台北醫學大學附設醫院暨萬芳醫院皮膚科核心教材
Topical anti-inflammatory agent
一、外用類固醇 (Topical corticosteroids)
二、非類固醇類消炎劑 (Topical immunomodulator): 需長期塗抺 steroid 者可考慮使用
Topical antibiotics Erythromycin Metronidazole Mupirocin (Pseudomonic Bacitracin
nd lipid pyrophosphate Æ interfere with cell wall synthesis
Neomycin Chloramphenic Fucidic acid
EF-G-GDP-ribosome complex Æ interfere with function of elongation factor
sulfadiazine Anti-pruritic therapy Antihistamines
¾ First generation H1-type antihistamine
Pharmacokineticss: 短效，作用快
Onset: 0.5-1 hr; Peak effect:1-2 hr; Duration: 4-6 hr
Pharmacodynamics: cytochrome P450, excrete in urine Effect: antihistamine, sedation, anticholinergic, antiemetic, motion sickness Side effect:
Sedation: develop tolerance within a few days Anticholinergic: dry mouth, blurred vision, constipation, urinary retention
¾ Second generation H1-type antihistamine
H2 blocker
Combination with H1 blocker: dermatographism
Antidepressant & Antianxiety
Doxepin (sinequan) Amitriptyline: H1&H2 blocker
Aprazolam (xanax) Fludiazepam (erispan)
Antifungal therapy Topical antifungal agent
Preparation Dermatophyte Candida Pityrosporum
Nystatin Sulconazole Miconazole (Antifungal) Isoconazole (Isogen) Terbinafine Butenafine (Mentax) Tolnaftate Systemic antifungal agent
¾ Ketoconazole (Yucomy)
200mg 1#-2# QD with meal Idiosyncratic hepatotoxicity (fulminant hepatitis 1/10000) Alcohol, hepatotoxic agent, hepatitis patients
¾ Fluconazole (Diflucan)
150mg QD; systemic candidiasis/cryptococcosis: 200-400mg QD Less hepatotoxicity
¾ Itraconazole (Sporanox)
100mg 2# QD with meal Idiosyncratic hepatotoxicity (1/160,000), GI upset, headache
¾ Terbinafine (Lamisil)
250mg 1# QD GI upset, headache, taste loss
¾ Nystatin (Mycostatin)
1# in 5ml N/S gargling QID Mucocutaneous candidiasis
Systemic antiviral therapy
¾ Acyclovir (Zovirax): 250mg / vial
(1) Herpes zoster: within 72 hrs (2) Varicella: within 24 hours
Dosage: 5~10mg/kg q8h IVD slow drip > 1 hour for 5-10 days Dose adjustment:
CrCl: 25-50 mL/min, usual dose every 12 hr; CrCl: 10-25 mL/min, usual dose every 24 hr; CrCl: < 10 mL/min, 50% of usual dose every 24 hr
¾ Famciclovir (Famvir): 250mg / tab
Herpes zoster: 500 mg q8h for 7 days Recurrent herpes simplex labialis: 1500 mg single dose Recurrent genital herpes simplex: z Acute: 1000 mg BID for 1 days z Suppression: 250 mg BID for up to 1 year Recurrent mucocutaneous herpes simplex, HIV(+): 500 mg BID for 7days
Herpes zoster CrCl: 40-59 mL/min, 500 mg every 12 hr; CrCl: 20-39 mL/min, 500 mg every 24 hr; CrCl: <20 mL/min, 250 mg every 24 hr; Hemodialysis: 250 mg following each dialysis
Precaution: Safety and efficacy in children< 18 yrs: not established
Brief Introduction of Psoriasis
¾ Classification:
Acute guttate, Chronic plaque, Inverse, Palmoplantar
Psoriatic erythroderma Pustular psoriasis:
Pustular psoriasis of Von Zumbusch, Palmoplantar pustulosis, Acrodermatitis continua
¾ Epidemiology: Age: (early-onset) peak at 22.5 y/o, (late-onset) peak at 55 y/o. Sex: F=M Heredity: polygenic trait. Most frequently associated are HLA-B13, -B17, -Bw57 and HLA-Cw6.
Trigger Factor: (TIDES: Trauma, Infection, Drug, Ethanol, Stress) z Physical trauma: Koebner’s phenomenon z Infection: acute Streptococcal infection Æ guttate psoriasis z Drugs: systemic steroid, lithium, antimalarial, interferon, β- blockers
¾ Pathogenesis:
Alteration of cell kinetics of keratinocytes.
