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台北醫學大學附設醫院暨萬芳醫院皮膚科核心教材 Topical anti-inflammatory agent
一、外用類固醇 (Topical corticosteroids) 二、非類固醇類消炎劑 (Topical immunomodulator): 需長期塗抺 steroid 者可考慮使用 Topical antibiotics
Erythromycin
Metronidazole
Mupirocin
(Pseudomonic
Bacitracin
nd lipid pyrophosphate Æ interfere with cell wall synthesis Neomycin
Chloramphenic
Fucidic acid
EF-G-GDP-ribosome complex Æ interfere with function of elongation factor sulfadiazine
Anti-pruritic therapy
Anti­histamines 
¾ First generation H1-type antihistamine ‹ Pharmacokineticss: 短效，作用快 Onset: 0.5-1 hr; Peak effect:1-2 hr; Duration: 4-6 hr ‹ Pharmacodynamics: cytochrome P450, excrete in urine ‹ Effect: antihistamine, sedation, anticholinergic, antiemetic, motion sickness ‹ Side effect: Sedation: develop tolerance within a few days Anticholinergic: dry mouth, blurred vision, constipation, urinary retention ¾ Second generation H1-type antihistamine H2 blocker 
Combination with H1 blocker: dermatographism Antidepressant & Antianxiety 
‹ Doxepin (sinequan) ‹ Amitriptyline: H1&H2 blocker ‹ Aprazolam (xanax) ‹ Fludiazepam (erispan) Antifungal therapy
Topical antifungal agent 
Preparation Dermatophyte Candida Pityrosporum Nystatin
Sulconazole
Miconazole
(Antifungal)
Isoconazole
(Isogen)
Terbinafine
Butenafine
(Mentax)
Tolnaftate
Systemic antifungal agent 
¾ Ketoconazole (Yucomy)
200mg 1#-2# QD with meal Idiosyncratic hepatotoxicity (fulminant hepatitis 1/10000) Alcohol, hepatotoxic agent, hepatitis patients ¾ Fluconazole (Diflucan)
150mg QD; systemic candidiasis/cryptococcosis: 200-400mg QD Less hepatotoxicity ¾ Itraconazole (Sporanox)
100mg 2# QD with meal Idiosyncratic hepatotoxicity (1/160,000), GI upset, headache ¾ Terbinafine (Lamisil)
250mg 1# QD GI upset, headache, taste loss ¾ Nystatin (Mycostatin)
1# in 5ml N/S gargling QID Mucocutaneous candidiasis Systemic antiviral therapy
¾ Acyclovir (Zovirax): 250mg / vial
(1) Herpes zoster: within 72 hrs (2) Varicella: within 24 hours ‹ Dosage: 5~10mg/kg q8h IVD slow drip > 1 hour for 5-10 days ‹ Dose adjustment: CrCl: 25-50 mL/min, usual dose every 12 hr; CrCl: 10-25 mL/min, usual dose every 24 hr; CrCl: < 10 mL/min, 50% of usual dose every 24 hr
¾ Famciclovir (Famvir): 250mg / tab
Herpes zoster: 500 mg q8h for 7 days Recurrent herpes simplex labialis: 1500 mg single dose Recurrent genital herpes simplex: z Acute: 1000 mg BID for 1 days z Suppression: 250 mg BID for up to 1 year Recurrent mucocutaneous herpes simplex, HIV(+): 500 mg BID for 7days Herpes zoster CrCl: 40-59 mL/min, 500 mg every 12 hr; CrCl: 20-39 mL/min, 500 mg every 24 hr; CrCl: <20 mL/min, 250 mg every 24 hr; Hemodialysis: 250 mg following each dialysis ‹ Precaution: Safety and efficacy in children< 18 yrs: not established Brief Introduction of Psoriasis
¾ Classification:
Acute guttate, Chronic plaque, Inverse, Palmoplantar Psoriatic erythroderma Pustular psoriasis: Pustular psoriasis of Von Zumbusch, Palmoplantar pustulosis, Acrodermatitis continua ¾ Epidemiology:
Age: (early-onset) peak at 22.5 y/o, (late-onset) peak at 55 y/o. Sex: F=M
Heredity: polygenic trait. Most frequently associated are HLA-B13, -B17,
-Bw57 and HLA-Cw6.
Trigger Factor: (TIDES: Trauma, Infection, Drug, Ethanol, Stress)
z Physical trauma: Koebner’s phenomenon
z Infection: acute Streptococcal infection Æ guttate psoriasis
z Drugs: systemic steroid, lithium, antimalarial, interferon, β- blockers
¾ Pathogenesis:

Alteration of cell kinetics of keratinocytes. ¾ Clinical Presentation:
Plaque: sharply marginated, silver-white scale, Auspitz’s sign(+)
Guttate: 2mm~1cm, salmon-pink papules±scales, Spare palms and soles.
Inverse: sharply demarcared, non-scaly, bright and fissured.
Localized: Palmoplantar pustulosis, Acrodermatitis of Halopeau, scalp
Generalized pustular: toxic, fever, diffuse erythema Æ clusters of tiny
nonfollicular very superficial yellowish to whitish pustules Æ confluent, circinate lesions and lake of pus. Nails: 25% involvement. Pitting, subungual hyperkeratosis, onycholysis,
yellowish-brown spots under nail plate(oil spot). ¾ Pathology:
1. Marked overall thickening of epidermis(acanthosis) and thinning of epidermis over elongated dermal papillae, Parakeratotic hyperkeratosis. 2. Increased mitosis of keratinocytes, fibroblasts, and endothelial cells. 3. Inflammatory cells in the dermis(lymphocyte/monocyte) and epidermis
(PMN), forming microabscess of Munro in the stratum corneum.
General management of Psoriasis
Vitamin D analogs: Calcipotriol (Daivonex), Calcitriol (Silkis)
Tarzarotene (Zorac)
Tar preparations: Polytar liquid, Polytar emollient Dithranol (Anthralin)
Emollients & Keratolytics: Salicylic acid
Systemic therapy
¾ Methotrexate
Folate antagonist, immunomodulation and antiinflammatory effects. Contraindication: hepatic disease, alcoholism, acute infection, pregnancy. Interaction: aspirin, NSAIDs, co-trimoxazole, etc. Side effect: liver cirrhosis Æ liver biopsy after accumulative dose 1.5gm ¾ Retinoids:
Side effect: xerosis, abnormal liver function, hyperlipidemia, teratogenicity. ¾ Cyclosporin:

Side effect: renal toxicity, hypertension, skin cancers, lymphoma. Precaution: avoid concomitant UVL therapy. Phototherapy
¾ Ultraviolet B(UVB): 290-320nm
Side effect: acute burn, long-term risk of skin cancer ¾ Photochemotherapy (PUVA): Psoralen plus Ultraviolet A
Oral 8-methoxypsoralen 2 hours before UVA(320-340nm) Cause DNA cross-linkage, inhibit mitosis and cell-mediated immunity. Dose depend on minimum erythema dose(MED) Side effect: pruritus, erythema, skin cancer, photoaging, cataract. Precaution: use sun-glasses (for UVA) within 24 hours of oral psoralen ¾ Bath PUVA
Management of Acne
Cleansing Gentle cleanser and warm water Topical agents Airol gel 杜鵑花酸。開始抹時可能刺、癢 Systemic therapy ¾ Antibiotis and antibacterial agents Tetracycline : 500-1000 mg/day, possible resistant strains z Contraindication: pregnancy, children < 8 y/o Doxycycline: 50-100 mg BID, photosensitivity reactions Minocycline: 100-200 mg/day, blue-black pigmentation Erythromycin: pregnant women or children: Trimethoprim-sulfamethoxazole combinations z Severe acne who do not respond to other antibiotics z Potential hematologic suppression, F/U approximately monthly. ¾ Retinoids: Isotretinoin (Roaccutane)
z 0.5-1 mg/kg per day, 2 mg/kg per day for very severe trunk involvement. z Total dose of 120-150 mg/kg of isotretinoin z Xerosis, abnormal liver function, hyperlipidemia, teratogenicity z Monitor CBC, LFT and TG Spironolactone (Aldactone)
50-100 mg BID, an androgen receptor blocker and inhibitor of 5α-reductase Hyperkalemia, irregular MC, breast tenderness, headache, fatigue z nausea, vomiting, abnormal menses, weight gain, and breast tenderness; thrombophlebitis, pulmonary embolism, and hypertension ¾ Glucocorticoids: usually restricted to the severely involved patient

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