Cefpodoxime (Vantin)         For treatment of  Pneumococcus and methicillin-sensitive Staphylococcus aureus     

Ceftibuten (Cedax)         Poor efficacy against Streptococcus pneumoniae,which limits its clinical usefulness

                                            FIRST-GENERATION CEPHALOSPORINS

The first-generation cephalosporins include cefadroxil (Duricef), cephalexin (Keflex) and cephradine (Velosef), which are similar drugs. They are all well absorbed, even in the presence of food, and they achieve high urinary concentrations. Dosages of these agents should be decreased in patients with severe renal failure.

Cefadroxil, cephalexin and cephradine are effective in the treatment of skin and soft tissue infections caused by Streptococcus species and methicillin-sensitive S. aureus. Many physicians consider these drugs to be preferable to the orally administered antistaphylococcal penicillins (cloxacillin and dicloxacillin) because they are associated with a lower incidence of gastrointestinal side effects and have a better taste.

The good urinary concentrations of first-generation cephalosporins make them second-line agents (after quinolone antibiotics and trimethoprim-sulfamethoxazole [Bactrim, Septra]) for the treatment of urinary tract infections caused by susceptible gram-negative organisms, although they are not effective against Pseudomonas or Enterococcus species. Their relative safety in pregnancy makes them a reasonable alternative for the treatment of urinary tract infections in pregnant women.

Cefadroxil, cephalexin and cephradine may be used to treat streptococcal pharyngitis in patients with delayed-reaction penicillin allergy. Indications for these agents in the treatment of other upper respiratory tract infections (bronchitis, pneumonia, otitis media and sinusitis) are unclear. First-generation cephalosporins are generally not effective against H. influenzae, M. catarrhalis and other gram-negative beta-lactamase-producing organisms.

                                 SECOND-GENERATION CEPHALOSPORINS AND CARBACEPHEM

The second-generation cephalosporins include cefaclor (Ceclor), cefprozil (Cefzil) and cefuroxime axetil (Ceftin). Compared with first-generation cephalosporins, these drugs have improved activity against common beta-lactamase-producing respiratory pathogens such as H. influenzae and M. catarrhalis.

As a result of their widespread use, bacterial resistance to second-generation cephalosporins has greatly increased.1 In addition, second-generation cephalosporins are generally much more expensive than first-generation agents or penicillins.

Structurally, loracarbef (Lorabid) is a carbacephem rather than a cephalosporin. However, loracarbef is so similar to cefaclor in spectrum of antimicrobial activity and side effects that it is usually listed as a second-generation cephalosporin.

The second-generation cephalosporins are heavily promoted for their coverage of relatively resistant organisms (e.g., H. influenzae) that cause respiratory tract infections such as otitis media, bronchitis and sinusitis. Much less expensive agents, such as trimethoprim-sulfamethoxazole, may be preferred. Cefuroxime axetil may be considered a second-line agent for the treatment of urinary tract infections.

                                        THIRD-GENERATION CEPHALOSPORINS

Third-generation cephalosporins include cefdinir (Omnicef), cefixime (Suprax), cefpodoxime (Vantin) and ceftibuten (Cedax). Secondary to better resistance to some plasmid-mediated beta lactamases, the third-generation agents demonstrate somewhat expanded coverage of gram-negative organisms compared with first- and second-generation cephalosporins. They have the advantage of convenient dosing schedules, but they are expensive.

The third-generation agents have variable loss of efficacy against gram-positive organisms, particularly Streptococcus pneumoniae and Staphylococcus species. Lack of gram-positive coverage limits the usefulness of ceftibuten in the treatment of otitis media and respiratory tract infections, except perhaps as a second-line agent when antibiotics with better gram-positive coverage have failed.  Poor coverage of Staphylococcus species precludes the use of cefixime and ceftibuten in the treatment of skin and soft tissue infections.

                                                        Practical Clinical Applications

Because of all the drugs that are available to treat common infections in the primary care setting, choosing an antibiotic can be difficult. The decision is individualized, based on the cost of treatment and the patient's financial resources, formulary restrictions from insurance companies, the availability of drug samples in the physician's office, the likelihood of a resistant organism, the severity of the infection, comorbid conditions in the patient and the risk of drug side effects. 

