Skin Diseases PDF

Chapter Thirteen: Skin 13.1-Common skin diseases by body location Common skin diseases by body location are shown in (Table 13-1) (1) Table 13-1: Common skin diseases by body location (1). 13.2-Dermatologic drug delivery systems 1-Dermatologic formulations are availa...

Chapter Thirteen: Skin 13.1-Common skin diseases by body location Common skin diseases by body location are shown in (Table 13-1) (1) Table 13-1: Common skin diseases by body location (1). 13.2-Dermatologic drug delivery systems 1-Dermatologic formulations are available in a variety of forms: solutions, suspensions or shake lotions, powders, lotions, emulsions, gels, creams, ointments, and aerosols. Each dermatologic delivery vehicle has specific characteristics and uses based on the type, relative acuteness, and location of the lesion (1) (Table 13- 2). 2-Powders are used mainly in intertriginous areas (e.g., groin, under the breasts, or in skin folds) to decrease friction, which can cause mechanical irritation. They also are useful in the treatment of tinea pedis (athlete‘s foot), tinea cruris (jock itch), and diaper dermatitis (diaper rash) (1). 3-Lotions are suspensions or solutions of powder in a water vehicle. They are especially advantageous in the treatment of conditions characterized by significant inflammation and tenderness. In these situations, creams or ointments may cause pain on application. Also, lotions are useful for hairy areas of the body and scalp (1). 4-Gels are most useful when applied to hairy areas or other areas such as the face or scalp, where it is considered cosmetically unacceptable to have the residue of a vehicle remain on the skin (1). 5-Creams are the most commonly used vehicle in dermatology. The most common mistake made by patients when applying creams is that they use too much or do not rub them in fully. Generally, if the cream can be seen on the skin after application, the patient has made one or both of these application mistakes (1). 6-Ointments are most useful on chronic lesions, relieving dryness, brittleness, and protecting fissures owing to their occlusive properties. They should not be used on acutely inflamed lesions. Ointments should not be applied to intertriginous 163 or hairy areas because they tend to trap heat and promote maceration. Ointments are greasy and may be cosmetically unacceptable (1). 7-Collodions are painted on the skin and allowed to dry to leave a flexible film over the site of application (2). Table 13-2: Appropriate dermatologic vehicle selection across the range of dermatologic lesions (1). 13.3-Anti-infective skin preparations 13.3.1-Antibacterial preparations 1- Some of the topical antibacterials used in superficial bacterial skin infections are summarized in (Table 13-3) (3). Table 14-3: Some topical antibacterials used in superficial bacterial skin infections (3). Drug Antibacterial activity Framycetin Staphylococcus aureus, streptococci, gram- 1 (Aminoglycoside) negative organisms 2 Bacitracin Gram-positive organisms. 3 Fusidic acid Gram-positive organisms. 4 Mupirocin Gram-positive organisms. Gram-positive cocci; anaerobic gram-positive 5 Clindamycin organisms. S. aureus, gram-negative organisms, 6 Silver sulfadiazine Pseudomonas. polymyxin B (gram-negative organisms); Polymyxin B/ 7 gramicidin (gram-positive organisms); bacitracin gramicidin/ bacitracin (gram-positive organisms). 2-Cellulitis, erysipelas, and leg ulcer infections require systemic antibacterial treatment. Impetigo requires topical antiseptic/antibacterial or systemic antibacterial treatment (2). 3-To minimize the development of resistant organisms it is advisable to limit the choice of antibacterials applied topically to those not used systemically (2). 4- Silver sulfadiazine is used in the treatment of infected burns (2). 5-Metronidazole is used topically for rosacea and to reduce the odor associated with anaerobic infections (2). 164  Topical antibacterials Scientific name Trade names Dosage form 1 2 3 4 5 Any extra notes: 13.3.2-Antifungal preparations 1-Most localized fungal infections are treated with topical preparations. Systemic therapy is necessary for scalp infection or if the skin infection is widespread, disseminated, or intractable; although topical therapy may be used to treat some nail infections, systemic therapy is more effective (2). 