly. The major problem associated with skin wounds is infection. Common wounds include lacerations (cuts or tears), abrasions (shearing or scraping of the skin), and puncture wounds; surgical incisions; and burn wounds.

Ulcerations

Cutaneous ulcerations are usually caused by trauma and impaired circulation. They may become inflamed or infected.

• Pressure ulcers (also called decubitus ulcers) may occur anywhere on the body when external pressure decreases blood flow. They are most likely to develop in clients who are immobilized, incontinent, malnourished, and debilitated. Common sites include the sacrum, trochanters, ankles, and heels. In addition, abraded skin is susceptible to infection and ulcer formation.

• Venous stasis ulcers, which usually occur on the legs, result from impaired venous circulation. Other signs of venous insufficiency include edema, varicose veins, stasis dermatitis, and brown skin pigmentation. Bacterial infection may occur in the ulcer.

Acne

Acne is a common disorder characterized by excessive production of sebum and obstruction of hair follicles, which normally carry sebum to the skin surface. As a result, hair follicles expand and form comedones (blackheads and whiteheads). Acne lesions vary from small comedones to acne vulgaris, the most severe form, in which follicles become infected and irritating secretions leak into surrounding tissues to form inflammatory pustules, cysts, and abscesses. Most clients have a variety of lesion types at one time.

Acne occurs most often on the face, upper back, and chest because large numbers of sebaceous glands are located in these areas. One etiologic factor is increased secretion of male hormones (androgens), which occurs at puberty in both sexes. This leads to increased production of sebum and proliferation of Propionibacterium acnes bacteria, which depend on sebum for survival. The P. acnes organisms contain lipase enzymes that break down free fatty acids and produce inflammation in acne lesions. Other causative factors may include medications (eg, phenytoin, corticosteroids) and stress, whose mechanism may involve stimulation of androgen secretion.

There is no evidence that lack of cleanliness or certain foods (eg, chocolate) cause acne.

External Otitis

External otitis is an infection of the external ear characterized by pain, itching, and drainage. The external ear is lined with epidermal tissue, which is susceptible to the same skin disorders that affect other parts of the body. External otitis is most often caused by Pseudomonas aeruginosa and Staphylococcus aureus organisms and may be treated with antimicrobial ear drops for approximately 7 to 10 days.

Anorectal Disorders

Hemorrhoids and anal fissures are common anorectal disorders characterized by pruritus, bleeding, and pain. Inflammation and infection may occur.

TYPES OF DERMATOLOGIC DRUGS

 

Many different agents are used to prevent or treat dermatologic disorders. Most agents fit into one or more of the following categories:

• Antimicrobials are used to treat infections caused by bacteria, fungi, and viruses.

When used in dermatologic infections, antimicrobials may be administered locally (topically) or systemically (orally or parenterally).

• Antiseptics kill or inhibit the growth of bacteria, viruses, or fungi. They are used primarily to prevent infection. They are occasionally used to treat dermatologic infections. Skin surfaces should be clean before application of antiseptics.

• Astringents (eg, dilute solutions of aluminum salts) are used for their drying effects on exudative lesions.

• Corticosteroids are used to treat the inflammation present in many dermatologic conditions. They are most often applied topically, but also may be given orally or parenterally.

• Emollients or lubricants (eg, mineral oil, lanolin) are used to relieve pruritus and dryness of the skin.

• Enzymes are used to débride burn wounds, decubitus ulcers, and venous stasis ulcers. They promote healing by removing necrotic tissue.

• Immunomodulators are newer drugs with immunosuppressant and anti-inflammatory effects. They are not steroids, do not cause the adverse effects associated with corticosteroids, and may be used as corticosteroid substitutes. They are used to treat moderate to severe atopic dermatitis. Two of these drugs are currently available, tacrolimus (Protopic) ointment and pimecrolimus (Elidel) cream. Systemic tacrolimus is used to prevent organ rejection in kidney and liver transplantations. The topical drugs are considered safe and effective in adults and children as young as 2 years. They may cause increased burning and itching during the first week of use but they are not associated with significant systemic absorption or increased risk of infections.

• Keratolytic agents (eg, salicylic acid) are used to remove warts, corns, calluses, and other keratin-containing skin lesions.

