Dermatology

Topical Spironolactone Gel for Treatment of Mild to Moderate Acne Vulgaris

Topical spironolactone may be effective for the treatment of patients with acne and increased sebum secretion. A study concluded that 5% spironolactone topical gel resulted in a decrease in total acne lesions in patients with acne vulgaris, while it had no significant efficacy on severity.

J Dermatolog Treat. 2012 Feb;23(1):21-5. Epub 2010 Oct 22.

Comparison of the efficacy of 5% topical spironolactone gel and placebo in the treatment of mild and moderate acne vulgaris: a randomized controlled trial.

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We can compound customized formulations which contain numerous medications to provide a synergistic effect for treatment of resistant acne.

Int J Dermatol 1995 Jun;34(6):434-7

Topical nicotinamide compared with clindamycin gel in the treatment of inflammatory acne vulgaris.

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J Dermatol 1996 Apr;23(4):243-6

Topical spironolactone reduces sebum secretion rates in young adults.

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Alopecia areata is a prevalent autoimmune skin disease with no cure or indicated treatment options. In the absence of an approved treatment, some patients are eager to try unconventional therapies. Recently emerging unconventional therapies for alopecia areata discussed include low-dose naltrexone.

J Investig Dermatol Symp Proc. 2018 Jan;19(1):S32-S33.

Emerging Unconventional Therapies for Alopecia Areata.

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Topical Melatonin for Androgenetic Alopecia

In the search for alternative agents to oral finasteride and topical minoxidil for the treatment of androgenetic alopecia (AGA), melatonin has been identified as a promising candidate based on in vitro and in vivo studies. Stressful influences such as UV radiation, smoking, and environmental pollutants lead to the formation of free radicals, resulting in damage to hair follicles. Melatonin may counteract the oxidative stress due to its strong anti-oxidant properties.

The authors concluded that topical application of a melatonin solution can be considered as a treatment option in androgenetic alopecia. In addition, a decrease in seborrhea and seborrheic dermatitis of the scalp was observed.

Br J Dermatol. 2004 Feb;150(2):341-5.

Melatonin increases anagen hair rate in women with androgenetic alopecia or diffuse alopecia: results of a pilot randomized controlled trial.

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Int J Trichology. 2012 Oct;4(4):236-45.

Topical melatonin for treatment of androgenetic alopecia.

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Various synergistic combinations are used for antifungal therapy. Research points to the practicality “of using ibuprofen, alone or in combination with azoles, in the treatment of candidosis, particularly when applied topically, taking advantage of the drug’s antifungal and anti-inflammatory properties.”

J Med Microbiol 2000 Sep;49(9):831-40

Antifungal activity of ibuprofen alone and in combination with fluconazole against Candida species.

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Chemical peelings with kojic acid, glycolic acid, and trichloroacetic acid, either alone or in combination, are effective therapy for diffuse melasma and localised hyperpigmentations (lentigo).

Dermatol Surg 1999 Jun;25(6):450-4

The use of chemical peelings in the treatment of different cutaneous hyperpigmentations.

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Ann Pharmacother 1996 Sep;30(9):954-6

Cholestyramine ointment to treat buttocks rash and anal excoriation in an infant.

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Dis Colon Rectum 1987 Feb;30(2):106-7

Cholestyramine ointment in the treatment of perianal skin irritation following ileoanal anastomosis.

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Concerns about emerging resistance and the potential harm of using permethrins have prompted a search for effective pediculicidal therapies that are not harmful to children with repeated use. An herbal formulation has been shown to be effective for head lice. Ivermectin can also be compounded for topical application or as an oral dose titrated for each patient for the treatment of head lice and scabies.

Clin Exp Dermatol 2002 Jun;27(4):264-7

Treatment of 18 children with scabies or cutaneous larva migrans using ivermectin.

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Twenty six male and female patients aged 5 to 17 years had head lice infestation confirmed by eggs presence and received treatments with a single 200 microgram/kg oral dose of. At day 14 after treatment, 20 had responded to the treatment (77%), and 6 patients (23%) presented with a complete disappearance of eggs and all clinical symptoms. At day 28, 7 patients appeared clear of infestation (27%), but 4 of the 6 patients with no eggs at day 14 presented with signs of reinfestation. This study suggests that ivermectin is a promising treatment of head lice, and a second dose at day 10 may be appropriate.

Trop Med Parasitol 1994 Sep;45(3):253-4

Efficacy of ivermectin for the treatment of head lice (Pediculosis capitis).

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Two hundred scabies patients were randomly allocated to receive either oral ivermectin in a single dose of 200 micrograms/kg body weight, or 1% lindane lotion for topical application overnight. Patients were assessed after 48 hours, two weeks and four weeks. After a period of four weeks, 82.6% of the patients in the ivermectin group showed marked improvement; only 44.44% of the patients in the lindane group showed a similar response. Oral ivermectin is easy to administer as a single oral dose, induces an early and effective improvement in signs and symptoms, and compliance is accordingly increased.

J Dermatol 2001 Sep;28(9):481-4

Oral ivermectin in scabies patients: a comparison with 1% topical lindane lotion.

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Isr Med Assoc J. 2002 Oct;4(10):790-3

The in vivo pediculicidal efficacy of a natural remedy.

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The following study found that 5% KOH aqueous solution proved to be as effective and less irritating when compared to the 10% KOH solution. This trial also emphasizes the effectiveness of topical KOH in the treatment of molluscum contagiosum, sparing affected children from more aggressive physical modalities of treatment.

Pediatr Dermatol 2000 Nov-Dec;17(6):495

Evaluation of the effectiveness of 5% potassium hydroxide for the treatment of molluscum contagiosum.

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Nail health can be a mirror of overall health. For example, Muehrcke’s lines (horizontal bands of nail discoloration) are typically caused by low serum albumin. Nail clubbing, which develops over years, is associated with low oxygen in the blood and has been described in patients suffering from severe gastrointestinal disorders, cardiovascular disease, and immune dysfunction. Koilonychia, a spoon-like depression of the nail bed, may indicate hypochromic anemia or other disruptions of iron absorption. Beau’s lines, indentations that run across the nail, can be a sign of trauma but can also be a sign of zinc deficiency. Finally, nail pitting, scaling, and thickening is common to psoriasis involving the nails and can accompany onychomycosis, or fungal infection of the nail.Topical preparations are the preferred route of treatment of nail disorders due to the relatively toxic effects of systemic therapy. Since treatment can be prolonged, oral regimens may require regular side effect monitoring and may even interact with other oral medications; elderly patients with comorbidities are particularly at risk for experiencing adverse effects and drug interactions from oral therapy. Generally, it’s important to use a combination of medications to promote healing and prevent nail disorder relapse.

Nail Psoriasis and Onychomycosis psoriatic nail disease generally occurs in patients with cutaneous psoriasis; however, it can rarely (5%) be seen in the absence of clinically evident psoriasis of the skin. Nail psoriasis can be treated using compounded topical agents and treatment may include an antifungal component since nail psoriasis and fungal nail infections are often comorbid conditions. Medications typically found in compounded nail psoriasis therapy include fluorouracil, glucocorticoids and/or vitamin D3 analogues. These agents can be compounded into creams, ointments, and gels. A study which included 48 patients, tested the efficacy of a preparation containing calcipotriol and clobetasol propionate in the treatment of nail psoriasis. After a year of treatment, nail thickness was reduced by 81.2% and 72.5% in finger and toe nails, respectively.

