Eczema(Dermatitis)

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Drugs that used in the treatment of Eczema Prepared by : Peshawa Akram & Ramazan HamaSalih College of pharmacy Fourth class Sulaimaniyah University

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What is eczema? Come from the Greek name for boiling, a reference to the tiny vesicles (bubbles) that are commonly seen in the early acute stage of the disease. Eczema is a general term for many types of skin inflammation (dermatitis). The most common form of eczema is atopic dermatitis (sometimes these two terms are used interchangeably). However, there are many different forms of eczema.

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Eczema is a non-contagious skin condition that causes severe itching inflammation, and sometimes pain at the site of a breakout. Complications associated with eczema include infection ( Staphylococcus aureus , herpes simplex, fungal infections) and psychosocial problems (behavioural problems, impaired performance due to lack of sleep, poor self confidence) Currently a cure for eczema is unavailable; however, many types of effective eczema treatment do exist. Treatments are usually based on the type of eczema that is present, the severity of the condition, a patient's medical history, and the outcome of any previously tried treatments.

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Clinical Types Acute Eczema : Erythema, swelling, vesicles & oozing  C rusting. Chronic Eczema : Lichenification, excoriations & hyper-or hypopigmentation. Subacute Eczema : Features of both.

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Main Types of Eczema : I) Contact Dermatitis. a. Primary Irritant Dermatitis. b. Allergic Contact Dermatitis. II) Atopic Eczema.

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I) Contact Dermatitis a. Primary Irritant Dermatitis Any individual; previous contact is not required. Soon after exposure. Direct damage by strong acids or alkalis or cumulative damage by mild irritants. Soaps, detergents, vegetables or solvents. housewives, dishwashers, nurses & surgeons.

Irritant CD: 

Irritant CD

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b. Allergic Contact Dermatitis Immunological reaction that develops in genetically susceptible individuals after exposure to allergen. Presentation of allergen by LCs to T-cells  Re- exposure to same antigen  L esions develop in sensitized individuals at sites of contact Nickel, chromate, rubber, resins, glues, cleansers, cosmetics & medications (sulfa powder, penicillin ointment & local antihistamines).

Allergic CD: 

Allergic CD

Allergic CD to Airborne Allergen: 

Allergic CD to Airborne Allergen

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II) Atopic Eczema Genetic hereditary predisposition to develop hay fever, bronchial asthma, allergic rhinitis or atopic dermatitis. AD is a common chronic relapsing inflammatory skin disease characterized by: Intense itching. Dry skin. Inflammation. Exudation. Physical & emotional distress for pts. and their families.

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Phases : a. Infantile Phase : Infantile Eczema 2 months-2 years. Acute eczema of cheeks & dorsa of hands or may involve whole body. b. Childhood Phase : 4-12 years. Groups of itchy papules involve the flexures particularly the antecubital & popliteal fossae & sides of the neck. c. Adult Phase : Over 12 years. Similar to childhood type + hyperpigmentation & lichenification.

Infantile AD: 

Infantile AD

Childhood AD: 

Childhood AD

Adult AD: 

Adult AD

AD in flexures: 

AD in flexures

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Xerotic eczema • Seborrhoeic dermatitis • Dyshidrosis • Discoid eczema • Venous eczema • Dermatitis herpetiformis • Neurodermatitis • Autoeczematization • Other Types of Eczema

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Treatment of Eczema a) Acute Eczema : I) Local Therapy : Drying antiseptic lotions (aluminum acetate, KMnO 4 1/8000 or normal saline). Corticosteroid creams. II) Systemic Therapy : Antihistamines. Corticosteroids. b) Chronic Eczema : Local : Corticosteroid ointments. Systemic : Corticosteroids.

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Treatment: There are many different ways to treat eczema. The ways to treat eczema are a combination of treatment and preventive measures. The methods for eczema remediation are: • Moisturizing • Itch relief • Corticosteroids • Immuno-modulators • Antibiotics • Managing mental and emotional state • Light therapy • Diet • Traditional remedies • Oral Retinoid • Anti-Fungal agents • Immunosuppressants

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Moisturizers- Moisturizers or emollients including bath oils, soap substitutes can be applied to the dermatitis as frequently as required to relieve itching, scaling and dryness. Emollients should also be used on the unaffected skin to reduce dryness. Emollient therapy helps to restore one of the skin's most important functions, which is to form a barrier to prevent bacteria and viruses getting into the body and therefore help to prevent a rash becoming infected. Emollients are safe and rarely cause an allergic reaction. Occasionally, products with lanolin may cause a reaction. Ideally, moisturizers should be applied three to four times a day. Apply in a gentle downward motion in the direction of hair growth to prevent accumulation of cream around the hair follicle (this can cause infection of the follicle).e.g. Vaseline

