Dermatology
Dermatologists, physicians, healthcare professionals and patients encounter numerous problems that may be helped with customized medications at MedLife Pharmacy & Compounding:
- Acne
- Psoriasis
- Eczema
- Rosacea
- Sunburn
- Hair loss
- Fever blisters
- Plantar Warts
- Warts and molluscum
- Fungal and viral infections
- Wrinkles and photoaged skin
- Pigmentation abnormalities
- Plant irritations (poison ivy, etc)
- Traumatized or diseased nails
- Head lice and Scabies
- Scarring and Keloids
When you have a problem that is difficult to treat, or if you are concerned about medication side-effects, call our professional compounding pharmacist. We can create customized formulations that contain the needed medications in the most appropriate vehicle to efficiently deliver the drug to the affected area.
Proper preparation is as important as drug selection. Our compounding pharmacy utilizes state-of-the-art equipment to create a formulation containing particles that are fine enough to be absorbed, and penetration enhancers are added when appropriate. We offer a choice of bases to facilitate the proper extent of absorption
Cosmetically appealing preparations
Compounding pharmacists continue to develop new bases to improve both the aesthetic and therapeutic aspects of compounded medications. For example, anhydrous gels deliver medications which facilitate rapid absorption of the active ingredient into the skin and prolonged retention of the drug in the stratum corneum and epidermis, with minimal systemic transport of active drug. This cosmetically appealing gels are very stable and well-accepted by patients. Ask us about hypoallergenic preparations.
Topical Anesthetics
The rapid proliferation of laser and cosmetic procedures has made adequate analgesia necessary for patient comfort and tolerability of optimal treatment settings necessary for maximal results.” The ideal topical anesthetic would have a rapid onset of activity and a high safety profile. Triple anesthetic gel “containing permeation enhancers can provide effective cutaneous anesthesia as early as 15 minutes after application without occlusion.” Use of a topical vitamin K cream after laser treatment can reduce the severity of bruising.
Barrier Creams
Barrier creams containing special base, can have medications such as cholestyramine which can be formulated to minimize the development of contact dermatitis, as part of skin care protocol, incontinence or to treat severe diaper rash.
Therapies for resistant problems
- We can compound customized formulations which contain numerous medications to provide a synergistic effect for treatment of resistant acne.
- Specific therapies are available for recalcitrant viral warts and molluscum contagiosum.
- Immunotherapy can be compounded to treat alopecia.
- Topical tamoxifen has potential as a novel therapeutic agent to treat abnormal dermal scarring.
- Topical treatment with sodium cromoglycate can be used as adjunctive or sole treatment for pyoderma gangrenosum.
- The natural antiviral 2-deoxy-D-glucose (2-DDG) inhibits the multiplication of herpes virus, and can be compounded in a variety of dosage forms.
- atients with vitiligo have low catalase levels in their epidermis in association with high levels of hydrogen peroxide. Topical application of a UVB-activated pseudocatalase cream can successfully remove epidermal H2O2 resulting in a significant repigmentation.
Skin and wound care
Dry skin can be treated with topical application of moisturizers such as silicone or urea. We utilize specialized equipment, such as an ointment mill, that allows us to compound formulations containing much higher concentrations of active ingredients that can be prepared using traditional methods.
Decubitus ulcers, venous stasis and diabetic ulcers, traumatic wounds, and burns may heal more quickly if treated topically. Medications which improve capillary blood flow can be added to a compounded medication to enhance circulation at the wound margins and promote healing of the injured area, and topical anesthetics can be added to relieve pain.
Psoriasis Vulgaris
What is it?
Psoriasis is a chronic, or long-term skin disease. It may cause skin irritation and outbreaks that can resemble a severe rash. Psoriasis comes in a variety of forms with distinct characteristics (as shown in the table below). This disease causes rapid skin cell growth that leads to thick, white, silvery, or red patches of skin. An individual with psoriasis has skin cells that quickly surface onto the skin within a span of days rather than weeks, like normal skin. Usually, psoriasis is most apparent in adults, but children and young adults may develop it too.
(source: American Academy of Dermatology)
| Forms of Psoriasis |
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(Source:National Psoriasis Foundation)
Treating Psoriasis, Improving Your Quality of Life
Having psoriasis can be embarrassing, and many people, especially teenagers, avoid swimming and other situations where patches can show. But there are many types of treatment that can help keep psoriasis under control.
“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.