J Drug Deliv Sci Technol. 2015; 30A: 63–73

Nail psoriasis: An updated review of clinical reports on therapy and formulation aspects for topical delivery

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Novel Formulations that Potentiate Antifungal Activities

Terbinafine, an orally and topically active antifungal agent, has been available for the treatment of dermatophytic infections and onychomycosis for more than a decade. Oral administration has been shown to be associated with drug-drug interactions, hepatotoxicity, low concentration at the infected sites, gastrointestinal and systemic side effects and other adverse effects. Since topical drug delivery can provide higher patient compliance, allow immediate access to the infected site and reduce unwanted systemic drug exposure, an improved topical drug delivery approach with high permeability, sustained release and prolonged retention at the site could overcome the limitations and side effects caused by oral administration. Conventional topical formulations cannot keep the drug in the targeted sites for a long duration of time. To overcome this limitation, our compounding pharmacy utilized a novel drug delivery system based on polymers and nanostructure carriers for the topical delivery of terbinafine and other medications.

Drugs Today (Barc). 2015 Mar;51(3):197-208.

Terbinafine: novel formulations that potentiate antifungal activities.

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Therapy for Onychomycosis

In a randomized, double-blind study of 70 patients with onychomycosis of the finger and toenails. The results indicated topical treatment of onychomycosis with a combination of fluconazole 1% and urea 40% was more effective (82.8%) than fluconazole 1% nail lacquer (62.8%) alone in treatment of onychomycosis. Fluconazole was well tolerated and side effects were negligible.

J Dermatolog Treat. 2012 Dec;23(6):453-6.

A comparative evaluation of combination therapy of fluconazole 1% and urea 40% compared with fluconazole 1% alone in a nail lacquer for treatment of onychomycosis: therapeutic trial.

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Treatment of Fingernail Lichen Planus

Nail lichen planus most commonly occurs during the fifth and sixth decade of life and can be notoriously recalcitrant to many forms of treatment. Prevost and English of the University of Pittsburgh Department of Dermatology reported a case of successful treatment of destructive inflammatory lichen planus of the nails with combined topical therapy of tazarotene gel and clobetasol gel, without the occurrence of potential adverse effects of systemic treatments.

J Drugs Dermatol. 2007 Feb;6(2):202-4.

Palliative treatment of fingernail lichen planus.

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Although surgical excision is the most popular method for removing nails, the use of concentrated urea plasters applied under occlusion may be superior. The use of urea plasters has inherent advantages – they are inexpensive, several nails can be treated in one session, and the procedure is essentially painless. Various synergistic combinations and topical medications with penetrant enhancers can be compounded for antifungal therapy. Topical medications usually have a lower adverse drug-reaction profile than systemic medications.

IJDVL 2012; 78(3):299-308

Nail avulsion: Indications and methods (surgical nail avulsion)

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Cutis. 1980 Jun;25(6):609-12

Urea ointment in the nonsurgical avulsion of nail dystrophies–a reappraisal.

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Cutis. 1980 Apr;25(4):397, 405

Combination urea and salicylic acid ointment nail avulsion in nondystrophic nails: a follow-up observation.

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JAMA 1979 Apr 13;241(15):1559, 1563

Urea plasters alternative to surgery for nail removal.

PMID: 430701 (No abstract available)

Clin Exp Dermatol 1982 May;7(3):273-6

The treatment of fungus and yeast infections of nails by the method of “chemical removal”.

PMID: 7105479 (No abstract available)

Management of onychomycosis, a fungal infection of the fingernails and toenails, usually consists of systemic antifungal medications, topical therapy (e.g., urea ointment, desiccating solutions, keratolytics, vital dyes), or surgical intervention (e.g., nail plate avulsion, laser therapy). Topical prescription antifungal preparations, containing the active ingredient of your choice, may be less likely to cause the serious systemic side effects that can occur with oral antifungal therapy and can provide a more economical alternative, as lower doses are needed when the medication is applied topically at the site. Penetrant enhancers can be included in the preparation to improve the effectiveness of topical antifungals.

Trop Med Int Health 1999 Apr;4(4):284-7

Treatment of toenail onychomycosis with 2% butenafine and 5% Melaleuca alternifolia (tea tree) oil in cream.

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Topical Metformin for Hyperpigmentation

There are numerous causes of hyperpigmentation, such as post-inflammatory etiologies, hormonally mediated factors, cosmetics, drug-induced causes, and UV radiation in addition to systemic conditions such as Addison’s disease and Wilson’s disease. These pigmentation disorders have traditionally been a relatively difficult condition to treat, and currently used depigmentation agents have little effect with sometimes severe side effects.

Metformin is primarily an antidiabetic drug but has been found to play an important role in a number of cutaneous disorders. By improving hyperinsulinemia, metformin has helped hormonal acne, hidradenitis suppurativa and acanthosis nigricans. Its antiandrogenic properties further serve as an add-on to the conventional management of hirsutism associated with polycystic ovarian syndrome (PCOS). Metformin has also been topically used in hyperpigmentary disorders with significant improvement.

Metformin acts on the melanogenic proteins tyrosinase, tyrosine-related protein (TRP)-1 and TRP-2 bringing about a reduction in their expression. This downregulates the expression of microphthalmia-associated transcription factor (MITF), which has been referred to as the master gene for melanocyte survival.

Only topical metformin (not oral) has resulted in improvement of hyperpigmentation disorders. Topical metformin solution was originally tested on the tails of mice for 8 weeks., and induced tail whitening. Then, researchers confirmed the antimelanogenic effect of metformin on reconstituted human epidermis and on human skin biopsies. These data emphasize the depigmenting effect of metformin and suggest a clinical strategy for using metformin in the topical treatment of hyperpigmentation disorders. In animal studies, metformin exerted an antagonistic role in pigmentation only as a topical preparation. Recently, there have been encouraging reports of the benefits of using metformin in treatment of cutaneous malignancies.

Several reports have demonstrated the inhibitory effect of metformin on the proliferation of many cancers including melanoma. Recently, it has been shown that metformin is able to modulate the cAMP level in the liver. As cAMP has a crucial role in melanin synthesis and skin pigmentation, the effect of metformin on melanogenesis was investigated both in vitro and in vivo. Treatment with topical metformin led to reduced melanin content in melanoma cells and in normal human melanocytes by decreasing cAMP accumulation and cAMP-responsive element–binding protein phosphorylation. This inhibitory effect is correlated with decreased expression of master genes of melanogenesis.

Indian J Pharmacol. 2016 Jan-Feb; 48(1): 4–10.

Metformin – For the dermatologist

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J Invest Dermatol. 2014 Oct;134(10):2589-2597.

Inhibition of melanogenesis by the antidiabetic metformin

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Topical metformin has also been used in hyperpigmentation disorders. Metformin acts on three melanogenic proteins and reduces their expression, and also inhibits the activity of PKC-β.5 Inhibiting PKC activity in vivo selectively blocks tanning and reduces basal pigmentation in the epidermis and in anagen hair shafts.

J Invest Dermatol. 2004 Jan; 122(1):159-66.

Topical application of a protein kinase C inhibitor reduces skin and hair pigmentation

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Pyogenic granuloma (PG)

Pyogenic granuloma (PG) is a common, acquired, benign vascular neoplasm of the skin and mucous membranes. It occurs most often in children and adolescents. First-line treatment options for PG are based on destructive approaches. Pain, permanent scarring, and pigmentation are potential complications of these therapies. Topical propranolol 1% ointment with occlusion was found to be effective in consecutive patients; 59.0% completely regressed in a mean of 66 days, 18.2% remained stable, and 22.7% did not respond. No side effects (e.g., skin irritation, allergy, bleeding) were observed. Early treatment was associated with a more favorable outcome.

Pediatr Dermatol. 2018 Jan;35(1):117-120.

Topical 1% propranolol ointment with occlusion in treatment of pyogenic granulomas: An open-label study in 22 children.