• Retinoids are vitamin A derivatives that are active in proliferation and differentiation of skin cells. These agents are commonly used to treat acne, psoriasis, aging and wrinkling of skin from sunlight exposure, and skin cancers. Retinoids (eg, etretinate and isotretinoin) are contraindicated in women of childbearing potential unless the women have negative pregnancy tests; agree to use effective contraception before, during, and after drug therapy; and agree to take the drugs as prescribed. These drugs have been associated with severe fetal abnormalities.

• Sunscreens are used to protect the skin from the damaging effects of UV radiation, thereby decreasing skin cancer and signs of aging, including wrinkles. Dermatologists recommend sunscreen preparations that block both UVA and UVB and have a “sun protection factor” value of 30 or higher. These highly protective sunscreens are especially needed by people who are fair skinned, allergic to sunlight, or using medications that increase skin sensitivity to sunlight (eg, estrogens, tetracycline).

Application of Dermatologic Drugs

Most dermatologic medications are applied topically. To be effective, topical agents must be in contact with the underlying skin or mucous membrane. Numerous dosage forms have been developed for topical application of drugs to various parts of the body and for various therapeutic purposes. Basic components of topical agents are one or more active ingredients and a usually inactive vehicle. The vehicle is a major determinant of the drug’s ability to reach affected skin and mucous membranes. Many topical preparations contain other additives (eg, emollients, dispersing agents) that further facilitate application to skin and mucous membranes. Commonly used vehicles and dosage forms include ointments, creams, lotions, aerosols, gels, otic solutions, and vaginal and rectal suppositories. Many topical drug preparations are available in several dosage forms. Topical medications are used primarily for local effects; systemic effects are usually undesirable. Factors that influence percutaneous absorption of topical agents include the following:

• Degree of skin hydration. Drug penetration and percutaneous  absorption are increased when keratin in the outermost layer of the epidermis is well hydrated.

• Drug concentration. Because percutaneous absorption occurs by passive diffusion, higher concentrations increase the amount of drug absorbed.

• Skin condition. Absorption from abraded, damaged, or inflamed skin is much greater than from intact skin.

• Length of contact time. Absorption is increased when drugs are left in place for prolonged periods.

• Size of area. Absorption is increased when topical medications are applied to large areas of the body.

• Location of area. Absorption from mucous membranes and facial skin is comparatively rapid. Absorption from thick-skinned areas (eg, palms of hands and soles of feet) is comparatively slow.

 

 

Herbal and Dietary Supplements

Many supplements are promoted for use in skin conditions. Most have not been tested adequately to ensure effectiveness. At the same time, however, topical use rarely causes serious adverse effects or drug interaction. Two topical agents for which there is some support of safety and effectiveness are aloe and oat preparations.

Aloe is often used as a topical remedy for minor burns and wounds (eg, sunburn, cuts, abrasions) to decrease pain, itching, and inflammation and to promote healing. Its active ingredients are unknown. Wound healing is attributed to moisturizing effects and increased blood flow to the area. Reduced inflammation and pain may result from inhibition of arachadonic acid metabolism and formation of inflammatory prostaglandins. Reduced itching may result from inhibition of histamine production.

Commercial products are available for topical use, but fresh gel from the plant may be preferred. When used for this purpose, a clear, thin, gel-like liquid can be squeezed directly from a plant leaf onto the burned or injured area several times daily if needed. Topical use has not been associated with severe adverse effects or drug interactions.

Aside from oral use as a cereal, good source of dietary fiber, and well-documented cholesterol-lowering product, oat preparations have long been used topically to treat minor skin irritation and pruritus associated with common skin disorders.

Oats contain gluten, which forms a sticky mass that holds moisture in the skin when it is mixed with a liquid and has emollient effects. For topical use, oats are contained in bath products, cleansing bars, and lotions (eg, Aveeno products) that can be used once or twice daily. They should not be used near the eyes or on inflamed skin. After use, they should be washed off with water.

Organic Anion Transporting

 

Assessment

Assess the client’s skin for characteristics or lesions that may indicate current or potential dermatologic disorders.