                                                                         Oral Penicillins

The antibiotic properties of Penicillium mold were first noted by Fleming in 1928.  Penicillins first became available commercially in the mid-1940s, and they remain one of the most important classes of antimicrobial agents. 

The orally administered penicillins include natural penicillins, penicillinase-resistant penicillins, aminopenicillins, beta-lactam- beta-lactamase inhibitor combinations and antipseudomonal penicillins. 

                                                                       NATURAL PENICILLINS

Penicillin V, the potassium salt of phenoxymethyl penicillin, is well absorbed orally, and peak serum levels are achieved within 60 minutes. Penicillin G is not as well absorbed and is therefore less useful for oral therapy. Penicillin V is indicated for the treatment of mild gram-positive infections of the throat, respiratory tract and soft tissues. This natural penicillin is still the drug of choice for the treatment of group A streptococcal pharyngitis in patients who are not allergic to penicillin.  Penicillin V is also useful for anaerobic coverage in patients with oral cavity infections.

                                                             PENICILLINASE-RESISTANT PENICILLINS

Penicillinase-resistant penicillins were developed because of the increasing resistance of staphylococci to natural penicillins. These chemically modified penicillins have a side chain that inhibits the action of penicillinase. 

The penicillinase-resistant penicillins are active against Streptococcus and Staphylococcus species, but they are not active against methicillin-resistant S. aureus, which is becoming an increasingly common organism.  These drugs also do not have activity against gram-negative organisms.

Penicillinase-resistant penicillins are primarily indicated for the treatment of skin and soft tissue infections.

 Cloxacillin (Tegopen) and dicloxacillin (Dynapen) have be.tter absorption. These drugs should be taken one to two hours before meals. 

 Nafcillin (Unipen) and oxacillin (Prostaphlin) are in the form of oral preparations, having poor absorbtion.

                                                        AMINOPENICILLINS

The aminopenicillins were the first penicillins discovered to be active against gram-negative rods such as E. coli and H. influenzae.

Amoxicillin is more completely absorbed than ampicillin. As a result, serum amoxicillin levels are twice as high as serum ampicillin levels. Because a smaller amount of amoxicillin remains in the intestinal tract, patients treated with this agent have less diarrhea than those treated with ampicillin. However, the more complete absorption of amoxicillin makes the drug less effective than ampicillin in the treatment of Shigella enteritis. Otherwise, amoxicillin and ampicillin have almost the same spectrum of antimicrobial activity.

Bacampicillin (Spectrobid) does not have any significant advantages over the other aminopenicillins, and it is more expensive.

Orally administered amoxicillin and ampicillin are used primarily to treat mild infections such as otitis media, sinusitis, bronchitis, urinary tract infections and bacterial diarrhea. Amoxicillin is the agent of choice for the treatment of otitis media. ) Because H. influenzae and E. coli are becoming increasingly resistant to the aminopenicillins, these drugs are becoming somewhat less effective clinically.

                              BETA-LACTAM-BETA-LACTAMASE INHIBITOR COMBINATION

The only penicillin available in an oral combination with a beta-lactamase inhibitor is amoxicillin-clavulanate. This combination drug provides increased antimicrobial coverage of beta-lactamase-producing strains of S. aureus, H. influenzae, N. gonorrhoeae, E. coli, M. catarrhalis and Proteus, Klebsiella and Bacteroides species. It has little activity against Pseudomonas or methicillin-resistant S. aureus.

In clinical situations in which there is increased development of beta-lactamase- producing organisms, amoxicillin-clavulanate may be the first choice for the treatment of otitis media, sinusitis, bronchitis, urinary tract infections and skin and soft tissue infections. Because of its anaerobic coverage, amoxicillin-clavulanate is an excellent drug for treating infections caused by human and animal bites.

Common side effects include gastrointestinal distress, diarrhea (alleviated by taking the drug with food or water), rashes and Candida superinfection.

                                            ANTIPSEUDOMONAL PENICILLINS

Carbenicillin (Geocillin) is the only available orally administered antipseudomonal penicillin. This drug has excellent oral absorption. However, it is metabolized so rapidly that serum levels remain low, which markedly limits its clinical usefulness.