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Topical Tranexamic Acid for Melasma

Topical tranexamic acid is a promising treatment for melasma. Tranexamic acid (TA) has been reported to have whitening effects especially for ultraviolet-induced hyperpigmentation including melasma.The aim of a 12-week double-blind split-face trial was to evaluate a topical solution of TA and compare it with combined solution of hydroquinone and dexamethasone as the gold standard treatment of melasma. A significant decreasing trend was observed in the Melasma Area and Severity Index (MASI) score of both groups with no significant difference between them during the study. No differences were seen in patients’ and investigators’ satisfaction of melasma improvement between two groups. However, the side effects of hydroquinone + dexamethasone were significantly prominent compared with TA. This study’s results suggest that topical tranexamic acid may be preferred over hydroquinone + dexamethasone for the treatment of melasma.

J Res Med Sci. 2014 Aug;19(8):753-7.

Topical tranexamic acid as a promising treatment for melasma.

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Topical tranexamic acid has been studied as an adjuvant treatment in melasma.

The main objective of the following study was to evaluate the benefits of topical TA combined with intense pulsed light (IPL) treatment in Asians with melasma. Thirteen subjects completed the study without serious adverse events. MI and mMASI decreased significantly from baseline to 12 weeks after the last IPL treatment on the topical TA side but not on the vehicle side. The prevention of rebound pigmentation by topical application of TA after IPL treatment was also statistically significant. Topical TA can be considered as an adjuvant to conventional treatment for melasma.

J Dermatolog Treat. 2016 Aug;27(4):373-7.

Topical tranexamic acid as an adjuvant treatment in melasma: Side-by-side comparison clinical study.

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Silymarin for Melasma

Melasma is a common acquired pigmentary disorder that occurs usually in women (more than 90% of cases) of all racial and ethnic groups. Melasma is an acquired increased pigmentation of the skin characterized by symmetrical and confluent grey-brown patches usually on the areas of the face exposed to the sun. Silymarin (also known as milk thistle) strongly prevents photocarcinogenesis, and significantly prevented melanin production. A study assessed the benefits of topical Silymarin (SM) cream in a double-blind placebo controlled study for treatment of 96 adult melasma patients seen at an outpatient clinic.

Clinically, patients treated with topical silymarin showed significant excellent pigment improvement & lesion size reduction from the 1st week. Silymarin significantly prevented melanin production in a dose-dependent manner. Silymarin showed tremendous improvement of melasma in a dose-dependent manner and was effective in the prevention of skin damage caused by U.V. sunlight. Patients’ satisfaction was recorded as 100%. During the period of treatment, no local or systemic adverse effects were observed.

BMC Dermatol. 2012; 12: 18.

The treatment of melasma by silymarin cream

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Pseudocatalase Cream for Vitiligo

Vitiligo is a spontaneous irregular depigmentation of skin. Patients with vitiligo have low catalase levels in their epidermis with high levels of hydrogen peroxide. Pseudocatalase cream is an externally applied UVB-activated product that can lead to recovery of the oxidative damage in the epidermis and remarkable repigmentation.

Skin Pharmacol Appl Skin Physiol 1999 May-Jun;12(3):132-8

Successful treatment of oxidative stress in vitiligo.

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J Pathol 2000 Aug;191(4):407-16

Melanocytes are not absent in lesional skin of long duration vitiligo.

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J Investig Dermatol Symp Proc 1999 Sep;4(1):91-6

In vivo and in vitro evidence for hydrogen peroxide (h4 O2) accumulation in the epidermis of patients with vitiligo and its successful removal by a UVB-activated pseudocatalase.

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Dermatology 1995;190(3):223-9

Treatment of vitiligo with a topical application of pseudocatalase and calcium in combination with short-term UVB exposure: a case study on 33 patients.

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Topical Phenylalanine for Vitiligo

Melanocytes may still be present in long-standing (>25 years) depigmented skin of patients with vitiligo. L-phenylalanine uptake and turnover in the pigment forming melanocytes is vital for initiation of melanogenesis. Phenylalanine hydroxylase activities increase linearly with inherited skin color yielding eightfold more activities in black skin compared to white skin. Camacho and Mazuecos performed an uncontrolled retrospective survey of a group of 193 patients (171 participants after screening) with evolving vitiligo who were treated with oral (50 or 100 mg/kg daily) and topical (10% gel) phenylalanine plus sun exposure. When the study closed, 100% repigmentation was achieved in 122 patients on the face, 35 on the trunk, and 33 on the limbs. Patients who were treated during the months of high solar radiation (and therefore also used the topical phenylalanine) achieved greater repigmentation. No side effects were reported.

Arch Dermatol. 1999;135:216-217

Treatment of vitiligo with oral and topical phenylalanine: 6 years of experience.

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J Drugs Dermatol 2002 Sep;1(2):127-31

Oral and topical L-phenylalanine, clobetasol propionate, and UVA/sunlight–a new study for the treatment of vitiligo.

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Mol Genet Metab 2005 Dec;86(4):27-33

Decreased phenylalanine uptake and turnover in patients with vitiligo.

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Researchers concluded that “although hydroquinone showed a better response, ascorbic acid may play a role in the therapy of melasma as it is almost devoid of side-effects; it could be used alone or in combination therapy.”

Int J Dermatol. 2004 Aug;43(8):604-7.

A double-blind randomized trial of 5% ascorbic acid vs. 4% hydroquinone in melasma.

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Melasma is a circumscribed brown macular hyperpigmentation of areas of the face and neck that are exposed to light, and is aggravated by sunlight, birth control pills, and pregnancy. This study demonstrates that a cream containing hydroquinone, glycolic acid, vitamins C and E, and sunscreen is a safe and effective treatment therapy for melasma.

Int J Dermatol. 2003 Dec;42(12):966-72.

Safety and efficacy of 4% hydroquinone combined with 10% glycolic acid, antioxidants, and sunscreen in the treatment of melasma.

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The antioxidant N-acetyl cysteine (NAC) has an antiproliferative effect on human keratinocytes and NAC has been used topically to satisfactorily treat lamellar ichthyosis.

Lancet. 1999 Nov 27;354(9193):1880.

Topical N-acetylcysteine for lamellar ichthyosis.

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Topically applied NAC can prevent skin irritation resulting from radiotherapy and protects from sun-induced erythema.

Semin Oncol. 1983 Mar;10(1 Suppl 1):86-92.

Topical use of N-acetylcysteine for reduction of skin reaction to radiation therapy.

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Topical 5-fluorouracil (5-FU) 5% with tape occlusion produced complete eradication of all plantar warts within 12 weeks of treatment in 19 of 20 patients. It was concluded that use of topical 5% 5-fluorouracil cream for plantar warts is safe, efficacious, and accepted by the patient.

J Drugs Dermatol. 2006 May;5(5):418-24.

Topical 5% 5-fluorouracil cream in the treatment of plantar warts: a prospective, randomized, and controlled clinical study.

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A medical record review was conducted by the Podiatry Division, Department of Orthopedics, Cabrini Medical Center, New York, NY to determine the clinical outcome and average time to resolution of verruca plantaris (plantar warts) in 20 patients treated with twice-daily applications of topical fluorouracil (5-FU) combined with topical 17% and 40% salicylic acid. Twice-daily application of topical fluorouracil and salicylic acid is a safe and effective treatment for verruca plantaris.

J Am Podiatr Med Assoc. 2005 Jul-Aug;95(4):366-9.

Treatment of verruca plantaris with a combination of topical fluorouracil and salicylic acid.

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Phys Ther. 2002 Dec;82(12):1184-91

Treatment of plantar verrucae using 2% sodium salicylate iontophoresis.