Methotrexate has been used as an effective systemic chemotherapeutic drug for psoriasis by dermatologists for over 30 years, but oral methotrexate can cause a decrease in red and white blood cell and platelet counts and severe liver damage, diarrhea, and stomach irritation occur as dose-related drug-induced side effects. “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.”
TOPICAL THERAPIES – Patient adherence may be the largest barrier to treatment success with topical therapies; frequent patient follow-up (initially every week) may improve adherence. Published guidelines for the treatment of psoriasis with topical therapies are available.
Emollients—Hydration and emollients are valuable and inexpensive adjuncts to psoriasis treatment. Keeping psoriatic skin soft and moist minimizes the symptoms of itching and tenderness. Additionally, maintaining proper skin hydration can help prevent irritation and thus the potential for subsequent Koebnerization (development of new psoriatic lesions at sites of trauma).
The most effective are ointments such as petroleum jelly or thick creams, especially when applied immediately after a hydrating bath or shower.
Corticosteroids – Topical corticosteroids remain the mainstay of topical psoriasis treatment despite the development of newer agents. The mechanism of action of corticosteroids in psoriasis is not fully understood. Corticosteroids exert anti inflammatory, antiproliferative, and immunosuppressive actions by affecting gene transcription.
The inherent potency of a topical corticosteroid is frequently reported using a I to VII scale based on vasoconstrictive assays. Although ointments are sometimes thought to be inherently more effective because of their occlusive properties, this is not uniformly correct. In practice, the efficacy/potency of a topical corticosteroid is dependent on many factors including skin type, plaque thickness, and, perhaps most importantly, compliance.
To minimize adverse effects and maximize compliance, the site of application needs to be considered in choosing the appropriately potent corticosteroid:
- On the scalp or in the external ear canal, potent corticosteroids in a solution or foam vehicle (eg,fluocinonide 0.05% or clobetasol propionate 0.05%) are frequently indicated. Clobetasol 0.05% shampoo or spray can also be used for scalp involvement.
- On the face and intertriginous areas, a low potency cream (eg,hydrocortisone1%) is often sufficient.
- For thick plaques on extensor surfaces, potent preparations (eg, betamethasone 0.05% or clobetasol propionate 0.05%) are often required.
The typical regimen consists of twice daily application of topical corticosteroids. Most patients will show a rapid decrease in inflammation with such therapy, but complete normalization of skin or lasting remission is unpredictable.
Topical corticosteroids generally can be continued as long as the patient has thick active lesions. Skin atrophy from topical corticosteroids usually is not a problem unless the medication is continuously applied after the skin has returned to normal thickness. Once clinical improvement occurs, the frequency of application should be reduced. For patients in whom lesions recur quickly, topical corticosteroids can be applied intermittently (such as on weekends only) to maintain improvement. The addition of non-corticosteroid treatments can also facilitate the avoidance of long-term daily topical corticosteroids.
The risks of cutaneous and systemic side effects associated with chronic topical corticosteroid use are increased with high potency formulations. Current data support limiting the continuous application of Class I topical corticosteroids to two to four weeks; thus, close clinician supervision should be employed if longer treatment durations are required. Data are less clear regarding treatment durations for less potent topical corticosteroids. Side effects of topical corticosteroids, including the potential for suppression of the hypothalamic axis, are discussed separately.
The cost of topical corticosteroids varies widely. The price of a 60 gram tube of a potent corticosteroid brand name product can be as high as $80 or more. There are now generic preparations in each potency class that have reduced the cost somewhat. Examples of available generics include, in order of increasing potency,hydrocortisone 1%, triamcinolone 0.1%, fluocinonide 0.05%, betamethasone dipropionate 0.05%, and clobetasol 0.05%.
Different formulations have been developed in an effort to enhance the delivery of topical corticosteroids. Betamethasone valerate in a foam was found to have superior efficacy for scalp psoriasis and was preferred by patients when compared with betamethasone valerate lotion. The foam becomes a liquid on contact with skin and is also well tolerated by patients with trunk and extremity psoriasis. A clobetasol propionate spray is also available; like foams, sprays are easy to apply to large areas. The main advantage of these newer preparations is likely greater patient acceptance, which may translate into greater adherence; the main disadvantage is cost.
Topical vitamin D analogs – Topical vitamin D analogs for the treatment of psoriasis include calcipotriene (calcipotriol),calcitriol, and tacalcitol. Although topical vitamin D analogs are effective as monotherapy for some patients, a systematic review found that combination therapy with a topical corticosteroid is more effective than either treatment alone.