                                                    DRESSINGS USED IN DERMATOLOGY

Wet dressings

Wet dressing is used as a soothing and cooling antiseptic on dry inflamed skin lesions as in oozing eczema.

Potassium permanganate is an effective and widely used dressing. Potassium permanganate five grains added to 3 qt make a solution of 1: 9000 concentration is an optimum wet dressing to dry oozing lesions as in acute dermatitis. 

Method of use:

The mother should have an idea how to use it. Clean gauze can be dipped in the solution and used gently to clean either compress gently the soaked gauze or passing it along the lesion. This can be repeated according to the need.

N.B.

Boric acid solutions should not be used in infants and young children for the possibility of toxic absorption.

Burrows solution alone or in combination with oatmeal Bur-Veen powders (Fougera) is also used as wet dressing.

Powders

Powders are used to the intertriginous, and interdigital areas. It is used to dry sweat after changing diapers.

Zinc oxide, starch, talcum and aluminium chloride (for hyperhidrosis) are the commonest powders used in infants and young children.

Baths

Baths are used to remove crusts, scales and accumulated dirts and exudations on the skin surface. Tap water and soapless soap can be used followed by application of the appropriate topical medication.

Common types of baths are :

1. Starch Baths - this can be prepared by mixing cornstarch with water and boiled while stirring for a while to make a thin paste and a gelatinous mixture.

   Indications and actions

• Soothing and antipruritic.

• Dryness of oozing lesions such as weeping eczema.

• Lichen planus

• Urticaria and other dermatoses.

2. Aveno Baths - have the same effect as starch baths.

3. Oatmeal Baths - precooked and packed oatmeal is more convenient than Aveno bath and easier to use.

4. Bran Baths - used in generalized irritable skin diseases as in chronic urticaria.

5. Tar baths - are used in generalized psoriasis. This should be used with care in young age groups.

6. Bicarbonate baths - used in urticaria, dermatitis herpetiformis and psoriasis.

7. Borax baths - used in seborrheic dermatitis and urticaria.

Antiseptics

Antiseptic topical preparations such as hydrogen peroxide, potassium permanganate solutions are the commonest used to clean wet oozing skin surface.

Hair fall formulas

Different products are available in the market for rubbing and topical application to the affected areas.

Alopecia

• Minoxidil lotions, gel and spray.

• Oxysorolene lotions (Meladenin lotion, Oxysoralenes lotion).

• Some natives use irritant substances to the area such as garlic, rubbed vigorously to the affected scalp area. This may cause severe irritation and in some cases hair begins to regrow in the bald area.

• Formula which may help hair to regrow:

  N.B.

Different ingredients may be added to this formula:

• Minoxidil (Regain) may be added which may give better effect.

• Salicylic acid 2% may be added in the presence of dandruff.

• Oil of Cade or crude coal tar can be added to treat cases of psoriasis and seborrheic dermatitis.

• Perfume may be added to be more acceptable especially for females.

• Other preparations available in the market for treatment of hair fall are either in the form of lotion, spray or ampoules for local use to the scalp. Some of these contain placenta preparations, vitamin E and many other products. The physician can diagnose and give the appropriate type.

Detergents

Detergents are cleansing agents used to clean the skin surface from debris, crusts and scales. These include ordinary soaps, liquids or the soapless types.

Details of detergents and skin bathing are discussed in other chapters.

Soaps and Shampoos

Numerous types of soaps and shampoos are available in the market.

Soaps

Soap is a cleansing agent, which is of great value from the sanitary point of view, but at the same time, it may do great harm to the skin if the strong allergenic types were used especially in young babies.

Soaps have an alkaline (PH 9-11) composed of sodium or potassium salts, which emulsifies fats with water to remove dirt and debris. The problem of certain types of soaps is not only the high alkaline contents, but also the additives as antiseptics, coloring materials, perfumes and others. These may lead to dryness, cracking of the skin surface and allergic contact dermatitis. Dryness and eczematization of the skin may result from excessive washing with soaps that may affect the fatty covering of the skin

Type of soaps:

Soaps are available in solid or liquid forms.

Commercial shampoos

Some shampoos has a high alkaline content to give more foam, which is considered by some patients as an effective preparation and can clean better. These may cause dryness of the scalp, dandruff, hair fall and itching.