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Cantharidin in a collodion vehicle has been used by dermatologists as a treatment for molluscum contagiosum and warts since the 1950s. Cantharidin lost FDA approval in 1962 because its manufacturers failed to submit data attesting to cantharidin’s efficacy. However, in 1999, the FDA included cantharidin on its “Bulk Substances List” of drugs which although not available as commercial products, were approved for compounding on a customized basis for individual patients. Because of cantharidin’s potential for toxicity, the FDA has proposed that cantharidin should be limited to “topical use in the professional office setting only.” Severe blistering can result from improper use, and ingestion, especially by children, can be fatal. Treatment of mucous membranes is contraindicated and placement of cantharidin near the eyes and eyelids should be avoided to prevent scleral erosion. Caution: The treatment of plantar warts with cantharidin is NOT recommended and may have a higher rate of significant complications including lymphangitis and refractory lymphedema.

Arch Dermatol. 2001;137:1357-1360

Cantharidin revisited: a blistering defense of an ancient medicine.

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J Am Acad Dermatol. 2000;43:503-507

Childhood molluscum contagiosum: experience with cantharidin therapy in 300 patients.

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Squaric Acid Dibutylester (SADBE) for Cutaneous Warts in Children

Warts are a common pediatric skin infection and clearance may be enhanced by contact sensitizers, such as squaric acid dibutylester (SADBE). Contact immunotherapy with SADBE is relatively safe and an effective alternative in the management of multiple and resistant cutaneous warts in children.

J Am Acad Dermatol. 2000 May;42(5 Pt 1):803-8

Squaric acid immunotherapy for warts in children.

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Pediatr Dermatol. 2000 Jul-Aug;17(4):315-8

Use of squaric acid dibutylester (SADBE) for cutaneous warts in children.

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J Am Acad Dermatol. 1999 Oct;41(4):595-9

Contact immunotherapy with squaric acid dibutylester for the treatment of recalcitrant warts.

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Topical Silymarin and MSM For Rosacea

A study evaluated a topical treatment of silymarin and methylsulfonylmethane (dimethyl sulfone, MSM) to improve erythematous-telangiectactic rosacea. A statistically significant improvement was observed in many clinical and instrumental parameters investigated. In particular, improvement of skin redness, papules, itching, hydration, and skin color occurred.

J Cosmet Dermatol. 2008 Mar;7(1):8-14.

Combined effects of silymarin and methylsulfonylmethane in the management of rosacea: clinical and instrumental evaluation.

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Clin Exp Dermatol 2003 Jan;28(1):61-3

Topical application of NADH for the treatment of rosacea and contact dermatitis.

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Emerging scar therapies can help treat and prevent painful, unsightly scars. At the surface, a wound from trauma or surgery may leave a scar that is raised and discolored; at a deeper level, blood vessel and nerve damage can result in associated pain and itching. Therefore, the best therapies involve a multi-prong approach to help smooth and lighten the physical appearance of the scar, while controlling or eliminating associated discomfort. Individually compounded scar therapy preparations may contain caffeine; vitamin A; avocado, coconut, and other tree oils; and medications including corticosteroids, antihistamines, as well as other agents such as verapamil that promote healing. Taking an individualized approach to treating scars with compounded topical scar therapy can be an important adjunct in the treatment of wounds and scars.

J Natl Med Assoc. 2004 Jan; 96(1): 108–116.

Prevention and treatment of excessive dermal scarring.

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Topical Pracaxi Oil Base for Scar and Wound Therapy

The objective of a case series by Banov et al. was to evaluate the utility of fatty acids found in pracaxi oil for wound and scar therapy. Initially, 21 patients with various surgical, traumatic, or burn wounds and scars were enrolled. A topical anhydrous silicone base containing pracaxi oil was applied alone or was compounded to include one or more additional medications tailored to the specific needs of each patient, such as 1% pentoxifylline, 1% caffeine, 1% tranilast, or 2% mupirocin. Patients were advised to apply the compounded topical medication to new or existing scar or wound areas by lightly massaging the compound into and around the scar or wound. The recommended application frequency was two to four times daily based on the attributes of the scar or wound. The mean duration of application of the compounded topical anhydrous base containing pracaxi oil was 11 days and ranged from 48 hours to 3 weeks based on the size and severity of the wound or scar.

The study found that the application of a compounded anhydrous silicone base containing pracaxi oil alone or in combination with other active substances led to considerable improvements in wound healing and scar attributes and is a potentially useful option in the treatment of burns or surgical, or traumatic wounds and scars.

Dermatol Ther (Heidelb). 2014 Dec;4(2):259-69.

Case series: the effectiveness of Fatty acids from pracaxi oil in a topical silicone base for scar and wound therapy.

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Topical Curcumin: A Review of Mechanisms and Uses in Dermatology

Curcumin is the active ingredient in the spice turmeric. While the effectiveness of oral curcumin is hindered by low bioavailability due to poor absorption by the oral route, this is not the case for topical curcumin.

Curcumin’s anti-inflammatory and anti-apoptotic activity is based on its inhibition of the enzyme phosphorylase kinase. Phosphorylase kinase is released within 5 minutes after injury. By inhibiting phosphorylase kinase in the injury pathway, curcumin blocks the activation of NF-kB, the transcription activator responsible for activating genes related to proliferation of inflammatory cells (T cells and macrophages), cell migration, cell cycling, epidermal proliferation, and fibroblast proliferation. Therefore, treatment with topical curcumin may reduce scarring and keloid formation. Apoptosis may allow more rapid replacement of the injured cells by normal healthy cells and may assist with wound healing. Following treatment with topical curcumin, more rapid healing has been observed in traumatic wounds, burns, and sun-damaged skin.

Low aqueous solubility, poor tissue absorption, rapid metabolism and short plasma half-life have made oral curcumin unsuitable for systemic administration for wound healing. Therefore, the therapeutic potential of topical curcumin appears to be more promising than that of oral curcumin. Recently, various topical formulations of curcumin such as films, fibers, emulsion, hydrogels and different nanoformulations have been developed for targeted delivery of curcumin at wounded sites.

Topical curcumin has been shown to benefit conditions associated with skin injury and inflammation, including surgical scars, psoriasis, rosacea, sunburn and acne. Topical curcumin has also been found to be effective in decreasing the markers of lactational mastitis in breastfeeding women such as pain, breast tension and erythema within 72 hours of administration.

While there are other anti-inflammatory medications available, e.g. topical corticosteroids, the therapeutic benefit of topical curcumin lies in the general safety of the substance and the absence of observable side effects.

Int J Dermatol Clin Res 3(1):010-017.

Topical Curcumin: A Review of Mechanisms and uses in Dermatology

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Drug Discov Today. 2017 Oct;22(10):1582-1592.

Curcumin and its topical formulations for wound healing applications.

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Oman Med J. 2014 Sep;29(5):330-4.

Effectiveness of topical curcumin for treatment of mastitis in breastfeeding women: a randomized, double-blind, placebo-controlled clinical trial.

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Novel Scar Therapies

Verapamil exhibits anti-proliferative properties that reduce collagen deposits and promotes scar tissue breakdown by increasing collagenase production. Another often used drug is pentoxifylline. In vitro, pentoxifylline inhibits the production of collagen; topical application improves blood flow and elasticity of scar tissue. Other agents used in scar therapy include: imiquimod 5% (immune-response modifier and Toll-like receptor (TLR) agonist), hyaluronic acid (corporal lubricant), and tranilast (suppresses collagen synthesis by fibroblasts). With so many options available, the key is to work closely with our compounding pharmacist to find the preparation that will work best for your patient’s skin type, scar location, and stage of healing. Medications may be compounded into a cream, ointment, or gel base. Several studies show the benefits of a silicone gel base in the treatment of scars. The mechanism by which silicone aids in scar healing is not well understood. One possible role is the creation of a physical barrier to prevent water loss through damaged scar tissue. It is thought that promoting hydration and proper temperature and oxygen transmission creates an environment conducive to healing. In one study, a total of 36 post-operative patients applied silicone gel twice daily resulting in statistically significant improvements in scar height, pain, pigmentation, pliability, pruritus and vascularity.

