KULIAH REGULER

2015

DERMATOVENEREOLOGICAL
THERAPY

1
 Dr. Muslimin, SpKK

Department of Dermatovenereology
Faculty of Medicine
Diponegoro University Semarang

2
Dermatovenereological
therapy

There are two parts of therapy in

dermatovenereology

Dermatological therapy
Venereological therapy

3
Dermatological therapy

Therapy used in treating skin

diseases consists:

topical therapy
systemic therapy
physical modalities

4
 Dermatological therapy (2)
The objectives: General principles:
to heal/cure Listen to what patient has to say.
Look at the whole person and not
to improve/repair
only at her/his rash.
to minimize Be realistic about what is
disability possible.
to prevent Make a diagnosis before
embarking on treatment.
Explain to the patient what is
going on.
Treatment of acute rashes.

5
 Venereological therapy
Therapy used in Regimens must be efficacious, easily
to administered, simple to
treating venereal
administered, and preferably single
disease consists: dose, safe.
topical therapy Timely treatment is essensial to stop
systemic therapy transmission of disease.
surgical therapy Inadequate or self treatment or
traditional treatment resistence to
General principles: antibiotics
Based on clinical Sex partner referral for diagnosis,
syndromes laboratory councelling, and treatment to prevent
test to confirm the further transmission and reinfection.
diagnosis.

6
 Topical therapy
Appropiate topical Assessment of
therapy requires: skins present
Accurate diagnosis.
condition:
Appreciation of the
History of disease
patients skin type.
acute/chronic, stage,
Assessment of skins
localize/generalize
present condition.
Choice of the correct Skin effloresense
therapeutic agent. intact/damage
Use of the correct
vehicle.

7
 Topical therapy (2)

Advantages of topical therapy:

Direct delivery to target tissue.
Reduced systemic side effects.
The success or failure of therapy is
observed directly.

8
 Topical therapy (3)

Adverse side Percutaneus

effects: absorption:
Irritation. Penetration through
Sensitization. the stratum
Akneiform corneum
folliculitis. Metabolism of drug
Pigmentation. Transdermal
Photoallergy/photot delivery sistems
oxicity.

9
 Topical therapy (4)
Penetration through Penetration
the stratum corneum enhancers:
interfered by: urea
skin temperature
salicylic acid
hydration of stratum
dimethyl sulphoxide
corneum
skin condition propylene glycol
location
age
topical agent

10
 Topical therapy (5)

Elements of topical Amount needed for

prescription: one application of
Medication cream:
Vehicle face : 2g
Concentration arm : 3g
Amount leg : 4g
How to apply whole body : 30 g
Ointment (-10%), lotion (+50%)

11
 Topical therapy (6)

Topical agent The functions of

contains: vehicle:
Vehicle or the base to transport the active
The active ingredient to stabilize constituent
The additives: to transfer
preservatives
colourants
fragrance
emulsifyng agents &
stabilizers

12
There are 3 building blocks for all preparation

Powder

Shake lotion
Ointment paste
Drying paste

Grease Creams Liquid

Ointment Cold cream Vanishing cream

w/o o/w 13
 Topical therapy (7)
Face
Site of lesions Hairy skin
Trunk/Extremities
Genitalia
Skin fold
The choice of Generalize
vehicle Powder/shake lotion
Cream
Tincture
Liquid
Ointment
The form of vehicle
Gel
14
 Topical therapy (8)
The choice of topical vehicle

VEHICLE COMPOSITION EXAMPLE USES

Powder Solid Zinc oxide - Absorbent, protective

Talcum venetum & cooling
Calamine - Acute or subacute
Titanium dioxide inflamation
- Face, body & flexures
- CI: exudating areas
Liquid/solution Liquid Water - Medicated bath
Alcohol - Soak/wet dressings
Ether Tincture - Compress
Propylene glycol - Oily skin & hairy
areas
Shake lotion Liquid & solid Calamine lotion - Anti pruritic, anti
Burrows lotion eczematous & cooling
- Dry surfaces/mildly
oozing
- CI: exudating & hairy
areas
15
 The choice of topical vehicle (2)

