CHAPTER 5 

 
Management of a skin problem is an art. It is not wise to rush in writing a prescription covering the front and back of the page. You can usually evaluate the physician skill from his prescription. The competent physician is the one who can treat his patient thoroughly with minimal curative medications, having no side effects, and with reasonable expenses. This can be summarized in few words "if you can‘t help to cure, don‘t do more harm."

The prescription should be written without hesitation, with confidence, efficiency and in a manner conveying to the patient that the writer knows what he is doing and is writing this prescription specially for this patient. This small piece of paper represents the culmination of the physician‘s skill, experience, diagnostic, therapeutic acumen as applied to the patient and having the great hope that it will be curative.

The medications prescribed should be recorded in the patient‘s file and not later in the day where it may be forgotten.

The physician should not misuse or abuse his position and should always be loyal and faithful to his patient. This can be considered when he has a demarcation line and philosophy that he gives the same attention and care to any patient as if he is his kid, or his sister , father or mother.

A patient with dry skin may need only emollients . An advice to minimize bathing, to use oily soap where that  may be all what is needed to relieve his skin problem.

"The physician should not hunt a small bird with a rocket; this means that mild lesions are treated with the less potent medications even if treatment will take longer time".

The patient should be carefully instructed on how to use the prescribed  medications. It is more easy with oral medications but for topical ones as ointments, strict instructions should be emphasized - how to apply, the amount which he should use, duration of treatment and where he has to be careful in using such medications.

Systemic medications prescribed should be clear. It is of prime importance to explain to the family of young patients on how to use it and the exact doses whether it comes in the form of drops, syrup or tablets.

Household measures are almost always used to measure the medications:

• One Drop is equivalent to 0.05 cc.

• One Teaspoon is equivalent to 5 cc.

• One Desert Spoon is equivalent to 8 cc.

• One tablespoon is equivalent to 15 cc.

• One Ordinary Glass is equivalent to 250 cc.

I will not forget the case of a patient to whom I prescribed anesthetic and antiphlogestic suppositories to relieve his congested piles. He came next morning in a very bad condition carried by his relatives reporting that the medications were about to kill the patient. I was really embarrassed, how come such side effects can occur from such suppositories. Immediately I asked the patient how he used the medications. The patient replied, according to the instructions, I  used these suppositories three times daily in spite of their bitter taste. The problem, I couldn‘t swallow these big capsules , but I  could solve that by mixing these with hot tea and drank them !!!!.

The physician should be very careful also in prescribing topical steroids especially for infants and young children and when this is strongly indicated. He has to use mometasone furoate 0.1% or mild hydrocortisone in the suitable base according to the skin problem.

Ointments are used for dry intact skin; creams are used for subacute cases where there is minimal oozing, while lotions are used to dry skin lesions as in wet weeping eczema.

The area involved also determines the type and the state of topical medications used. Hairy areas need lotions, intertriginous areas need very mild types as in the axilla or the napkin area. The face also should have special care when using steroid locally.

Salicylates, selenium sulfides should not be used for newborn infants due to the possibility of toxic absorption.

It is not uncommon to have patients used potent steroids and even mild ones presenting with severe erythema, telangiectasia, acniform eruption and moon face. The delicate thin facial skin as a result of that becomes very sensitive that may be affected by very mild stimuli even by the wind blow.

The skin of such patients becomes addicted to the topical steroid applied to the face. The patient sometimes continues and insists to use this medication by himself believing that this is the proper medication that can cure his skin problem, in spite of warnings of its side effects. This will lead to deterioration and to more complications and instead of having one problem, there will be another.

When I have any doubt with diagnosing a skin lesion, or when the patient has a sensitive, eczematous lesion, e.g., the diaper area or the face, I usually prescribe mild non-harmful preparation such as Pufexamac (Droxaryl cream or Flogocid ointment) until a diagnosis can be reached. This is much better than rushing to give the patient different vague medications of suspicious value. These may cause the patient a lot of psychic and financial burden besides it may distort the morphology of the original disease and make diagnosis more difficult. This preparation is safe and gives good results and worth wise to be used especially for skin problems in infants and children.