Dermatol Ther (Heidelb). 2013 Dec;3(2):157-67.

Efficacy and safety of an advanced formula silicone gel for prevention of post-operative scars.

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Jpn J Pharmacol. 1992 Oct;60(2):91-6.

The mechanism involved in the inhibitory action of tranilast on collagen biosynthesis of keloid fibroblasts.

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J Am Acad Dermatol. 2006 Dec;55(6):1024-31.

Topical treatments for hypertrophic scars.

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Burns. 2014 Nov;40(7):1255-66.

Up-to-date approach to manage keloids and hypertrophic scars: a useful guide.

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Silicone Gel for Treatment of Fresh Surgical Scars

A randomized controlled trial studied 110 patients (55 men, 55 women) who had undergone outpatient surgery at the Department of Dermatology, University of Florence. The patients were divided into two groups: a treatment group (group A) and a control group (group B). Subjects (n = 65) in group A were prescribed silicone gel to be applied to the wound twice a day for 60 days after the removal of stitches. Subjects (n = 45) in group B were prescribed the use of zinc oxide cream. All subjects, in both study and control groups, were examined by the same dermatologists every month for 3 months after surgery, then every 2 months for a total follow-up of 8 months from the date of surgery. In the treatment group, only 18 patients (27%) had formation of a non-physiological scar: diastasic scar in 10 patients (15%), hypertrophic scar in 6 (9%) and atrophic scar in 2 (3%). No keloid scars were recorded. In the control group, 25 (55%) had an altered scar: keloid scars in 5 patients (11%), hypertrophic scar in 10 (22%), diastasic scar in 8 (18%) and atrophic scar in 2 (4%). The results of this study indicate that silicone gel is able to reduce the formation of keloid and hypertrophic scars and the signs/symptoms associated with the healing process (paraesthesia, pulling sensation, alterations in color).

Clin Exp Dermatol. 2009 Aug;34(6):688-93.

The use of silicone gel in the treatment of fresh surgical scars: a randomized study.

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EGCG for Wound Healing and Scar Prevention

EGCG (the polyphenols in green tea) may potentially accelerate the wound-healing process and prevent scarring. This potential benefit is particularly exciting for people with conditions such as diabetes, which inhibits the wound-healing process.

Green Tea Linked To Skin Cell Rejuvenation.

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Br J Plast Surg 1998 Sep;51(6):462-9

Topical tamoxifen–a potential therapeutic regime in treating excessive dermal scarring?

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Topical anesthesia is needed for common procedures such as suturing, wound cleaning, and injection administration. The ideal topical anesthetic would provide complete anesthesia following a simple pain-free application, not containing narcotics or controlled substances, and have an excellent safety profile. The combination of topical anesthetics lidocaine and tetracaine and the vasoconstrictor epinephrine has been used successfully for anesthesia prior to suturing linear scalp and facial lacerations in children. A triple-anesthetic gel containing benzocaine, lidocaine, and tetracaine (“BLT”) has also been reported to be effective when applied prior to laser and cosmetic procedures. Convenience of application without the need for occlusion is an advantage of these topical anesthetics. The following article concludes: “LAT gel (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) worked as well as TAC gel (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) for topical anesthesia in facial and scalp lacerations. Considering the advantages of a noncontrolled substance and less expense, LAT gel appears to be better suited than TAC gel for topical anesthesia in laceration repair in children.”

Pediatrics 1995 Feb;95(2):255-8

Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years.

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The following article reported that a triple-anesthetic gel containing benzocaine, lidocaine, and tetracaine (“BLT”) applied prior to treatment with a 532-nm KTP laser resulted in significantly lower pain scores than with 3 other topical anesthetics at 15, 30, 45, and 60 minutes after application.

Cosmetic Dermatology 2003 Apr;16(4):35-7

Topical Triple-Anesthetic Gel Compared With 3 Topical Anesthetics

Topical Metformin: Therapy Against Skin Photodamage

Excessive inflammation and cell death induced by ultraviolet (UV) cause skin photodamage (premature aging). Topical metformin possesses anti-inflammatory and cytoprotective effects and can inhibit inflammation and cell death in UVB-induced acute skin damage. Cell viability and cell death of keratinocytes were evaluated upon UVB irradiation in the presence or absence of metformin. Topical metformin 0.6% cream was applied topically on UVB-irradiated mice, and the cream alleviated UVB-induced skin damage. These findings indicate the potential value of metformin topical therapy against skin photodamage.

J Dermatol Sci. 2021 Apr; 102(1):25-35.

Possible treatment for UVB-induced skin injury: Anti-inflammatory and cytoprotective role of metformin in UVB-irradiated keratinocytes

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Topical EGCG Ameliorates Radiation-Induced Acute Skin Damage in Breast Cancer Patients

There are few effective treatment options for radiation-induced dermatitis in breast cancer patients. Despite technological advances, acute radiation skin toxicity (ARST) is the most common side effect of breast cancer radiotherapy, occurring in more than 90% of patients. Complications such as pain, discomfort, irritation, itching, and burning-feeling may cause restriction in movement, unplanned treatment interruptions, and a decreased chance of receiving an effective dose. These issues might reduce patients’ survival rates, as well as their quality of life.

Epigallocatechin-3-gallate (EGCG) facilitates the healing process in ultraviolet radiation-induced erythema in human skin. It has been demonstrated that EGCG enhances viability of human skin cells and decreases apoptosis induced by X-ray irradiation. The study suggests topical EGCG may be an effective treatment for radiation-induced dermatitis and has acceptable toxicity.

Oncotarget. 2016 Jul 26;7(30):48607-48613.

Epigallocatechin-3-gallate ameliorates radiation-induced acute skin damage in breast cancer patients undergoing adjuvant radiotherapy.

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Topical Melatonin: Protective Effects Against UV Radiation

Ultraviolet (UV) radiation is the main etiologic factor for skin cancer. The endogenous hormone melatonin has been proposed to have protective effects against sunlight and topically-applied melatonin has a protective effect against UV-induced erythema. Four human studies and 16 experimental studies evaluated melatonin’s protective effect against UVR-induced damage to cellular structures and pathways. Melatonin acts directly as an antioxidant, and indirectly by regulating gene expression and inducing a DNA stabilizing effect. The destructive effects of the UVR are significantly counteracted or modulated by melatonin in the context of a complex intracutaneous melatoninergic anti-oxidative system with UVR-enhanced or UVR-independent melatonin metabolites. Therefore, endogenous intracutaneous melatonin production, together with topically-applied exogenous melatonin or metabolites would be expected to represent one of the most potent anti-oxidative defense systems against UV-induced damage to the skin. Treatment of the skin with melatonin 15 minutes before UV irradiation proved to almost completely suppress the development of UV-induced erythema. In contrast, no significant protective effects of melatonin were observed when it was applied after UV irradiation. Free radical scavenging of UV-generated hydroxyl radicals and interference with the arachidonic acid metabolism are possible mechanisms of the melatonin action.

Following topical application of 0.1% melatonin solution, plasma melatonin levels increased but did not exceed the physiological night peak.

Photodermatol Photoimmunol Photomed. 2014 Aug;30(4):180-8.

Melatonin’s protective effect against UV radiation: a systematic review of clinical and experimental studies.

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Int J Mol Sci. 2014 Sep 30;15(10):17705-32.

Local melatoninergic system as the protector of skin integrity.

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Dermatology. 1997;195(3):248-52.

Suppression of UV-induced erythema by topical treatment with melatonin (N-acetyl-5-methoxytryptamine). Influence of the application time point.