Vehicle Composition Examples Uses

Cream Oil in water (O/W) Vanishing cream to make the skin became dry
~ milk Aqueous cream not suitable for the dry skin
used on acute/subacute
inflammation, hairy & the
flexure areas
Water in oil (W/O) Cold cream easier to apply than ointments,
~ butter Petroleum (vaselin) more greasier than the
Lanolin vanishing cream
Ointment Oil, little or no water Vaselin, paraffin, the best penetration & used in
lanolin chronic inflammation
CI: wet surfaces, hairy &
flexure areas
Paste Oil & solid Zinc oxide paste the best protection
Zinc oxide linament CI: exudating, hairy & flexure
Titanium dioxide areas
paste* * sun block agent
Gel Semisolid Methylcellulose, Solid or semisolid in the cold &
agar/gelatin in a become liquid on warming up
liquid As alternatives to lotions on
hairy & oily skin 16
 The active ingredients are used for topical therapy
The active ingredients The effects of therapy Uses
1. Boric acid Anti septic, astringent 3% solution compress
10% ointment, powder, shake lotion
2. Benzoic acid Anti fungal, anti septic 5-10% Whitfield ointment
3. Salisilic acid Keratoplasty 1-2% 2-4% ointment
Keratolytic > 3%
Anti bacterial, anti fungal
4. TCA solution
Caustic
5. Aluminium chloride solution
Anti fungal, anti hyperhidrotic
6. Anastesin powder
Anti pruritic
7. Gamexan, ointment, cream, lotion
Pediculoid
crotamiton,
permethrin
8. Liquor carbonate Emulsion, ointment
Anti pruritic, anti eczema
detergent
9. Resorcinol ointment
Anti bacterial, anti fungal,
keratolytic, anti pruritic, anti
eczema 17
 The active ingredients are used for topical therapy (2)

The active ingredients The effects of therapy Uses

10. Rivanol Anti septic, astringent Compress
11. Selenium sulfide Anti seborhoe, anti fungal Shampoo
12. Sulfur praecipitatum Anti pruritic, keratolytic, anti Ointment
bacterial
13. Sodium thiosulfide Anti fungal Solution
14. Talcum venetum Closer, Glider Powder
15. Zinc oxide Anti septic, tissue granulation Powder, compress
16. Eritromycin 2% Bacteriostatic Acne Ointment, gel, lotion
Clindamycin 1% Bacteriostatic Acne Ointment, gel, lotion
Gentamycin 0,1% Cream, ointemnt
Bactericyd
Mupirocyn 2% Ointment
Bactericyd, bacteriostatic
Bactericyd
Fucidic acid 2% Cream, ointment
Rosacea
Metronidazol 1% Cream, gel
Silver sulfadiazine Bactericyd burn Cream
17. Corticosteroids Anti inflammation, Ointment, cream, gel
immunosuppressant, anti
proliferation
18
 Topical therapy (9)
Soaks/Compresses

Materials
Normal saline solution
KMnO4 solution
0.1% acetic acid solution
3% boric acid solution
0.1% rivanol solution

19
 Methods for soaks
Open soaks Close soaks
application of a water employ occlusion over a
compress without compress
occlusion cause heat retention
cause cooling & drying excellent for debridement of
by evaporation wound & ulcer maceration
effective for drying applied for 1-2 hours 2-3x a
moist, oozing, acute day
inflammation skin applied 24 hour 2-3 day,
eruptions rewet the dressing 4-5x for
applied for 20 3x a day removing thick crusts

20
 The active ingredients are used for topical therapy (3)

Corticosteroids Topical side effects:

chronic, extensive
use of potent topical
steroids even under
occlusion
systemic side effects:
adrenal suppression
Cushings syndrome Reduced wound healing
growth retardation
striae & atrophy
acne
perioral dermatitis
rosacea
purpura & teangiectasia
masking effect
Glaucoma
Allergic contact dermatitis
Hypopigmentation
Hirsutism (face)
Folliculitis & miliaria