Until 2009, calcipotriene was the only topical vitamin D analog available in the United States. Calcipotriene is obtainable as a cream, solution, ointment, or foam (Dovonex, Sorilux), or as a combination ointment with betamethasone dipropionate (Taclonex). Topical calcitriol ointment has been prescribed in Europe for years, and is now available in the United States (Vectical). When compared with calcipotriol, calcitriol appears to induce less irritation in sensitive areas of the skin (eg, skin folds).
Calcipotriene — Calcipotriene (calcipotriol) is an established therapy in psoriasis. The precise mechanism is not clear, but a major effect is the hypoproliferative effect on keratinocytes. An immune modulating effect has been postulated for calcipotriene, but has not been shown to be significant in psoriasis to date.
In a systematic review of randomized controlled trials, calcipotriene was at least as effective as potent topical corticosteroids, calcitriol, short contact dithranol, tacalcitol, coal tar and combined coal tar 5%, allantoin 2%, and hydrocortisone 0.5%. Only potent topical corticosteroids appeared to have comparable efficacy at eight weeks. Skin irritation is the main adverse event associated with calcipotriene.
Combined use of calcipotriene and super potent corticosteroids has demonstrated increased clinical response and tolerance in clinical trials compared to either agent used alone. One regimen employed daily use of both calcipotriene ointment and halobetasol ointment for two weeks, followed by weekend use of the halobetasol ointment and weekday use of calcipotriene. This regimen produced six-month remission maintenance in 76 percent compared with 40 percent with weekend halobetasol alone. A similar regimen with calcipotriene ointment and clobetasol propionate foam also appears to be effective.
In addition, a randomized trial found that a preparation that combines calcipotriene with betamethasone dipropionate (0.064%) was effective with once daily usage, and more effective than once daily therapy with either betamethasone or calcipotriene; this combination preparation (Taclonex) typically costs more than $400 for a 60 g tube. Patients who use topical corticosteroids in combination with calcipotriene must be monitored for adverse effects as with corticosteroid monotherapy.
Thus, topical calcipotriene may be used as an alternative or adjunct to topical corticosteroid therapy. It is applied twice daily when used as monotherapy. No controlled trials guide how best to use topical corticosteroids in conjunction with calcipotriene. Once daily use of each may be adequate. Acidic products can inactivate topical calcipotriene, and some topical corticosteroids may be acidic. A reasonable approach to combination therapy is to have patients apply topical calcipotriene and topical corticosteroids each once daily at different times of day.
Other than skin irritation, side effects of topical calcipotriene are usually minimal; the risk of hypercalcemia is low when the drug is used appropriately. However, topical calcipotriene is more expensive than most potent corticosteroids.
Calcitriol – The mechanism of action of calcitriol is thought to be similar to that of calcipotriene and involves the drug’s ability to inhibit keratinocyte proliferation and stimulate keratinocyte differentiation. In addition, it has been demonstrated that calcitriol inhibits T cell proliferation and other inflammatory mediators. In two randomized trials with a total of 839 patients with mild to moderate plaque psoriasis, calcitriol 3 mcg/g ointment was more effective than vehicle. At the end of the study periods (up to eight weeks), 39.6 and 32.7 percent of the calcitriol groups versus 21.2 and 12 percent of the vehicle groups exhibited at least marked global improvement.
In a systematic review, calcipotriene and calcitriol were equally effective. However, on sensitive areas of the skin, calcitriol appears to be less irritating than calcipotriene. An intraindividual randomized trial of 75 patients compared treatment with calcitriol 3 mcg/g ointment to calcipotriene 50 mcg/g ointment for mild to moderate psoriasis on facial, hairline, retroauricular, and flexural areas. Perilesional erythema, perilesional edema, and stinging or burning sensations were significantly lower in the areas treated with calcitriol. A 52-week open-label study of the safety of calcitriol ointment did not reveal an adverse effect on calcium homeostasis.
Calcitriol ointment is expensive; the cost of a 100 gram tube is approximately $400. The drug is applied twice daily.
Tar – The use of tar is a time-honored modality for treating psoriasis, although newer (and less messy) treatment options have reduced its popularity. The precise mechanism of action of tar is not known; it has an apparent antiproliferative effect.
Tar can be helpful as an adjunct to topical corticosteroids. There are no commercially available corticosteroid/tar combinations. Tar products are available without a prescription in the form of shampoos, creams, lotions, ointments, and oils. Newer products include a solution (Psorent) and a foam (Scytera). Some patients may prefer the less messy new formulations.