Side Effects:

• Dryness of the scalp and dandruff.

• Hair fall and Hair brittleness

• Local sensitization and continuous scalp itching

• Alters the PH of the scalp.

• Secondary infections of the scalp such as recurrent scalp carbuncles and folliculitis, which may lead to cicatricial alopecia.

Some times, we are faced with patients complaining of chronic scalp itching, excoriation and carbuncles that have used different medications without an effect. This problem was solved in a simple way, by using the proper shampoo.

Shampoos for newborn and young children should be mild and free from chemicals such as tars, cosmetics, perfumes and coloring materials. These types should be pH balanced. The optimum pH is around 5 in order not to affect the protective fatty acids of the scalp.

Commercial preparations, which may be suitable:

• Numis med shampoos

• Seba med shampoos

• Protein 21 shampoos are available for normal, dry and greasy hair.

• Head & shoulder shampoo.

Medicated Shampoos:

Tar shampoos - used for cleaning the scalp from dandruff, seborrheic dermatitis and psoriasis.

Salicylic acid containing shampoos to clear the scalp from dandruff.

Azoral shampoo (Nizoral) - is an effective shampoo in fungal lesions of the scalp and seborrheic dermatitis.

Selenium sulfide (Selsun) - used to treat seborrhea and scalp dandruff. Using this medication for a long time may cause hair fall.

Anti-sweating preparations

1. Aluminum compounds - Aluminum chloride 10-30 % in distilled water or 60% alcohol.

   Functions of Aluminium compounds:

• Increase the permeability of the sweat ducts resulting in complete dermal resorption of the sweat. These preparations may occlude the sweat ducts leading to sweat retention and causing hidradenitis suppurativa.

• Diminishes body odor due to its antibacterial effect.

2. Topical anticholinergic compounds such as scopolamine hydrobromide locally.
    

3. Gluteraldehyde are indicated in hyperhidrosis of palms and soles. Higher concentrations of 10% are used for the feet while 2-5 % concentrations are used for sweating of hands. This preparation can be used three times daily.

   Cidex is a ready made preparation composed of 2 % gluteraldehyde and can be used easily for excessive hand sweating.

4. Tannic acid (5 % in 70 % alcohol).
    

5. Dusting powders for the feet, which can be used before dressing of socks.
    

6. Oral anti-cholenergic: Pro-banthine 15 mg can be given three times daily may inhibit very much sweating especially when combined with the topical aluminium preparations.

Emollients

Emollients: are used to moisten dry skin. Different types of emollients are available in the market such as Petroleum jelly, Moisturel cream, Formula 405, Alpha keri.

Antipruritic preparations

The most common used antipruritic topical preparations are topical corticosteroids. Topical antihistamines, anesthetics should not be used for a long period as these may cause local sensitization.

Keratolytics

These medications are used to remove the scales in dry skin lesions. Salicylates alone or in combination of corticosteroids topically can be used. Care of using these preparations in young age should be taken into consideration for the possibility of complications such as salicylism .

Shaked Lotions

Shaked lotions are the most commonly prescribed as calamine lotion. When the suspension is applied to the skin, the water evaporates, giving cooling sensation and leaving the powders to dry on the skin surface.

Shake lotions should include not less than 40 per cent of the total and glycerin about 15 per cent since the latter in higher concentration may irritate the skin and make the lotion stickier.

To these shake lotions other drugs may be added such as salicylic acid, sulfur, Resorcin according to the type of lesion to be treated.

                               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 

FORMULAS USED IN DERMATOLOGY

In the past, before the production and manufacture of the vast types of the ready prepared medications, formulas were the most common used in dermatological treatments. In spite of that, some physicians till now sometimes prefer to prescribe certain formulas where he can add different medications adjusted to the skin lesion. These formulae may be more effective but the problem is that not all the pharmacist can do the job in the proper way besides the unreasonable and non-convincing overpricing of such preparations.

Abbreviations used in formulas

Formula for Generalized Pruritus

Apply the mixture to the affected area every 4 hours. Care of the toxicity of phenol in young children especially when the skin surface is abraded or ulcerated.

