Use of ointment in various skin / dermatological conditions

 

 IF THERE IS A SPECIFIC MEDICAL CONDITION WHICH YOU WOULD LIKE TO KNOW THAT OINTMENT USE IS NEEDED, PLEASE EMAIL ME AT allan.hsu@osaka.com

 IF you find useful information on this site, please kindly donate to us via Paypal link for continuing server hosting cost of this website, thank you

 

 Diaper dermatitis in infants and children

The most effective way to treat irritant diaper dermatitis is to eliminate direct skin contact with urine and feces (ie, by discontinuing or limiting the use of diapers). However, in today's society, diapers are necessary to limit fecal contamination and the spread of enteric diseases . If possible, an infant with irritant diaper dermatitis should be allowed periods of rest without a diaper, allowing the skin to be exposed directly to air. Frequent diaper changes limit prolonged skin contact with stool and urine [6.

Topical barriers — Topical barriers in the form of ointments or pastes are considered first-line therapy for treating and preventing irritant diaper dermatitis . Topical barriers are applied with every diaper change; they should be applied thickly and can be covered with petroleum jelly to prevent sticking to the diaper .

The use of topical barrier ointments and pastes for the treatment of diaper dermatitis is based upon long-standing clinical experience; there are few randomized controlled trials comparing these agents to placebo or to one another.

Topical barriers physically block chemical irritants and moisture from contacting the skin; they also minimize friction. Topical barriers should be long-lasting and adherent to macerated and eroded skin. Pastes and ointments generally are better barriers than creams and lotions, which are poorly adherent, minimally occlusive, and contain preservatives .

The most common over-the-counter topical barriers contain petrolatum, zinc oxide, or both (examples include Desitin, Triple Paste, A & D Ointment, and Balmex). Some also contain lanolin, paraffin, or dimethicone (a silicone oil) .

Topical barriers or medications that contain fragrance, preservatives, and other ingredients with irritant or allergic potential (eg, neomycin) should be avoided. Products containing boric acid, camphor, phenol, benzocaine, and salicylates also should be avoided because of the potential for systemic toxicity and/or methemoglobinemia . These agents are contained in some commercially available products for diaper dermatitis.

 

Burns

Povidone-iodine ointment, including a liposomal preparation, effectively combines antisepsis therapy with a desired moist wound environment. Despite a broad spectrum of antimicrobial activity , use of povidone-iodine containing products in burn care is controversial because of cytotoxicity and delay in wound reepithelialization. Another drawback to povidone-iodine ointment compared to other topical agents is that it must be applied four times a day for maximal antimicrobial effect.

Polysporin is the combination of bacitracin  zinc and polymyxin B sulfate. When used in combination, this antibiotic ointment can be used to treat partial-thickness burns, especially those that involve the face and perineum [10]. Bacitracin and polymyxin are nontoxic to the wound, but their efficacy in the treatment of infected wounds has not been clearly established. Neomycin is frequently mixed with bacitracin and polymyxin to reduce the risk of adverse events [10]. Ease of application and of removal for wound cleansing are advantages of these preparations compared to silver sulfadiazine.

 

 

Acute palmoplantar eczema (dyshidrotic eczema)

 Acute palmoplantar eczema (more popularly known as dyshidrotic eczema or pompholyx) is an intensely pruritic, vesicular eruption affecting the palms, soles, or both . It is characterized by deep-seated lesions ranging from small vesicles to large tense bullae clinically and by spongiotic vesicles histologically. Recurrence is common and patients typically experience frequent episodes for months or years.

For patients with mild to moderate dyshidrotic eczema that has not responded to general measures, we suggest super high potency or high potency topical corticosteroids (group one to three  rather than calcineurin inhibitors, which are approximately equivalent to moderate potency corticosteroids.

Topical corticosteroids are applied twice daily for two to four weeks. Ointments generally are preferred to other vehicles (creams, solutions, or foams) because they contain fewer potential irritants such as additives or preservatives. However, some patients prefer other vehicles because ointments make their hands too greasy for performing tasks.

The efficacy of topical corticosteroids versus placebo or no treatment for dyshidrotic eczema has not been adequately evaluated in randomized trials. However, they are used in clinical practice because of their antiinflammatory properties and their efficacy in other forms of hand eczema.

When patients and/or clinicians prefer to avoid long-term use of topical corticosteroids for the treatment of mild to moderate dyshidrotic eczema , the topical calcineurin inhibitor tacrolimus is an alternative  Tacrolimus 0.1% ointment is applied twice daily until resolution.

Pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an uncommon inflammatory and ulcerative skin disorder characterized histopathologically by the accumulation of neutrophils in the skin. The most common presentation of PG is the rapid development of one or more painful, purulent ulcer with undermined borders on sites of normal or traumatized skin.