• When a skin rash is present, interview the client and inspect the area to determine the following:

• Appearance of individual lesions. Lesions should be described as specifically as possible so changes can be identified. Terms commonly used in dermatology include macule (flat spot), papule (raised spot), nodule (small, solid swelling), vesicle (blister), pustule (puscontaining lesion), petechia (flat, round, purplish-red spot the size of a pinpoint, caused by intradermal or submucosal bleeding), and erythema (redness). Lesions also may be described as weeping, dry and scaly, or crusty.

• Location or distribution. Some skin rashes occur exclusively or primarily on certain parts of the body (eg, face, extremities, trunk), and distribution may indicate the cause.

• Accompanying symptoms. Pruritus occurs with most dermatologic conditions. Fever, malaise, and other symptoms may occur as well.

• Historic development. Appropriate questions include

• When and where did the skin rash appear?

• How long has it been present?

• Has it changed in appearance or location?

• Has it occurred previously?

• Etiologic factors. In many instances, appropriate treatment is determined by the cause. Some etiologic factors include the following:

• Drug therapy. Many commonly used drugs may cause skin lesions, including antibiotics (eg, penicillins, sulfonamides, tetracyclines), narcotic analgesics, and thiazide diuretics. Skin rashes due to drug therapy are usually generalized and appear abruptly.

• Irritants or allergens may cause contact dermatitis. For example, dermatitis involving the hands may be caused by soaps, detergents, or various other cleansing agents. Dermatitis involving the trunk may result from allergic reactions to clothing.

• Communicable diseases (ie, measles, chickenpox) cause characteristic skin rashes and systemic signs and symptoms.

• When skin lesions other than rashes are present, assess appearance, size or extent, amount and character of any drainage, and whether the lesion appears infected or contains necrotic material. Bleeding into the skin is usually described as petechiae (pinpoint hemorrhages) or ecchymoses (bruises). Burn wounds are usually described in terms of depth (partial or full thickness of skin) and percentage of body surface area. Burn wounds with extensive skin damage are rapidly colonized with potentially pathogenic microorganisms. Venous stasis, pressure, and other cutaneous ulcers are usually described in terms of diameter and depth.

• When assessing the skin, consider the age of the client. Infants are likely to have “diaper” dermatitis, miliaria (heat rash), and tinea capitis (ringworm infection of the scalp). School-aged children have a relatively high incidence of measles, chickenpox, and tinea infections. Adolescents often have acne. Older adults are more likely to have dry skin, actinic keratoses (premalignant lesions that occur on sun-exposed skin), and skieoplasms.

• Assess for skieoplasms. Basal cell carcinoma is the most common type of skin cancer. It may initially appear as a pale nodule, most often on the head and neck. Squamous cell carcinomas may appear as ulcerated areas. These lesions may occur anywhere on the body but are more common on sun-exposed parts, such as the face and hands. Malignant melanoma is the most serious skin cancer. It involves melanocytes, the pigment-producing cells of the skin.

Malignant melanoma may occur in pigmented nevi (moles) or previously normal skin. Ievi, malignant melanoma may be manifested by enlargement and ulceration. In previously normal skin, lesions appear as irregularly shaped pigmented areas. Although it can occur in almost any area, malignant melanoma is most likely to be located on the back in white people and in toe webs and soles of the feet in African-American or Asian people.

• Color changes and skin rashes are more difficult to detect when assessing dark-skinned clients. Some guidelines include the following:

• Adequate lighting is required; nonglare daylight is best. The illumination provided by overbed lights or flashlights is inadequate for most purposes.

• Some skin rashes may be visible on oral mucous membranes.

• Petechiae are not visible on dark brown or black skin,  but they may be visible on oral mucous membranes or the conjunctiva.

• When skin disorders are present, assess the client’s psychological response to the condition. Many clients, especially those with chronic disorders, feel self-conscious and depressed.

 

PRINCIPLES OF THERAPY

Goals

General treatment goals for many skin disorders are to relieve symptoms (eg, dryness, pruritus, inflammation, infection), eradicate or improve lesions, promote healing and repair, restore skin integrity, and prevent recurrence. Specific goals often depend on the condition being treated.