2-Important: To prevent relapse, local antifungal treatment should be continued for 1–2 weeks after the disappearance of all signs of infection (2). 3-Topical antifungal include: The imidazole antifungals (clotrimazole, econazole, ketoconazole, miconazole and tioconazole), Terbinafine, tolnaftate, nystatin, griseofulvin, amorolfine, and compound benzoic acid ointment (Whitfield‘s ointment). 4-Cutaneous antifungals are available as ointments, creams, powders, and aerosols. Creams or solutions are the most efficient and effective dosage forms for delivery of the active ingredient to the epidermis. Sprays and powders are less effective because often they are not rubbed into the skin. They are probably more useful as adjuncts to a cream or a solution or as prophylactic agents in preventing new or recurrent infections (4). 5-Pityriasis versicolor can be treated with ketoconazole shampoo (apply once daily for maximum 5 days, leave preparation on for 3–5 minutes before rinsing) (2). 6-Antifungal treatment may not be necessary in asymptomatic patients with tinea infection of the nails. If treatment is necessary, a systemic antifungal is more effective than topical therapy (2). 7-Combination products of an antifungals and corticosteroids are available to treat used to control used to control symptoms of redness and itch (5) (in the first few days only) (2). 165  Antifungal preparations (including Combination products) Scientific name Trade names Dosage form 1 2 3 4 5 6 7 Any extra notes: 13.3.3-Antiviral preparations 1-Aciclovir cream can be used for the treatment of initial and recurrent labial herpes simplex infections (cold sores) (2). Important: Aciclovir is best applied at the earliest possible stage (Apply 5 times a day for 5–10 days, to be applied to lesions approximately every 4 hours), usually when prodromal changes of sensation are felt in the lip and before vesicles appear (2). 2-Penciclovir cream is also licensed for the treatment of herpes labialis; it needs to be applied more frequently than aciclovir cream (2). 3-Systemic treatment is necessary for buccal or vaginal infections and for herpes zoster (shingles) (2). Antiviral preparations Scientific name Trade names Dosage form Any extra notes: 166 13.3.4-Parasiticidal preparations 13.3.4.1-Scabies 1-Permethrin is used for the treatment of scabies (apply 5% preparation over whole body then wash off after 8–12 hours); malathion can be used if permethrin is inappropriate (apply preparation over whole body, and wash off after 24 hours) (2). 2-Benzyl benzoate is an irritant and should be avoided in children; it is less effective than malathion and permethrin (2). 3-Ivermectin by mouth has been used, in combination with topical drugs, for the treatment of hyperkeratotic (crusted) scabies that does not respond to topical treatment alone; further doses may be required (2). 4-All members of the affected household should be treated simultaneously. Treatment should be applied to the whole body including the scalp, neck, face, and ears. Particular attention should be paid to the webs of the fingers and toes and lotion brushed under the ends of nails (2). 5-It is now recommended that malathion and permethrin should be applied twice, one week apart; in the case of benzyl benzoate in adults, up to 3 applications on consecutive days may be needed. It is important to warn users to reapply treatment to the hands if they are washed (2). 6-The itch and eczema of scabies persists for some weeks after the infestation has been eliminated and treatment for pruritus and eczema may be required. Application of crotamiton can be used to control itching after treatment with more effective acaricides (2). 7-A topical corticosteroid may help to reduce itch and inflammation after scabies has been treated successfully; however, persistent symptoms suggest that scabies eradication was not successful. Oral administration of a sedating antihistamine at night may also be useful (2). Preparations for scabies Scientific name Trade names Dosage form 1 2 3 Any extra notes: 13.3.4.2-Head lice 1-Head lice infestation (pediculosis) should be treated using lotion or liquid formulations (shampoos are diluted too much in use to be effective) (2). 