Dermatologic Therapy

Dermatologic Therapy

John C. Hall MD

Many hundreds of medications are available for use in treating skin diseases. Most physicians, however, have a few favorite prescriptions that they prescribe day in and day out. These few prescriptions may then be altered slightly to suit an individual patient or disease. Prescription pads printed with commonly used preparations can help save the clinician time and are always legible for the patient. Prescription pads that cannot be photocopied are mandatory.

Treatment of most of the common skin conditions is simpler to understand when the physician is aware of three basic principles:

1. The first principle is to treat the skin lesion by its type of skin lesion, more than the cause, influences the kind of local medication used. The old adage “If it’s wet, dry it with a wet dressing, and if it’s dry, wet it with an ointment” is true in most cases. For example, to treat a patient with an acute oozing, crusting dermatitis of the dorsum of the hand, whether due to poison ivy or soap, the physician should prescribe wet soaks. For a chronic-looking, dry, scaly patch of psoriasis on the elbow, an ointment is indicated because it holds moisture in the skin; an aqueous lotion or a wet dressing is more drying. Bear in mind, however, that the type of skin lesion can change rapidly under treatment. The patient must be followed closely after beginning therapy. An acute oozing dermatitis treated with water soaks can change, in 2 or 3 days, to a dry, scaly lesion that requires an ointment. Conversely, a chronic dry patch may become irritated with greasy ointment and begin to ooze.

2. The second basic principle in treatment is first do no harm and never overtreat. It is important for the physician to know which of the chemicals prescribed for local use on the skin are the greatest irritants and sensitizers. It is no exaggeration to say that a commonly seen dermatitis is actually due to patient overtreatment before coming to the office (overtreatment contact dermatitis). The patient, many times has gone to the neighborhood drugstore, or to a friend, and used any, and many, of the medications available for the treatment of skin diseases. It is certainly not unusual to hear the patient tell of using an athlete’s foot salve for the treatment of the lesions of pityriasis rosea.

3. The third principle is to instruct the patient adequately regarding the application of the medicine prescribed. The patient does not have to be told how to swallow a pill, but does have to be told how to put on a wet dressing. Most patients with skin disorders are ambulatory, so there is no nurse to help them; they are their own nurses. The success or the failure of therapy rests on adequate instruction of the patient or person responsible for the care. Even in hospitals, particularly when wet dressings or aqueous lotions are prescribed, it is wise for the physician to instruct the nurse regarding the procedure.

With these principles of management in mind, let us now turn to the medicine used. It is important to stress that we are endeavoring to present here only the most basic material necessary to treat most skin diseases. For instance, there are many solutions for wet dressings, but Domeboro solution is our preference. Other physicians have preferences different
from the drugs listed and their choices are respected, but to list all of them does not serve the purpose of this book.

Two factors have guided us in the selection of medications presented in this formulary. First, the medication must be readily available in most drugstores; second, it must be a very effective medication for one or several skin conditions. The medications listed in this formulary also are listed in a complete way in the treatment section for the particular disease. Instructions for more complete use of the medications, however, are as described in this formulary.


A particular topical medication is prescribed to produce a specific beneficial effect.

Effects of Locally Applied Drugs

Anesthetic agents are used in the skin to decrease pain when injections, laser, cryotherapy, electrolysis, excisions, or other procedures are performed. These include lidocaine hydrochloride 3% cream (LidaMantle), 30% to 40% lidocaine compounded in Velvachol or Acid Mantle cream, EMLA cream or disc (2.5% lidocaine and 2.5% prilocaine), and ethyl chloride spray. Anesthetic agents for mucous membranes are used to temporarily ameliorate discomfort from mucous membrane diseases. They include viscous solution of lidocaine (2%) and Hurricaine liquid or gel spray (20% benzocaine); for ophthalmic use, Alcaine solution (0.5% proparacaine) and Pontocaine (0.5% tetracaine) are used.

Antipruritic agents relieve itching in various ways. Commonly used chemicals include menthol (0.25%), phenol (0.5%), camphor (2%), pramoxine hydrochloride (1%), sulfur (2% to 5%), and coal tar solution (liquor carbonis detergens [LCD]) (2% to 10%). These chemicals are added to various bases for the desired effect. Numerous safe and unsafe proprietary preparations for relief of itching are also available. The unsafe preparations are those that contain sensitizing antihistamines, benzocaine, and related—caine derivatives. Itch-X gel and spray is over the counter (OTC) and contains 1% pramoxine hydrochloride and 10% benzyl peroxide (Itch-X lotion is OTC, 1% hydrocortisone).

Keratoplastic agents tend to increase the thickness of the horny layer. Salicylic acid (1% to 2%) is an example of a keratoplastic agent that will thicken the horny layer.

Keratolytics remove or soften the horny layer. Commonly used agents of this type include salicylic acid (4% [Salex lotion and cream] to 10%), resorcinol (2% to 4%), urea (20% to 50%), and sulfur (4% to 10%). A strong destructive agent is trichloroacetic acid. Urea in 5% to 10% concentration (Eucerin Plus lotion and Carmol) is moisturizing, whereas in 20% to 50% (Vanamide, Keralac, Carmol) concentration, it is keratolytic. Urea is also available in a nail stick applicator, Kerastick (50%), for onychoschizia and in a Redi-Cloth (Kerol [42%]). α-Hydroxy acids (lactic acid [Lac-Hydrin 5% or 12% cream and lotion or AmLactin and AmLactin XL 12% cream or lotion]), which are sold over the counter, and glycolic acid (Aqua Glycol is sold OTC in various concentrations and is available as facial cleanser, toner, face cream, shampoo, body cleanser, hand lotion, and body lotion) in 5% to 12% concentrations are moisturizers, whereas in higher concentrations up to 80%, are keratolytic and can be used in the office for facial peeling, with caution. Some moisturizers combine ureas and α-hydroxy acids such as U-Kera E (40% urea, 2% glycolic acid) and Eucerin Plus. Kerol Topical Suspension (50% urea with lactic acid and salicylic acid) is keratolytic and can be massaged into callosities for 60 seconds after bath or shower.

Antieczematous agents remove oozing and vesicular excretions by various actions. Soaks for 10 minutes twice a day or clean towels soaked in a solution for 10 minutes twice a day are very effective. The commonest agents include water soaks or compresses (lukewarm to cool), Domeboro solution
packets or dissolvable tablets that are nonprescription, coal tar solution (2% to 5%), hydrocortisone 0.5% to 2% (0.5% and 1% are available without a prescription), and more potent corticosteroid derivatives incorporated in solutions, foams, and creams.

Antiparasitic agents destroy or inhibit living infestations. Examples include permethrin (Elimite or Acticin) cream for scabies, γ-benzene hexachloride (Kwell) cream and lotion for scabies and pediculosis, crotamiton (Eurax) for scabies, and permethrin (Nix) for pediculosis. For scabies and lice, 10% sulfur can be mixed in petrolatum and is effective and very safe, even in infants and pregnant women, but is malodorous and stains.

Antiseptics destroy or inhibit bacteria, fungi, and viruses. Alcohol hand sanitizers are effective on hands and cloroxcontaining cleansers are very effective on inanimate fomites such as counters, floors, exam tables, and so on.

Antibacterial topical medications include gentamicin (Garamycin), retapamulin ointment (Altabax), mupirocin (Bactroban), bacitracin (recently found to cause a significant number of cases of contact dermatitis), Polysporin, and neomycin (Neosporin), which causes an appreciable (at least 1%) incidence of allergic contact sensitivity. Soaps, such as Lever 2000 and Cetaphil antibacterial soap, can have extra antibacterial additives.

Antifungal and anticandidal topical agents include miconazole (Micatin, Monistat-Derm), clotrimazole (Lotrimin, Mycelex), ciclopirox (Loprox), econazole (Spectazole), oxiconazole (Oxistat), naftifine (Naftin), ketoconazole (Nizoral), butenafine hydrochloride (Mentax, Lotrimin Ultra), and terbinafine (Lamisil). Sulfur (3% to 10%) is an older but effective antifungal and anticandida agent. Nystatin is anticandida but not antifungal.

Antiviral topical agents are acyclovir (Zovirax) ointment or cream and penciclovir (Denavir).

Emollients soften and moisturize the skin surface. Nivea oil, mineral oil, and white petrolatum are good examples. Newer emollients are more cosmetically elegant and effective.

Ointments moisturize the skin. Examples include Vaseline Petroleum Jelly, Lanolin, Aquaphor, Cetaphil, and Eucerin.

Creams dry the skin but are more cosmetically acceptable than ointments because they do not feel greasy and do not leave oil marks on paper products. Examples are Dermovan and Acid Mantle cream. Newer moisturizers attempt to restore the normal skin barrier for protection and to increase penetration of other topicals applied on top of these agents. Three examples are Mimyx, Atopiclair, and CeraVe.

Types of Topical Dermatologic Medications


1. Tar bath

Coal tar solution (USP, LCD) 120.0 ml

Or Cutar bath oil

Sig: Add 2 tbsp to a tub of lukewarm water, 6- to 8-in deep.

Actions: Antipruritic and antieczematous

2. Starch bath

Limit or Argo starch, small box

Sig: Add half box of starch to a tub of cool water, 6- to 8-in deep.

Actions: Soothing; antieczematous and antipruritic

Indications: Generalized itching and urticaria

3. Aveeno (regular and oilated) colloidal oatmeal bath

Sig: Add 1 cup to the tub of water.

Actions: Soothing and cleansing

Indications: Oilated for generalized itching and dryness of skin, winter, and senile itch. Regular for oozing, draining, wet dermatitis.

4. Oil baths (see section on oils and emulsions) for dry skin.

5. Bleach baths and compresses. For baths, add 1 cup of bleach to full tub of water to soak for several minutes, and add 1 tablespoonful to 1 quart of water to use as compresses for several minutes b.i.d. to treat recurrent recalcitrant Staphylococcus aureus folliculitis and secondary infection in atopic dermatitis.

Soaps and Shampoos

1. Dove soaps, Neutrogena soaps, Cetaphil, Basis

Action: Mild cleansing agents

Indications: Dry skin or winter itch

2. Dial soap, Lever 2000, Cetaphil antibacterial soap

Actions: Cleansing and antibacterial

Indications: Acne, pyodermas

3. Capex shampoo 120.0

Sig: Shampoo as needed.

Actions: Anti-inflammatory, antipruritic, and cleansing

Indications: Dandruff, psoriasis of scalp

Comment: Contains fluocinolone acetonide, 0.01%

4. Selsun Suspension or Head and Shoulders Intensive Treatment shampoo 120.0

Sig: Shampoo hair with two separate applications and rinses. You can leave the first application on the scalp for 5 minutes before rinsing off. Do not use another shampoo as a final cleanser. Contains selenium sulfide.

Actions: Cleansing and antiseborrheic

Indications: Dandruff, itching scalp (not toxic if used as directed but poisonous if swallowed, so keep out of reach of small children).

5. Tar shampoos: Tarsum (can be applied overnight or for several hours as a scalp oil and then shampooed out), Polytar, T/Gel (regular and maximum strength), Pentrax, Ionil T, and so on

Sig: Shampoo as necessary, even daily.

Actions: Cleansing and antiseborrheic

Indications: Dandruff, psoriasis, atopic eczema of the scalp

6. Nizoral shampoo 120.0 or Loprox shampoo

Sig: Shampoo two or three times a week.

Actions: Anticandidal and antiseborrheic

Indication: Dandruff, tinea versicolor, and tinea capitis infection

Comment: Nizoral is available as 1% OTC or as 2% with a prescription.

Loprox shampoo is similar, with ciclopirox as the active ingredient

7. T-Sal, Salex, and other salicylic acid shampoos

Indications: Psoriasis and seborrheic dermatitis

Wet Dressings or Soaks

1. Burow’s solution, 1:20

Sig: Add 1 Domeboro tablet or packet to 1 pint of tap water. Cover affected area with sheeting wet with solution and tie on with gauze bandage or string. Do not allow any wet dressing to dry out. It can also be used as a solution for soaks.

Actions: Acidifying, antieczematous, and antiseptic

Indications: Oozing, vesicular skin conditions

2. Vinegar solution

Sig: Add ½ cup of white vinegar to 1 quart of water for wet dressings or soaks, as described for Burrow’s solution.

Indications: Antieczematous, antiyeast, antifungal, antibacterial including antipseudomonas

3. Salt solution

Sig: Add 1 tbsp of salt to 1 quart of water for wet dressings or soaks, as above.

Indications: Antieczematous, cleansing


1. Purified talc (USP), ZeaSORB powder, or ZeaSORB-AF powder 60 (contains miconazole)

Sig: Dust on locally b.i.d. (supply in a powder can)

Actions: Absorbent, protective, and cooling

Indications: Intertrigo, diaper dermatitis

2. Tinactin powder, Micatin powder, ZeaSORB-AF powder, or Desenex powder

Sig: Dust on feet in the morning

Actions: Absorbent, antifungal, and antiyeast

Indications: Prevention and treatment of tinea pedis and tinea cruris as well as candida intertrigo

Comment: These powders are available OTC.

3. Mycostatin powder 15.0

Sig: Dust on locally b.i.d.

Action: Anticandida

Indication: Candida intertrigo

Shake Lotions

1. Calamine lotion (USP) 120

Sig: Apply locally to affected area t.i.d. with fingers or brush.

Actions: Antipruritic and antieczematous

Indications: Widespread, mildly oozing, inflamed dermatoses

2. Nonalcoholic white shake lotion

  • Zinc oxide 24.0

  • Talc 24.0

  • Glycerin 12.0

  • Distilled water q.s. ad 120.0

3. White shake lotion

  • Zinc oxide 24.0

  • Talc 24.0

  • Glycerin 12.0

  • Distilled water q.s. ad 120.0

4. Proprietary lotions

  • Sarna lotion (with menthol and camphor), Sarna for Sensitive Skin contains pramoxine

  • Cetaphil lotion

  • Aveeno anti-itch lotion (contains pramoxine)

Oils and Emulsions

1. Zinc oxide, 40%

Olive oil q.s. 120.0

Sig: Apply locally to affected area by hand or brush t.i.d.

Actions: Soothing, antipruritic, and astringent

Indications: Acute and subacute eczematous eruptions

2. Bath oils

Nivea skin oil, Alpha-Keri, Cutar bath oil (contains tar)

Sig: Add 1 to 2 tbsp to a tub of water. Caution: Avoid slipping in tub.

Actions: Emollient and lubricant

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May 28, 2016 | Posted by in Dermatology | Comments Off on Dermatologic Therapy

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