cream) is an excellent preparation and can control soft tissue infection
alone in mild cases or combined with systemic antibiotics.
Fucidin ointment and
cream and ointment) is also an effective topical antibacterial
Different types of
antibiotics may be used for treatment of soft tissue infections. This
usually depends on the culture and sensitivity results. Flucoxacillin are
commonly used and for those allergic to Penicillin, Erythrocin or (Zithromax) can be used. Aminoglycosides and B
lactams, other new
antibiotics can be used in severe infections.
indicated in Staphylococcus aureus, Streptococcal, Corynebacterium
diphtheria and Entemeba histolytica.
Polymyxin B sulfates
vials: used in Pseudomonas aeruginosa, E. coli and Staph aureus
Fucidin vials and topical
preparations are also effective but they are expensive medications.
Oral Beta-Lactam Antibiotics
antibiotics include penicillins, cephalosporins and related compounds. As
a group, these drugs are active against many gram-positive, gram-negative
and anaerobic organisms.
Indications for Oral Beta-Lactam Antibiotics
Infection Preferred drug(s)
Skin and soft tissue infections First-generation cephalosporins,
Otitis media Amoxicillin
, cloxacillin (Tegopen), dicloxacillin (Dynapen)
Streptococcal pharyngitis Penicillin V
Sinusitis Amoxicillin, trimethoprim- sulfamethoxazole
Animal and human bites Amoxicillin-clavulanate
Bacterial endocarditis Amoxicillin
Pneumonia Macrolide antibiotics,
Bronchitis Doxycycline, trimethoprim- sulfamethoxazole,
Urinary tract infection Quinolone antibiotics, trimethoprim-
cephalosporins, doxycycline, nitrofurantoin(Furadantin)
Differences among B -Lactams
1- First-generation agents
Cefadroxil (Duricef) Kinetics allow once-daily or twice-daily dosing;
Cephalexin (Keflex) well
tolerated; good pharmacokinetics
Cephradine (Velosef) Similar properties as cephalexin, but not as
Structurally, the cephalosporins have a beta-lactam ring
(which they share with all penicillins) and a thiazolidine ring. These
drugs are divided into generations based on their spectrum of
Although the cephalosporins are often thought of as new
and improved derivatives of the penicillins, they were actually discovered
as naturally occurring substances separate from the penicillins. Brotzu
noted the periodic clearing of microorganisms from sea water near a sewage
outlet and isolated a substance with antibacterial properties that was
produced by the fungus Cephalosporium acremonium. After further
study and modification of this substance, the first commercially available
cephalosporin (cephalothin) was introduced in 1962.
The effectiveness of an individual cephalosporin depends
on its ability to overcome the mechanisms of resistance that bacteria have
developed to combat beta-lactam antibiotics.
2- Second-generation agents
Second-generation agents are labeled for treatment of urinary tract infections.
Cefaclor (Ceclor, May cause serum sickness-like syndrome
Ceclor CD) absorption
decreased by food.
Cefprozil (Cefzil) Absorption is not affected by food
Cefuroxime axetil Parenteral form available (cefuroxime sodium
(Ceftin) [Zinacef]); absorption enhanced by food.
3- Third-generation cephlosporins
Cefixime (Suprax) : Oral suspension better absorbed than tablets
therefore,these are less likely to cause diarrhea.
Cefpodoxime (Vantin) For treatment of Pneumococcus and methicillin-sensitive Staphylococcus aureus
Ceftibuten (Cedax) Poor efficacy against Streptococcus pneumoniae,
which limits its clinical usefulness
The first-generation cephalosporins include cefadroxil (Duricef),
cephalexin (Keflex) and cephradine (Velosef), which are similar drugs.
They are all well absorbed, even in the presence of food, and they achieve
high urinary concentrations. Dosages of these agents should be decreased
in patients with severe renal failure.
Cefadroxil, cephalexin and cephradine are effective in
the treatment of skin and soft tissue infections caused by Streptococcus
species and methicillin-sensitive S. aureus. Many physicians consider
these drugs to be preferable to the orally administered antistaphylococcal
penicillins (cloxacillin and dicloxacillin) because they are associated
with a lower incidence of gastrointestinal side effects and have a better
The good urinary concentrations of first-generation
cephalosporins make them second-line agents (after quinolone antibiotics
and trimethoprim-sulfamethoxazole [Bactrim, Septra]) for the treatment of
urinary tract infections caused by susceptible gram-negative organisms,
although they are not effective against Pseudomonas or Enterococcus
species. Their relative safety in pregnancy makes them a reasonable
alternative for the treatment of urinary tract infections in pregnant
Cefadroxil, cephalexin and cephradine may be used to
treat streptococcal pharyngitis in patients with delayed-reaction
penicillin allergy. Indications for these agents in the treatment of other
upper respiratory tract infections (bronchitis, pneumonia, otitis media
and sinusitis) are unclear. First-generation cephalosporins are generally
not effective against H. influenzae, M. catarrhalis and other
gram-negative beta-lactamase-producing organisms.
SECOND-GENERATION CEPHALOSPORINS AND CARBACEPHEM
The second-generation cephalosporins include cefaclor (Ceclor),
cefprozil (Cefzil) and cefuroxime axetil (Ceftin). Compared with
first-generation cephalosporins, these drugs have improved activity
against common beta-lactamase-producing respiratory pathogens such as H.
influenzae and M. catarrhalis.
As a result of their widespread use, bacterial
resistance to second-generation cephalosporins has greatly increased.1 In
addition, second-generation cephalosporins are generally much more
expensive than first-generation agents or penicillins.
Structurally, loracarbef (Lorabid) is a carbacephem
rather than a cephalosporin. However, loracarbef is so similar to cefaclor
in spectrum of antimicrobial activity and side effects that it is usually
listed as a second-generation cephalosporin.
The second-generation cephalosporins are heavily
promoted for their coverage of relatively resistant organisms (e.g., H.
influenzae) that cause respiratory tract infections such as otitis media,
bronchitis and sinusitis. Much less expensive agents, such as
trimethoprim-sulfamethoxazole, may be preferred. Cefuroxime axetil may be
considered a second-line agent for the treatment of urinary tract
Third-generation cephalosporins include cefdinir (Omnicef),
cefixime (Suprax), cefpodoxime (Vantin) and ceftibuten (Cedax). Secondary
to better resistance to some plasmid-mediated beta lactamases, the
third-generation agents demonstrate somewhat expanded coverage of
gram-negative organisms compared with first- and second-generation
cephalosporins. They have the advantage of convenient dosing schedules,
but they are expensive.
The third-generation agents have variable loss of
efficacy against gram-positive organisms, particularly Streptococcus
pneumoniae and Staphylococcus species. Lack of gram-positive coverage
limits the usefulness of ceftibuten in the treatment of otitis media and
respiratory tract infections, except perhaps as a second-line agent when
antibiotics with better gram-positive coverage have failed. Poor
coverage of Staphylococcus species precludes the use of cefixime and
ceftibuten in the treatment of skin and soft tissue infections.
and cefdinir retain good coverage of Staphylococcus and Streptococcus
species. Thus, they are probably the more useful third-generation
Practical Clinical Applications
Because of all the drugs that are available to treat
common infections in the primary care setting, choosing an antibiotic can
be difficult. The decision is individualized, based on the cost of
treatment and the patient's financial resources, formulary restrictions
from insurance companies, the availability of drug samples in the
physician's office, the likelihood of a resistant organism, the severity
of the infection, comorbid conditions in the patient and the risk of drug
The antibiotic properties of Penicillium mold were first
noted by Fleming in 1928. Penicillins first became available
commercially in the mid-1940s, and they remain one of the most important
classes of antimicrobial agents.
The orally administered penicillins include natural
penicillins, penicillinase-resistant penicillins, aminopenicillins, beta-lactam-
beta-lactamase inhibitor combinations and antipseudomonal penicillins.