167 2-A contact time of 8–12 hours or overnight treatment is recommended for lotions and liquids (2). 3-In general, a course of treatment for head lice should be 2 applications of product 7 days apart to kill lice emerging from any eggs that survive the first application. All affected household members should be treated simultaneously (2). 4-Dimeticone is effective against head lice; it is less active against eggs and treatment should be repeated after 7 days. Malathion, an organophosphorus insecticide, is an alternative, but resistance has been reported (2). Drugs for Head lice Scientific Trade Dosage Application name names form 1 2 Any extra notes: 13.4-Preparations for minor cuts and abrasions Cetrimide is used to treat minor cuts and abrasions. The effervescent effect of hydrogen peroxide is used to clean minor cuts and abrasions (2). Scientific name Trade names Dosage form Any extra notes: 13.5-Skin cleansers, and antiseptics 1-Wound cleansing is required to remove any dirt or foreign bodies and to remove exudate and slough (pus and necrotic tissue). This helps to prevent infection and aids healing. Commonly used cleansing solutions are sodium chloride 0.9%, hypochlorite, hydrogen peroxide, povidone-iodine, and chlorhexidine (6). 2-Hydrogen peroxide, an oxidising agent, can be used in solutions of up to 6% for skin disinfection, such as cleansing and deodorizing wounds and ulcers (2). 3-For irrigating ulcers or wounds, lukewarm sterile sodium chloride 0.9% solution is used (2). 168 4-Potassium permanganate solution 1 in 10000, a mild antiseptic with astringent properties, can be used for exudative eczematous areas; treatment should be stopped when the skin becomes dry (2). 5-Alcohol (indications: skin preparation before injection). (cautions : flammable; avoid broken skin) (2). 6-Wound dressings and packing preparations help to protect the wound and provide the correct environment for wound healing. Some also help by absorbing exudates (6). (e.g. sofra-tulle®). Skin cleansers, and antiseptics Scientific name Trade names Dosage form 1 2 3 4 5 Any extra notes: 13.6-Emollients and barrier preparations 1-Emollients (like soft paraffin) soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders (like eczema) (2). 2-Barrier preparations often contain water-repellent (e.g. zinc oxide, castor oil). They are used on the skin around stomas, bedsores, and pressure areas in the elderly where the skin is intact (2). 3-Notes concerning napkin rash (2) : A-The first line of treatment is to ensure that nappies are changed frequently. The rash may clear when left exposed to the air and a barrier preparation can be helpful. B-If the rash is associated with a fungal infection, an antifungal cream such as clotrimazole cream is useful. C-Mild corticosteroid such as hydrocortisone 0.5%or 1% can be used if inflammation is causing discomfort, but it should be avoided in neonates. 169  D-Preparations containing hydrocortisone should be applied for no more than a week. The hydrocortisone should be discontinued as soon as the inflammation subsides. Emollients and Barrier preparations (including preparations for napkin rash) Scientific name Trade names Dosage form 1 Zinc oxide 2 Zinc and castor oil 3 4 Any extra notes: 13.7-Topical local anaesthetics and antipruritics 1-An emollient may be of value where the pruritus is associated with dry skin (2). 2-Preparations containing crotamiton are sometimes used but are of uncertain value. Preparations containing calamine are often ineffective (2). 3-Topical antihistamines and local anaesthetics are only marginally effective and occasionally cause sensitization. For insect stings and insect bites, a short course of a topical corticosteroid is appropriate. Short-term treatment with an oral sedating antihistamine may help in insect stings where sedation is desirable (2). 4-Calamine preparations are of little value for the treatment of insect stings or bites (2). 5-Topical preparation containing doxepin 5%p is licensed for the relief of pruritus in eczema; it can cause drowsiness [may affect performance of skilled tasks (e.g. driving)] and there may be a risk of sensitization (2). Topical local anaesthetics and antipruritics Scientific name Trade names Dosage form 1 2 3 4 171 Any extra notes: 13.8-Topical corticosteroids 1-Topical corticosteroids are used for the treatment of inflammatory conditions of the skin (other than those arising from an infection), in particular eczema, contact dermatitis, insect stings (2). 