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Br J Dermatol. 2004 Feb;150(2):341-5.

Melatonin increases anagen hair rate in women with androgenetic alopecia or diffuse alopecia: results of a pilot randomized controlled trial.

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Cosmeceuticals for Aging Skin

Skin aging includes intrinsic and extrinsic processes, with cell damage caused by metabolic processes, free radicals, and cosmic irradiation. Topical and oral administration of antioxidants such as vitamins E and C, coenzyme Q10, alpha-lipoic acid, and glutathione enhance anti-aging effects. Other antioxidants such as green tea, dehydroepiandrosterone, melatonin, selenium, and resveratrol, have also age management and anti-inflammatory effects. Topical bleaching agents such as hydroquinone, kojic acid, and azelaic acid can help reduce signs of aging. Studies confirm the efficacy of these topical agents in combination with superficial and/or medium depth or deep peeling agents for photodamaged skin treatment. Based on individual patient needs, preparations may also contain retinoids, hydroxy acids, bleaching agents, moisturizers, and sunscreens.

Coll Antropol. 2010 Sep;34(3):1145-53.

Modern approach to topical treatment of aging skin.

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Topical Palmitoyl Pentapeptide Provides Improvement in Photoaged Human Facial Skin

Palmitoyl pentapeptide is a synthetic topical agent designed to stimulate collagen production and thus provide a skin anti-wrinkle benefit. To determine if palmitoyl pentapeptide is effective, a clinical study was conducted with 93 Caucasian female subjects, aged 35-55. They participated in a 12-week, double-blind, placebo-controlled, split-face, left-right randomized clinical study assessing two topical products: moisturizer control product vs. the same moisturizer product containing 3 ppm palmitoyl pentapeptide. Palmitoyl pentapeptide was well tolerated by the skin and provided significant improvement vs. placebo control for a reduction in wrinkles/fine lines by both quantitative technical and expert grader image analysis. In self-assessments, subjects also reported significant fine line/wrinkle improvements and noted directional effects for other facial improvement parameters.

Int J Cosmet Sci. 2005 Jun;27(3):155-60.

Topical palmitoyl pentapeptide provides improvement in photoaged human facial skin.

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Topically applied antioxidants exert their benefits by offering protection from damaging free radicals produced when skin is exposed to ultraviolet light or allowed to age naturally. Appropriate formulation and use which is supervised by a knowledgeable healthcare professional will maximize the benefits while minimizing any potential side effects of these therapies.

Biofactors 1999;9(2-4):371-8

Coenzyme Q10, a cutaneous antioxidant and energizer.

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Coenzyme Q10 (ubiquinone, CoQ10) is an important antioxidant that is taken to strengthen immune and cardiac function. The processes of aging and photoaging of the skin (due to sunlight) are associated with an increase in cellular oxidation, which may occur as the body’s own levels of CoQ10 decline. A reduction in wrinkle depth was shown following topical application of CoQ10 0.3%, and results indicated that CoQ10 has the efficacy to prevent many of the detrimental effects of photoaging. Wrinkles around the region of the eyes (“crow’s feet”) may be reduced by long-term application of CoQ10.

Z Gerontol Geriatr 1999 Apr;32(2):83-8

Modulation of oxidative stresses in human aging skin

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Vitamin C has been incorporated into a variety of cosmeceuticals designed to protect and rejuvenate photoaged skin. Ascorbyl Palmitate (Vitamin C Ester) is a lipid soluble, neutral pH, non-acidic (thus, non-irritating and non-stinging) form of Vitamin C which can reach cells within the skin rapidly in amounts greater than can be achieved by water soluble Vitamin C (L-Ascorbic Acid).

Dermatol Surg. 2005 Jul;31(7 Pt 2):814-7

Topical vitamin C: a useful agent for treating photoaging and other dermatologic conditions.

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Alpha Lipoic Acid (ALA) is a powerful antioxidant and scavenger with anti-inflammatory properties that promotes optimum efficiency for production of energy and removal of intracellular waste products, essential for cellular healing and elimination of wrinkles and facial scars. Twelve weeks of treatment with a cream containing 5% ALA improves clinical characteristics related to photoaging of facial skin.

Br J Dermatol. 2003 Oct; 149(4): 841-9

Randomized, placebo-controlled, double-blind study on the clinical efficacy of a cream containing 5% alpha-lipoic acid related to photoageing of facial skin.

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Topical niacinamide 5% (vitamin B3) reduces yellowing, wrinkling, red blotchiness, and hyperpigmented spots in aging facial skin.

Int J Cosmet Sci. 2004 Oct;26(5):231-8.

Topical niacinamide reduces yellowing, wrinkling, red blotchiness, and hyperpigmented spots in aging facial skin.

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Topical 2% progesterone increases elasticity and firmness in the skin of peri- and postmenopausal women.

Br J Dermatol. 2005 Sep;153(3):626-34.

Effects and side-effects of 2% progesterone cream on the skin of peri- and postmenopausal women: results from a double-blind, vehicle-controlled, randomized study.

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DMAE (2-dimethylaminoethanol, deanol), when applied topically to the skin, may improve the appearance of sagging skin, boost the effects of other antioxidants, increase smoothness, reduce fine lines and give facial muscles a leaner look. In a randomized clinical study, 3% DMAE facial gel applied daily for 16 weeks has been shown to be safe and efficacious in the mitigation of forehead lines and periorbital fine wrinkles, and in improving lip shape and fullness and the overall appearance of aging skin.

Br J Dermatol. 2007 Mar;156(3):433-9.

The antiwrinkle effect of topical concentrated 2-dimethylaminoethanol involves a vacuolar cytopathology.

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Am J Clin Dermatol. 2005;6(1):39-47.

The role of dimethylaminoethanol in cosmetic dermatology.

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Antioxidants such as vitamins E and C, coenzyme Q10, alpha-lipoic acid, glutathione, and others can help reduce signs of aging.

Acta Dermatovenerol Alp Panonica Adriat. 2008 Jun;17(2):47-54.

Skin aging.

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Alpha-lipoic acid (ALA) 0.5% and proanthocyanidin (PA) 0.3% administered transdermally in a cosmetic formulation supplemented with 2% benzyl alcohol as a penetration enhancer, significantly enhanced collagen synthesis and deposition.

Connect Tissue Res. 2005;46(4-5):251-7.

Transdermal delivery of amino acids and antioxidants enhance collagen synthesis: in vivo and in vitro studies.

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Topical Application of Phytonadione, Retinol and Vitamins C and E to Reduce Infraorbital Dark Circles and Wrinkles of the Lower Eyelids

Infraorbital dark circles and wrinkles of the lower eyelids are cosmetic problems that worsen with age. Fifty-seven healthy adult volunteers with dark under-eye circles and wrinkles were enrolled in an open label study to determine whether a gel containing 2% phytonadione, 0.1% retinol and 0.1% vitamins C and E is effective in reducing dark under-eye circles and wrinkles of the lower eyelids. The gel formulation was applied twice daily to the lower eyelid site for 8 weeks. Hemostasis, pigmentation and wrinkles were evaluated by a physician and by the patients after 4 and 8 weeks of treatment. Topical application of the gel decreased not only hemostasis but also wrinkles after 8 weeks of treatment. Of 57 patients, 27 (47%) had reductions in hemostasis. However, pigmentation was not clearly removed by this gel.

J Cosmet Dermatol. 2004 Apr;3(2):73-5

The effects of topical application of phytonadione, retinol, and vitamins C and E on infraorbital dark circles and wrinkles of the lower eyelids.