Penicillin V, the potassium salt of phenoxymethyl
penicillin, is well absorbed orally, and peak serum levels are achieved
within 60 minutes. Penicillin G is not as well absorbed and is therefore
less useful for oral therapy. Penicillin V is indicated for the treatment
of mild gram-positive infections of the throat, respiratory tract and soft
tissues. This natural penicillin is still the drug of choice for the
treatment of group A streptococcal pharyngitis in patients who are not
allergic to penicillin. Penicillin V is also useful for anaerobic
coverage in patients with oral cavity infections.
Penicillinase-resistant penicillins were developed
because of the increasing resistance of staphylococci to natural
penicillins. These chemically modified penicillins have a side chain that
inhibits the action of penicillinase.
The penicillinase-resistant penicillins are active
against Streptococcus and Staphylococcus species, but they are not active
against methicillin-resistant S. aureus, which is becoming an increasingly
common organism. These drugs also do not have activity against
Penicillinase-resistant penicillins are primarily
indicated for the treatment of skin and soft tissue infections.
Cloxacillin (Tegopen) and dicloxacillin (Dynapen)
have be.tter absorption. These drugs should
be taken one to two hours before meals.
Nafcillin (Unipen) and oxacillin (Prostaphlin) are
in the form of oral preparations, having poor absorbtion.
The aminopenicillins were the first penicillins
discovered to be active against gram-negative rods such as E. coli and H.
Amoxicillin is more completely absorbed than ampicillin.
As a result, serum amoxicillin levels are twice as high as serum
ampicillin levels. Because a smaller amount of amoxicillin remains in the
intestinal tract, patients treated with this agent have less diarrhea than
those treated with ampicillin. However, the more complete absorption of
amoxicillin makes the drug less effective than ampicillin in the treatment
of Shigella enteritis. Otherwise, amoxicillin and ampicillin have almost
the same spectrum of antimicrobial activity.
Bacampicillin (Spectrobid) does not have any significant
advantages over the other aminopenicillins, and it is more expensive.
Orally administered amoxicillin and ampicillin are used
primarily to treat mild infections such as otitis media, sinusitis,
bronchitis, urinary tract infections and bacterial diarrhea. Amoxicillin
is the agent of choice for the treatment of otitis media. ) Because H.
influenzae and E. coli are becoming increasingly resistant to the
aminopenicillins, these drugs are becoming somewhat less effective
BETA-LACTAM-BETA-LACTAMASE INHIBITOR COMBINATION
The only penicillin available in an oral combination
with a beta-lactamase inhibitor is amoxicillin-clavulanate. This
combination drug provides increased antimicrobial coverage of beta-lactamase-producing
strains of S. aureus, H. influenzae, N. gonorrhoeae, E. coli, M.
catarrhalis and Proteus, Klebsiella and Bacteroides species. It has little
activity against Pseudomonas or methicillin-resistant S. aureus.
In clinical situations in which there is increased
development of beta-lactamase- producing organisms,
amoxicillin-clavulanate may be the first choice for the treatment of
otitis media, sinusitis, bronchitis, urinary tract infections and skin and
soft tissue infections. Because of its anaerobic coverage,
amoxicillin-clavulanate is an excellent drug for treating infections
caused by human and animal bites.
Common side effects include gastrointestinal distress,
diarrhea (alleviated by taking the drug with food or water), rashes and
Carbenicillin (Geocillin) is the only available orally
administered antipseudomonal penicillin. This drug has excellent oral
absorption. However, it is metabolized so rapidly that serum levels remain
low, which markedly limits its clinical usefulness.
DRESSINGS USED IN
Wet dressing is used as a
soothing and cooling antiseptic on dry inflamed skin lesions as in oozing
Potassium permanganate is
an effective and widely used dressing. Potassium permanganate five grains
added to 3 qt make a solution of 1: 9000 concentration is an optimum wet
dressing to dry oozing lesions as in acute dermatitis.
Method of use:
The mother should have an
idea how to use it. Clean gauze can be dipped in the solution and used
gently to clean either compress gently the soaked gauze or passing it
along the lesion. This can be repeated according to the need.
Boric acid solutions
should not be used in infants and young children for the possibility of
Burrows solution alone or
in combination with oatmeal Bur-Veen powders (Fougera) is also used as wet
Powders are used to the
intertriginous, and interdigital areas. It is used to dry sweat after
Zinc oxide, starch,
talcum and aluminium chloride (for hyperhidrosis) are the commonest
powders used in infants and young children.
Baths are used to remove
crusts, scales and accumulated dirts and exudations on the skin surface.
Tap water and soapless soap can be used followed by application of the
appropriate topical medication.
Common types of baths are
Starch Baths - this
can be prepared by mixing cornstarch with water and boiled while
stirring for a while to make a thin paste and a gelatinous mixture.
Indications and actions
Dryness of oozing
lesions such as weeping eczema.
Urticaria and other
Aveno Baths - have
the same effect as starch baths.
Oatmeal Baths -
precooked and packed oatmeal is more convenient than Aveno bath and
easier to use.
Bran Baths - used in
generalized irritable skin diseases as in chronic urticaria.
Tar baths - are used
in generalized psoriasis. This should be used with care in young age
Bicarbonate baths -
used in urticaria, dermatitis herpetiformis and psoriasis.
Borax baths - used
in seborrheic dermatitis and urticaria.
preparations such as hydrogen peroxide, potassium permanganate solutions
are the commonest used to clean wet oozing skin surface.
Hair fall formulas
Different products are
available in the market for rubbing and topical application to the
gel and spray.
(Meladenin lotion, Oxysoralenes lotion).
Some natives use
irritant substances to the area such as garlic, rubbed vigorously to the
affected scalp area. This may cause severe irritation and in some cases
hair begins to regrow in the bald area.
Formula which may help
hair to regrow:
Different ingredients may
be added to this formula:
Minoxidil (Regain) may
be added which may give better effect.
Salicylic acid 2% may
be added in the presence of dandruff.
Oil of Cade or crude
coal tar can be added to treat cases of psoriasis and seborrheic
Perfume may be added
to be more acceptable especially for females.
available in the market for treatment of hair fall are either in the form
of lotion, spray or ampoules for local use to the scalp. Some of these
contain placenta preparations, vitamin E and many other products. The
physician can diagnose and give the appropriate type.
Detergents are cleansing
agents used to clean the skin surface from debris, crusts and scales.
These include ordinary soaps, liquids or the soapless types.
Details of detergents and
skin bathing are discussed in other chapters.
Soaps and Shampoos
Numerous types of soaps
and shampoos are available in the market.
Soap is a cleansing
agent, which is of great value from the sanitary point of view, but at the
same time, it may do great harm to the skin if the strong allergenic types
were used especially in young babies.
Soaps have an alkaline
(PH 9-11) composed of sodium or potassium salts, which emulsifies fats
with water to remove dirt and debris. The problem of certain types of
soaps is not only the high alkaline contents, but also the additives as
antiseptics, coloring materials, perfumes and others. These may lead to
dryness, cracking of the skin surface and allergic contact dermatitis.
Dryness and eczematization of the skin may result from excessive washing
with soaps that may affect the fatty covering of the skin
Soaps are available in
solid or liquid forms.
Soaps - contains hexachlorophene, iodine, salicylamides.
(Phisohex, Safeguard and Cidal)
Soaps - contains tar (Poly tar Soap).
Soaps (used for dry skin and in dry areas) - contains
increased fat or oil. (Oileatum, Surgras soap).
Soaps - Soap-like preparations (PH around 7.5) (Dove,
- has balanced PH suitable for babies and those with sensitive
skin. (Seba med, Numis med).
Fig. 22. Dryness of Skin
Some shampoos has a high
alkaline content to give more foam, which is considered by some patients
as an effective preparation and can clean better. These may cause dryness
of the scalp, dandruff, hair fall and itching.
Dryness of the scalp
Hair fall and Hair
and continuous scalp itching
Alters the PH of the
of the scalp such as recurrent scalp carbuncles and folliculitis, which
may lead to cicatricial alopecia.