General Aspects of Dermatologic

Drug Therapy

1. Pharmacologic therapy may include a single drug or multiple agents used concurrently or sequentially.

2. For severe skin conditions, a dermatologist is best qualified to prescribe medications and other treatments.

Because many skin conditions are so visible, early and aggressive treatment may be needed to prevent additional tissue damage, repeated infections, scarring, and mental anguish.

3. Topical medications are preferred, when effective, and many preparations are available. Astringents and lotions are usually used as drying agents for “wet,” oozing lesions, and ointments and creams are used as “wetting” agents for dry, scaling lesions.

4. To relieve pruritus, a common symptom of inflammatory skin disorders, skin lubricants, systemic antihistamines, and topical corticosteroids are important elements.

Drawings showing causes of pruritus by location.

 

5. Topical corticosteroids are used for both acute and chronic inflammatory and pruritic lesions. However, when acute lesions involve extensive areas or chronic lesions are resistant to topical drugs, systemic corticosteroid therapy may be needed. Prednisone 0.5 to 1 mg/kg/day is often used for 1 to 3 weeks.

Use of Topical Corticosteroids

Because of the extensive use of topical corticosteroids and the risks of potentially serious adverse effects, numerous precautions, guidelines, and recommendations have evolved to increase safety and effectiveness of these drugs.

Drug Selection

Choice of drug depends mainly on the acuity, severity, location, and extent of the condition being treated. For acute lesions, a more potent corticosteroid may be needed, at least initially; for chronic lesions, the least potent preparation that is effective is indicated.

• Low-potency drugs (eg, hydrocortisone) are preferred when likely to be effective. They are especially recommended for use in children, on large areas, and on body

sites especially prone to corticosteroid damage (eg, face, scrotum, axillae, flexures and skin folds).

 

• Mid-potency drugs (eg, flurandreolide) are usually effective ionintertriginous areas in children and adults.

• High-potency drugs (eg, amcinonide) usually are used for more acute or severe disorders and areas resistant to lower-potency agents. Short-term or intermittent use (eg, every other day, 3 or 4 consecutive days per week, once per week) may be more effective and cause fewer adverse effects than continuous use of lower-potency products. These drugs may also be alternated with lowerpotency agents.

• Very–high-potency drugs (eg, clobetasol, halobetasol) usually are used for less absorptive areas such as soles of feet, palms of hands, and thick skin plaques. Usage should not exceed 2 consecutive weeks and total dosage should not exceed 50 g/week because of the potential for these drugs to suppress the hypothalamic–pituitary– adrenal (HPA) axis. Clobetasol suppresses the HPA axis at doses as low as 2 g/day. These drugs should not be used with occlusive dressings or for children younger than 12 years of age.

• Drug potency and clinical use vary with the dosage form, and many topical corticosteroids are available in creams, ointments, and other preparations. Creams are usually the most acceptable to clients; ointments penetrate the epidermis better and are often used for chronic dry or scaly lesions; lotions are recommended for intertriginous areas and the scalp. Some preparations are available in aerosol sprays, gels, and other dosage forms.

Dosage

Dosage depends on the drug concentration, the area of application, and the method of application.

• The skin covering the face, scalp, scrotum, and axillae is more permeable to corticosteroids than other skin surfaces, and these areas can usually be treated with less potent formulations, smaller amounts, or less frequent applications.

• Drug absorption and risks of systemic toxicity are significantly increased when the drug is applied to inflamed skin or covered by an occlusive dressing. Application should be less frequent and limited to isolated, resistant areas when occlusive dressings are used.

• The drug should be applied sparingly. Some clinicians recommend twice-daily applications until a clinical response is obtained, then decreasing to the least-frequent schedule needed to control the condition.

• With continuous use, one or two applications daily may be as effective as three or four applications, because the drugs have a repository effect.

• If an occlusive dressing is applied, leave it on overnight or at least 6 hours. However, do not leave it in place for more than 12 hours in a 24-hour period.

• After long-term use or after using a potent drug, taper dosage by switching to a less potent agent or applying the drug less frequently. Discontinuing the drug abruptly can cause a rebound effect, in which the skin condition worsens.

Drug Selection in Selected Skin Conditions

The choice of topical dermatologic agents depends primarily on the reason for use and client response.