2-Topical corticosteroids are not recommended in the routine treatment of urticaria (2). 3-Application: A-Topical corticosteroids should be applied no more than twice daily. Increasing the application from twice daily to four times daily does not produce superior responses, and may lead to increased frequency of topical and systemic adverse effects (1). B-One fingertip unit (approximately 500 mg) is sufficient to cover an area that is twice that of the flat adult handprint (palm and fingers) (2). 4-Preparations should be rubbed thoroughly and, when possible, applied while the skin is moist (e.g., after bathing and drying off). Hydration of the skin increases percutaneous absorption and the resultant therapeutic effect of topical steroids (1). 5-Children, especially infants, are particularly susceptible to side-effects. A mild corticosteroid such as hydrocortisone 1% ointment or cream is useful for treating nappy rash and for atopic eczema in childhood. A moderately potent or potent corticosteroid may be appropriate for severe atopic eczema on the limbs, for 1–2 weeks only, switching to a less potent preparation as the condition improves (2). 6-Thinning of the skin, telangiectasia (a visible permanent dilatation of small cutaneous blood vessels), localized fine hair growth, hypopigmentation, and striae (pink, red or purple lines or bands) can result from repeated application of topical corticosteroids (1). 7-Mild corticosteroids are generally used on the face. Potent corticosteroids should generally be avoided on the face and skin flexures (2). 8-When topical treatment has failed, intralesional corticosteroid injections may be used (2). 171 9-Topical corticosteroid preparation potencies (Table 13-4) (6). Table 13-4: potencies of topical corticosteroid (6). Topical Corticosteroids (including Combination products) Scientific name Trade names Dosage form potencies 1 2 3 4 5 6 7 8 Any extra notes: 13.9-Preparations for psoriasis 1-Psoriasis is a chronic inflammatory skin disorder characterized by enhanced epidermal proliferation leading to erythema, scaling, and thickening of the skin (6). 172 2-There are several types of psoriasis including guttate, flexural, pustular, and erythrodermic, but chronic plaque psoriasis (psoriasis vulgaris) is the most common form. In chronic plaque psoriasis; the areas most commonly affected are the extensor sides of the knees, elbows, and hands, and the scalp and sacrum (6). 3-There is no cure and treatment is designed to induce a remission or suppress disease to a tolerable level (6). 4-Drug therapy for psoriasis are summarized in (Table 13-5) (1, 2, 7, 8). Table 13-5: Drug therapy for psoriasis (1, 2, 7, 8) Topical Agents for the Agents for the Treatment of Treatment of Psoriasis Severe Psoriasis 1 Emollients 1 Psoralens plus UVA (PUVA) 2 Keratolytics (salicylic acid, urea, Acitretin, Alitretinoin α-hydroxy acids [i.e., glycolic and 2 lactic acids]) 3 Topical corticosteroids 3 Methotrexate, ciclosporin, 4 Coal tar 4 mycophenolate, tofacitinib 5 Anthralin Immunomodulators (etanercept, 6 Calcipotriene and calcitriol 5 infliximab, adalimumab, golimumab, 7 Retinoids (Tazarotene) secukinumab, ixekizumab) 8 Ultraviolet B (UVB) 9 Calcineurin inhibitor (Tacrolimus and Pimecrolimus) 5-Topical drugs are the treatment of first choice for chronic plaque psoriasis (6). A-Different dosage forms are available such as creams, lotions, gels, foams, ointments, shampoos, oil solutions, tapes, and sprays. Ointments are recommended for dry and thick lesions to enhance absorption and reduce loss of skin moisture (8). B-Creams are indicated for acute, but moist appearing, lesions that do not require ointment-based products. Solutions/shampoos and gels are recommended for scalp lesions and foams and sprays are usually used for lesions in genital areas (8). C-Ointments are the most occlusive and most potent formulations because of enhanced penetration into the dermis. Patients may prefer the less greasy creams or lotions for daytime use (7). 6-Corticosteroids are the topical first-line treatment for mild to moderate psoriasis. Additionally, topical corticosteroids can be combined with other topicals or systemic/biologic agents to enhance therapy (8). 7-Calcipotriene and calcitriol are vitamin D3 analogs that bind to vitamin D receptors, which inhibit keratinocyte proliferation. These agents can be used as first-line monotherapy or in combination with a topical corticosteroid for mild plaque psoriasis (7). 173 8-Retinoids: Tazarotene is a topical retinoid. It may be combined with a topical corticosteroid to enhance efficacy and reduce irritation. Tazarotene is contraindicated in pregnancy and should not be used in women of childbearing potential unless effective contraception is being used (7). 9-Coal tar is used infrequently due to limited efficacy and poor patient adherence and acceptance (it has an unpleasant odor, and stains clothing) (7). 10-Salicylic acid has keratolytic properties and has been used in shampoos or bath oils for scalp psoriasis. It enhances penetration of topical corticosteroids, thereby increasing corticosteroid efficacy (7). 11-Topical tacrolimus and pimecrolimus have a role in the treatment of psoriasis. They are indicated also for atopic eczema (2). 12-Phototherapy and photochemotherapy: Phototherapy consists of either ultraviolet A (UVA) or ultraviolet B (UVB), as light therapy for psoriatic lesions (4). Phototherapy and photochemotherapy are generally used in the management of moderate to severe disease (8). UVA is generally given with a photosensitizer such as an oral psoralen to enhance efficacy; this regimen is called PUVA (psoralen + UVA treatment) (7). 13-Psoriasis refractory to topical therapy may respond to systemic drugs (acitretin, methotrexate, ciclosporin, mycophenolate , and tofacitinib and Biologic agents ) (6-8). 14-Biologic agents are considered for moderate-to-severe psoriasis when other systemic agents are inadequate or contraindicated or when comorbidities exist. Cost considerations tend to limit their use as first-line therapy (1). 15-Acitretin; A-It is a metabolite of etretinate, is a retinoid (vitamin A derivative) (2). B-Acitretin is teratogenic. In women with a potential for child-bearing, the possibility of pregnancy must be excluded before treatment and effective contraception must be used during treatment and for at least 3 years afterwards (2). C-Monitor serum-triglyceride, serum-cholesterol, and liver function before and during treatment (2). D-Taken with or just after meal. Patient should protect the skin from sunlight—even on a bright but cloudy day (2). E-Abstinence from alcoholic beverages should be observed during therapy and for at least 2 months after acitretin is discontinued (9). 174  Preparations for psoriasis (including both topical and systemic products) Scientific name Trade names Dosage form 1 2 3 4 5 Any extra notes: 13.10-Acne and rosacea 13.10.1-Acne 1-Mild to moderate acne is generally treated with topical preparations. Systemic treatment with oral antibacterials is generally used for moderate to severe acne or where topical preparations are not tolerated or are ineffective or where application to the site is difficult (2). 2-Severe acne is usually treated with oral isotretinoin (2). 3-Concerning topical preparations: A-Topical preparations for acne include: Benzoyl peroxide, azelaic acid, topical retinoid and topical antibacterials (2). B- It is usual to start with a lower strength and to increase the concentration of benzoyl peroxide gradually (to minimize skin irritation) (2). C-Benzoyl peroxide can bleach clothing and bedding. If it is applied at night, white sheets and pillowcases are best used and patients can be advised to wear an old T-shirt or shirt to minimize damage to good clothes (9). D-Topical tretinoin, its isomer isotretinoin, and adapalene (a retinoid-like drug), are useful for treating mild to moderate acne. Several months of treatment may be needed to achieve an optimal response and the treatment should be continued until no new lesions develop. Patients should be warned that some redness and skin peeling can occur initially but settles with time (2). E-Topical retinoids should be applied at night, a half hour after cleansing (7). F-Important: Topical retinoids are contra-indicated in pregnancy; women of child-bearing age must use effective contraception (2). 175  G-Topical antibacterials are probably best reserved for patients who wish to avoid oral antibacterials or who cannot tolerate them. Topical preparations of erythromycin and clindamycin are effective for inflammatory acne (2). Clindamycin is currently the preferred topical antibiotic for acne therapy (8). 4-Oral antibiotics are indicated for use in patients with moderate to severe acne and forms of inflammatory acne that are resistant to topical therapy. Tetracycline, doxycycline, and minocycline are the most commonly prescribed oral antibiotics for acne. Erythromycin, azithromycin, and trimethoprim (± sulfamethoxazole) are appropriate second-line agents for use when patients cannot tolerate or have developed resistance to tetracycline or its derivatives (8). 5-Topical antibiotics and oral antibiotics should never be used as monotherapy or as long-term maintenance therapy. Additionally, the use of topical antibiotics in combination with oral antibiotics should be avoided due to increased risk of bacterial resistance (8). 6-Cyprindiol (cyproterone acetate with ethinylestradiol) contains an anti- androgen. It is licensed for use in women with moderate to severe acne that has not responded to topical therapy or oral antibacterials, and for moderately severe hirsutism (although it is an effective hormonal contraceptive, it should not be used solely for contraception) (2). 7-Oral retinoid for acne: A-The retinoid isotretinoin reduces sebum secretion. It is used for the systemic treatment of severe acne (such as nodular acne or acne at risk of permanent scarring) resistant to adequate courses of standard therapy with systemic antibacterials and topical therapy (2). B-Isotretinoin is a toxic. It is given for at least 16 weeks; repeat courses are not normally required (2). C-Side-effects of isotretinoin include severe dryness of the skin and mucous membranes, nose bleeds, and joint pains (2). D-The drug is teratogenic. Women must practise effective contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment. They should be advised to use at least 1 method of contraception, but ideally they should use 2 methods of contraception (2). 8-Spironolactone in higher doses is an antiandrogenic compound. Doses of 50 to 200 mg have been shown to be effective in acne in select women (7). 9-Corticosteroids : A-Oral corticosteroids in high doses used for short courses may provide temporary benefit in patients with severe inflammatory acne. Low- 176  dose prednisone (5–15 mg daily) given alone or with high estrogen-containing combination oral contraceptives has shown efficacy for acne and seborrhea. Long-term adverse effects preclude oral corticosteroid use as a primary therapy for acne (7). B-Intralesional triamcinolone injections are effective for large individual inflammatory nodules (7). 13.10.2-Rosacea 1-The pustules and papules of rosacea respond to topical azelaic acid, topical ivermectin or to topical metronidazole (2). 2-Alternatively oral administration of oxytetracycline or tetracycline, or erythromycin , can be used; courses usually last 6–12 weeks and are repeated intermittently. Doxycycline can be used [unlicensed indication] if oxytetracycline or tetracycline is inappropriate (e.g. in renal impairment) (2). 3-Topical brimonidine tartrate is licensed for the treatment of facial erythema in rosacea (2). Topical and oral preparations for acne and Rosacea Scientific name Trade names Dosage form 1 2 3 4 5 Any extra notes: 13.11-Preparations for warts and calluses 1-Warts (verrucas) are caused by a human papillomavirus, which most frequently affects the hands, feet (plantar warts), and the anogenital region (2). 2-Salicylic acid is a useful keratolytic which may be considered first-line for wart (Apply daily, treatment may need to be continued for up to 3 months); it is also suitable for the removal of corns and calluses (2). 3-Lactic acid is included in some preparations with salicylic acid. However, there is no evidence to support greater efficacy when lactic acid is added (5). 177 4-Advise patient to apply carefully to wart and to protect surrounding skin (e.g. with soft paraffin or specially designed plaster); rub wart surface gently with file or pumice stone once weekly (2). 5-Other treatment options for wart are formaldehyde, glutaraldehyde, cryotherapy (cryotherapy causes pain, swelling, and blistering) silver nitrate (2). 