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Protection and Reversal of Photodamage with Topical Antioxidants

Topical vitamins C and E, as well as topical selenium, protect skin against sunburn, suntan and skin cancer and also reverse the mottled pigmentation and wrinkles of photoaging. However, only certain forms of these antioxidants are stable and active after percutaneous absorption. Benefits of topical application are that the skin attains far higher levels of each antioxidant than can be achieved by taking these vitamins orally and topical application arms the skin with a reservoir of antioxidants that cannot be washed or rubbed off, protecting the skin for several days after application.

J Cosmet Dermatol. 2004 Jul;3(3):149-55

Photodamage of the skin: protection and reversal with topical antioxidants.

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Topical application of niacinamide (such as in a 2% cream) has a stabilizing effect on epidermal barrier function, seen as a reduction in transepidermal water loss and an improvement in the moisture content of the horny layer, and it may be used as a treatment adjunct in atopic dermatitis. In aging skin, topical application of niacinamide improves the surface structure and pigmentary disorders, smoothes out wrinkles, and inhibits photocarcinogenesis.

Cutis 2006 Jan;77(1 Suppl):11-6.

Pharmacologic doses of nicotinamide in the treatment of inflammatory skin conditions: a review.

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Int J Dermatol 2005 Mar;44(3):197-202.

Moisturizing effects of topical nicotinamide on atopic dry skin.

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J Cosmet Dermatol 2004 Apr;3(2):88-93

Nicotinic acid/niacinamide and the skin.

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Niacinamide can be combined with other active ingredients such as DMAE, sodium hyaluronate, benzoyl peroxide, or metronidazole in a customized medication that can be used as anti-wrinkle or age management therapy or to treat acne or rosacea.

Br J Dermatol. 2003 Oct; 149(4): 841-9

Randomized, placebo-controlled, double-blind study on the clinical efficacy of a cream containing 5% alpha-lipoic acid related to photoaging of facial skin.

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Estrogen Therapy to Prevent or Reverse Skin Aging

Declining estrogen levels are associated with a variety of cutaneous changes, many of which can be reversed or improved by topical or systemic estrogen supplementation. Studies of postmenopausal women indicate that estrogen deprivation is associated with declining dermal collagen content, diminished elasticity and skin strength, loss of moisture in the skin, epidermal thinning, atrophy, fine wrinkling, and impaired wound healing. Keratinocytes, Langerhans’ cells, melanocytes, sebaceous glands, collagen content, and the synthesis of hyaluronic acid are under hormonal influence. Estrogen may attenuate inflammation in psoriatic lesions. Alone or together with progesterone, estrogen prevents or reverses skin atrophy, dryness, and wrinkles associated with chronological or photo-aging. Estrogen and progesterone stimulate the proliferation of keratinocytes while estrogen suppresses apoptosis and thus prevents epidermal atrophy. Estrogen maintains skin moisture by increasing acid mucopolysaccharide or hyaluronic acid levels in the dermis and accelerates cutaneous wound healing. Low estrogen levels that accompany menopause exacerbate the deleterious effects of both intrinsic and environmental aging. Estrogens clearly have a key role in skin aging homeostasis as evidenced by the accelerated decline in skin appearance seen in the perimenopausal years. At Yale University School of Medicine, the effects of long-term hormone replacement therapy (HRT) on skin rigidity and wrinkling at 11 facial locations were assessed using the Lemperle scale by a plastic surgeon who was blinded to HRT use. Skin rigidity at the cheek and forehead was measured with a durometer. Demographics including age, race, sun exposure, sunscreen use, tobacco use, and skin type were similar. Rigidity was significantly decreased in HRT users compared to nonusers at both the cheek and forehead. Average wrinkle scores were lower in hormone users than in nonhormone users. The study concluded that long-term postmenopausal HRT users have more elastic skin and less severe wrinkling than women who never used HRT, suggesting that hormone therapy may have cosmetic benefits. In another study, the dermal collagen of 15 postmenopausal women who had received systemic estrogen replacement was analyzed before and after using a topical 0.01% estrogen treatment. Epithelial and dermal thickness improved after topical estrogen therapy. Facial skin collagen significantly increased after 16 weeks of treatment. Systemic estrogen levels did not significantly increase after topical therapy.

Dermatol. 2004;13 Suppl 4:36-40

Skin aging and sex hormones in women — clinical perspectives for intervention by hormone replacement therapy.

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Exp Dermatol. 2006 Feb;15(2):83-94

Biology of estrogens in skin: implications for skin aging.

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J Am Acad Dermatol. 2005 Oct;53(4):555-68; quiz 569-72

Estrogen and skin: the effects of estrogen, menopause, and hormone replacement therapy on the skin.

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Fertil Steril. 2005 Aug;84(2):285-8

Long-term effects of hormone therapy on skin rigidity and wrinkles.

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Am J Clin Dermatol. 2003;4(6):371-8

Skin aging and menopause: implications for treatment.

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Am J Clin Dermatol. 2001;2(3):143-50

Estrogen and skin. An overview.

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J Dermatol Sci. 2005 Apr;38(1):1-7

Regulatory roles of sex hormones in cutaneous biology and immunology.

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A low-dose, topical gel form of diclofenac sodium has been developed in Europe for pain relief and reduction of redness after sunburn.

Eur J Dermatol. 2004 Jul-Aug;14(4):238-46

The efficacy and safety of low-dose diclofenac sodium 0.1% gel for the symptomatic relief of pain and erythema associated with superficial natural sunburn.

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Pramoxine Reduces Uremic Pruritus

Wake Forest University School of Medicine conducted a randomized, double-blind, controlled comparative trial in a community hemodialysis center to evaluate the efficacy of 1% pramoxine hydrochloride lotion versus control lotion in the treatment of uremic pruritus in adult hemodialysis patients. Pramoxine 1% lotion was applied twice daily to all affected areas of pruritus for 4 weeks, resulting in a 61% decrease in itch intensity. “This safe, convenient and effective topical lotion may potentially benefit the large number of patients affected by pruritus associated with end-stage renal disease.”

J Dermatolog Treat. 2008 Sep 24:1-5.

A pramoxine-based anti-itch lotion is more effective than a control lotion for the treatment of uremic pruritus in adult hemodialysis patients.

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The following studies evaluated a topical formulation of 1% naltrexone to treat patients with localized and generalized atopic dermatitis with severe itching, and more than 70% of patients using the 1% naltrexone cream experienced a significant reduction of pruritus.

J Cutan Med Surg. 2005 Oct;9(5):215-6

Successful treatment of refractory aquagenic pruritus with naltrexone.

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Itching Relieved with Topical Naltrexone

Pruritus is a very common and distressing skin problem. More than 70% of patients with localized and generalized atopic dermatitis with severe itching who used topical naltrexone 1% cream experienced a significant reduction of pruritus.

J Am Acad Dermatol. 2007 Jun;56(6):979-88

Treatment of pruritus with topically applied opiate receptor antagonist.

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Aquagenic pruritus is an intense prickling sensation that develops in affected individuals immediately after contact with water at any temperature. Endogenous opiates, like naltrexone, can modify pruritus by influencing the peripheral and central sensation of itch, and have been found to be successful in suppressing the perception of pruritus from many diverse origins including aquagenic pruritus.

J Cutan Med Surg. 2005 Oct;9(5):215-6

Successful treatment of refractory aquagenic pruritus with naltrexone

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Combination Antimicrobial, Steroid, Moisturizer for Atopic Dermatitis (AD/Eczema)

Atopic dermatitis (AD, eczema) often affects adults, especially those over 70 years of age. AD is characterized by pruritus, impaired skin barrier, and dysbiosis. Guidelines concur that moisturizers to improve barrier function and topical corticosteroids to reduce inflammation and itch are of central importance in AD therapy, but there is disagreement regarding the use of topical antimicrobials. The American Academy of Dermatology concludes that topical antimicrobials are generally not recommended, whereas the Joint Task Force states that an anti-inflammatory agent combined with an antiseptic may help patients colonized with Staphylococcus aureus. This recommendation has important implications given that approximately 70% of lesional skin is colonized with S. aureus and that colonization is correlated with disease severity. S. aureus colonization precedes AD flares, impedes skin barrier, and may drive inflammation.