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Topical Immunomodulators(calcineurin ihibitors)- Topical immunomodulators (TIMs) are a new type of non-steroidal anti-inflammatory drug for the treatment of eczema. Mild burning sensations have been reported when applying TIMs. In general, however, TIMs have fewer side effects than corticosteroids. TIMs are topical drugs that modulate the immune response (alter the reactivity of cell-surface immunologic responsiveness). Studies have shown that this class of drugs will improve or completely clear eczema in more than 80 percent of treated patients, with a side-effect profile comparable with topical steroids.e.g. Tacrolimus ointment ( 0.03% & 0.1%). & Pimecrolimus cream ( 1%). Apply a thin layer of tacrolimus ointment to affected skin areas twice daily rub in gently and completely. Tratment should be continued for one week after clearing sign and symptoms. Shold not be used with occlusive dressing.

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A major advantage of calcineurin inhibitors is that calcineurin isn’t required for collagen synthesis  No atrophy occurs with them, regardless of the route of administration. Skin penetration Target Mechanism Effect Skin atrophy Pimecrolimus & Tacrolimus Cyclosporin Hydrocortisone Binds FKBP & - calcineurin No Calcineurin(-) TNF  , IL2, 3, 4 & 5 + _ + Binds cyclophilin & - calcineurin No Glucocorticoid rec. - TNF  , IL1, 2, 6 & collagen expression Binds GC receptor  transcription factor Yes -

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Corticosteroids- according to their duration of action are classified into: Short to medium acting: e.g.Hydrocortisone butyrate 0.1% cream apply thinly 1-2 times daily. Intermediate acting: e.g. Triamcinolone 0.1% ointment apply thinly 1-2 times daily. Long acting : e.g. Betamethasone (as valerate) 0.1% cream apply thinly 1-2 times daily. Severe cases may be treated with oral corticosteroids. The dose is higher than with hydrocortisone cream, and the chance of having side effects is greater. Corticosteroids have a long list of side effects. They should not be used for extended periods of time. clobetasol propionate 0.05 cream: is a super high potency corticosteroids. has anti-inflammatory,antipruritic and vasoconstriction properties. It is very effective and widely used. Dose: treatment should be limited to 2 consecutive weeks and amounts greater than 50mg .

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Oral corticosteroids Side effects of oral corticosteroids that are used on a short-term basis include: an increase in appetite, weight gain, insomnia, fluid retention mood changes, such as feeling irritable, or anxious. Side effects of oral corticosteroids used on a long-term basis (longer than three months) include: osteoporosis (fragile bones), hypertension (high blood pressure), diabetes, weight gain, increased vulnerability to infection, cataracts and glaucoma (eye disorders), thinning of the skin, bruising easily muscle weakness.

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Antibiotics- Damaged skin is susceptible to bacterial infection. People living with eczema tend to develop more skin infections than others. Antibiotics, topical or oral, may be required to treat eczema. Oral eczema treatments are not used as frequently as topical therapies. However, oral medication may be required to treat complications, or especially severe cases of eczema. Many different types of antibiotics are available. Consult your medical professional to find out about the side effects of antibiotics prescribed to you. Oral or topical antibiotics reduce the surface bacterial infections that may accompany flares of Atopic dermatitis. In the treatment of stasis dermatitis, oral antibiotics are useful when cellulitis is present; topical antibiotics are useless and often cause contact dermatitis.e.g. clindamycin t opical solution , gentamicin – topical ointment .

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Clindamycin dosage and application: Clindamycin Topcal solution(50ml) Each ml contains : 10 mg of clindamycin Squeeze few drops of the solution on a small piece of cotton or face pad and apply to affected area twice daily after cleaning the skin with soap and rinsing well with water. Gentamicin Sulfate Cream Each gram contains: 3mg of gentamicin supplied in 30 gram tubes, a small amount of gentamicin sulfate cream should be applied gently to the lesions three or four times daily . If necessary this may be covered with a dressing.

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Antifungal agents - Indicated for suspected candidiasis or proven candidal infection by a medical practitioner. Commonly used topical antifungal agents are nystatin cream or ointment and econazole nitrate cream . Dosage and Administeration: Nystatin cream-ointment. Each gram contain: 100,000 units Nystatin. Supply in atube of 15 gm Apply 2-4 times daily .

