Topical therapy of ì bullous diseases. Peter Marinkovich Stanford University

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1 Topical therapy of ì bullous diseases Peter Marinkovich Stanford University

2 Categories of topical therapy ì Lo$ons ì Creams ì Ointments ì Solu$ons

3 Lotions In general poor moisturizers not op$mal for dry skin care Contain more water than oil Contain highest quan$$es of preserva$ves and other allergenic substances Useful for scalp and other hair bearing areas

4 Creams Lighter (vanishing) versus thicker creams Contain roughly equal amounts of water and oil Contain intermediate quan$$es of preserva$ves and allergy producing substances BeEer moisturizing agents compared to lo$ons

5 Ointments Contain mostly oil, very liele or no water In general, the best moisturizers Contain liele or no preserva$ves and fewest allergenic substances Vaseline: nothing you can be allergic to in it Very inexpensive One of the best moisturizers

6 Solutions Water based soaks used to deliver therapeu$c compounds to skin Skin loses its oils when soaked in water OKen helpful to apply ointments akerwards to keep skin from drying out

7 Topical therapy and acne Oils on the skin in general worsen acne Founda$ons, packed powders, hair products, moisturizers, sunscreens, topical an$bio$cs Non- comedogenic is more of a marke$ng than a medical term Oil free topical products are the best choice on face, back on shoulders of pa$ents prone to acne

8 Contact Dermatitis Topical medicines Benadryl Neomycin/Neosporin Formaldehyde releasing preserva$ves Quaternium deriva$ves Imidazole urea Diazolydinal urea

9 Fragrances Berloque derma$$s/bergamont oil Citrus oils photosensi$ve derma$$s Fragrance- free versus unscented

10 Topical Antibiotics Considera$ons Examples Development of resistant organisms Contact derma$$s ie neosporin Mupirocin: staph Silvadene: pseudomonas Others include bacitracin, polysporin Beneficial to rotate to prevent resistance

11 Topical disinfectants Chlorhexidine, iodine, hibiclens, in general too harsh for daily use, will irritate skin Dilute chlorine solu$on is a great way to disinfect skin on a regular basis.05% w/v sodium hypochloride/tepid water Works out to approximately 1 tsp chlorox bleach (not super chlorox) to 1 quart water. Can soak clean hand towels and lay over wound, or scale up and soak in tub

12 Topical corticosteroids: indications Pemphigus group of diseases: an$bodies are pathogenic topicals don t work so well Subepidermal bullous diseases, require local immune factors topicals work quite well

13 Topical Corticosteroid toxicity Face: development of steroid acne Axilla, inguinal, medial thighs, breasts, all prone to striae Exacerba$on of solar purpura Oral cavity and fold areas: promo$on of yeast infec$ons

14 Topical corticosteroid choices Palms and soles Stronger agents: eg. halobetasol ointment Back, scalp, chest arms legs Intermediate to strong agents, eg. fluocininide, triamcinolone, halobetasol ointments Face, folds, really thin photodamaged skin Milder agents, eg. 2.5% hydrocor$sone cream, fluocinolone lo$on

15 Other topical anti- inflammatories Topical Tacrolimus or Pimicrolimus Benefits: do not thin skin like steroids Can be slightly irrita$ng especially on face and groin areas Are in general of the same potency of mild topicosteroids Expensive

16 Topical therapy of the oral cavity Brush with sokest toothbrush, floss regularly Avoid toothpastes with ionic detergents like SDS or sodium lauryl sulfate Avoid alcohol containing mouthwashes Dental trays helpful to deliver steroids to gingiva Swish and spit dexamethasone Prevent yeast: nysta$n or miconazole Teeth cleaning every 3 months.

17 Wound dressings Keep wounds moist to prevent s$cking of dressings (extra vaseline can help) Avoid tape use coban or kerlex Fancy dressings like silicon based are nice, but expensive For large areas, plain petroleum gauze (not xeroform) and telfa are cheaper and work just fine

18 Wound care example part 1: Soaking the wounds: Enter tub or place clean cloth on wound with dilute chlorine solu$on or dilute mild soap soak for 20 minutes with dressings on AKer soaking gently remove dressings, being careful not to pull off adherent wound debris

19 Wound care example part 2: Assessing the wounds: Rinse wounds with plain water, pat dry and assess skin Look for progress on wound healing, measure wound areas with ruler Assess for signs of infec$on; redness, tenderness, swelling, warmth, pus Culture poten$ally infected areas with swab Pop intact blisters on the side with sterile needle, gently drain, keep blister roof intact to use as a biological wound covering

20 Wound care example part 3: Covering the wounds: Apply topical an$bio$c as well as copious amounts of petroleum jelly/vaseline Cover wounds with telfa (less occlusive) or plain petroleum gauze (more occlusive) Keep dressings in place with out using tape if possible. Kerlex or coban wraps can be quite helpful

21 Wound care special considerations: The necro$c wound Debridement can remove wound debris and help wounds heal but.. Try not to pick at wounds yourself: leave debreedment for your doctor to perform Chemical (enzyma$c) as well as physical (ie silver nitrate/ or scalpel) debreedment can be used by your doctor. The exuda$ve wound Weeping wet wounds can be treated for 1-2 days with Burrow s solu$on soaks 20 min/day

22 Thanks and any questions?