Tar can also be compounded into creams and ointments. A commonly used compound is 2 or 3 percent crude coal tar in triamcinolone cream 0.1 percent applied twice daily to individual plaques. An alternative is 4 to 10 percent LCD (liquor carbonis detergens, a tar distillate) in triamcinolone cream or ointment, used similarly. A preparation of 1 percent tar in a fatty-acid based lotion (Exorex) may be superior to conventional 5 percent tar products and appears to have efficacy similar to that of calcipotriene.
Topical tar preparations, including shampoos, creams, and other preparations, can be used once daily. Patients should be warned that tar products have the potential to stain hair, skin, and clothing. It may help to use them at night and wear inexpensive night clothes (eg, old pajamas) as they tend to be messy. Patients may also find the odor of tar products unpleasant.
For shampoos, the emphasis should be on making sure the product reaches the scalp. Tar shampoo should be left in place for 5 to 10 minutes before rinsing it out.
Tazarotene – Tazarotene is a topical retinoid that was found to be safe and effective in two randomized, vehicle-controlled trials that included 1303 patients with psoriasis. The 0.1 percent cream was somewhat more effective than 0.05 percent cream, but with a slightly higher rate of local side effects. Another study found that once daily administration of tazarotene gel, 0.05 or 0.1 percent, compared favorably with the twice daily administration of topical fluocinonide 0.05 percent. Absorption of tazarotene was minimal over the 12-week course of the study, suggesting that systemic toxicity is unlikely during long-term therapy. A small uncontrolled study of short contact tazarotene found that a 20 minute application followed by washing appeared to be less irritating than traditional use, and seemed to have similar efficacy.
Calcineurin inhibitors – Topical tacrolimus 0.1 percent and pimecrolimus 1 percent are effective in the treatment of psoriasis. Facial and intertriginous areas may be suited to these treatments, which can allow patients to avoid chronic topical corticosteroid use:
- An eight-week randomized trial in 167 patients ages 16 and older found that twice daily treatment to intertriginous and facial lesions with tacrolimus 0.1 percent ointment resulted in more patients achieving clearance of lesions or excellent improvement compared with placebo (65 versus 32 percent).
- An eight-week randomized trial in 57 adults with moderate to severe inverse psoriasis found that twice daily treatment with pimecrolimus 1 percent cream resulted in more patients clearing or almost clearing lesions compared with placebo (71 versus 21 percent).
Topical tacrolimus and pimecrolimus are generally well-tolerated when used to treat facial and intertriginous psoriasis. However, corticosteroid therapy may be more effective, at least compared to pimecrolimus. This was suggested in a four-week randomized trial in 80 patients with intertriginous psoriasis that compared various therapies applied once daily.Betamethasone valerate 0.1 percent was more effective than pimecrolimus 1 percent.
In 2005, the US Food and Drug Administration (FDA) issued an alert about a possible link between topical tacrolimus and pimecrolimus and cases of lymphoma and skin cancer in children and adults, and in 2006 placed a “black box” warning on the prescribing information for these medications. No definite causal relationship has been established; however, the FDA recommended that these agents only be used as second line agents for atopic dermatitis. If these drugs are used for the treatment of psoriasis, it would be reasonable to follow the additional safety recommendations made by the FDA for their use in atopic dermatitis.
Anthralin – Topical anthralin (also known as dithranol) is an effective treatment for psoriasis that has been utilized since the early 20th century. The mechanism of action of anthralin in psoriasis is not well understood, but may involve anti inflammatory effects and normalization of keratinocyte differentiation.
Skin irritation is an expected side effect of anthralin that can limit the use of this therapy. This side effect and the ability of anthralin to cause permanent red-brown stains on clothing and temporary staining of skin have contributed to a decline in the use of anthralin therapy.
In order to minimize irritation, anthralin treatment is usually prescribed as a short-contact regimen that is titrated according to patient tolerance. For example, treatment may begin with concentrations as low as 0.1% or 0.25% applied for 10 to 20 minutes per day, with weekly stepwise increases in duration to reach a total contact time up to one hour. Then, weekly, serial increases in the concentration of anthralin can be performed (eg, 0.5, 1, and 2%) based upon patient tolerance and lesion response.
In the United States, anthralin is commercially marketed only as a 1% or 1.2% cream or a 1% shampoo. Thus, in the outpatient setting in the United States, the initial treatment regimen often consists of 1% or 1.2% anthralin applied for 5 to 10 minutes per day. Subsequently, the application time is titrated up to 20 to 30 minutes as tolerated.