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Antihistamines- Antihistamines are occasionally prescribed to control itching and help the eczema sufferer sleep. Their effectiveness as anti-itch medication is limited, however, as histamines are not important components of eczema-associated itching. Antihistamines can make you very drowsy. Driving while on antihistamines is not recommended. sedating antihistamines such as promethazine (Phenergan) diphenhydramine (Benadry) are more effective at relieving itch than the newer, nonsedating antihistamines. Dosage and Administration: Diphenhydramine 25-50 mg Two times daily or at night.

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Phototherapy- involves the use of light to treat a medical condition. Ultraviolet light therapy improves eczema symptoms in some people. Phototherapy may only use ultraviolet light, or may combine the use of ultraviolet light with psoralen , a drug that increases light sensitivity. While ultraviolet rays occur naturally in sunlight, excessive sun exposure causes sunburn, which can make symptoms worsen. Phototherapy uses carefully measured amounts of ultraviolet light; a safety measure that cannot be duplicated by simple exposure to the sun. A side effect of this is photo damage or increased risk of skin cancers.

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Coal tar- has been used to treat the itching and inflammation caused by skin conditions for hundreds of years. The tar contains chemicals that soothe the skin. Coal tar is very sticky and messy. It can cause sun sensitivity, and may irritate acute dermatitis. Retinoid- is licensed for the treatment of sever chronic hand eczema refractory to potent topical corticosteroids, patient with hyperkeratotic features are more respond to Oral Alitretinoin . This drug only prescribed by or under the supervision of dermatologist . Alitretinoin is teratogenic and must not given to pregnant women.

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Dosage and Administration: Alitretinoin10 mg 3 times daily orally, then reduced to once daily if not tolerated. In Patient with CVD and Diabetes should be used once daily initially. Duration of treatment:12-24 weeks discontinue if no response after 12 weeks. Isotretinoin gel 0.05% Apply topically 1-2 times daily.

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Immunosuppressants- When eczema is severe and does not respond to other forms of treatment, immunosuppressant drugs are sometimes prescribed. These dampen the immune system and can result in dramatic improvements to the patient's eczema. However, immunosuppressants can cause side effects on the body. As such, patients must undergo regular blood tests and be closely monitored by a doctor. the most commonly used immunosuppressants for eczema are ciclosporin , azathioprine and methotrexate . These drugs were generally designed for other medical conditions but have been found to be effective against eczema.

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Dosage and Administration: Methotrexate 2.5mg tablet. Should be taken 1 hr before or 1-2 hrs after meal. Generally 7.5-16 mg in a week not exceed 20 mg. If not effective after 8 weeks with the maximum dose should discontinued. Side effects: Bone marrow depression Hepatotoxic Hair loss Skin rash Mouth sore

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Summary Atopic eczema has a strong familial component and is closely associated with other atopic diseases and environmental factors in susceptible individuals. Emollients and barriers creams are the mainstay of treatment and should be used even when no eczema is present. Topical corticosteroids should be used sparingly and for as short a time as possible. Once the flare has been controlled maintenance treatment can be instigated using the corticosteroid for 2 consecutive days per week. Topical corticosteroids combined with antimicrobials are no more effective than topical corticosteroids alone and are not recommended for first-line use in infected eczema. Topical calcineurins – tacrolimus and pimecrolimus – should not be used first-line but may be useful for moderate to severe eczema unresponsive to topical corticosteroids in children aged over 2 years, and in adults.

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Refrences: 1.Williams HC . Epidemiology of atopic dermatitis. Clin Exp Dermatol2000 ; 25 : 522 –9. 2.Herd RM , Tidman MJ, Prescott RJ, et al. The cost of atopic dermatitis. Br J Dermatol . 3.Hoare C , Li Wan Po A, Williams HC. Systematic review of treatments for atopic eczema. HTA Monographs2000 ; 4 (37) http://www.hta.nhsweb.nhs.uk/execsumm/summ437.htm . 4.Williams HC , Burney PG, Hay RJ, et al. The UK working party’s diagnostic criteria for atopic dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol 1994 ; 131 : 383 –96. 5.Henry PM , Williams HC, Bingham EA. Fortnightly review: management of atopic eczema. BMJ1995 ; 310 : 843 –7. 6.National Institute for Clinical Excellence . Frequency of application of topical corticosteroids for atopic eczema. http://www.nice.org.uk/pdf/FAD_atopic_eczema.pdf (accessed 9 June 2004). 7.Ezcemacanada.com. (nd). Treating eczema . Retrieved June 19, 2002, from www.eczemacanada.ca/treating/treating.htm. 8.National Eczema Association for Science and Education . (nd). Living with eczema . Retrieved June 19, 2002, from www.nationaleczema.org/patiented.html . 9.BNF 10.http://en.wikipedia.org/wiki/eczema

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