21
 The active ingredients are used for topical therapy (3)
Regional Differences in Penetration of
Glucocorticoids

Mucous membrane Upper arms & legs

Scrotum Lower arms & legs
Eyelids Dorsa of hands and
Face feet
Chest & back Palmar & plantar skin
Nails
Less penetration

22
 The active ingredients are used for topical therapy (4)
Classification of topical steroids

Group 1 Mildly Group 2 Group 3 Potent Group 4 Very

potent Moderately potent
potent
Alclometasone Betamethasone Beclomethasone dipoprionate Clobetasol
dipropionate valerate 0.025% propionate
0.05% 0.025% Betamethasone dipoprionate 0.05%
Fluocinolone Clobetasone 0.05% Diflucortolone
acetonide butyrate 0.05% Betamethasone valerate 0.1% valerate 0.3%
0.0025% Desoxymethaso Desoxymethasone 0.25% Halcinonide
Hydrocortisone ne 0.05% Diflucortolone valerate 0.1% 0.1%
0.5-2.5% Fluocinolone Fluocinolone acetonide 0.025%
acetonide Fluocinonide 0.05%
0.00625% Hydrocortisone 17-butyrate
Flurandrenolone 0.1%
0.0125% Mometasone furoate 0.1%
Triamcinolone acetonide 0.1%
23
 Systemic therapy
CLASSIFICATION EXAMPLES DOSES
1. Antibacterial Penicilline V A: 250-500 mg (400,000-800,000units)/6-8 hours
C: 15-50 mg/kg/d in 3 or 4 divided doses
Aqueous penicillin G A: 5 million units or more
C: 50,000-100,000 unit/kg/g
Penicillin G procaine A: 600,000-1 million unit or more daily
C: 25,000-50,000 units/kg/d every 12 hours
Penicillin G benzathine A: 1.2 million units
C: 27 kg 900,000 units
C: < 27 kg 300,000-600,000 units
Ampicillin A: 250-500 mg/6 hours
C: < 20 kg 50 mg/kg/d every 6 hours
Amoxicillin A: 0.5 g/8 hours
C: < 20 kg 50 mg/kg/d every 8 hours
Ampicillin + clavulanic A: 250 500 mg/8 hours
acid C: 20 mg/kg/d every 8 hours
Eritromisin A: 250-500 mg/6 hours
C: 30-50 mg/kg/d every 6 hours
24
 Systemic therapy (2)
1. Antibacterial 1st generation
sephalosporins
Sefalexin A: 1-4 g/d 4 divided doses
C: 25-50 mg/kg/d 4 divided doses
Sefadroxil A: 1-2 g/d 2 divided doses
C: 30 mg/kg/d 2 divided doses
Clindamycin A: 150-300 mg/d
C: 8-16 mg/kg every 6 hours
Tetracycline A: 1-2 g/d 2 or 4 divided doses
C: < 8 years 25-50 mg/kg/d
Doxycycline
A: 1st d 100 mg/12 hours 100 mg/d
Minocycline C: > 8 years 2 mg/lb/d every 12 hours
A: 1st d 100 mg/12 hours 100 mg/d
C: > 8 years 1st d 4mg/kg/d every 12
hours 2 mg/kg/d every 12 hours
Trimethoprim- A: 160/80 every 12 hours
Sulfamethoxazole
C: T 8 mg/kg/d, S 40 mg/kg/d every
12 hours
Dapson
A: 1st dose 50 mg/d 100-30025mg/d
C: 1st dose 0.5 mg/kg/d
 Systemic therapy (3)

3. Anti histamine Sedation

CTM
Oxatomide 3 x 4-12 mg/d
Cyproheptadine
Non sedation
Terfenadin 2 x 60 mg/d
Astemizol 10 mg/d
Loratadine 10 mg/d