The patient should know more about his skin problem. So we should give them a brief idea about the nature of his condition, how long his problem is expected to resolve, and measures to be taken to prevent recurrence and to avoid triggering factors. These instructions may be more important than the prescription in his hand.

Printed instructions especially when the condition is related to different external or internal stimuli will save time and are easy to the patient to refer to when needed.

Some patients should be instructed to come back for follow up. If such patient is told "call this office if your skin problem will not improve within five days." The patient may not call back, and won‘t be grateful. He will complain that you couldn‘t cure his skin problem. The well followed-up patient usually will be cured and will be grateful.

Hygiene is very important and considered as a part of treatment. It is a learning experience and the physician should instruct the mother about the ideal way on how to clean her baby. This may appear so easy for others, but it is very important to give instructions on how to take care of the skin of infants and children.

It should be noted that nothing should be applied to the skin of any baby without taking into careful consideration of the potential hazards of percutaneous absorption. The best-documented hazards are related to aniline dyes, hexachlorophene, boric acid, antiseptics, alcohol, and corticosteroids.

A number of other substances should never be used in neonates. These include neomycin, boric acid, resorcinol (e.g. in Castellan‘s solution), and gamma benzene hexachlorid, Benzyl benzoate and Salicylic acid.

Antiseptics such as chlorhexidine and iodine should be used with the greatest caution. Care should also be taken with agents used to launder, sterilize or mark napkins and bed linen. Fatal cases were recorded among infants due to phenol absorbed from the skin surface as a result of phenol in mothballs used for storage of clothes and sheets.

COMMON MEDICATIONS USED IN DERMATOLOGY
ANTIHISTAMINES 

General Considerations:

In dermatology ,  antihistamines are the mostly  frequently prescribed medications. These may be specific, empirical or placebo. It is very important that the physician should have a wide knowledge concerning the pharmacology of the drugs prescribed, the efficiancy of the drug, drug interactions, unwanted side effects, as over dose, under dose and the idiosyncrasy.

Old generation antihistamines cross the brain barrier causing sometimes-unwanted side effects such as sedation and drowsiness.

The new generation antihistamines are better tolerated and most are non-sedating. The practitioner should have a wide scope of knowledge also on the other characteristic of antihistamines, such as the long acting, short acting, dosage and the indications in different age groups.

Sometimes antihistamines are given as a placebo in certain dermatoses. In these cases we use the less expensive and those with minimal side effects.

Antihistamines are the first line of treatment in pruritic skin diseases antagonizes histamine at the H1 receptor site. There are different antihistamines either working as antihistamine or on other mediators.

Antihistamines have a CH2CH2N = grouping resembling the histamine molecule and thus allowing them to block histamine receptors.

There are different histamine receptors.

1. H1-receptors: Their main therapeutic effect is a peripheral one antagonizing the action of histamine. These have an important role in treatment of skin disorders mediated by the effect of histamine as vasodilatation, increased permeability of small blood vessels, smooth-muscle contraction and itching.

2. H2-receptors: Mediate their effects on gastric acid production. However, they also play a role in skin blood vessels, as well as having an effect on the immune system.

3. H3-receptors: Found in the brain and are responsible for autoregulation of histamine production and release.

The dosage of systemic drugs are calculated roughly on the basis of body weight or better according to the body surface especially in children. The old generation antihistamines are better given in three or four divided daily doses. The second-generation antihistamines are given usually as one daily dose at bedtime to prevent scratching at night and may help irritable children and his family in having undisturbed sleeps.

It should be noted that two antihistamines from different groups or generations or different families may be sometimes required to relieve certain reluctant pruritic skin diseases not responding to the traditional treatment such as in some cases of chronic urticaria.

Old generation antihistamines cross the brain barrier and should be given with great care to young children or to those who need concentration in their work as drivers and others.

New relatively non-sedating antihistamines such as Loratidin, Cetrizine and terfenadine block the release of histamine and other inflammatory mediators from mast cells and basophils.