Acne

Numerous prescription and nonprescription antiacne products are available.

• Antimicrobial drugs include both topical and systemic agents. Topical drugs usually are used for mild to moderate acne, often in combination with a topical retinoid to maximize effects.

Benzoyl peroxide

is an effective topical bactericidal agent that is available iumerous preparations (eg, gel, lotion, cream, wash) and concentrations (eg, 2.5% to 10%). Lotion and cream preparations are the least irritating. Clindamycin and erythromycin are also available in topical dosage forms. These drugs reduce P. acnes bacteria and are approximately equally effective.

 A prescription product combining benzoyl peroxide and erythromycin in a gel form (Benzamycin) is reportedly more effective than either agent alone. Oral antimicrobials are useful with widespread or severe, disfiguring acne or when a rapid response is needed.

Tetracyclines, which have both antibacterial and anti-inflammatory activity, are commonly used for long-term treatment. These drugs are usually given twice daily to increase compliance. Therapeutic effects usually occur within a few weeks, but maximal effects may require 2 to 3 months.

• Retinoids, in both systemic and topical forms, are commonly used for moderate to severe acne. When used alone, topical tretinoin may take several months to decrease acne lesions significantly. Thus, it is usually used in combination with other products. Adapalene and tazarotene are newer topical retinoids. Isotretinoin is usually given to clients with severe acne who do not respond to safer drugs. Its antiacne effects include suppression of sebum production, inhibition of comedone formation, and inhibition of inflammation. Approximately 70% to 80% of clients treated appropriately (usually 1 mg/kg/day for 5 months) have a longterm remission. The main drawbacks are teratogenic and other adverse effects. This oral drug must never be given to a woman of childbearing age unless she agrees to practice adequate contraceptive measures.

Anorectal Disorders

In anorectal disorders, most preparations contain a local anesthetic, emollients, and perhaps a corticosteroid. These preparations relieve pruritus and pain but do not cure the underlying condition. Some preparations contain ingredients of questionable value, such as vasoconstrictors, astringents, and weak antiseptics. No particular mixture is clearly superior.

Dermatitis

 

 Both systemic and topical agents are usually needed. Sedating, systemic antihistamines such as diphenhydramine or hydroxyzine are often used to relieve itching and promote rest and sleep. An oral antibiotic such as clindamycin, dicloxacillin, a cephalosporin, or a macrolide may be given for a week to treat secondary infections. An oral corticosteroid such as prednisone may be needed initially for severe inflammation, but topical corticosteroids are most often used. Coal tar preparations have anti-inflammatory and antipruritic actions and can be used alone or with topical corticosteroids. However, these agents have an unpleasant odor and they stain clothing. They are usually applied at bedtime.

Additional preparations include moisturizers and lubricants (eg, Aquaphor) for dry skin and itching; mild skin cleansers (eg, Basis, Cetaphil) to avoid further skin irritation; and baking soda or colloidal oatmeal (Aveeno) in baths or soaks for pruritus.

External Otitis

Otic preparations of various dermatologic medications are used. Hydrocortisone is the corticosteroid most often included in topical otic preparations. It relieves pruritus and inflammation in chronic external otitis. Systemic analgesics are usually required.

Pressure Ulcers

In pressure ulcers, the only clear-cut guideline for treatment is avoiding further pressure on the affected area. Many topical agents are used, most often with specific procedures for dressing changes, skin cleansing, and so on. No one agent or procedure is clearly superior. Consistent implementation of a protocol (ie, position changes, inspection of current or potential pressure areas, dressing changes, use of alternating, pressure-relieving mattresses) may be more effective than drug therapy.

Psoriasis

Localized lesions are usually treated by a combination of topical agents, such as a corticosteroid during daytime hours and a coal tar ointment at night. Coal tar preparations work slowly but produce longer remissions. Newer antipsoriasis drugs such as calcipotriene or tazarotene may also be used. Calcipotriene is reportedly as effective as topical fluocinonide. However, its onset of action is slower than that of a topical corticosteroid. A combination of calcipotriene and a topical coricosteroid may be used initially for rapid improvement, after which the calcipotriene can be continued as monotherapy. Tazarotene is a topical retinoid thatmay cause cutaneous irritation.