Soothing and antipruritic lotion:

Apply on the area every four hours or as needed.

Compresses

Different types of compresses are used in skin diseases. Antiseptics have different effects either an antiseptic, drying or soothing agents.

Cold milk compresses

Fresh milk is kept in the fridge till it becomes cool. Clean gauze is soaked and applied repeatedly to the skin surface.This is a soothing preparation , used in acute erythema, sunburn, peri-orbital hyper-pigmentation (as compresses first and applying Eldoquine 2%).

Potassium permanganate compresses

These are used in different concentrations. Potassium permanganate compresses in concentration of 1:9000 are used by clean gauze moisten with the solution and applied repeatedly to the skin lesion for 10 minuets every four hours. When the gauze is dry it should be moistened again and repeated application each time is necessary.

The brown staining of the skin can be removed with lemon juice.

Dalibor‘s solution:

Antifungal Formula

Castellani‘s paint, Carbolfuchsin solution

Paint on toenails and between toes once daily.

Whitefield‘s ointment

Rub into the affected areas morning and evening.

Anti-sweating Formulas

Formula for onychomycosis

Candidal paronychia

A solution of 3 % Thymol iodide in alcohol

N.B. Topical antifungal preparations whether a formula or of the Azole group. (Daktarin, Lamasil topically) should be combined with oral Azole (Lamasil tablets) for 3-6 months.

Antiviral drugs

Soft warts

(Intertriginous or anogenital warts)

Podophyllin is an effective, safe and easy to use for treatment of intertriginous or anogenital warts. This preparation can be used in concentrations of 20-25% Podophyllin either in collodion, acetone or in tincture Benzoin co.

Podophyllin, 10-20% in  collodion is preferred because the preparations can stick and dry immediately when applied to the lesion and no slipping or dribbling to normal adjacent tissues.

                                                 Fig.100a&b. Herpes progenitalis, infant 11months (before treatment)

(Recurrence after expensive and unsuccessful surgical excision besides different topical medications for the last three months in other medical centers. The father claims that cost was more than 3500 $ !!

       Fig.100c.  Photo of the same infant treated in our medical center after three applications of 20% topical Podophyllin in Benzoin co , one application every two days and washed after four hours\The cost of that treatment was only THREE DOLLARS !!!!!.

Fig.100.d&e.The same child after 10 days(she was given mupericin cream (Bactroban cream) applied once daily for the exfoliated area)

                                The same child (complete healing without any  complications after 10 days)

This is an effective preparation and I consider it superior to other lines of treatment used for anogenital warts and gives excellent results. It is applied every other day and washed after 6 hours. 

Other topical preperations for ano-genital warts are Immiquimod (Aldara cream and Podofilix(Condylox gel 0.25 cream are also effective but they are more expensive than Podophyllin.

Mycophenolate mofetil is reported to be antibacterial, antifungal, antiviral, and immunosuppressive. It has been used systemically in the treatment of psoriasis, pyoderma gangrenosum, bullous pemphigoid, pemphigus vulgaris, and systemic vasculitis.  The usual dosage is 1 g orally twice daily. Side effects such as gastrointestinal intolerance and minor urinary symptoms are usually mild and are predominantly dose dependent. Bone marrow suppression with mild to moderate leucocytosis and anaemia is seen in less than 5% of patients. Early reports suggesting an increased risk of carcinogenicity, especially lymphoma, have not been borne out in subsequent studies.  Topical mycophenolic acid is being assessed for its value in inflammatory skin conditions such as eczema and psoriasis.

Imiquimod ( induces production of interferon alfa, along with pro-inflammatory cytokines such as interleukin 1, interleukin 6, interleukin 8, and tumour necrosis factor alpha. It is an immune enhancing agent with antiviral and anti-tumour effects. Interferon alfa has been shown to be an effective treatment for several cutaneous conditions, including anogenital warts and non-melanoma skin cancer. However, it is not absorbed after topical application and requires intralesional injections. Imiquimod is applied topically, is well absorbed, and induces local interferon alfa. 