Some H1 antagonists can be given safely to children as young as one year as Trimeperazine which can be given to small infants 6 month of age.

Children less than 12 years should not be given antihistamines like azatadine, pyrilamine and clemastine.

OLD GENERATION ANTIHISTAMINES

1. Alkylamines:

2. Ethanolamines - Diphenhidramine HCL (Benadryl capsules), 10, 25, 50 mg, elixir 12.5 mg /tsp. and also is available as injections 50 mg /vial.

   Children dose is 5 mg./kg. /day divided into four daily doses or two-teaspoon at bedtime may be very helpful to control itching in children.

   The adult dose is 25-50 mg. three times daily.

3. Promethazine - (Phenergan) is promethazine HCL. The drug is available either in tablet forms of 12.5 mg, 25, and 50 mg or in syrup form of 6.25 mg/tsp.

   The drug is photosensitizer and sometimes causes vague muscle spasm.

   Doses of promethazine:

   Children - 0. 5 mg./kg/day three times daily.

   Adult - 25 mg daily

4. Piperadine - Cyproheptadine HCL (Periactin) tablets 4 mg. or syrup 2mg/tsp.:

   Children can be given 0. 25mg./kg./day.

   Syrup of Periactin, 2 mg per teaspoon can be given at bedtime for older children. If drug is taken during the daytime it may keep the child drowsy.

   I give half teaspoon when the child comes from the school and one-teaspoon at bedtime. That usually gives good results.

5. Piperazine:

   Hydroxyzine HCL (Atarax)

   The drug is available in tablet form of different strengths: 10 mg, 25 mg, 

   50 mg or 100 mg. and syrup 10mg/tsp.

   Atarax is an antihistamine, anticholinergic and sedative.

   Dose of Atarax:
   Children can be given 2 mg./kg. /day.

   Adult dose is 10-25 mg. /6-8 hours.

   Atarax is my favorite drug especially in atopic patients and those having urticaria. It gives very good results alone or in severe chronic cases can be combined with another antihistamine such as Benadryl syrup. I usually give one teaspoon of Atarax at night and a teaspoon of Benadryl (10 mg) at bedtime.

   Such combination is very helpful to control itching at night, enabling the patient to deep sleep and that inturn  helps the exhausted parents to have undisturbed sleep too. These medications are usually curative for chronic cases where other medications failed to control the skin lesion.

   Vistaril (hydroxyzine pamoate): this drug is available as an oral suspension 25 mg/tsp., capsules 25, 50, 100 mg and intramuscular vials 25 mg/cc or 50 mg/cc.

N.B.

1. Old generation antihistamines such as Cyproheptadine, Chloropheneramine, promethazine should not be given to children under two years of age.

2. Children less than 6 years should not be given antihistamines like Bromopheneramine (sustained release), Chloropheneramine, Tripolidine, and Phenindamine.

3. Hydroxyzine (Atarax tablets 10mg) contains starch and Tartrazinein its coating which may cause dermatitis and exacerbation of the pre-existing skin lesion, while the 25 mg. & 100mg are free from Tartrazine in the coating).

4. The main side effects of the old generation antihistamines are: drowsiness, dry mouth, lack of concentration and dizziness. 

NEW GENERATION ANTI-HISTAMINES

New antihistamines include pharmacologically different compounds where most of these groups are non-sedating in the ordinary daily doses.

New generation antihistamines include: Terfenadine, Loratidine, Cetrizine, Mequitizine and Astemazole.

Action & Dosage:

The new generation antihistamines are characterized by decreased sedation and less anticholinergic side effects.

Terfenadine, astemazole, loratidine are new antihistamines and all have a similar effect, while loratidene, terfenadine and cetrizine are superior to astemazole in their speed of action in relieving symptoms.

1. Terfenadene (Teldane 60mg):

   Terfenadene is considered as the first non-sedating antihistamine and the most widely used non-sedating antihistamine. It is a potent and specific antagonist of H1-receptors. It has effective symptom relief, without unwanted side effects and has no effect on judgment or performance. The pharmacokinetics of terfenadine is not significantly affected by food.