26
 Systemic therapy (3)

Working mechanism: Anti proliferative

Anti Inflamation
Immunosuppressant

27
Systemic therapy (4)

1. Kapsomers kapsid
2. Asam nukleat
3. Nukleokapsid
4. Peplomer
5. Envelop
6. Matriks protein
7. Kapsomers kapsid
8. Asam nukleat
9. Nukleokapsid
28
Systemic therapy (5)

29
 Terapi sistemik (5)
Antihistamin

Cara kerja: dengan menghambat reseptor

H1 and H2 pada sel target.
Interaksi histamin & reseptor jaringan H1:
Permeabilitas vena meningkat
Kontraksi otot polos
Resistensi jalan nafas meningkat
Kemotaksis eosinofil & netrofil meningkat
Stimulasi mukosa hidung

30
 Antihistamin (2)

Interaksi histamin & reseptor jaringan H2:

Permeabilitas vena meningkat
Cardiac rate meningkat
Kontraksi otot jantung meningkat
Sekresi asam lambung meningkat
Stimulasi CD8 & limfosit
Peningkatan produksi mukosa jalan nafas
Inhibisi kemotaksis netrofil & eosinofil

31
 Antihistamin (3)

Antihistamin H1
Antihistamin tradisional/klasik/tipe H1
generasi I
Antihistamin tipe H1 generasi II/sedasi
rendah

32
 Antihistamin tradisional/klasik/tipe
H1 generasi I

Efek: Klasifikasi:
Alkilamine = chlorpheniramine
antihistamin
maleate/chlortrimethone maleate
sedasi Aminoalkyl ether =
antikolinergik diphenhidramine HCl
aktivitas antiemetik Ethylenediamine =
Tripelennamine HCl
efek anti motion
Phenotiazine = Prometazine HCl
sickness
Piperidine = Siproheptadine HCl
Piperazine = Hydroxyzine HCl

33
Antihistamin tipe H1 generasi II/sedasi
rendah

Efek sedasi & Macam:

antikolinergik lebih Terfenadine
rendah Astemizole
Cetirizine
Loratadine
Acrivastine
Oxatomide
Fexofenadine
Desloratadine

34
 Antihistamin (4)

Antihistamine H2 Obat lain dengan

kurang lipofilik aktivitas
efek terhadap antihistamin:
susunan saraf antidepresan
pusat lebih rendah trisiklik
jenis: ketotifen
cimetidine
Ranitidine
Famotidine
Nizatadine

35
 Kortikosteroid
Perbandingan potensi

Obat Dosis
setara
Kortison 25
Kortisol 20
Prednison/predinosolon 5
Metil prednisolon/triamsinolon 4
Betametason 0,60
Deksametason 0,75

36
 Kortikosteroid (2)

Indikasi Kontrindikasi:
mutlak: pemfigus, lupus absolut: herpes
eritematosus sistemik, simpleks, TBC tidak
nekrolisis epidermal diterapi
toksik, sindrom Steven
Johnson
relatif: ulkus
peptikum, infeksi,
relatif: pemfigoid bulosa,
eritema nodusum, lupus
DM, hipertensi,
eritematosus diskoid, kehamilan
eritroderma, eritema
multiforme

37
 Kortikosteroid (3)
Komplikasi: DM
Hipertensi limfositopenia,
Perubahan mood, psikosis, monositopenia,
pseudotumor netrofilia
Supresi aksis hipotalamus- infeksi oportunistik
pituitari-adrenal, osteoporosis, nekrosis
hirsutism, menstruasi aseptik kepala femur
ireguler, kegemukan, & humerus, miopati
moon face, buffalo hamp glaukoma & katarak
ulkus peptikum,
retensi Na & cairan,
pankreatitis
hipokalemia alkalosis

