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Chapter 6: Principles of Management

Lindsey M. Voller; Ingrid C. Polcari; Carol Soutor

INTRODUCTION TO CHAPTER

Most of the common skin disorders can be treated with a formulary of generic, widely available topical and oral medications. Several medicinal products are over the counter including those used for fungal and bacterial infections, acne, urticaria, pruritus, and head lice. Topical medications are effective for most common skin disorders and they have fewer serious adverse side effects when compared to their oral counterparts. Oral medications may be needed if a skin disease is widespread or more severe.

There are several things to consider before prescribing a topical product such as the vehicle, quantity to dispense, and cost.

VEHICLE SELECTION

The vehicle of a topical product may be as important as the active ingredient. Table 6-1 lists commonly used vehicles. "If it's dry, wet it and if it's wet, dry it" is still a good general guideline for the treatment of common dermatoses. Most skin disorders, especially the chronic dermatoses (e.g., psoriasis, chronic contact dermatitis) are "dry"; therefore, ointments are preferred as they are more moisturizing. Also, ointments do not contain preservatives which can cause stinging and burning. The main problem with ointments, especially in adults, is that they are greasy and can stain clothing and bedding. Creams are a good option for the "wet" dermatoses, such as acute contact dermatitis, and other blistering or exudative dermatoses. They are also a good option for adults who don't want to use an ointment. However, some cream preparations are slightly drying and preservatives and other ingredients may sting or burn.

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Table 6-1. Vehicles for topical products.
Vehicle Formulation Indications
Ointment 80% oil and 20% or less water, petroleum jelly base, greasy, no preservatives, effective at moisturizing skin. May stain paper, clothing, and bedding. Best choice for most "dry," thick, lichenified, or fissured dermatoses (e.g., atopic dermatitis and psoriasis), doesn't sting.
Cream Oil and 20%–80% water emulsion, moderate moisturizing effects, some residue, contains preservatives. Acute dermatitis and cases in which ointments are not tolerated (e.g., hot, humid climate, intertriginous skin, and cosmetic concerns).
Lotion Similar to cream with more water and lower viscosity, spreads easily, minimal residue, and contains preservatives. Used in many moisturizers and sunscreens, cosmetically acceptable.
Gel Transparent base that liquefies on contact with skin, residue minimal, but may be shiny, drying. Best choice for hair bearing areas, cosmetically acceptable. Often used for acne and rosacea medications.
Solution Low viscosity, transparent, base of water and or alcohol, very drying, evaporates quickly leaving no residue. Best for use in scalp dermatoses, too drying and irritating for use on other body areas.
Foam Leaves minimal residue, may be drying. Usually used in hair bearing areas.
Powder Talc-based, drying, decreases frictional forces in intertriginous areas. Good choice for body fold areas and feet.

QUANTITY TO DISPENSE

The quantity of medication to be ...

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