Application to surrounding unaffected skin should be avoided to minimize irritation. For patients with well-defined plaques, petrolatum or zinc oxide may be applied to the surrounding skin as a protectant prior to application. After the desired contact period has elapsed, anthralin should be washed off the treated area.
Benefit from anthralin therapy is often evident within the first few weeks of therapy. When administered by patients in the outpatient setting, anthralin appears to be less effective than topical vitamin D or potent topical corticosteroid therapy.
Scarring and Keloids
Injuries to the skin can sometimes be accompanied with scars; some may be temporary but others can be permanent and may grow into a keloid or hypertrophic scarring.
Hypertrophic scars usually develop a month or two after a wound infection, unlike keloids which can sometimes take several months or years to form. Hypertrophic scars undergo rapid growth for about six months then eventually shrink and flatten out over a few years.
(source:National Center for Biotechnology Information)
A scar that eventually outgrows its healing wound is a keloid scar. These types of scars are usually characterized as thick, shiny, hairless, raised, firm, and rubbery. Most keloid scars initially have a red or purple tint to them and can be found on the shoulders, head, or neck. Although they don’t generally cause pain, individuals that they form on may feel embarrassed by its appearance, and therefore would seek treatments to disguise or heal them.
A scar that eventually outgrows its healing wound is a keloid scar. These types of scars are usually characterized as thick, shiny, hairless, raised, firm, and rubbery. Most keloid scars initially have a red or purple tint to them and can be found on the shoulders, head, or neck. Although they don’t generally cause pain, individuals that they form on may feel embarrassed by its appearance, and therefore would seek treatments to disguise or heal them.
Treatment of Keloids
Some keloids can be removed surgically or through steroid injections directly into the scar for a period of a few months. If an individual chooses to surgically remove the keloid, there is a higher chance of the scar recurring, possibly even larger than it was before. Topical Retinoid creams or scar silicone sheeting can also be used for shrinking of keloids.
(source: NHS Choices)
PCCA PracaSil – Plus
At MedLife Pharmacy & Compounding, we have this distinctive and elegant topical anhydrous silicone base which can be used alone or with various actives for the potential use in scar formulations. We have found PracaSil-Plus to be an ideal choice for use on all types of scar tissue, including new scars, old scars, surgical scars, keloids, stretch marks, or any skin conditions that would benefit from barrier protection.
PCCA has infused unique ingredients and technology into PracaSil-Plus, giving it potential healing and soothing power, emolliency and mild penetration. It contains an Amazonian oil, Pracaxi oil. The indigenous cultures of the Amazon rainforest commonly use Pracaxi oil for dermatologic conditions and it is well-recognized in that region for its potential healing properties. Pracaxi oil is rich in organic acids with antioxidant, antibacterial and antifungal properties. In the Amazon, Pracaxi oil has also been used for generations for treatment of skin spots, severe acne (and scars), and is useful for psoriasis and rosacea.
Anecdotally, the directions for use are typically: Apply twice daily (estimate of 2-6 grams), duration of 10-14 weeks.
Cosmeceuticals
Cosmeceuticals is the marriage of cosmetics and pharmaceuticals. Like cosmetics, cosmeceuticals are topically applied, but they contain ingredients that influence the biological function of the skin. Cosmeceuticals improve the appearance of skin by delivering nutrients necessary for healthy skin.Examples of cosmeceuticals include anti-aging creams and moisturizers containing active ingredients such as vitamins, phytochemicals, enzymes and antioxidants. The most advanced cosmeceuticals are a combination cosmetics and micronutrition. Dermatologists, doctors and patients face many problems that may be relieved with customized cosmeceuticals.
Skin Therapy
Anti-Aging Skin Therapy
Stretch Mark removal/reduction
After a proper analysis reveals areas of dry, oily, or aging skin, we can provide the appropriate correction for each skin type in a cosmetic base containing the exfoliants, emollients, and micronutrients necessary for cellular repair. Antioxidants such as Alpha Lipoic Acid and Vitamin C Ester are vital to the energy production of skin cells and formation of collagen. Amino acids such as DMAE tone and add firmness to the skin, prevent age spots, and aid in healing the micro-scarring which causes wrinkles.
We work together with prescribers and their patients to provide innovative solutions to challenging dermatologic problems. Please contact our compounding pharmacist for more information or to discuss other customized “problem-solving” therapies.