6-The treatment of external anogenital warts is by topical application of podophyllin or imiquimod (It is also licensed for the treatment of superficial basal cell carcinoma) (2). (ALDARA ®: imiquimod cream): Manufacturer advises cream should be rubbed in and allowed to stay on the treated area for 6–10 hours for warts or for 8 hours for basal cell carcinoma, then washed off with mild soap and water. The cream should be washed off before sexual contact (2). Preparations for warts and calluses Scientific name Trade names Dosage form 1 2 3 Any extra notes: 13.12-Sunscreen preparations 1-Sunscreen preparations contain substances that protect the skin against UVA and UVB radiation, but they are no substitute for covering the skin and avoiding sunlight (2). 2-The sun protection factor (SPF) provides guidance on the degree of protection offered against UVB; for example, a SPF of 8 should enable a person to remain 8 times longer in the sun without burning (2). 3-For optimum photoprotection, sunscreen preparations should be applied thickly and frequently. As maximum protection from sunlight is desirable, preparations with the highest SPF should be prescribed (2). 4-All products should be applied 20 to 30 minutes before exposure to the sun, reapplied after 30 minutes and then every 2 hours (5). 5-Sunscreen must be applied to all exposed areas of the body including the nose ad lips but avoid contact with eye (4). 178  Sunscreen preparations Scientific name Trade names Dosage form SPF 1 2 Any extra notes: 13.13-Hair conditions 13.13.1-Androgenetic alopecia 1-Finasteride is licensed for the treatment of androgenetic alopecia in men. Continuous use for 3–6 months is required before benefit is seen, and effects are reversed 6–12 months after treatment is discontinued (2). 2-Topical application of minoxidil (1mL twice daily to be applied to the affected areas of scalp) may stimulate limited hair growth in a small proportion of adults but only for as long as it is used. Ensure hair and scalp dry before application. Patients and their carers should be advised to wash hands after application of liquid or foam (2). 3-Minoxidil is available in 2% and 5% concentrations (5). The 2% and 5% products are approved for use in both men and women (4). Preparations for androgenetic alopecia Scientific name Trade names Dosage form 1 2 Any extra notes: 13.13.2-Hirsutism 1-Hirsutism may result from hormonal disorders or as a side effect of drugs. Topical eflornithine can be used as an adjunct to laser therapy for facial hirsutism in women (2). 2-Co-cyprindiol (cyproterone with ethinylestradiol) may be effective for moderately severe hirsutism. Metformin is an alternative in women with polycystic ovary syndrome. Systemic treatment is required for 6–12 months before benefit is seen (2). 179  Preparations for hirsutism Scientific name Trade names Dosage form 1 2 Any extra notes: 13.13.3-Dandruff and seborrhoeic dermatitis 1-Seborrhoeic dermatitis (seborrhoeic eczema) is associated with species of the yeast Malassezia and affects the scalp, paranasal areas, and eyebrows. Dandruff is considered to be a mild form of seborrhoeic dermatitis (2). 2-Ketoconazole shampoo is used for seborrhoeic dermatitis and dandruff (leave preparation on for 3–5 minutes before rinsing ) (treatment: apply twice weekly for 2–4 weeks) (prophylaxis: apply every 1–2 weeks). Selenium sulfide shampoo is also used (apply twice weekly for 2 weeks, then apply once weekly for 2 weeks, then apply as required) (2). 3-Cradle cap in infants may be treated with olive oil applications overnight, followed by using a baby shampoo the next morning. Selenium and etoconazole should be used for resistant or more moderate disease) (5). Preparations for dandruff and seborrhoeic dermatitis Scientific name Trade names Dosage form 1 2 Any extra notes: 13.14-Antiperspirants 1-Hyperhidrosis (excessive sweating) can be generalized or focal, affecting the palms of the hands, soles of the feet, or axillae (6). 2-Drug therapy should be tried initially but is often ineffective in severe cases. Aluminium salts, such as aluminium chloride or aluminium chlorohydrate in alcoholic solvents applied topically, may be successful in milder forms of focal hyperhidrosis (6). 181