Generalized psoriasis, which requires systemic treatment or body light therapy, should be managed mainly by dermatologists. Systemic therapy often involves oral retinoids or methotrexate. Acitretin has replaced etretinate as the oral retinoid of choice for treatment of severe psoriasis. Acitretin is a metabolite of etretinate that can be converted back to etretinate, especially in the presence of alcohol. The drug, like other oral retinoids, is teratogenic. Thus, women of childbearing potential who take acitretin should be instructed to avoid ingesting alcohol and to use adequate contraception while taking the drug and for at least 3 years thereafter. Methotrexate is an antineoplastic drug that may cause significant adverse effects. Phototherapy can involve natural sunlight, which is highly effective. Most clients with psoriasis notice some remission during summer months. Office phototherapy treatments are  usually performed three to five times weekly.

Rosacea

Mild skin cleansers (eg, Cetaphil), oral tetracycline, and topical metronidazole are commonly used; oral isotretinoin and topical metronidazole are also effective. These medications prevent or treat acneiform lesions; they have little to no effect on other aspects (eg, erythema, telangiectasia, hyperplasia of connective tissue and sebaceous glands).

Urticaria

Systemic drug therapy with antihistamines (H1 receptor antagonists) is the major element of drug therapy. In addition, an epinephrine injection may be used initially and topical medications may be applied to relieve itching. With chronic urticaria, the goal of treatment is symptom relief. Antihistamines are most effective when given before histamine-induced urticaria occurs and should be given around the clock, not just when lesions appear.

Dosage Forms

The choice of dosage form for topical drug therapy depends largely on the reason for use. Guidelines include the following:

• Ointments are oil-based substances that usually contain a medication in an emollient vehicle, such as petrolatum or lanolin. Ointments occlude the skin and promote retention of moisture. Thus, they are especially useful in chronic skin disorders characterized by dry lesions. Ointments should usually be avoided in hairy, moist, and intertriginous areas of the body because of potential maceration, irritation, and secondary infection.

• Creams (emulsions of oil in water, which may be greasy or nongreasy) and gels (transparent colloids, which dry and leave a film over the area) retain moisture in the skin but are less occlusive than ointments.

These preparations are cosmetically acceptable for use on the face and other visible areas of the body. They also may be used in hairy, moist, intertriginous areas.  Creams and gels are especially useful in subacute dermatologic disorders.

• Lotions are suspensions of insoluble substances in water. They cool, dry, and protect the skin. They are most useful in subacute dermatologic disorders. Sprays

and aerosols are similar to lotions.

• Powders have absorbent, cooling, and protective effects. Powders usually should not be applied in acute, exudative disorders or on denuded areas because they tend to cake, occlude the lesions, and retard healing. Also, some powders (eg, cornstarch) may lead to secondary infections by promoting growth of bacteria and fungi.

• Topical otic medications are usually liquids. However, creams or ointments may be used for dry, crusted lesions, and powders may be used for drying effects.

• Topical vaginal medications may be applied as douche solutions, vaginal tablets, or vaginal creams used with an applicator.

• Anorectal medications may be applied as ointments, creams, foams, and rectal suppositories.

 

Use in Children

Children may develop a wide range of dermatologic disorders, including dermatitis and skin rashes in younger children and acne in adolescents. Few guidelines have been developed for drug therapy of these disorders. Infants, and perhaps older children, have more permeable skin and are more likely to absorb topical drugs than adults. In addition, absorption is increased in the presence of broken or damaged skin. Therefore, cautious use of topical agents is advised. With topical corticosteroids, suppression of the HPA axis, Cushing’s disease, and intracranial hypertension have been reported in children. Signs of impaired adrenal function may include delayed growth and low plasma cortisol levels. Signs of intracranial hypertension may include headaches and swelling of the optic nerve (papilledema) on ophthalmoscopic examination. The latter may lead to blindness if pressure on the optic nerve is not relieved.

Because children are at high risk for development of systemic adverse effects with topical corticosteroids, these drugs should be used only if clearly indicated, in the smallest effective dose, for the shortest effective time, and usually without occlusive dressings. In addition, a low-potency agent should be used initially in infants and in intertriginous areas of older children. If a more potent drug is required for severe dermatitis, the child should be examined often and the strength of the drug reduced as skin lesions improve.