Imiquimod cream (Aldara cream5%) applied three times per week eradicates about 50% of anogenital warts. The recurrence rate is the same as placebo. The most common side effect is local inflammation. Trial applications of 1% imiquimod cream three time a day for five days a week for the treatment of molluscum contagiosum resulted in resolution in over 80% of patients and lesions. There were no adverse effects.  The potential of imiquimod in the treatment of cutaneous malignancy is the subject of current therapeutic trials. *(Recent advances in dermatology)

     Precautions

Severe reaction may occur from Podophyllin, especially in sensitive patients if applied concentrated. The dilution of the preparation may solve this problem.

In children and young females I give lower concentration, 10-15 % only and to be applied twice weekly and washed after-4 hours.

Care should be taken when applying Podophyllin to soft tissues or the intraurethral warts and anal warts because of the possibility of local scarring when used in higher concentrations.

Strong preparation rarely may cause urethral stricture in complicated cases with severe inflammation. Meanwhile, if the preparation is used with caution, it gives excellent results for urethral and internal anal warts, which will satisfy very much both the patient and the physician.

I have treated patients by Podophyllin who suffered a lot and tried different lines of medication even surgical removal of anogenital warts and the result was dramatic relief with 20% Podophyllin in collodion.

Hairy tongue formula

2-4% Podophyllin can be painted very cautiously to the area every two days.

Formula for common warts and corns

1. Planter warts and corns

Precautions

• The area to be treated is encircled by Vaseline ointment in order that the medication will not affect the healthy tissue.

• The medication should not come in contact with the mucous membranes of the mouth, nose and eyes.

• It should be kept away from children‘s reach.

• Young age groups should not use the medication by themselves. It is very important that one of the family members should apply the medication to the child and to be kept away.

After application of the preparation to plantar warts, the area is shaved to remove the dead tissue, where a few days after application, black dots can be seen within the lesion. This represents the thrombotic vessels caused by the virus.

Application of medication is continued twice daily mainly on the black dots of the lesion, till the patient feels deep pain after application especially in plantar warts of the sole. This sign indicates that the medication has reached the healthy deeper tissue. Application is continued for another three or four days after that. The total period of medication usually takes about 9 days.

This formula is very effective mainly in plantar warts were it works very well where other lines of treatment even surgical methods failed to cure the condition.  

2. Lesions of the face and intertriginous areas

   The skin of these areas is delicate. Lower concentrations of salicylic acid and lactic acid in the formula should be used.

Formula for miliaria

(Prickly heat)

Formula for hyperkeratosis

Topical corticosteroids in combination with salicylic acid (Locasalen, Salidecoderm, Diprosalic ointment) may also give good results either applied directly to the hyperkeratotic areas or under occlusion methods.

Formula for hyperpigmentation

Hydroquinone:

Eldoquine ointment is available in different strengths; 2 % and 4% concentrations. Some preparations contain in addition sunscreen agents.

This formula should be prepared in special cream base .It should be kept in refrigerator. It is a good formula for hyperpigmentation if used for about one month.

Other commercial preparations used for hyperpigmentation are: Artra 2% cream and Neostrata lightening cream.

                                                      phototherapy

Phototherapy has been used since a long time in treatment of skin disease.PUVA has been used with psoralenes for treatment vitilligo
Recently more studies and other machines are available and applied for certain skin diseases with variable results.
1- UVA1 phototherapy (340-400 nm) is effective in the treatment of inflammatory skin diseases such as acutely exacerbated atopic dermatitis, localized scleroderma, urticaria pigmentosa and disseminated granuloma annulare. 

2-Narrowband UVB radiation (311-313 nm) is used successfully as monotherapy or combined with dithranol, oral retinoids or 8-MOP in psoriasis, atopic dermatitis (AD) or photosensitivity disorders such as polymorphic light eruption. Narrow band is safe and can be given to young children and pregnants.

 3- Bath water delivery of 8-methoxypsoralen and subsequent UVA-irradiation (PUVA bath therapy) for the treatment of psoriasis as well as for mycosis fungoides, localized scleroderma, urticaria pigmentosa or lichen planus is an effective alternative to its systemic application.  