Physicians from Brown University, in Providence, RI, and Northwestern University, Chicago, evaluated the degree of improvement in the severity and extent of AD lesions after using a compounded antibacterial (mupirocin), steroid (betamethasone valerate), and moisturizer (vanishing cream base) combination (CASM). This was a nonblinded retrospective review of 116 patients with AD. Multiple patients in the study had previously failed mid- or higher-potency topical steroids, systemic immunosuppressives, or phototherapy. Patients were instructed to apply the compound four times daily to the affected areas for the first 5 to 7 days, twice daily for the next 3 to 5 days, and then once daily if needed to any remaining areas for up to 1 week. They were asked to stop the medication when their symptoms cleared but could restart if they experienced a flare-up. Patients were assessed at baseline and at one follow-up visit, with an average follow-up period of 49.5 days.

Despite using a weaker steroid, almost 70% of the patients previously taking medium-potency steroids or stronger responded to CASM. Although CASM was applied more frequently than traditional therapy, the simplified treatment regimen facilitated compliance. The physicians concluded CASM may offer additional benefits for patients who have plateaued with standard therapies.

“In summary, CASM appears to be an innovative approach to treating AD, including refractory cases. With a sound scientific rationale and relatively limited safety concerns, CASM warrants further study for the treatment of AD.”

Pediatric Dermatology Vol. 34 No. 3 322–325, 2017

Case Series Study of the Efficacy of Compounded Antibacterial, Steroid, and Moisturizer in Atopic Dermatitis

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Results from this study indicate that coal tar can be maintained as a safe treatment in dermatological practice.

J Invest Dermatol. 2010 Apr;130(4):953-61.

No increased risk of cancer after coal tar treatment in patients with psoriasis or eczema.

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Two double-blind, randomized, clinical evaluations were conducted to investigate the anecdotal belief that tachyphylaxis occurs in long-term treatment of scalp seborrheic dermatitis and dandruff when using a single pyrithione zinc-based product. Evaluation of data showed a consistent benefit for all products at all time points; therefore, no evidence of decreased benefit over time was found within 48 weeks of treatment.

Int J Dermatol. 2009 Jan;48(1):79-85.

Does tachyphylaxis occur in long-term management of scalp seborrheic dermatitis with pyrithione zinc-based treatments?

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Traditionally used in an ointment vehicle for psoriasis, clobetasol propionate 0.05% is also available in spray, foam, lotion, and shampoo formulations, which may provide for improved convenience and acceptance with similar efficacy, safety, and tolerability as the traditional ointment and cream formulations. For patients who prefer a less messy vehicle, adherence and outcomes are likely to be better with the formulations other than the traditionally recommended ointment.

Am J Clin Dermatol. 2009;10(6):397-406.

Topical clobetasol propionate in the treatment of psoriasis: a review of newer formulations.

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Topical vitamin B12 offers a new therapeutic approach for eczema (atopic dermatitis) and psoriasis and may be suitable for long-term therapy as no long-term adverse effects have been reported.

British Journal of Dermatology 2004; 150: 977-983.

Topical vitamin B12–a new therapeutic approach in atopic dermatitis-evaluation of efficacy and tolerability in a randomized placebo-controlled multicenter clinical trial.

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Dermatology 2001;203:141-147

Vitamin B(12) cream containing avocado oil in the therapy of plaque psoriasis.

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Salicylic acid has been used alone as a treatment for psoriasis but is most commonly used to increase the penetration of other topical preparations, primarily corticosteroids. In this small study, the use of 6% salicylic acid gel in conjunction with tacrolimus ointment showed statistically significant improvement for the treatment of plaque psoriasis compared with the use of salicylic acid alone.”For patients with localized psoriasis, and for many of those with moderate psoriasis as well, the mainstay of treatment is still topical therapy. The quality of life is greatly affected in such patients, and they often express high levels of dissatisfaction with current treatment options. Safe, convenient, and effective topical regimens, such as combination therapy with topical tacrolimus and salicylic acid, can be of great benefit in this large population.”

Arch Dermatol. 2005 Jan;141(1):43-6.

Topical tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis treatment.

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“Methotrexate has been used as an effective systemic chemotherapeutic drug for psoriasis by dermatologists for over 30 years. Nevertheless, pharmacokinetic data indicate that oral methotrexate can cause a decrease in red and white blood cell and platelet counts and can also cause severe liver damage, diarrhea, and stomach irritation, as dose-related drug-induced side effects. Such indications have limited its prescription by physicians. However, [Syed and Nordstrom of the Department of Dermatology, University of California-San Francisco, and researchers from three other locations note that] if its incorporation in a gel as a topical agent, in a proper dosage. imparts better results without the cited side effects, then such a formulation appears to justify a clinical evaluation. Furthermore, published data have indicated that 70% of patients prefer topical therapy for treating psoriasis.”

This article concludes: “methotrexate 0.25% in a hydrophilic gel is well tolerated and significantly more effective than placebo as a patient-applied topical medication to treat psoriasis vulgaris.”

J Cutan Med Surg 2001; 299-302

Management of psoriasis vulgaris with methotrexate 0.25% in a hydrophilic gel: a placebo-controlled, double-blind study.

Click here to view the PubMed abstract for this article.

This article concludes: “Methotrexate 0.25% in a hydrophilic gel is well tolerated but is not very effective in controlling the lesions of psoriasis on the palms and soles; however, a higher concentration in a different base with better penetration could possibly provide better results.”

J Dermatol 2004 Oct;31(10):798-801

Topical 0.25% methotrexate gel in a hydrogel base for palmoplantar psoriasis.

Click here to access the PubMed abstract of this article.

Tiwari, Kumar, et al. published a case report of topical methotrexate delivered by iontophoresis for the treatment of recalcitrant palmoplantar psoriasis. In a 46 y.o. male with well-defined bilateral palmar plaques of 6 years duration which were resistant to several therapies, the right palm was treated, as it had more severe lesions. Iontophoresis was performed using cotton gauze soaked in 4 to 6 ml of methotrexate disodium solution 10 mg/ml, once a week for four weeks. The researchers reported 75% improvement after four weeks of therapy. Iontophoresis allows high concentrations of drug to be delivered to a limited area and may offer a method of reducing total drug accumulation and reduced side effects.

Int J Dermatol. 2003 Feb;42(2):157-9

Topical methotrexate delivered by iontophoresis in the treatment of recalcitrant psoriasis–a case report.

Click here to view the citation for this article.

The following list is just a few of the preparations that we can compound for dermatology. We work together with practitioners and patients to solve medication challenges. All formulations are customized per prescription to meet the unique needs of each patient. Therapeutic results depend not only on the selection of drug, but also the use of a proper base and preparation technique. Please contact our compounding pharmacist to discuss the dosage form, strength, and medication or combination that is most appropriate for your patient.

• Alpha Lipoic Acid cream
• “BLT” gel (benzocaine, lidocaine, and tetracaine)
• Cholestyramine ointment
• 2-Deoxy D-Glucose (2-DDG) in various dosage forms such as creams, lip balms, and oral rinses
• Dapsone cream
• KOH solution – 5% and 10%
• Kojic Acid, Hydroquinone, Retinoic Acid gel
• Pseudocatalase cream
• Tamoxifen topical
• Trichloroacetic Acid/Lactic Acid/Azelaic Acid topical solution
• Urea 40% ointment