 

Use in Older Adults

Older adults often have thin, dry skin and are at risk of pressure  ulcers if mobility, nutrition, or elimination is impaired. Principles of topical drug therapy are generally the same as for younger adults. In addition, topical corticosteroids should be used with caution on thinned or atrophic skin.

Classification and Treatment of Burns

Burn Classification

Note: The list below shows 4 burn degrees. While most of the public does not recognize the 4th degree, it is the correct term. The table below, with 3 degrees, is also correct. Both are acceptable.

Determining burn depth is important. Things to consider are temperature, mechanism, duration of contact, blood flow to skin, and anatomic location. Epidermal depth varies with body surface, which can offer varying degrees of thermal protection. Older adults and young children also have thinner skin

First degree:

• Includes only the outer layer of skin, the epidermis

• Skin is usually red and very painful

• Equivalent to superficial sunburn without blisters

• Dry in appearance

• Healing occurs in 3-5 days, injured epithelium peels away from the healthy skin

• Hospitalization is for pain control and maybe fluid imbalance

 

Second degree: Can be classified as partial or full thickness.

• Partial thickness

• Blisters can be present

• Involve the entire epidermis and upper layers of the dermis

• Wound will be pink, red in color, painful and wet appearing

• Wound will blanch when pressure is applied

• Should heal in several weeks (10-21 days) without grafting, scarring is usually minimal

• Full thickness

• Can be red or white in appearance, but will appear dry.

• Involves the destruction of the entire epidermis and most of the dermis

• Sensation can be present, but diminished

• Blanching is sluggish or absent

• Full thickness will most likely need excision & skin grafting to heal

 

Third degree:

• All layers of the skin is destroyed

• Extend into the subcutaneous tissues

• Areas can appear, black or white and will be dry

• Can appear leathery in texture

• Will not blanch when pressure is applied

• No pain

 

Fouth degree: Full thickness that extends into muscle and bone.

 

	First	Second (Superficial or Deep)	Third (Full Thickness)
Depth (how deep the burn is)	Epithelium	Epithelium and top aspects of the dermis	Epithelium and dermis
How the wound looks	No blisters; dry pink	Moist, oozing blisters; Moist, white, pink, to red	Leathery, dry, no elasticity; charred appearance
Causes	Sunburn, scald, flash flame	Scalds, flash burns, chemicals	Contact with flame, hot surface, hot liquids, chemical, electric
Level of Pain (sensation)	Painful, tender, and sore	Very painful	Very little pain, or no pain
Healing Time	Two to five days; peeling	Superficial: five to 21 days. Deep: 21-35 days	Small areas may take months to heal; large areas need grafting.
Scarring	No scarring; may have discoloration	Minimal to no scarring; may have discoloration	Scarring present

 

Burn injury is the destruction of the layers of the skin and associated structures.
1st Degree Burn	2nd Degree Burn	3rd Degree Burn

 

To distinguish a minor burn from a serious burn, the first step is to determine the extent of damage to body tissues. The three burn classifications of first-degree burn, second-degree burn and third-degree burn will help you determine emergency care.

1st-degree burn

The least serious burns are those in which only the outer layer of skin is burned, but not all the way through.

• The skin is usually red

• Often there is swelling

• Pain sometimes is present

Treat a first-degree burn as a minor burn unless it involves substantial portions of the hands, feet, face, groin or buttocks, or a major joint, which requires emergency medical attention.

2nd-degree burn

When the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn.

• Blisters develop

• Skin takes on an intensely reddened, splotchy appearance

• There is severe pain and swelling.

If the second-degree burn is no larger than 3 inches (7.6 centimeters) in diameter, treat it as a minor burn. If the burned area is larger or if the burn is on the hands, feet, face, groin or buttocks, or over a major joint, treat it as a major burn and get medical help immediately.