UVA1 phototherapy

UVA1 phototherapy utilizes long wave UVA radiation (340-400 nm) while filtering out the erythematogenic UVA and UVB wavelengths (290-340 nm). It has been shown to be very effective in the treatment of several inflammatory skin diseases such as atopic dermatitis, localized scleroderma, urticaria pigmentosa, disseminated granuloma annulare and in some cases in systemic sclerosis, lichen sclerosus et atrophicans, graft-versus-host disease (GvHD), cutaneous T cell lymphoma and psoriasis in HIV-infected individuals. Different dosage regimen have been proposed for UVA1 phototherapy: low dose (10-20 J/cm² per single dose), medium dose (50-60 J/cm² per single dose) or high dose (130 J/cm² per single dose) UVA1 therapy.  

Narrowband (TL-01) UVB

The narrowband UVB lamp with an emission spectrum peaking at 311-313 nm (Philips TL-01/100 W) was developed as an alternative to broadband UVB (290-320 nm) for the phototherapy of psoriasis to reduce erythemogenicity and the risk of skin carcinogenesis.. Narrowband UVB phototherapy was also used in the management of atopic eczema, resulting in the amelioration of pruritus, restoration of a normal sleep pattern and a reduction of topical steroid use . In patients with photosensitivity diseases such as polymorphic light eruption, TL-01 produces a "hardening" photoprotective effect . Long-term side effects of narrowband UVB phototherapy, such as potential skin carcinogenesis, seem to be at least equal to and possibly less frequent than would be expected from broadband UVB sources.

Balneophototherapy

Balneophototherapy combines bath water delivery of water soluble photosensitizers or antiinflammatory agents for example 8-methoxypsoralen (8-MOP) or different salt solutions with a subsequent UVB- or UVA-irradiation [reviewed in 23]. In recent years, the combination of brine baths or 8-MOP-baths with UVB- or UVA-phototherapy using artificial light sources has been used increasingly in the treatment of psoriasis and atopic dermatitis . Administration of 8-MOP in a dilute bath water solution seems to be an effective alternative to its widely used systemic application, avoiding side effects such as nausea, vomiting, elevation of liver transaminases or even photodamage to the eyes and furthermore reduces cumulative UVA doses . 

PUVA bath therapy proved to be effective in psoriasis, mycosis fungoides, lichen planus, localized scleroderma, urticaria pigmentosa and chronic palmoplantar eczema [23, 29]. PUVA bath therapy can also be combined with oral acitretin for the efficient treatment of severe psoriasis [30]. Several case reports documented a beneficial effect of bath PUVA in the treatment of prurigo, vitiligo or severe atopic dermatitis .

Extracorporeal photopheresis (ECP)

Extracorporeal photopheresis (ECP) was first introduced 1987 by Edelson et al. as a therapeutic regimen for Sezary's syndrome . However, in recent years, it has been used successfully for other indications such as chronic graft-versus-host disease (GvHD), systemic scleroderma, pemphigus vulgaris, rheumatoid arthritis, lupus erythematodes and even severe atopic dermatitis . 

Sunscreen preparations

Sunscreens are UV-absorber that contain certain ingredients such as p-amino benzoic acid esters, methyl-, phenyl- and benzyl salicylates, benzyl cinnamate, digalloyl trioleate (photosensitizer), 4-isopropyl-dibenzoylmethane, 3-(4-methylbenzylidene)-camphor and 4-tertiarybutyl-4'-methoxy-dibenzoylmethane.

Sunscreens were presented in the market in 1928 as an emulsion of benzyl salicylic acid and benzyl cinnamate and later other sunscreens were available as quinine bisulfate and quinine oleate. Sun block usually reflects or scatters all UV rays. This should be applied about 20 minutes before exposure to sun and should be reapplied after two hours. It should be noted that children and other sensitive groups should be instructed to use sunscreens routinely, like brushing their teeth.

Sunscreens of at least 15 SPF lip preparation is available and should be used to protect the lips from actinic injury

The best way to prevent the effects of sun exposure (other than avoiding the sun!) is to apply sunscreen. Sunscreen is FDA-approved for anyone over 6 months of age.

Children and sunburn

It's no secret that the sun's ultraviolet rays damage skin, causing premature aging and increasing the risk of developing skin cancer later in life. That risk increases significantly for a young child who suffers even one blistering sunburn. Still, many parents allow their children to spend long periods of time in the sun without proper protection.

The best way to avoid the sun's damaging effects is to restrict your child's prolonged exposure to the sun whenever possible and to teach appropriate self-care skills—adequate cover and the liberal use of sunscreen.

Finally, as a role model for your child, you should protect your own skin by following the self-care strategies for preventing sunburn and over-exposure.

Symptoms/Signs:

• Skin is reddened and warm to the touch
• Minor swelling and itching in affected areas
• Blistering with more serious burns

Consult Your Doctor If Your Child:

• Experiences nausea, fever, chills, or lightheadedness. Your child needs immediate medical care.
• Has blistering that is extensive and severe.
• Has a sunburn that seems to worsen or spread 24 hours after exposure.

Home Care Ideas:

• Give your child ibuprofen as a pain reliever and anti-inflammatory.
• Apply cold compresses several times a day, or have him or her soak in a cool bath with an oatmeal bath preparation added to the bath water.
• Avoid using soap on your sunburned child, or use only a mild soap to wash burned areas; rinse well.
• Apply aloe vera gel or moisturizer to burned areas immediately after bathing your child.
• Never peel areas of skin where blisters have broken or dried.
• Apply sunscreen with an SPF of 15 or higher 30 minutes before your child goes outside. Don't forget the lips. Reapply after sweating or swimming. Replace sunscreen every summer.
• Never apply sunscreen to an infant less than 6 months old. Keep him or her out of the sun altogether.
• Be sure your child is covered well—a hat and long sleeves.
• Avoid exposure when the sun is most intense (10 a.m. to 3 p.m.). A good rule of thumb: keep your child out of the sun when his or her shadow is shorter than he or she is. Also, remember water, snow, high altitude, and proximity to the equator intensify the sun's effects.

METHODS OF PROTECTION FROM THE EFFECT OF SUN

The harmful effects of sun are strongest between 10 a.m. and 4 p.m.

1. Use a broad-spectrum sunscreen with a Sun Protection Factor.

2. Re-apply sunscreen every 2 hours when outdoors, even in cloudy days especially when in seashores and snowy areas.

3. Wear protective , tightly woven clothing , such as long sleeved shirts and pants .

4. Wear a wide-brimmed hat and sunglasses when outdoors.

5. Stay in the shade whenever possible. If your shadow is shorter than you are, you are likely  more exposed to sun damage.

6. Avoid reflecting surfaces.

7. Children are more sensitive to the effect of sun.

8. Minimize sun exposure.

9. Avoid tanning beds.

10. Avoid photosensitizers whether drugs or certain plants and trees.

Different types of sunscreens:

• Para-aminobenzoic acid: Absorbs UVL between 280-320 nm.

  PreSun (5 % PAMB in 55 % Alcohol)

  Solar cream (4% PABA and 5% titanium oxide)

• Benzophenon compounds

  Absorb UVL from 250-360 nm.

  Solbar (3% Oxybenzone and 3% Dioxybenzone)

  Uval (10% Sulisobenzone).

• RVP (red vetrinary petrolatum):

  Absorbs UVL to 340 nm.

  Water protective because it is greasy.

  Preparations available in the market:

  RVP (95 %RVP)

  RVP aqua (3% RVP and 20% zinc oxide)

  RVPABA lipstick (20% RVP, 5% PABA).

  SVP Sun block

• Drying lotions

  R/x
  Zinc oxide	20
  Talc	20
  Glycerin	15
  Alcohol	70%
  Water	aa-q.s. ad 100

Sunshades

These preparations block light and most of them contain Titanium dioxide or Zinc oxide powder.

• Solar cream (4%PABA, 5% Titanium dioxide).

• A-Fil (5% Methyl anthranilate, 5% Titanium dioxide)

• Reflecta (Titanium dioxide).

Insect repellents

Different insect repellents are available commercially. Most of insect repellents contain either Diethyltoluamide (DEET) Or Ethyl hexanediol (E-H).

1. Diethyltolamide products :

• Mosquito repellent lotion (McKesson ) contains 50% Deet.

• Off liquid (S.C. Johnson), 50% Deet.

• Cutter insect repellent cream , 30% Deet .

2. Ethylhexanediol (E-H) products

• Walgreen spray, 20% E-H.

• Deet products: either in the form of lotion, or stick preparations.

References

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