Although multiple local and systemic therapies have been utilized for PG, high quality efficacy studies are lacking for most interventions. Topical and systemic corticosteroids, topical tacrolimus, and systemic cyclosporine are among the most commonly utilized pharmacologic agents.

Use of a barrier cream or ointment, such as zinc oxide paste or petrolatum, may help to prevent skin breakdown at the wound edge . Patients should be monitored for clinical signs of wound infection (eg, fever, warmth, swelling, malodor, lymphangitic streaks, increased drainage, or pain), and should be treated appropriately with antibiotics if infection occurs. Hyperbaric oxygen has been reported to be of benefit for wound healing in a few patients with PG, but data are insufficient to recommend the routine use of this therapy

 

Anal fissures

An anal fissure is one of the most common benign anorectal conditions, which may result from high anal pressure. The goals of therapy are to break the cycle of sphincter spasm and tearing of the anal mucosa, and to promote healing of the fissure. Medical therapy is successful in the majority of patients , with surgery being reserved for refractory cases

Topical nitroglycerin ointment  increases local blood flow and reduces pressure in the internal anal sphincter, which may further facilitate healing. It is applied as a 0.2 to 0.4 percent ointment. Trials have generally shown a beneficial effect of nitroglycerin compared with placebo. The most common side effect is headache.

Sjögren's syndrome

Sjögren’s syndrome (SS) is a chronic multisystem inflammatory disorder characterized by diminished lacrimal and salivary gland function. This results in the “sicca complex,” a combination of dry eyes (xerophthalmia) and dry mouth (xerostomia). A variety of other disease manifestations may also be present, including systemic signs and extraglandular features. The ocular condition of aqueous tear deficiency is termed “keratoconjunctivitis sicca” (a literal Latin translation of dry inflammation of cornea) but is also called keratitis sicca, xerophthalmia, or dry eye syndrome.

SS occurs in a primary form not associated with other diseases and in a secondary form associated with other autoimmune rheumatic conditions, including rheumatoid arthritis and systemic lupus erythematosus.

 Artificial tears and lubricants are generally available without a prescription and may be in the form of liquid eyedrops, gels, or ointments. Gels and ointments often affect vision during use and are usually not required in patients with mild disease. Typically, the major components include:

At night, a longer-acting lubricant ointment (eg, Refresh PM, Lacrilube, Duratears, or Viscotears) is useful for patients with moderate to severe disease because it reduces the rate of tear evaporation; it may also cause blurring, which limits daytime use. Only a small amount (such as 1/8 inch [2 to 3 mm]) should be used, since larger amounts are likely to lead to blockage of the meibomian glands and to increase risk of blepharitis. Patients using lubricants at night should perform lid-scrubs (using warm water and diluted baby shampoo [about 1 part in 300]) in the morning to prevent blepharitis.

 

Hemorrhoids

 Hemorrhoids are normal vascular structures in the anal canal. Approximately 5 percent of the general population is affected by symptoms related to hemorrhoidal disease [1] The cardinal features of hemorrhoidal disease include bleeding, anal pruritus, prolapse, and pain due to thrombosis. Although these symptoms may strongly suggest the diagnosis, confirmation by flexible sigmoidoscopy, anoscopy, or colonoscopy should be performed in most patients who present with bleeding.

The surgical principles for excising a thrombosed external hemorrhoid include:

 

Conjunctivitis

Conjunctivitis literally means "inflammation of the conjunctiva." The conjunctiva is the mucous membrane that lines the inside surface of the lids and covers the surface of the globe up to the limbus (the junction of the sclera and the cornea). The portion covering the globe is the "bulbar conjunctiva," and the portion lining the lids is the "tarsal conjunctiva."

The conjunctiva is comprised of an epithelium and a substantia propria. The epithelium is a non-keratinized squamous epithelium that also contains goblet cells. The substantia propria is highly vascularized and is the site of considerable immunologic activity.

The conjunctiva is generally transparent. When it is inflamed, as in conjunctivitis, it looks pink or red at a distance. Up close the examiner can discern fine blood vessels, termed "injection," in contrast to extravasated blood, which is seen in subconjunctival hemorrhage. Degenerative, inflammatory, and infiltrative processes can cause the conjunctiva to become opacified, taking on a white, yellow, or fleshy appearance. All conjunctivitis is characterized by a red eye, but not all red eyes are conjunctivitis.

Bacterial — Appropriate choices for bacterial conjunctivitis include erythromycin ophthalmic ointment or polymyxin/trimethoprim drops. The dose is 0.5 inch (1.25 cm) of ointment deposited inside the lower lid or 1 to 2 drops instilled four times daily for five to seven days. It is reasonable to reduce the dose from four times daily to twice daily, if there is improvement in symptoms after a few days. Sulfa ophthalmic drops are also available but are not a first-line option because of the potential for rare but serious allergic events.