38
 Terapi nutrisi
Tujuan: memberi Defisiensi vitamin:
keseimbangan kheilitis, dermatitis
anabolisme-katabolisme seboroik (vit
tergantung kondisi B2=riboflavin)
seseorang stomatitis angularis
Komponen: (vit B6=piridoksin)
protein pelagra (niasin) 4D:
karbohidrat dermatitis, diare,
lemak dimensia, death
vitamin & mineral

39
 Terapi nutrisi (2)

Defisiensi mineral: Bentuk:

akrodermatitis diet biasa
enteropatika (Zn) diet padat, lunak,
dermatitis saring, bubur
diare diet cair
alopesia diet khusus: TKTP,
Karsinoma Sel rendah garam, bebas
Basal (Se) lemak, bebas gluten
total parenteral
nutrisi (TPT)

40
 Physical methods of therapy

Surgical
Environmental climate
therapy
Dead sea psoriasis
Sea coast atopics Cutting Electrosurgery Cryotherapy

Wave

Phototerapy Ionizing radiation (X ray)

UVA UVB Skin kancers Benign conditions

(rarely & great caution)
PUVA for psoriasis Psoriasis Kaposis sarcoma
Acne
Nummular dermatitis Lymphoma
Keloids
Parapsoriasis
Hemangiomas
Pityriasis rosea
Acne 41
 Cutaneous surgery

Cold steel surgery: Cryosurgery

elliptic excission, Chemical peel
skin graft, flap,
biopsy, MOHS, Liposuction
blepharoplasty, scalp LASER
reduction & hair
transplantation Soft tissue
Electrosurgery augmentation
Dermabrasion
Curettage

42
 Bedah kulit (2)
Bedah
listrik/electrosurgery
suatu tindakan bedah
dengan menggunakan alat
listrik yang
membangkitkan aliran
listrik terkontrol destruksi
jaringan yang selektif
macam: elektrodesikasi,
elektrofulgurasi,
elektrokoagulasi,
elektroseksi, elektrolisis
Bedah kimia (chemical
peeling)
suatu tindakan bedah dengan
mengoleskan bahan kimia
perubahan anatomi;
makro/mikro lesi pada
epidermis/dermis
macam:
superfisial: TCA 10%, as.
Retinoat, AHA
medium: TCA 35-50%, AHA
deep: TCA 70%, fenol jenuh 88%
43
 Bedah kulit (3)
Bedah beku (cryosurgery) Dermabrasi
suatu tindakan bedah suatu tindakan
dengan menggunakan bedah untuk
bahan kriogen
mengelupaskan kulit
membekukan jaringan
nekrosis
selapis demi selapis
dengan
macam:
menggunakan alat
nitrogen cair (-1960C)
N2O (-89,50C)
dermabrader
CO2 (-78,50C) macam:
Freon 22, 12 (-410C, -600C) sikat kawat
diamond fraise

44
 Bedah kulit (4)
Laser: Light Sifat:
Amplification by monokromatis,
Stimulating Emission of kolomasi, koheren
Radiation spektrum optik
Prinsip: amplifikasi cahaya (gelombang kasat
mata-infra merah)
Tujuan:
memotong Respon jaringan:
koagulasi refleksikan
neovaskularisasi dibiaskan
proliferasi fibroblas ditransmisikan
epitelisasi
diserap

45
 Laser (2)
Macam: Berpulsa dengan energi
Kontinu (CW) tinggi
Argon: adenoma sebasea,
telangiektasis, lesi jinak
Laser Dye: nevus araneus,
berpigmen, granuloma rosasea
piogenikum Laser Ruby: lesi jinak
CW Nd YAG: berpigmen
CW CO2: veruka vulgaris,
kondiloma akuminata, keloid,
Laser Q-Switched Ruby: tato
moluskum kontagiosum, tumor Laser Q-Switched Alexandrite
apendik kulit, psoriasis, tato,
Laser Q-Switched Nd YAG
nevus epidermal
Laser Copper Vapox
Laser KTP

46
A view of Marburg, Germany 47