For minor burns, including first-degree burns and second-degree burns limited to an area no larger than 3 inches (7.6 centimeters) in diameter, take the following action:

• Cool the burn. Hold the burned area under cool (not cold) running water for 10 or 15 minutes or until the pain subsides. If this is impractical, immerse the burn in cool water or cool it with cold compresses. Cooling the burn reduces swelling by conducting heat away from the skin. Don’t put ice on the burn.

• Cover the burn with a sterile gauze bandage. Don’t use fluffy cotton, or other material that may get lint in the wound. Wrap the gauze loosely to avoid putting pressure on burned skin. Bandaging keeps air off the burn, reduces pain and protects blistered skin.

• Take an over-the-counter pain reliever. These include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) or acetaminophen (Tylenol, others). Use caution when giving aspirin to children or teenagers. Though aspirin is approved for use in children older than age 2, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. Talk to your doctor if you have concerns.

Minor burns usually heal without further treatment. They may heal with pigment changes, meaning the healed area may be a different color from the surrounding skin. Watch for signs of infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, seek medical help. Avoid re-injuring or tanning if the burns are less than a year old — doing so may cause more extensive pigmentation changes. Use sunscreen on the area for at least a year.

Caution

• Don’t use ice. Putting ice directly on a burn can cause a person’s body to become too cold and cause further damage to the wound.

• Don’t apply egg whites, butter or ointments to the burn. This could cause infection.

• Don’t break blisters. Broken blisters are more vulnerable to infection.

3rd-degree burn

The most serious burns involve all layers of the skin and cause permanent tissue damage. Fat, muscle and even bone may be affected. Areas may be charred black or appear dry and white. Difficulty inhaling and exhaling, carbon monoxide poisoning, or other toxic effects may occur if smoke inhalation accompanies the burn.

For major burns, call emergency medical help. Until an emergency unit arrives, follow these steps:

1.     Don’t remove burned clothing. However, do make sure the victim is no longer in contact with smoldering materials or exposed to smoke or heat.

2.     Don’t immerse large severe burns in cold water. Doing so could cause a drop in body temperature (hypothermia) and deterioration of blood pressure and circulation (shock).

3.     Check for signs of circulation (breathing, coughing or movement). If there is no breathing or other sign of circulation, begin CPR.

4.     Elevate the burned body part or parts. Raise above heart level, when possible.

5.     Cover the area of the burn. Use a cool, moist, sterile bandage; clean, moist cloth; or moist cloth towels.

Get a tetanus shot. Burns are susceptible to tetanus. Doctors recommend you get a tetanus shot every 10 years. If your last shot was more than five years ago, your doctor may recommend a tetanus shot booster.

Medications:

• Intravenous (IV) fluids. Doctors deliver fluids continuously through a vein (intravenously) to prevent dehydration and organ failure.

• Pain relievers. Healing burns can be incredibly painful. In many cases, morphine is required — particularly during dressing changes. Anti-anxiety medications may also be helpful.

• Burn creams. A variety of products can be applied to the burn to help keep it moist, reduce pain, prevent infection and speed healing.

• Antibiotics. If you develop an infection, you may need intravenous antibiotics.

• Tetanus shot. Your doctor might recommend a tetanus shot after a burn injury.

Physical therapy

If the burned area is large, especially if it covers any joints, you may need physical therapy exercises designed to stretch the skin so the joints can remain flexible. Other types of exercises can improve muscle strength and coordination.

Surgical and other procedures

In some cases, you may need one or more of the following procedures:

• Breathing assistance. If you’ve been burned on the face or neck, your throat may swell shut. If that appears likely, your doctor may insert a tube down your windpipe (trachea) to keep oxygen supplied to your lungs.

• Tube feeding. Your metabolism goes into overdrive when your body starts trying to heal your burns. To provide adequate nutrition for this task, a feeding tube may be threaded through your nose to your stomach.

• Decompression. If a burn scab (eschar) goes completely around a limb, it can tighten and cut off the blood circulation. An eschar that goes completely around the chest can make it difficult to breathe. Cutting the eschar in several places can relieve this pressure.

• Skin grafts. Sections of your own healthy skin are needed to replace the scar tissue caused by deep burns. Donor skin from cadavers or pigs can be used as a temporary solution.

• Reconstruction. Plastic surgeons can improve the appearance of burn scars and increase the flexibility of joints affected by scarring.