These agents cover the most common pathogens responsible for bacterial conjunctivitis, and patients should respond to this treatment within one to two days by showing a decrease in discharge, redness, and irritation. Patients who do not respond should be referred to an ophthalmologist.

Ointment is preferred over drops for children, those with poor compliance, or those in whom it is difficult to administer eye medications. Ointment stays on the lids and can have therapeutic effect even if it is not clear that any of the dose was applied directly to the conjunctiva. Because ointments blur vision for 20 minutes after the dose is administered, drops are preferable for most adults who need to read, drive, and perform other tasks that require clear vision immediately after dosing.

Alternative therapies include bacitracin ointment, sulfacetamide ointment, polymyxin-bacitracin ointment, fluoroquinolone drops, or azithromycin drops. Aminoglycoside drops and ointments are poor choices since they are toxic to the corneal epithelium and can cause a reactive keratoconjunctivitis after several days of use.

The fluoroquinolones are effective and well-tolerated; they are the treatment of choice for corneal ulcers and are extremely effective against pseudomonas. However, fluoroquinolones are not first-line therapy for routine cases of bacterial conjunctivitis because of concerns regarding emerging resistance and cost. The exception is conjunctivitis in a contact lens wearer; once keratitis has been ruled out, it is reasonable to treat these individuals with a fluoroquinolone due to the high incidence of pseudomonas infection.

Azithromycin was approved in the United States in 2008 as an ophthalmic solution for bacterial conjunctivitis in patients one year of age and older. It is dosed less frequently than other ophthalmic solutions (1 drop twice daily for two days, then one drop daily for five days), but is considerably more expensive than erythromycin or sulfacetamide, and its availability raises a concern about promoting the emergence of organisms resistant to azithromycin

 

Viral — There is no specific antiviral agent for the treatment of viral conjunctivitis. Some patients derive symptomatic relief from topical antihistamine/decongestants. These are available over-the-counter (Naphcon-A®, Ocuhist®, generics). It is worthwhile to explain that these agents treat the symptoms but not the disease; just as "cold remedies" treat the symptoms rather than the cause of a cold. Warm or cool compresses may provide additional symptomatic relief. Systemic agents play no role in viral conjunctivitis.

Some providers prescribe antibiotic ointments for viral conjunctivitis to provide lubrication. A more sensible alternative is to use nonantibiotic lubricating agents such as those used for noninfectious conjunctivitis (table 1). (See 'Noninfectious, nonallergic conjunctivitis' above.)

Patients must be told that the eye irritation and discharge may get worse for three to five days before getting better, that symptoms can persist for two to three weeks, and that use of any topical agent for that duration might result in irritation and toxicity, which can itself cause redness and discharge. Clinicians must be wary of trying one agent after another in patients with viral conjunctivitis who are expecting drugs to "cure" their symptoms. Patient education is often more effective than prolonged or additional therapies for patients who experience improvement but incomplete resolution of symptoms after a few days.

Noninfectious nonallergic — The conjunctival surface regenerates rapidly from insults that precipitate noninfectious conjunctivitis, leading to spontaneous resolution of symptoms. Nevertheless, these patients may feel better more quickly with the use of topical lubricants, which can be purchased over-the-counter as drops and ointments. Preservative-free preparations are more expensive and are necessary only in severe cases of dry eye or in highly allergic patients.

Lubricant drops can be used as often as hourly with no side effects. The ointment provides longer lasting relief but blurs vision; thus, many patients use the ointment only at bedtime. It may be worthwhile to switch brands if a patient finds one brand of drop or ointment irritating since each preparation contains different active ingredients, vehicles, and preservatives.

 

Dermatitis of the vulva

Vulvar dermatitis (also called vulvar eczema) is the most common vulvar dermatosis in women. One-third to one-half of women's vulvar complaints stem from this problem.

Women with vulvar dermatitis experience chronic irritation and/or pruritus, which causes them to persistently rub and scratch the vulva. These activities lead to histological changes in the dermis, termed squamous hyperplasia or lichen simplex chronicus

Mild symptoms — Mild symptoms usually respond to low to medium potency topical corticosteroid ointments (eg, hydrocortisone 1% or 2.5%, desonide 0.05%, or triamcinolone 0.1% daily for two to four weeks, then twice per week). Topical corticosteroid can be used one or more times daily, although a clear benefit has not been demonstrated with more than once daily application. Therapy is continued indefinitely, at the minimum frequency necessary to control pruritus.

Moderate to severe symptoms — For moderate to severe symptoms, a higher potency corticosteroid ointment is often required. We use clobetasol propionate or betamethasone dipropionate 0.05% ointment at night daily for 30 days, and then reevaluate. Another acceptable regimen is to give one of these steroids twice daily for two weeks, then daily for two weeks, then Monday and Wednesday and Friday for two weeks, and then reevaluate. If there is a partial response, we either continue corticosteroids for another two weeks or else switch to intralesional injections or calcineurin inhibitors. Potent topical steroids have been used for up to twelve weeks on the vulva without adverse effects.

 

Otitis externa

The term external otitis (also known as otitis externa or swimmer’s ear) refers to inflammation of the external auditory canal or auricle.

There are five fundamental steps in the management of external otitis:

Treatment of external otitis usually involves topical drug therapy rather than oral antibiotics or surgery, as the disease is limited to the skin of the ear canal.

Several topical agents are available for treating external otitis, including antibiotics, antiseptics, glucocorticoids, and acidifying solutions . They are administered as single agents and combination formulas. Most are used in a liquid form, although ointments and powders are also available.

Otomycosis is a fungal infection of the external auditory canal . Otomycosis can occur as the primary infection or can develop along with bacterial external otitis, usually as a result of antibiotic therapy.

The mainstay of therapy for otomycosis is meticulous cleaning of the ear canal and topical antifungal therapy . All debris and visible fungal elements must be removed by the clinician. This should be done under direct vision with a cerumen loop or cotton swab. Binocular magnified vision facilitates removal of debris that is often focused in the medial aspect of the ear canal, coating the tympanic membrane.

Several ototopical medications are used adjunctively to treat otomycosis, including antifungals, antiseptics, acidifying solutions, glucocorticoids, and drying agents. Topical antifungals are considered first-line pharmacologic treatment . Clotrimazole  has the greatest zone of inhibition for common fungi. Clotrimazole and miconazole also have antibacterial effects against S. aureus but not P. aeruginosa. Some antifungals are available in liquid form, others only as a cream or ointment that is either injected into the ear canal or swabbed in the lateral ear canal and allowed to melt down in the ear canal. We use clotrimazole 1% solution, applied twice daily for 10 to 14 days, and then reassess the ear canal. If fungal elements are identified, the ear canal should again be meticulously cleaned and undergo a further 10 to 14 day course of topical antifungal with reassessment thereafter. Persistent otomycosis should be managed by an otolaryngologist to ensure optimal cleaning of the external canal (usually with microscopic otoscopy). Ear cleaning followed by topical therapy and reassessment in two weeks may be required for several cycles to achieve eradication

 

Vulvodynia

Vulvar pain can impact quality of life through detrimental effects on daily comfort and sexual function. Approximately 15 percent of women have experienced vulvar pain lasting three or more months

Topical lidocaine is an important adjunct in managing pain, in our experience.

Topical anesthetics may be applied up to six times per day to provide temporary and partial relief of vulvar pain. We suggest an ointment or a cream compounded in a neutral base since gels and commercial creams can irritate the vestibular epithelium. In our practice, we use topical lidocaine 5 percent compounded in a neutral base. 

Topical anesthetics may cause stinging or sensitization. Male partners may experience penile numbness and should avoid oral contact.

Topical anesthetics can be applied to the vestibule, as needed, to permit vaginal intercourse in women with minor pain on penetration (ie, 1 to 2 on a scale of 1 to 10). One teaspoon of lidocaine 5 percent ointment is applied to the vestibule 20 to 30 minutes prior to intercourse. Avoiding the clitoral area is important. Any excess is wiped away just prior to sexual activity to minimize oral or penile numbness.

Consistent use of topical anesthetics for several weeks may provide extended partial pain relief. A randomized trial that evaluated treatments for vestibulodynia compared topical lidocaine 5 percent applied to the vestibule four times per day for 16 weeks to electromyographic biofeedback. Both treatments resulted in significant improvement in pain, sexual function, and psychosocial adjustment at 12-months follow-up.

 

Anal Crohn's disease

Crohn's disease is a chronic recurrent inflammatory bowel disorder that can affect any gastrointestinal site from the oral cavity to the anus. The major perianal complications include fissures, fistulas, abscesses, and stenosis, alone or in combination, which affect approximately 35 to 45 percent of patients during the course of the disease. Symptoms can vary from anal pain and purulent discharge to bleeding and incontinence, and can be associated with significant morbidity and impaired quality of life,

Topical nitroglycerin — Topical nitroglycerin  0.2 percent is beneficial for patients with spontaneous chronic anal fissures. Its efficacy in patients with anal fissures in Crohn's disease has not been evaluated. Other topical ointments such as calcium channel blockers in reduced concentrations (1 percent) have been used.

 

 

 

 

  

 

 

 

LINKS:

My personal website : http://www.osaka.com

Learn about Acute disseminated encephalomyelitis (ADEM) : http://www.adem.org