¾ Clinical Presentation: Plaque: sharply marginated, silver-white scale, Auspitz’s sign(+) Guttate: 2mm~1cm, salmon-pink papules±scales, Spare palms and soles. Inverse: sharply demarcared, non-scaly, bright and fissured. Localized: Palmoplantar pustulosis, Acrodermatitis of Halopeau, scalp Generalized pustular: toxic, fever, diffuse erythema Æ clusters of tiny
nonfollicular very superficial yellowish to whitish pustules Æ confluent, circinate lesions and lake of pus.
Nails: 25% involvement. Pitting, subungual hyperkeratosis, onycholysis,
yellowish-brown spots under nail plate(oil spot).
¾ Pathology:
1. Marked overall thickening of epidermis(acanthosis) and thinning of epidermis
over elongated dermal papillae, Parakeratotic hyperkeratosis.
2. Increased mitosis of keratinocytes, fibroblasts, and endothelial cells.
3. Inflammatory cells in the dermis(lymphocyte/monocyte) and epidermis (PMN), forming microabscess of Munro in the stratum corneum. General management of Psoriasis
Vitamin D analogs: Calcipotriol (Daivonex), Calcitriol (Silkis) Tarzarotene (Zorac)
Tar preparations: Polytar liquid, Polytar emollient
Dithranol (Anthralin) Emollients & Keratolytics: Salicylic acid
Systemic therapy ¾ Methotrexate
Folate antagonist, immunomodulation and antiinflammatory effects. Contraindication: hepatic disease, alcoholism, acute infection, pregnancy. Interaction: aspirin, NSAIDs, co-trimoxazole, etc. Side effect: liver cirrhosis Æ liver biopsy after accumulative dose 1.5gm
¾ Retinoids:
Side effect: xerosis, abnormal liver function, hyperlipidemia, teratogenicity.
¾ Cyclosporin:
Side effect: renal toxicity, hypertension, skin cancers, lymphoma.
Precaution: avoid concomitant UVL therapy.
Phototherapy ¾ Ultraviolet B(UVB): 290-320nm
Side effect: acute burn, long-term risk of skin cancer
¾ Photochemotherapy (PUVA): Psoralen plus Ultraviolet A
Oral 8-methoxypsoralen 2 hours before UVA(320-340nm)
Cause DNA cross-linkage, inhibit mitosis and cell-mediated immunity.
Dose depend on minimum erythema dose(MED)
Side effect: pruritus, erythema, skin cancer, photoaging, cataract.
Precaution: use sun-glasses (for UVA) within 24 hours of oral psoralen
¾ Bath PUVA Management of Acne
Cleansing Gentle cleanser and warm water Topical agents Airol gel
杜鵑花酸。開始抹時可能刺、癢
Systemic therapy ¾ Antibiotis and antibacterial agents
Tetracycline : 500-1000 mg/day, possible resistant strains
z Contraindication: pregnancy, children < 8 y/o
Doxycycline: 50-100 mg BID, photosensitivity reactions Minocycline: 100-200 mg/day, blue-black pigmentation Erythromycin: pregnant women or children: Trimethoprim-sulfamethoxazole combinations
z Severe acne who do not respond to other antibiotics z Potential hematologic suppression, F/U approximately monthly.
¾ Retinoids: Isotretinoin (Roaccutane)
z 0.5-1 mg/kg per day, 2 mg/kg per day for very severe trunk involvement. z Total dose of 120-150 mg/kg of isotretinoin z Xerosis, abnormal liver function, hyperlipidemia, teratogenicity z Monitor CBC, LFT and TG
Spironolactone (Aldactone)
50-100 mg BID, an androgen receptor blocker and inhibitor of 5α-reductase Hyperkalemia, irregular MC, breast tenderness, headache, fatigue
z nausea, vomiting, abnormal menses, weight gain, and breast tenderness;
thrombophlebitis, pulmonary embolism, and hypertension
¾ Glucocorticoids: usually restricted to the severely involved patient
Schmitt-Thompson Pediatric Office-Hours Version Clinical Content DEFINITION * Viral infection of the voicebox (larynx)* The croupy cough is tight, low-pitched, and barky (like a barking seal)* The voice or cry is hoarse (laryngitis) BACKGROUND STRIDOR: A COMPLICATION OF CROUP* Stridor is a harsh, raspy sound heard with breathing in* Loud or continuous stridor mean
Post Doctoral Fellow, University of California, Los Angeles Semel Institute, Department of Psychiatry and Behavioral Sciences Visiting Scholar, University of Southern California School of Social Work, Serious Mental Illness Cluster Doctorate of Philosophy, University of California, Irvine Department of Psychology and Social Behavior Minor: Quantitative Methods, Developmental Dissertation: