Published on 25/03/2015 by admin
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Chapter 638 Principles of Therapy
Joseph G. Morelli
Competent skin care requires an appreciation of primary versus secondary lesions, a specific diagnosis, and knowledge of the natural course of the disease. If the diagnosis is uncertain, it is better to err on the side of less rather than more aggressive treatment.
In the use of topical medication, consideration of vehicle is as important as the specific therapeutic agent. Acute weeping lesions respond best to wet compresses, followed by lotions or creams. For dry, thickened, scaly skin or for treatment of a contact allergic reaction possibly due to a component of a topical medication, an ointment base is preferable. Gels and solutions are most useful for the scalp and other hairy areas. The site of involvement is of considerable importance because the most desirable vehicle may not be cosmetically or functionally appropriate, such as an ointment on the face or hands. A patient’s preference should also play a part in the choice of vehicle because compliance is poor if a medication is not acceptable to a patient. Cosmetically acceptable foam delivery systems have been developed, and the number of products available is increasing.
Most lotions are mixtures of water and oil that can be poured. After the water evaporates, the small amount of remaining oil covers the skin. Some shake lotions are a suspension of water and insoluble powder; as the water evaporates, cooling the skin, a thin film of powder covers the skin. Creams are emulsions of oil and water that are viscous and do not pour (more oil than in lotions). Ointments have oils and a small amount of water or no water at all; they feel greasy, lubricate dry skin, trap water, and may be occlusive. Ointments without water usually require no preservatives because microorganisms require water to survive.
Therapy should be kept as simple as possible, and specific written instructions about the frequency and duration of application should be provided. Physicians should become familiar with one or two preparations in each category and should learn to use them appropriately. Prescribing nonspecific proprietary medications that may contain sensitizing agents should be avoided. Certain preparations, such as topical antihistamines and sensitizing anesthetics, are never indicated.
Wet dressings cool and dry the skin by evaporation and cleanse it by removing crusts and exudate, which would cause further irritation if permitted to remain. The dressings decrease pruritus, burning, and stinging sensations, and are indicated for acutely inflamed moist or oozing dermatitis. Although various astringent and antiseptic substances may be added to the solution, cool or tepid tap water compresses are just as effective. Dressings of multiple layers of Kerlix, gauze, or soft cotton material may be saturated with water and remoistened as often as necessary. Compresses should be applied for 10-20 min at least every 4 hr and should usually be continued for 24-48 hr.
Alternatively, cotton long johns can be soaked in water and then wrung as dry as possible. These are placed on the child and covered with dry pajamas, preferably sleeper pajamas with feet. The child should sleep in these overnight. This type of dressing can be used nightly for up to 1 wk.
Bath oil has little benefit in the treatment of children. It offers little moisturizing effect but increases the risk of injury during a bath. Bath oil may lubricate the surface of the bathtub, causing an adult or child to fall when stepping into the tub. Tar bath solutions can be prescribed and may be helpful for psoriasis and atopic dermatitis. Colloids such as starch powder and colloidal oatmeal are soothing and antipruritic for some patients when added to the bathwater. Oilated colloidal oatmeal contains mineral oil and lanolin derivatives for lubrication if the skin is dry. These can also lubricate the bathtub surface. Ordinary bath soaps may be irritating and drying if patients have dry skin or dermatitis. Synthetic soaps are much less irritating. When skin is acutely inflamed, avoidance of soap is advised. Some patients find that lipid-free cleansers containing cetyl alcohol are soothing.
Lubricants, such as lotions, creams, and ointments, can be used as emollients for dry skin and as vehicles for topical agents such as corticosteroids and keratolytics. In general, ointments are the most effective emollients. Numerous commercial preparations are available. Some patients do not tolerate ointments, and some may be sensitized to a component of the lubricant; some preservatives of creams are also sensitizers. These preparations can be applied several times a day if necessary. Maximal effect is achieved when they are applied to dry skin 2 or 3 times daily. Lotions containing menthol and camphor in an emollient vehicle can be used to help control pruritus and dryness.
Special shampoos containing sulfur, salicylic acid, zinc, and selenium sulfide are useful for conditions in which there is scaling of the scalp. Most shampoos also contain surfactants and detergents. Tar-containing shampoos are useful for psoriasis and severe seborrheic dermatitis. They should be used as frequently as necessary to control scaling. Patients should be instructed to leave the lathered shampoo in contact with the scalp for 5-10 min.
Shake lotions are useful antipruritic agents; they consist of a suspension of powder in a liquid vehicle. Water-dispersible oil may be added for lubrication. These preparations can be used effectively in combination with wet dressings for exudative dermatitis. Cooling occurs as the lotion evaporates and the powder deposited on the skin absorbs moisture.
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