   The onset of action of the drug is from 1-2 hours and the peak effect is from 3-4 hours. The daily dose of 60mg is given twice daily. Each dose has an effect for 12 hours only. It has been reported that the two tablets can be given and have the same effect as that of a twice daily dose.

   Terfenadene was believed to be devoid of the side effects if the recommended dose is not exceeded. In the recommended daily dose, this drug is free of sedation. Exceeding the recommended dose may increase the risk of cardiac arrhythmia that may lead to syncope, ventricular fibrillation and sudden death.

   Recently different side effects such as arrythmia and cardiac fibrillations were recorded, that is why the drug was drawn from certain markets. Meanwhile, the whole story is not clear, hence some still believes that the drug has its indication and is effective, if it is given according to the recommended instructions.

Drug interaction:

Avoid combination of the drug with ketoconazole, H2 antagonists, macrolides and erythrocin.

Dosage:

The pediatric dose is 15-mgm/12 hour for children from 3-6 years. and 30mg. /12 hours for children around 12 years of age .

The adult daily dose is 60 mg twice daily. This dose may be doubled to 120 mg daily in severe cases .

2. Cetrizine (Zyrtec 10mg)

   Cetrizine is rapidly absorbed with little metabolism and is mostly excreted unchanged in urine and this is why the dose should be reduced if given to a patient with renal disease.

   The onset of action is within one hour and the peak effect is from 4-8 hours. The drug has long acting effect where a single dose may have its action for about 24 hours.

   Cetrizine has been demonstrated to cause sedation and functional impairment compared to placebo. This effect appears to be dose related.

   The drug is not recommended for use in pregnancy.

   Dosage:

   The adult dose is 5-10 mg once daily.

3. Loratidine (Claritin 10mg):

   Loratidine is well absorbed and extensively metabolized. Time of onset is delayed, usually after 5 days.

   Loratidine may produce impairment of performance at high doses , should be given with care to old patients,and to those who have renal and liver impairment.

   The onset of action is rapid, (within one hour) and the peak of its effect is 4-6hours. The drug has long acting effect, where a single dose of one tablet 10-mg can work for 24 hours.

   The drug has no sedation, anticholinergic side effect or dose limitation warnings.

   Pregnancy: FDA Category B

Dosage:

The drug is available in syrup and tablet form of 10mg that is given in once-daily dose. The adult dose is 10 mg. daily.

4. Astemazole (Hismanal 10mg)

   Astemazole is a potent H1 receptor antagonist. Its activity is at 5-HT receptors. Astemazole absorption is delayed and reduced in the presence of food. This may explain the weight gain in some patients using astemazole

   Peak plasma level of astemazole is reached within one hour and the terminal half-life is around 11 days following a single 10mg daily dose. The relief of symptoms is slow, it usually begins after two days.

   Astemazole has a delayed onset of action usually from 1-3 days. It has the longest peak of action with prolonged duration compared with the new generation antihistamines, which is from 9-12 days.

   Astemazole has also been shown to be free of sedative side effects like terfenadine, but exceeding the recommended daily dose, both may increase the risk of cardiac arrhythmia, syncope, ventricular fibrillation and even sudden death.

   Astemazole has been approved by the FDA with the Category C in pregnancy.

Interaction of Astemazole

Plasma levels of astemazole may be increased as a result of interaction with various drugs such as ketoconazole, H2 -antagonists, erythrocin and macrolides.

Dosage:

The pediatric dose (above 40 kg) is 0.2 mg/kg. /day. Astemizole has a very high affinity for H1 receptor and its effects are not reversible after discontinuation of the drug.

The adult dose is 10 mg daily. This antihistamine is safe, very long acting, effective and has minimal side effects).

5. Acrivastine

   The adult daily dose is 8 mg three times daily (rapid-acting antihistamine).