Some times, we are faced
with patients complaining of chronic scalp itching, excoriation and
carbuncles that have used different medications without an effect. This
problem was solved in a simple way, by using the proper shampoo.
Shampoos for newborn and
young children should be mild and free from chemicals such as tars,
cosmetics, perfumes and coloring materials. These types should be pH
balanced. The optimum pH is around 5 in order not to affect the protective
fatty acids of the scalp.
which may be suitable:
Tar shampoos - used for
cleaning the scalp from dandruff, seborrheic dermatitis and psoriasis.
Salicylic acid containing
shampoos to clear the scalp from dandruff.
- is an effective shampoo in fungal lesions of the scalp and seborrheic
- used to treat seborrhea and scalp dandruff. Using this medication for a
long time may cause hair fall.
Aluminum compounds -
Aluminum chloride 10-30 % in distilled water or 60% alcohol.
Functions of Aluminium
permeability of the sweat ducts resulting in complete dermal resorption of
the sweat. These preparations may occlude the sweat ducts leading to sweat
retention and causing hidradenitis suppurativa.
Diminishes body odor
due to its antibacterial effect.
anticholinergic compounds such as scopolamine hydrobromide locally.
indicated in hyperhidrosis of palms and soles. Higher concentrations of
10% are used for the feet while 2-5 % concentrations are used for
sweating of hands. This preparation can be used three times daily.
Cidex is a ready made
preparation composed of 2 % gluteraldehyde and can be used easily for
excessive hand sweating.
Tannic acid (5 % in
70 % alcohol).
Dusting powders for
the feet, which can be used before dressing of socks.
Pro-banthine 15 mg can be given three times daily may
inhibit very much sweating especially when combined with the topical
Emollients: are used to
moisten dry skin. Different types of emollients are available in the
market such as Petroleum jelly, Moisturel cream, Formula 405, Alpha keri.
The most common used
antipruritic topical preparations are topical corticosteroids. Topical
antihistamines, anesthetics should not be used for a long period as these
may cause local sensitization.
These medications are
used to remove the scales in dry skin lesions. Salicylates alone or in
combination of corticosteroids topically can be used. Care of using these
preparations in young age should be taken into consideration for the
possibility of complications such as salicylism .
Shaked lotions are the
most commonly prescribed as calamine lotion. When the suspension is
applied to the skin, the water evaporates, giving cooling sensation and
leaving the powders to dry on the skin surface.
Shake lotions should
include not less than 40 per cent of the total and glycerin about 15 per
cent since the latter in higher concentration may irritate the skin and
make the lotion stickier.
To these shake lotions
other drugs may be added such as salicylic acid, sulfur, Resorcin
according to the type of lesion to be treated.
There is a continual search in dermatology for more selective
anti-inflammatory drugs to replace broad spectrum steroids. Tacrolimus
(FK506), which is related to cyclosporin, is a powerful immune
suppressor that was introduced to reduce organ transplant rejection.
Like cyclosporin, it has been used systemically to treat
psoriasis, atopic dermatitis, and pyoderma gangrenosum.
Unlike cyclosporin, tacrolimus seems to be effective when applied
topically. Initial open trials suggest
that over 90% of children and adults rapidly achieve at least
good improvement of atopic dermatitis. There is no systemic
accumulation. Adverse effects occur in about half but are
transient and are predominantly burning and erythema at the
FORMULAS USED IN
In the past, before the
production and manufacture of the vast types of the ready prepared
medications, formulas were the most common used in dermatological
treatments. In spite of that, some physicians till now sometimes prefer to
prescribe certain formulas where he can add different medications adjusted
to the skin lesion. These formulae may be more effective but the problem
is that not all the pharmacist can do the job in the proper way besides
the unreasonable and non-convincing overpricing of such preparations.
Abbreviations used in
|: twice daily
|: three times daily
|: before meals
p.c. (post cibum)
|: after meals
|: sufficient amount
|: every hour
|:let it be made
|: of each
Formula for Generalized
Burrow‘s solution -
Zinc oxide -
Lanolin anhydrous -
Peanut oil -
Lime water qs ad -
Apply the mixture to the
affected area every 4 hours. Care of the toxicity of phenol in young
children especially when the skin surface is abraded or ulcerated.
Soothing and antipruritic
Zinc oxide -
| aa 24
Lime water q.s ad -
Liquid petrolatum qs
Apply on the area every
four hours or as needed.
Different types of
compresses are used in skin diseases. Antiseptics have different effects
either an antiseptic, drying or soothing agents.
Cold milk compresses
Fresh milk is kept in the
fridge till it becomes cool. Clean gauze is soaked and applied repeatedly
to the skin surface.This is a soothing preparation , used in acute
erythema, sunburn, peri-orbital hyper-pigmentation (as compresses first
and applying Eldoquine 2%).
These are used in
different concentrations. Potassium permanganate compresses in
concentration of 1:9000 are used by clean gauze moisten with the solution
and applied repeatedly to the skin lesion for 10 minuets every four hours.
When the gauze is dry it should be moistened again and repeated
application each time is necessary.
The brown staining of the
skin can be removed with lemon juice.
Camphor water ad
1 tablespoon added to 1
quart of water and used for local compresses.
| 1: 20
| - 0.1
| - 3.0
Tincture iodine strong
| - q. s. ad
Paint on toenails and
between toes once daily.
| - 6.0
| - 12.0
| - 5.0
| - q.s. add 100.0
Rub into the affected
areas morning and evening.
Formula for onychomycosis
In water and isoprpyl
A solution of 3 % Thymol
iodide in alcohol
N.B. Topical antifungal
preparations whether a formula or of the Azole group. (Daktarin, Lamasil
topically) should be combined with oral Azole (Lamasil tablets) for 3-6
Side Effects You May Have
Could Cause Problems For...
Tell Your Doctor if You're Taking...
loss of appetite
pregnant or nursing women
people with kidney disease, allergies
pregnant or nursing women
loss of appetite
people with kidney disease, blood disorders, allergies
pregnant or nursing women
Podophyllin is an
effective, safe and easy to use for treatment of intertriginous or
anogenital warts. This preparation can be used in concentrations of 20-25%
Podophyllin either in collodion, acetone or in tincture Benzoin co.
10-20% in collodion is preferred because the preparations can stick and dry
immediately when applied to the lesion and no slipping or dribbling to
normal adjacent tissues.
Fig.100a&b. Herpes progenitalis, infant 11months (before
(Recurrence after expensive
and unsuccessful surgical excision besides different topical medications
for the last three months in other medical centers. The father claims that
cost was more than 3500 $ !!
Photo of the same infant treated in our medical center after three
applications of 20% topical Podophyllin in Benzoin co , one
application every two days and washed after four hours\The
cost of that treatment was only THREE DOLLARS !!!!!.
Fig.100.d&e.The same child after 10 days(she
was given mupericin cream (Bactroban cream) applied once daily for
the exfoliated area)
The same child (complete
healing without any complications
after 10 days)
This is an effective
preparation and I consider it superior to other lines of treatment used
for anogenital warts and gives excellent results. It is applied every
other day and washed after 6 hours.
preperations for ano-genital warts are Immiquimod (Aldara cream and
Podofilix(Condylox gel 0.25 cream are also effective but they are more
expensive than Podophyllin.
Mycophenolate mofetil is reported to be antibacterial, antifungal,
antiviral, and immunosuppressive. It has been used systemically in
the treatment of psoriasis, pyoderma gangrenosum, bullous pemphigoid,
pemphigus vulgaris, and systemic vasculitis.
The usual dosage is 1 g orally twice daily. Side effects
such as gastrointestinal intolerance and minor urinary symptoms
are usually mild and are predominantly dose dependent. Bone
marrow suppression with mild to moderate leucocytosis and
anaemia is seen in less than 5% of patients. Early reports
suggesting an increased risk of carcinogenicity, especially
lymphoma, have not been borne out in subsequent studies.
Topical mycophenolic acid is being assessed for its value in
inflammatory skin conditions such as eczema and psoriasis.
Imiquimod ( induces production of interferon alfa, along with
pro-inflammatory cytokines such as interleukin 1, interleukin 6, interleukin
8, and tumour necrosis factor alpha. It is an immune enhancing
agent with antiviral and anti-tumour effects. Interferon alfa
has been shown to be an effective treatment for several cutaneous conditions,
including anogenital warts and non-melanoma skin cancer. However,
it is not absorbed after topical application and requires intralesional
injections. Imiquimod is applied topically, is well absorbed,
and induces local interferon alfa.
Imiquimod cream (Aldara cream5%) applied three times per week
eradicates about 50% of anogenital warts. The recurrence rate is the same
as placebo. The most common side effect is local inflammation. Trial
applications of 1% imiquimod cream three time a day for five
days a week for the treatment of molluscum contagiosum resulted in
resolution in over 80% of patients and lesions. There were no
adverse effects. The potential of
imiquimod in the treatment of cutaneous malignancy is the
subject of current therapeutic trials. *(Recent advances in
Severe reaction may occur
from Podophyllin, especially in sensitive patients if applied
concentrated. The dilution of the preparation may solve this problem.
In children and young
females I give lower concentration, 10-15 % only and to be applied twice
weekly and washed after-4 hours.
Care should be taken when
applying Podophyllin to soft tissues or the intraurethral warts and anal
warts because of the possibility of local scarring when used in higher
Strong preparation rarely
may cause urethral stricture in complicated cases with severe
inflammation. Meanwhile, if the preparation is used with caution, it gives
excellent results for urethral and internal anal warts, which will satisfy
very much both the patient and the physician.
I have treated patients by
Podophyllin who suffered a lot and tried different lines of medication
even surgical removal of anogenital warts and the result was dramatic
relief with 20% Podophyllin in collodion.
Hairy tongue formula
2-4% Podophyllin can be
painted very cautiously to the area every two days.
Formula for common warts
Planter warts and
Mist 30 c.c. . to be
applied cautiously twice daily.
The area to be treated
is encircled by Vaseline ointment in order that the medication will not
affect the healthy tissue.
The medication should
not come in contact with the mucous membranes of the mouth, nose and eyes.
It should be kept away
from children‘s reach.
Young age groups
should not use the medication by themselves. It is very important that one
of the family members should apply the medication to the child and to be
After application of the
preparation to plantar warts, the area is shaved to remove the dead
tissue, where a few days after application, black dots can be seen within
the lesion. This represents the thrombotic vessels caused by the virus.
Application of medication
is continued twice daily mainly on the black dots of the lesion, till the
patient feels deep pain after application especially in plantar warts of
the sole. This sign indicates that the medication has reached the healthy
deeper tissue. Application is continued for another three or four days
after that. The total period of medication usually takes about 9 days.
This formula is very
effective mainly in plantar warts were it works very well where other
lines of treatment even surgical methods failed to cure the condition.
Lesions of the face
and intertriginous areas
The skin of these areas
is delicate. Lower concentrations of salicylic acid and lactic acid in the
formula should be used.
Formula for miliaria
70% Alcohol q.s.ad
in combination with salicylic acid (Locasalen, Salidecoderm, Diprosalic
ointment) may also give good results either applied directly to the
hyperkeratotic areas or under occlusion methods.
Eldoquine ointment is
available in different strengths; 2 % and 4% concentrations. Some
preparations contain in addition sunscreen agents.
This formula should be
prepared in special cream base .It should be kept in refrigerator. It is a
good formula for hyperpigmentation if used for about one month.
preparations used for hyperpigmentation are: Artra 2% cream and Neostrata
Phototherapy has been used since a long
time in treatment of skin disease.PUVA has been used with psoralenes for
Recently more studies and other machines are available and applied for
certain skin diseases with
1- UVA1 phototherapy (340-400 nm) is effective in the treatment of
inflammatory skin diseases such as acutely exacerbated atopic dermatitis,
localized scleroderma, urticaria pigmentosa and disseminated granuloma
2-Narrowband UVB radiation (311-313 nm) is used successfully as
monotherapy or combined with dithranol, oral retinoids or 8-MOP in
psoriasis, atopic dermatitis (AD) or photosensitivity disorders such as
polymorphic light eruption. Narrow band is safe and can be given to young
children and pregnants.
3- Bath water delivery of 8-methoxypsoralen and
subsequent UVA-irradiation (PUVA bath therapy) for the treatment of
psoriasis as well as for mycosis fungoides, localized scleroderma,
urticaria pigmentosa or lichen planus is an effective alternative to its
UVA1 phototherapy utilizes long wave UVA radiation (340-400 nm) while
filtering out the erythematogenic UVA and UVB wavelengths (290-340 nm). It
has been shown to be very effective in the treatment of several
inflammatory skin diseases such as atopic dermatitis, localized
scleroderma, urticaria pigmentosa, disseminated granuloma annulare and in
some cases in systemic sclerosis, lichen sclerosus et atrophicans, graft-versus-host
disease (GvHD), cutaneous T cell lymphoma and psoriasis in HIV-infected
individuals. Different dosage regimen have been proposed for UVA1
phototherapy: low dose (10-20 J/cm2 per single dose), medium
dose (50-60 J/cm2 per single dose) or high dose (130 J/cm2
per single dose) UVA1 therapy.
Narrowband (TL-01) UVB
The narrowband UVB lamp with an emission spectrum peaking at 311-313 nm
(Philips TL-01/100 W) was developed as an alternative to broadband UVB
(290-320 nm) for the phototherapy of psoriasis to reduce erythemogenicity
and the risk of skin carcinogenesis.. Narrowband UVB phototherapy was also
used in the management of atopic eczema, resulting in the amelioration of
pruritus, restoration of a normal sleep pattern and a reduction of topical
steroid use . In patients with photosensitivity diseases such as
polymorphic light eruption, TL-01 produces a "hardening"
photoprotective effect . Long-term side effects of narrowband UVB
phototherapy, such as potential skin carcinogenesis, seem to be at least
equal to and possibly less frequent than would be expected from broadband
Balneophototherapy combines bath water delivery of water soluble
photosensitizers or antiinflammatory agents for example 8-methoxypsoralen
(8-MOP) or different salt solutions with a subsequent UVB- or
UVA-irradiation [reviewed in 23]. In recent years, the combination of
brine baths or 8-MOP-baths with UVB- or UVA-phototherapy using artificial
light sources has been used increasingly in the treatment of psoriasis and
atopic dermatitis . Administration of 8-MOP in a dilute bath water
solution seems to be an effective alternative to its widely used systemic
application, avoiding side effects such as nausea, vomiting, elevation of
liver transaminases or even photodamage to the eyes and furthermore
reduces cumulative UVA doses .
PUVA bath therapy proved to be effective in psoriasis, mycosis
fungoides, lichen planus, localized scleroderma, urticaria pigmentosa and
chronic palmoplantar eczema [23, 29]. PUVA bath therapy can also be
combined with oral acitretin for the efficient treatment of severe
psoriasis . Several case reports documented a beneficial effect of
bath PUVA in the treatment of prurigo, vitiligo or severe atopic
Extracorporeal photopheresis (ECP) was first introduced 1987 by Edelson
et al. as a therapeutic regimen for Sezary's syndrome . However, in
recent years, it has been used successfully for other indications such as
chronic graft-versus-host disease (GvHD), systemic scleroderma,
pemphigus vulgaris, rheumatoid arthritis, lupus erythematodes and even
severe atopic dermatitis .
UV-absorber that contain certain ingredients such as p-amino benzoic acid
esters, methyl-, phenyl- and benzyl salicylates, benzyl cinnamate,
digalloyl trioleate (photosensitizer), 4-isopropyl-dibenzoylmethane,
presented in the market in 1928 as an emulsion of benzyl salicylic acid
and benzyl cinnamate and later other sunscreens were available as quinine
bisulfate and quinine oleate. Sun block usually reflects or scatters all
UV rays. This should be applied about 20 minutes before exposure to sun
and should be reapplied after two hours. It should be noted that children
and other sensitive groups should be instructed to use sunscreens
routinely, like brushing their teeth.
Sunscreens of at
least 15 SPF lip preparation is available and should be used to protect
the lips from actinic injury
The best way to prevent the effects of sun exposure
(other than avoiding the sun!) is to apply sunscreen. Sunscreen is
FDA-approved for anyone over 6 months of age.
It's no secret that the
sun's ultraviolet rays damage skin, causing premature aging and increasing
the risk of developing skin cancer later in life. That risk increases
significantly for a young child who suffers even one blistering sunburn.
Still, many parents allow their children to spend long periods of time in
the sun without proper protection.
The best way to avoid the sun's damaging effects is to restrict your
child's prolonged exposure to the sun whenever possible and to teach
appropriate self-care skills—adequate cover and the liberal use of
Finally, as a role model for your child, you should protect your own skin
by following the self-care strategies for preventing sunburn and
- Skin is reddened and warm
to the touch
- Minor swelling and itching
in affected areas
- Blistering with more
Consult Your Doctor If Your Child:
- Experiences nausea, fever,
chills, or lightheadedness. Your child needs immediate medical care.
- Has blistering that is
extensive and severe.
- Has a sunburn that seems to
worsen or spread 24 hours after exposure.
Home Care Ideas:
- Give your child ibuprofen
as a pain reliever and anti-inflammatory.
- Apply cold compresses
several times a day, or have him or her soak in a cool bath with an
oatmeal bath preparation added to the bath water.
- Avoid using soap on your
sunburned child, or use only a mild soap to wash burned areas; rinse
- Apply aloe vera gel or
moisturizer to burned areas immediately after bathing your child.
- Never peel areas of skin
where blisters have broken or dried.
- Apply sunscreen with an SPF
of 15 or higher 30 minutes before your child goes outside. Don't
forget the lips. Reapply after sweating or swimming. Replace sunscreen
- Never apply sunscreen to an
infant less than 6 months old. Keep him or her out of the sun
- Be sure your child is
covered well—a hat and long sleeves.
- Avoid exposure when the sun
is most intense (10 a.m. to 3 p.m.). A good rule of thumb: keep your
child out of the sun when his or her shadow is shorter than he or she
is. Also, remember water, snow, high altitude, and proximity to the
equator intensify the sun's effects.
|The long term
consequences (skin cancer) of unprotected skin sun exposure have now
been well documented. E. However, chronic unprotected low level
exposure to UV radiation is also a risk factor. . As with adults,
children should have sunscreen applied at least one-half hour before
Parents often ask what SPF (Sun Protection Factor) to use. Use at
least an SPF of 15. Children with a fairer complexion are at greater
risk for the adverse effects of sun exposure, so they should use a
The totally opaque ointment, zinc oxide, is used most often in
situations where sun damage can be more severe due to repeated
Side effects of sunscreens is a rash from the SPF
chemicals. If your child has sensitive skin, you would be well
advised to use a lower number (though not below 15) and re-apply it
regularly. Use one labeled "hypoallergenic". These
are usually (para-amino-benzoic acid)-free, colorless
and odorless .
. Fair-skinned, freckled children should even wear a shirt when
Ophthalmologists are now warning us of the long term hazards of
UV exposure to the eyes which may cause harmful effect to eyes and
may cause cataract. Sun glasses that filter out both UV-A and UV-B
rays are recommended even for young children.
Avoidance of outdoor exposure from 10 a.m. to 2 p.m. when
the sun's radiation is the strongest . . . Cloudy weather may give a
false impression that UV protection for skin and eyes is not needed.
Ultraviolet light penetrates clouds this is why glass filters out UV
must be used .Infrared rays of the sun are not filtered out by
Sunscreens and sunblocks, used generously, may
help prevent skin aging and many skin cancers. Studies are
conflicted, however, over whether sunscreens provide protection
against melanoma, and some even question their value against more
common skin cancers. In fact, there is some indication that they may
encourage people -- particularly those with fair skin -- to stay out
in the sun too long and thereby actually increase the risks for
melanoma. It should be noted, however, that people may not apply
enough sunscreen and many of the studies showing little protection
were conducted before the development of newer products with high
sun protection factors (SPFs). The bottom line is not that people
should avoid sunscreens but that they should always use them in
combination with other sun-protective measures. Any sunscreens
should contain a wide spectrum of UVA-blocking ingredients, which
include butyl methoxydibenzoyl-methane (also called avobenzone or
Parsol 1789), dioxybenzone, oxybenzone, sulisobenzone, methyl
anthranilate, octocrylene, and octyl methoxycinnamate or ethylhexyl
p-methoxycinnamate. Assuming the same ingredients are used,
inexpensive products work as well as expensive ones.
Sunscreen-containing shampoos, conditioners, and hair sprays are now
available. Waterproof formulas last for about 40 minutes in the
water, whereas water-resistant formulas last half as long.
Sunblocks prevent nearly all UVA
and UVB rays from reaching the skin, but to be fully protective they
must contain zinc oxide or titanium dioxide. Standard sunblocks are
white, pasty, and unattractive, but a new form of so-called
microfine zinc oxide (Z-Cote) is transparent and nearly as
protective as the older types. Zinc oxide, in any case, may be more
beneficial than titanium oxide.
Calculating SPFs and Using Sunscreens
The SPF is an indexed number based on the amount of UV radiation
required to turn sunscreen- or sunblock-treated skin red compared to
non-treated skin. Sunscreens should
not be used on babies younger than six months. Older children should
apply sunscreen of at least SPF 4, with 15 being best. For adults,
any sunscreen or sunblock used should have an SPF factor of 15 or
higher. Adults who rarely tan and burn easily should use SPF 20 to
30. Some experts recommend SPF 30 on the face and 15 on the body.
Sunscreen or sunblock should be applied liberally 15 to 30 minutes
before venturing outdoors and reapplied every two hours or so even
on overcast days and especially after exercise or swimming.
Protective Sunglasses and
sun-protective clothing is extremely important and protects even
better than sunscreens. Everyone, including children, should wear
hats with wide brims. (Even wearing a hat, however, may not be fully
protective against skin cancers on the head and neck.) Clothing is
being designed for blocking UV rays and is being rated using SPR
ratings or the UPF (ultraviolet protection factor) index, with 50
UPF being the highest. People should look for loosely-fitted,
unbleached, tightly woven fabrics. Washing clothes over and over
improves UPF by drawing fabrics together during shrinkage. Clothing
treated with a new compound called Rayosan increases the UPF rating
of normal summer-weight cotton by 300%. Everyone over age one should
wear sunglasses that block all UVA and UVB rays when in the sun.
A recent study found that dihydroxyacetone (DHA), the active
chemical in self-tanning lotions, is similar to melanin and may help
filter out UVA and UVB radiation. More research is needed on this
One study indicated that people
who reduced their intake of fat to 20% of their daily diet were
significantly less likely than those on a high-fat diet to develop
Antioxidants are substances that
act as scavengers of oxygen-free radicals -- unstable particles that
can damage the body's cells and even their genetic material. The
most well-known antioxidants are vitamins A, C, E, and beta
carotene. There is some evidence that topical products (e.g.,
lotions and creams) containing such antioxidants may help protect
the skin when applied before sun exposure -- although they have no
benefits if they are applied afterward. Researchers are also
interested in the possible protective effects of combined forms of
topical vitamins A and D. One small study found that taking a
combination of vitamins C and E may help reduce sunburn reactions,
and another study reported that such supplements were associated
with a lower risk for basal cell carcinoma. (Vitamin A supplements
should never be taken, however, to cure skin problems without a
doctor's recommendation.) Drinking green or black tea, which
contains powerful flavonoids, helped block the carcinogenic effects
of UVB radiation in one study.
1- UVA1 phototherapy (340-400 nm) is effective in the
treatment of inflammatory skin diseases such as acutely exacerbated
atopic dermatitis, localized scleroderma, urticaria pigmentosa and
disseminated granuloma annulare.
2-Narrowband UVB radiation (311-313 nm) is used successfully as
monotherapy or combined with dithranol, oral retinoids or 8-MOP in
psoriasis, atopic dermatitis (AD) or photosensitivity disorders such
as polymorphic light eruption.
3-Bath water delivery of 8-methoxypsoralen and subsequent
UVA-irradiation (PUVA bath therapy) for the treatment of psoriasis
as well as for mycosis fungoides, localized scleroderma, urticaria
pigmentosa or lichen planus is an effective alternative to its
systemic application. The combination of salt water brine baths in
different concentrations and subsequent UVA/B irradiation is used
increasingly for the treatment of psoriasis or AD. Extracorporeal
photopheresis (ECP) has proven to be a very effective treatment
modality for cutaneous T cell lymphoma, chronic graft-versus-host
disease and certain autoimmune diseases such as systemic scleroderma
Topical vitamin A works as an
antioxidant on the skin, which means it disarms molecules called
free radicals. These are unleashed by blood cells any time the skin
is irritated (by sun, smoke, or pollution). Free radicals are a
byproduct of the fight against the irritant, and if left unchecked,
they damage DNA and healthy skin collagen (the springy stuff that
gives you a firm face). The compromised collagen can cause wrinkling
and slackened skin, and damaged DNA can potentially lead to skin
Retinoic acid, a derivative of
vitamin A , is the active ingredient in the prescription treatments
Retin-A and Renova, which can reduce wrinkles, fade brown spots, and
smooth surface roughness -- all signs of aging that can be brought
on by excessive sun exposure.
Cosmetic companies are now
producing nonprescription lotions made with another form of vitamin
A called retinol. Research in the March 2000 Journal of
Investigative Dermatology shows that a 1% preparation of retinol
is partially converted by the skin into retinoic acid, which results
in collagen growth and reversal of some aging signs.
One industry study tested a
product containing pantothenic acid, niacin, and vitamin E on skin
with rosacea, a condition of dry, ruddy, rough skin that irritates
easily. Skin treated with this product experienced a 36% increase in
hydration, although it's not clear if this improvement was from
vitamin E or the B vitamins.
In another study (funded by
Procter & Gamble), B vitamins were shown to be effective
exfoliators; that is, they removed dead surface skin cells that
clump up and make skin texture appear dull.
vitamin C, also an antioxidant, works to neutralize damaging free
radical molecules in the skin, thus helping to protect skin from the
harmful effects caused by sunlight's UVA and UVB rays that can lead
to skin damage.
In one animal study, vitamin C
(L-ascorbic acid) was shown to be effective as an additive in
sunscreen for protection against UVA and UVB damage. Its antioxidant
powers are the reason, according to researcher Sheldon Pinnell, MD,
in the July 1996 issue of Acta Dermato-Venereologica. Though
it's not a substitute for sunscreen, it may aid in skin protection.
Another form of C called vitamin C
ester, or ascorbyl palmitate, may actually reverse existing sun
damage. An article in the Feb. 21, 1997, issue of the Journal of
Geriatric Dermatology found that ascorbyl palmitate reduced
inflammation and redness in sunburned human skin in half the time of
a placebo cream. The sooner irritation is stopped, the less damage
free radicals can do to skin. Vitamin C ester can be found in a few
Like vitamins A and C, vitamin E
is an antioxidant, and, when added to sunscreen, it seems to provide
further protection from the sun by shielding against UVB rays
OF PROTECTION FROM THE EFFECT OF SUN
effects of sun are strongest between 10 a.m. and 4 p.m.
broad-spectrum sunscreen with a Sun Protection Factor.
sunscreen every 2 hours when outdoors, even in cloudy days especially
when in seashores and snowy areas.
protective , tightly woven clothing , such as long sleeved shirts and
wide-brimmed hat and sunglasses when outdoors.
Stay in the
shade whenever possible. If your shadow is shorter than you are, you
are likely more exposed to sun damage.
more sensitive to the effect of sun.
photosensitizers whether drugs or certain plants and trees.
types of sunscreens:
acid: Absorbs UVL between 280-320 nm.
PreSun (5 % PAMB in 55 %
Solar cream (4% PABA and
5% titanium oxide)
Absorb UVL from 250-360
Solbar (3% Oxybenzone and
RVP (red vetrinary
Absorbs UVL to 340 nm.
Water protective because
it is greasy.
Preparations available in
RVP (95 %RVP)
RVP aqua (3% RVP and 20%
RVPABA lipstick (20% RVP,
SVP Sun block
| aa-q.s. ad 100
These preparations block
light and most of them contain Titanium dioxide or Zinc oxide powder.
Solar cream (4%PABA,
5% Titanium dioxide).
A-Fil (5% Methyl
anthranilate, 5% Titanium dioxide)
repellents are available commercially. Most of insect repellents contain
either Diethyltoluamide (DEET) Or Ethyl hexanediol (E-H).
lotion (McKesson ) contains 50% Deet.
Off liquid (S.C.
Johnson), 50% Deet.
repellent cream , 30% Deet .
La Rosa M, Ranno
C,Musarra I et al. Double-blind study of cetrizine in atopic eczema in
children.Ann Allergy 1994;73:117-122.
Arndt KA. Manual of
Dermatologic Therapeutics 3rd edn. Boston: Little, Brown & Co.,
Belaich S , Bruttman
G, De Greef H et al. Comparative effects of loratidine and terfenadine
in the treatment of chronic idiopathic urticaria. Ann Allergy
Kalivas J ,Breneman
D, Therap M et al. Urticaria : clinical efficacy of cetrizine in
comparison with hydroxyzine and placebo. Jallergy Clin Immunol 1990;86:
Dermatological Formulations: Percutaneous Absorption. Drugs and the
Pharmaceutical Sciences vol 18. New York: Marcel Dekker, 1983.
Blank JH, Scheuplein
RJ. In: Hibbott HW, ed. Handbook of Cosmetic Science. Oxford: Pergamon,
Bigby M, Stern R.
Cutaneous reactions to non-steroid anti-inflammatory drugs. J Am Acad
Dermatol 1985; 12: 866-77.
Bordoni A, Biagi PC,
Masi M et al. Evening primrose oil (Efamol) in the treatment of children
with atopic eczema. Drugs Exp Clin Res 1988; 14: 291-7.
Baran RL. Untoward
reaction to injections of insoluble corticosteroids. Arch Dermatol 1974;
110: 465 (letter).
August PJ, Staughton RCD. Observations on the systemic effect of topical
clobetasol propionate ointment. Br Med J 1975; iv: 203-4.
Dermatological Formulations: Percutaneous Absorption. Drugs and the
Pharmaceutical Sciences vol 18. New York: Marcel Dekker, 1983.
Cornell RC, Stoughton
RB. Six-month controlled study of effect of desoximetasone and
betamethasone-l7-valerate on the pituitary-adrenal axis. Br J Dermatol
1981; 105: 91-5.
Coh CL. Cross
sensitivity to multiple topical corticosteroids. Contact Derm 1989; 20:
Cutierez GT. A clinical trial of clobetasol proprionate in Fillipino
vitiligo patients. Clin Ther 1987; 9: 474-82.
Committee on Safety
of Medicines. Suspension of product licence for benoxaprofen. Lancet
1982; ii: 396.
Daly BM, Shuster S.
Effect of aspirin on pruritus. Br Med J 1986; 293: 907-8.
Cashin CH, Dawson
W, Kitchen EA. The pharmacology of benoxaprofen
(2-4-chlorophenyl-alpha-methyl-5-benoxazole acetic acid) LRC 3794, a new
compound with anti-inflammatory activity apparently unrelated to
inhibition of prostaglandin synthesis. J Pharm Pharmacol 1977; 29:
,Sylvester DGH, Kennedy CTC et al.Treatment of itching in atopic eczema
with antihistamines with low sedative profile. Br Med J 1989;298:96.
Therapeutic Bulletin. Non-sedative antihistamines: Terfenadine and
Astemizole 1984; 22: 21-3.
Gibson JR, Kirsch
J, Darley CR. An attempt to evaluate the relative clinical potencies of
various diluted and undiluted proprietary corticosteroid preparations.
Clin Exp Dermatol 1983; 8: 489-93.
Patterson R. Safety of therapy for allergic symptoms during pregnancy.
Ann Intern Med 1978; 89: 234-7.
Harvey J, Parish H,
Ho PPK et al. The preferential inhibition of 5-lipoxygenase product
formation by benoxaprofen. J Pharm Pharmacol 1983; 35: 44-5.
Kerdel FA, Soter
NA. Antihistamines in dermatology. In: Rook AJ, Maibach HI, eds. Recent
Advances in Dermatology Vol 6. Edinburgh: Churchill Livingstone, 1983:
chapter 12, 265-76.
Krause L, Shuster
S. Mechanism of action of antipruritic drugs. Br Med J 1983; 287:
1199-200. Poland MK. Topical Skin Therapeutics. Edinburgh: Churchill
Krause L, Shuster
S. Mechanism of action of antipruritic drugs. Br Med J 1983; 287:
Kragballe K, Herlin
T. Benoxaprofen improves psoriasis. A double blind study. Arch Dermatol
1983; 119: 548-52.
Lane AT. Prose NS,R
EHDER pa et al . Comparison of once daily furoate cream 0.1%, twice
daily hydrocortisone cream , 2.5% and twice daily alclometasone
dipropionate cream in the treatment of pediatric patients with atopic
dermatitis. Pediatr Dermatol 1997, in press.
Lubach D, Bensmann
A, Bornemann U. Steroid-induced dermal atrophy. lnvestigations on
discontinuous application. Dermatologica 1989; 179: 67-72.
Riches DJ. Comparative trial of two non-sedating antihistamines ,
loratidine versus astemazole, in Chinese patients with chronic
urticaria. Immunol Allergy Pract 1992; 14: 223-229.
Stoughton RB. Method for comparing percutaneous absorption of steroids.
Arch Dermatol 1962; 86: 608-10.
Miller JA, Levene
CM. Steroids in dermatology. Br J Hosp Med 1982; 28: 331-8.
Munro D. The effect
of percutaneously absorbed steroids on hypothalmic-pituitary-adrenal
function after intensive use in inpatients. Br J Dermatol 1976; 94
(Suppl. 12): 67-76.
Anti-inflammatory agents as inhibitors of prostaglandin synthesis in
man. Med Clin North Am 1981; 65: 713-57.
Mauvais-Jarvis P et
al., eds. Percutaneous Absorption of Steroids. New York: Academic Press,
Mauvais-Jarvis P et
al., eds. Percutaneous Absorption of Steroids. New York: Academic Press,
Sorensen PN. Claucoma induced by application of corticosteroids to the
periorbital region. Arch Dermatol 1978; 114: 953-4.
Rommer SJ, Church MK.
The pharmacology and mechanism of action of histamine H1 antagonists. Clin
Exp Allergy 1990; 20 (Suppl. 2): 3-17.
Hammerstrom S. Nomenclature for leukotrienes. Prostaglandins 1980; 19:
Antihistamines. Pharmacology and clinical use. Drugs 1976; 12: 258-73.
Brogden RN, Heel RL. Astemizole; a review of its pharmacodynamic
properties and therapeutic efficacy. Drugs 1984; 28: 38-61.
Rommer SJ, Church
MK. The pharmacology and mechanism of action of histamine H1
antagonists. Clin Exp Allergy 1990; 20 (Suppl. 2): 3-17.
Simons FER. New
H1-receptor antagonists: clinical pharmacology. Clin Exp Allergy 1990;
20 (Suppl. 2): 19-24.
Antihistamines. Pharmacology and clinical use. Drugs 1976; 12: 258-73.
Sorkin EM, Heel RC.
Terfenadine: a review of its pharmacodynamic properties and therapeutic
efficacy. Drugs 1985; 29: 34-56.
Oliet EJ, Estes SA.
Perianal comedones associated with chronic topical fluorinated steroid
use. J Am Acad Dermatol 1982; 7: 407 (letter).
Smith JG, Wehr RF,
Chalker DK. Corticosteroid induced cutaneous atrophy and telangiectasia.
Arch Dermatol 1976; 112: 1115-17.
ML, Peets EA. Once daily 0.1% mometasone furoate cream versus twice daily
0.1% betamethasone valerate cream in the treatment of a variety of
dermatoses. J Int Med Res 1990;18:460-467
||Ruzicka T, Assman T, Homey B.
Tacrolimus: the drug for the new millennium? Arch Dermatol
1999; 135: 574-580
||Alaiti S, Kang S, Fiedler VC,
Ellis CN, Spurlin DV, Fader D, et al. Tacrolimus (FK506)
ointment for atopic dermatitis: a phase I study in adults and
children. J Am Acad Dermatol 1998; 38: 69-76
51-Mandell GL, Perti WA. Antimicrobial
agents: penicillins, cephalosporins, and other b-lactam
antibiotics. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW,
et al., eds. Goodman & Gilman's The pharmacologic basis of
therapeutics. 9th ed. New York: McGraw-Hill, Health Professions
52-Tenover FC, McGowan JE. The
epidemiology of bacterial resistance to antimicrobial agents.
In: Evans AS, Brachman PS, eds. Bacterial infections in humans:
epidemiology and control. 3d ed. New York: Plenum, 1998:85.
53-McManus MC. Mechanisms of bacterial
resistance to antimicrobial agents. Am J Health Syst Pharm
54-Bush K, Jacoby GA, Medeiros AA. A
functional classification scheme for beta-lactamases and its
correlation with molecular structure. Antimicrob Agents
55-Gilbert DN, Moellering RC Jr, Sande
MA, eds. The Sanford guide to antimicrobial therapy. 29th ed.
Hyde Park, Vt.: Antimicrobial Therapy, 1999:33,52-3,64.
56-Wright AJ. The penicillins. Mayo
Clin Proc 1999;74:290-307 [Published erratum appears in Mayo
Clin Proc 1999;74:1184].
57-Rolinson GN. Forty years of beta-lactam
research. J Antimicrob Chemother 1998;41:589-603.
58-Dowell SF, Butler JC, Giebink GS,
Jacobs MR, Jernigan D, Musher DM, et al. Acute otitis media:
management and surveillance in an era of pneumococcal
resistance--a report from the Drug-resistant Streptococcus
pneumoniae Therapeutic Working Group. Pediatr Infect Dis J
1999;18:1-9 [Published erratum appears in Pediatr Infect Dis J
59-Stohlmeyer LA, Kraus DM. Oral
cephalosporins: focus on new agents. J Pediatr Health Care 1996;
60-Rodman DP, Knight JT, Anderson RL.
A critical review of the new oral cephalosporins. Considerations
and place in therapy. Arch Fam Med 1994;3:975-80 [Published
erratum appears in Arch Fam Med 1995;4:723].
61-Ceftibuten--a new oral
cephalosporin. Med Lett Drugs Ther 1996;38:23-4.
62-Cefdinir--a new oral cephalosporin.
Med Lett Drugs Ther 1998;40:85-7.
63-The choice of antibacterial drugs.
Med Lett Drugs Ther 1999;41:95-104.
64-The Cochrane Library, CD-Rom
version. Issue 2. Oxford, England: The Cochrane Collaboration
and Update Software Ltd., 1999.
65-POEMs for Primary Care. Retrieved
May 5, 2000, from the World Wide Web: http://www.infopoems.com/POEMs/poems_home.htm.
66-National Guideline Clearinghouse.
Retrieved May 5, 2000, from the World Wide Web: http://www.
67-Damoiseaux RA, van Balen FA, Hoes
AW, de Melker RA. Antibiotic treatment of acute otitis media in
children under two years of age: evidence based? Br J Gen Pract
68-Principi N, Marchisio P,
Bigalli L, Massironi E. Amoxicillin twice daily in the
treatment of acute otitis media in infants and children.
Eur J Pediatr 1986; 145:522-5.
Hildes-Ripstein GE, Longstaffe SE, Wincott JL, Sitar DS,
Klassen TP, et al. Treatment of acute otitis media with
a shortened course of antibiotics: a meta-analysis. JAMA
70-Feder HM, Gerber MA,
Randolph MF, Stelmach PS, Kaplan EL. Once-daily therapy
for streptococcal pharyngitis with amoxicillin.
Pediatrics 1999; 103:47-51.
71-de Ferranti SD, Ioannidis
JP, Lau J, Anninger WV, Barza M. Are amoxycillin and
folate inhibitors as effective as other antibiotics for
acute sinusitis? A meta-analysis. BMJ 1998;317:632-7.
72-de Bock GH, Dekker FW,
Stolk J, Springer MP, Kievit J, van Houwelingen JC.
Antimicrobial treatment in acute maxillary sinusitis: a
meta-analysis. J Clin Epidemiol 1997;50:881-90.
73-Dajani AS, Taubert KA,
Wilson W, Bolger AF, Bayer A, Ferrieri P, et al.
Prevention of bacterial endocarditis. Recommendations by
the American Heart Association. JAMA 1997;277:1794-801.
74-Bartlett JG, Breiman RF,
Mandell LA, File TM. Community-acquired pneumonia in
adults: guidelines for management. The Infectious
Diseases Society of America. Clin Infect Dis
75-Smucny JJ, Becker LA,
Glazier RH, McIsaac W. Are antibiotics effective
treatment for acute bronchitis? A meta-analysis. J Fam
76-Richard W. Sloan, M.D.,
R.Ph., coordinator of this series, is chairman and
residency program director of the Department of Family
Medicine at York (Pa.) Hospital and clinical associate
professor in family and community medicine at the Milton
S. Hershey Medical Center, Pennsylvania State
University, Hershey, Pa.
77-KEITH B. HOLTEN, M.D., is
director of the family practice residency program at
Clinton Memorial Hospital, Wilmington, Ohio. He is also
associate professor of clinical family medicine at the
University of Cincinnati College of Medicine. Dr. Holten
received his medical degree from the University of
Louisville (Ky.) School of Medicine and completed a
residency in family medicine at St. Elizabeth's
Hospital, Dayton, Ohio.
78-EDWARD M. ONUSKO, M.D., is
associate director of the family practice residency
program at Clinton Memorial Hospital and assistant
professor of clinical family medicine at the University
of Cincinnati College of Medicine. Dr. Onusko graduated
from Case Western Reserve University School of Medicine,
Cleveland, and completed a residency in family medicine
at University Hospitals of Cleveland.
79-Address correspondence to
Keith B. Holten, M.D., Family Practice Residency
Program, Clinton Memorial Hospital, 825 W. Locust St.,
Wilmington, OH 45177. Reprints are not available from
Boehncke WH, Sterry W, Kaufmann R. Treatment of
psoriasis by topical photodynamic therapy with
polychromatic light. Lancet 1994; 343: 801.
81. Fijan S, Hönigsmann H,
Ortel B. Photodynamic therapy of epithelial skin tumours
using delta-aminolevulinic acid and desferrioxamine. Br
J Dermatol 1995; 133: 282-8.
83. Krutmann J, Czech W,
Diepgen T, et al. High-dose UVA1 therapy in the
treatment of patients with atopic dermatitis. J Am
Acad Dermatol 1992; 26: 225-30.
84. Krutmann J, Diepgen T,
Luger TA, et al. High-dose UVA1 therapy for
atopic dermatitis: results of a multicenter trial. J
Am Acad Dermatol 1998; 38: 589-93.
85. Schempp CM, Effinger T,
Czech W, et al. Characterization of
non-responders in high-dose UVA1 therapy of patients
with atopic dermatitis. Hautarzt 1997; 48: 94-9.
86. Meffert H, Sönnichsen N,
Herzog M, et al. UVA-1-Kaltlichttherapie des akut
exazerbierten, schweren atopischen Ekzems. Dermatol
Monatsschr 1992; 178: 291-6.
87. Kowalzick L, Kleinheinz A,
Weichenthal M, et al. Low dose versus
medium dose UV-A1 treatment in severe atopic eczema. Acta
Derm Venereol 1995; 75: 43-5.
88. Dittmar HC, Pflieger D, Schöpf
E, et al. UVA1-Phototherapie: Pilotstudie zur
Dosisfindung bei der akut exazerbierten Atopischen
Dermatitis. Hautarzt 2000 (in press).
89. Stege S, Schöpf E, Ruzicka
T, et al. High-dose UVA1 for urticaria
pigmentosa. Lancet 1996; 347: 64.
90. Stege S, Berneburg M, Humke
S, et al. High-dose UVA1 radiation therapy for
localized scleroderma. J Am Acad Dermatol 1997;
91. Kerscher M, Dirschka T,
Volkenandt M. Treatment of localized scleroderma by UVA1
phototherapy. Lancet 1995; 346: 1166.
92. Morita A, et al.
Ultraviolet A1 (340-400 nm) phototherapy for scleroderma
in systemic sclerosis. J Am Acad Dermatol 2000;
93. Muchenberger S, Schëpf E,
Simon JC. UVA1-phototherapy for generalized granuloma
anulare. Arch Dermatol 1997; 133: 1605.
94. Storbeck K, Hölzle E,
Lehmann P, et al. Die Wirksamkeit eines neuen
Schmalspektrum-UV-B-Strahlers (Philips TL 01 100W, 311
nm) im Vergleich zur konventionellen UV-B-Phototherapie
der Psoriasis. Z Hautkr 1991; 66: 708-12.
95. Van Weelden H, Baart de la
Faille H, Young E, et al. A new development in
UVB phototherapy of psoriasis. Br J Dermatol
1988; 119: 11-9.
96. Green C, Lakshmipathi T,
Johnson BE, et al. A comparison of the efficiency
and relapse rates of narrowband UVB (TL-01) monotherapy vs
etretinate-PUVA (re-PUVA) in the treatment of psoriasis
patients. Br J Dermatol 1992; 127: 5-9.
97. Van Weelden H, Baart de la
Faille H, Young E, et al. Comparison of
Narrow-band UV-B phototherapy and PUVA photochemotherapy
in the treatment of psoriasis. Acta Derm Venereol
(Stockh) 1990; 70: 212-5.
98. Ortel B, Perl S, Kinaciyan
T, et al. Comparison of narrow-band (311 nm) UVB
and broad-band UVA after oral or bath-water
8-methoxypsoralen in the treatment of psoriasis. J Am
Acad Dermatol 1993; 29: 736-40.
99. Collins P, Ferguson J.
Narrowband (TL-01) UVB air-conditioned phototherapy for
atopic eczema in children. Br J Dermatol 1995;
100. British Photodermatology
Group. An appraisal of narrowband (TL-01) UVB
phototherapy. British Photodermatology Group Workshop
Report (April 1996). Br J Dermatol 1997; 137:
101. Young A. Carcinogenicity
of UVB phototherapy assessed. Lancet 1995; 345:
102. De Gruijl FR. Long-term
side effects and carcinigenesis risk in UVB therapy. In:
The fundamental bases of phototherapy. Hönigsmann
H, Jori G, Young AR, eds. Milan: OEMF SpA, 1996: 153-70.
103. Röcken M, Kerscher M,
Volkenandt M, et al. Balneophototherapy. Hautarzt
1995; 46: 437-50.
104. Kerscher M, Lehmann P,
Plewig G. PUVA bath therapy. Indications and practical
application. Hautarzt 1994; 45: 526-8.
105. Vallat VP, Gilleaudeau P,
Battat L, et al. PUVA bath therapy strongly
suppresses immunological and epidermal activation in
psoriasis: a possible cellular basis for remittive
therapy. J Exp Med 1994; 180: 283-96.
106. Collins P, Rogers S.
Bath-water compared with oral delivery of
8-methoxypsoralen PUVA therapy for chronic plaque
psoriasis. Br J Dermatol 1992; 127: 392-5.