TOPICAL PREPARATIONS
TOPICAL CORTICOSTEROIDS

Since the year of 1952 when topical steroids first became commercially available, many preparations that are different in their potency and structure have been used to treat different skin lesions.

Corticosteroids are anti-inflammatory, anti-allergic and anti-proliferative preparations. In pediatric patients, the topical application of a steroid should be limited to the least amount and for the shortest period to cause the therapeutic response.

Children and infants are more susceptible to the different topical steroids especially the fluorinated types. This is because they have larger skin surface area in relation to body weight.

The effectiveness of topical corticosteroids depends on the pharmacological structure, potency, state of the skin surface, age, duration of application and the degree of penetration into the skin.

Cortisone and hydrocortisone preparations have minimal anti-inflammatory reaction and very few side effects while fluorinated groups have high anti-inflammatory reactions and many side effects such as striae, telengectasia, skin atrophy and even systemic unwanted side effects.

Mometasone furoate (Elocom) is the only topical steroid approved for use for children in USA. Even 0.5% and 1% hydrocortisone formulations that are available without prescription are not approved for use in children.

Different topical steroids are now available with different bases and strengths.

INDICATIONS OF TOPICAL CORTICOSTEROIDS

• Allergic skin diseases.

• Vasoconstrictive effects: mainly the fluorinated types.

• Pruritic skin lesions: such as eczema.

• Papulo-squamous hyper plastic lesions as lichen planus and psoriasis.

• Collagen diseases: discoid lupus erythematosus.

• Vesiculo-bullous diseases: pemphigus and dermatitis herpetiformis.

• Infiltrating diseases: such as sarcoid and granuloma annulare.

Methods of Use:

1. Direct application to the skin lesions.

   Apply the medication to moist skin after bathing or soaking the area in water, if possible. Rub the medication thoroughly to the skin surface.

Note:

• Ointments are more effective than creams and gels.

• Fluorinated medications (Betamethasone valerate 0.1%, flucinolone acetonide 0.025 %, Triamcinolone acetonide0.1%) are about thousand times potent than 0.1% hydrocortisone)

2. Occlusion method.

   This method is done by covering the area by cellophane tape after application of the medication or using special tapes contains the active corticosteroid (Cordran tape). The area to be treated is washed first then the ointment is rubbed to the area and occluded.

   It was found that the potency of the corticosteroid by the occlusion method increases to about hundred times than the free application on the skin surface. This is mainly related to the hydration of the occluded area, increase penetration of the preparation and at the same time the entire applied amounts are kept all over the time in contact with the skin surface and not removed by any means.

   Occlusion method is used mainly for solitary or few lesions as hypertrophic lichen planus, solitary psoriasis patches and is not used for wide areas in order not to produce unwanted local and systemic side effects.

    

TYPES OF TOPICAL CORTICOSTEROIDS

Mild steroid : mometasone furoate (Elocom): Very mild and has a good effect. It is more safe steroid than other available topical steroid. This type of topical corticosteroid can be used in young ages.

Weak steroids : hydrocortisone, Colbetasone (Eumovate)

Moderately potent : flucocortolone (Ultralan)

Potent betamethasone valerate: (Celestoderm), Flucinolone (Synalar).

Very potent: Colbetasol Propionate (Dermovate)

SOME TOPICAL CORTICOSTEROIDS AVAILABLE IN THE MARKET

1. Mometasone furoate (Elocom): safe and "FDA" approved for use in children.

2. Hydrocortisone, Eumovate ointment , cream and lotion .

3. Fluorinated steroids: more potent but more expensive than hydrocortisone.

     Different types of fluorinated steroids available are:

• Lococorten ( fluoromethasone) ointment , cream and lotion or in combination with salicylic acid, tar or vioform.

• Betamethasone valerate (Betnovate ointment , cream and scalp lotion). Celestoderm ointment and cream. These preparations may be available in combination with antibiotic; Gentamycin; Celestoderm with Garamycin for infected eczematized lesions.

• Betamethasone dipropionate (Diprosone, ointment, cream and lotion)

• Dexamethasone: this is available as (Decodron cream) or in combination with antibiotic (Decoderm compound) or with antibacterial antifungal (Decoderm trivalent), spray, ophthalmic), or combined with salicylic acid (Salidecoderm ointment).

• Triamcinolone (Arsticort ointment and cream).

• Kenalog (ointment, cream, lotion, orabase for mouth lesions)

Dermovate (Colbetasol) ointment, cream and lotion. This is one of the most potent topical steroid. Dermovate should not in any way be applied to the skin of infants, young children, to the face or delicate skin of the crural areas.

                  NONSTEROIDAL TOPICAL PREPERATIONS

1- Pufexamac : This an effective and safe topical nonsteroidal preperation especially in the pediatric age.

Indications:

* Atopic dermatitis

* insect bites and papular urticaria

* All types of irritant skin conditions.

* photo-toxic and photo-allergic reactions.

*Burns and sun burn .

* Drug reactions.

* After laser surgery especially skin resurfacing which minimizes erythema and enhances rappid healing.

This drug can replace corticosteroid topical medication in most of skin problem but with safer ,cheaper and almost without any side effects wether locally or systemic.

Pufexamac is available in the market as " Droxaryl cream or Parfenac cream. The cream is available also in combination with antifungal preperation and available in the market as"Flogocid".This is very effective in diaper dermatitis and other irritant skin problems mainly in infants.

 

2-	Immunomodulating agents

There is a continual search in dermatology for more selective anti-inflammatory drugs to replace broad spectrum steroids. Tacrolimus (FK506), which is related to cyclosporin, is a powerful immune suppressor that was introduced to reduce organ transplant rejection. Like cyclosporin, it has been used systemically to treat psoriasis, atopic dermatitis, and pyoderma gangrenosum. 

Unlike cyclosporin, tacrolimus seems to be effective when applied topically. Initial open trials suggest that over 90% of children and adults rapidly achieve at least good improvement of atopic dermatitis. There is no systemic accumulation. Adverse effects occur in about half but are transient and are predominantly burning and erythema at the application site 

Tacrolimus (Protopic cream): is a non-steroid topical preperation .This is safe and effective in eczematous skin condition mainly atopic dermatitis.The drug prooved recently to be effective in vitilligo.Tacrolimus ointment is a steroid-free topical immunomodulator developed for the treatment of atopic dermatitis, a common, chronic inflammatory skin disease. By inhibiting T-cell activation and cytokine production, topically applied tacrolimus modulates inflammatory responses in the skin. Numerous clinical trials have shown that it is effective and well tolerated for the treatment of atopic dermatitis, its licensed indication. In addition, numerous publications suggest that tacrolimus ointment may provide effective treatment for a variety of other inflammatory skin disorders, many of which are very difficult to manage with standard therapy.

PREPARATIONS FOR SCALP AND HAIRY AREAS

Hairy areas such as the scalp should be treated by lotion preparations, which are easily washed, non-sticky and cosmetically more acceptable.

SOME TOPICAL STEROIDS LOTIONS:

Lococorten lotion

Locoid scalp application

Betnovate scalp application

Diprosalic lotion (Diprosone & Salicylic acid)

Dermovate for scalp applications.

These preparations can be easily washed by normal shampoos. In certain lesions such as psoriasis and seborrheic dermatitis we use tar shampoos, which are more effective and can act as an additional remedy to the scalp lesion.

Steroid lotions can be used twice weekly or once daily according to the strength of the steroid in the lotion, age of the patient and the type of the lesion to be treated.

Steroid lotions should be also used cautiously and should not  reach the eyes. The same precautions for other steroid preparations should be considered.

SIDE EFFECTS OF STEROIDS

• Aggravates viral, bacterial or fungal skin infections.

• Potent steroids may cause exacerbation of the skin lesion, or exacerbates existing systemic diseases such as diabetes and hypertension.

• Thinning of the skin especially that of the face and intertriginous areas due to skin atrophy.

• Stretch marks

• Telengectasia

• Moon face

• Acniform eruption.

• Adrenal failure due to systemic or local absorption of the potent topical steroid.

• Undescended testicles.

These side effects depend on the type of steroid used, the site, the duration of treatment, the surface area and the amount of steroid applied. It was found that 75 g. of a potent steroid used for more than two weeks produces some of such side effects. This is why it is crucial to discuss to the patient or his family, the side effects of steroids.

When topical steroids are prescribed to the newborn and children, there are many hazards, which may result from abuse or misuse of these topical preparations.

It is not uncommon to see some healthy persons especially, females without any skin lesion, using Colbetasol (Dermovate ointment) for a very long time on belief that this steroid can cause whitening of their dark complexions.

Topical steroids are better used twice daily for a short period. It is wise to explain to the patient how many tubes he has to use, amount for each application and for how long.

SYSTEMIC STEROIDS

1. Oral perpetrations:

   Corticotrophin (ACTH) stimulates the production of adrenocortical hormones. Hydrocortisone, corticosterone and androgenic hormones are secreted in response of ACTH stimulation.

   The natural adrenocortical steroids are either glucocorticoids or androgenic corticoids.The glucocorticoids, such as cortisone, are ant-inflammatory, influence carbohydrate metabolism and protein catabolism.

   Androgenic corticoids include deoxycorticosterone and aldosterone, have an effect on controlling electrolyte balance and sodium retention.

   ACTH and corticotrophin effect: increase in these products leads to:

   Increase in the excretion of 17-hydroxycoricosteroids.

   Increased pigmentation.

   Hypertension, sodium retention, edema and potassium loss.

   Reduction of cholesterol.

   Oral preparations are well absorbed from the gastrointestinal tract.

2. Parenteral preparations:

   Some physicians prefer steroid injections due to the following:

• It is easy to administer.

• They have control of the dosage.

• It has fewer side effects than oral preparations.

SOME TYPES OF ORAL CORTICOSTEROIDS

Steroids vary in their potency:

Cortisone 25mg = prednisone 5mg= Dexamethasone

0.75mg. = triamcinolone 4mg.= betametasone0.5 mg.

Fluorinated steroids are potent anti-inflammatory and have less electrolyte disturbance.

Betamethasone tablets(Celestone,0.5 mg.).

Dexamethasone tablets0.5mg.

Methylprednisolone tablets(Medrol 2 and 4mg.).

Prednisolone tablets 1and 5mg.

Prednisone 1 and 5mg.

Triamcinolone tablets 1,2 and 5mg.  

Some types of injectable corticosteroids:

Triamcinolone injections (kenacort 40mg/ml given deeply intramuscularly weekly or every two weeks.

Methylprednisolone (Depot medrol 40mg/ml) can be given weekly, safer and has fewer side effects than Triamcinolone. 

Locally injectable corticosteroids

Certain skin lesions either single or few in number can be treated by local infiltration with corticosteroids.

Triamcinolone injections (Leddercort 25mg/4ml is the most commonly used preparation.

Precautions

The solution can be infiltrated with the same concentration available as that in the supplied vial or sometimes diluted by normal saline depending on the type of lesion infiltrated, site of infiltration (delicate skin of the face and intertriginous areas need lower concentrations).

Strong concentrated preparations may cause local atrophy and skin depigmentation.

During infiltration the needle that is used for infiltration should not be too superficial or injected very deep in the tissues.

Method of application

Aspirate the solution from the vial where the amount aspirated depends on the size and number of lesions to be treated.

In children or very sensitive persons rarely local topical anesthetic (Emla cream, Astra) can be applied forty minuets before infiltration.

Infiltrate the sides of the lesion from the periphery and each time try to go gently deeper under the lesion.

Indications of Corticosteroid Infiltration

• Solitary lesions of hypertrophic lichen planus

• Solitary lesions of neurodermatitis.

• Solitary lesion of discoid lupus erythematosus.

• Solitary lesions of psoriasis.

• Necrobiosis diabeticorum.

• Keloids

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