Dermatology
Our compounding professionals can prepare individualized therapies for a myriad of dermatologic problems.
Compounding pharmacists continue to improve both the aesthetic and therapeutic aspects of customized medications, offering alternatives and advantages for dermatology. We can compound medications into cosmetically appealing creams, topical sprays and powders, as well as create customized oral dosage forms (such as flavored troches or lollipops) and various preparations for other routes of administration. Compatible drugs can be combined into a single dosage form to simplify a medication administration schedule and improve compliance. USP approved chemicals can be utilized to enhance the absorption of topically applied medications. We commonly prepare unique formulations that physicians develop to meet specific needs of their patient population, or "tried and true" formulas acquired during medical training.
Acne
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.
Afzali BM, Yaghoobi E, Yaghoobi R, Bagherani N, Dabbagh MA. Click here to access the PubMed abstract of this article.
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 by inflammatory acne vulgaris. Click here to access the PubMed abstract of this article.
J Dermatol 1996 Apr;23(4):243-6
Topical spironolactone reduces sebum secretion rates in young adults. Click here to access the PubMed abstract of this article.
Athlete's Foot
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.
Click here to access the PubMed abstract of this article.
Chemical Peels
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.
Click here to access the PubMed abstract of this article.
Diaper Rash/Incontinence
Ann Pharmacother 1996 Sep;30(9):954-6
Cholestyramine ointment to treat buttocks rash and anal excoriation in an infant.
Click here to access the PubMed abstract of this article.
Dis Colon Rectum 1987 Feb;30(2):106-7
Cholestyramine ointment in the treatment of perianal skin irritation following ileoanal anastomosis.
Click here to access the PubMed abstract of this article.
Head Lice and Scabies
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. Click here to access the PubMed abstract of this article.
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). Click here to access the PubMed abstract of this article.
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. Click here to access the PubMed abstract of this article.
Isr Med Assoc J. 2002 Oct;4(10):790-3
The in vivo pediculicidal efficacy of a natural remedy.
Click here to access the PubMed abstract of this article.
Molluscum Contagiosum
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.
Click here to access the PubMed abstract of this article.
Nail Infection / Removal
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 affects of systemic treatments.
J Drugs Dermatol. 2007 Feb;6(2):202-4.
Palliative treatment of fingernail lichen planus.
Click here to access the PubMed abstract of this article.
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.
Cutis. 1980 Jun;25(6):609-12
Urea ointment in the nonsurgical avulsion of nail dystrophies--a reappraisal.
Click here to access the PubMed abstract of this article.
Cutis. 1980 Apr;25(4):397, 405
Combination urea and salicyclic acid ointment nail avulsion in nondystrophic nails: a follow-up observation.
Click here to access the PubMed abstract of this article.
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)
Pigmentation Abnormalities
Patients 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 remarkable repigmentation.
J Investig Dermatol Symp Proc 1999 Sep;4(1):91-6
In vivo and in vitro evidence for hydrogen peroxide (H2O2) accumulation in the epidermis of patients with vitiligo and its successful removal by a UVB-activated pseudocatalase.
Click here to access the PubMed abstract of this article.
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.
Espinal-Perez LE, Moncada B, Castanedo-Cazares JP.
Click here to access the PubMed abstract of this article.
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.
Guevara IL, Pandya AG.
Click here to access the PubMed abstract of this article.
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.
Redondo P, Bauzá A.
Click here to access the PubMed abstract of this article.
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.
Kim JA, Baker DG, Hahn SS, Goodchild NT, Constable WC.
Click here to access the PubMed abstract of this article.
Plantar Warts/Warts
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, randomised, and controlled clinical study. Click here to access the PubMed abstract of this article.
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. Click here to access the PubMed abstract of this article.
Phys Ther. 2002 Dec;82(12):1184-91
Treatment of plantar verrucae using 2% sodium salicylate iontophoresis. Click here to access the PubMed abstract of this article.
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 customised 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.
Click here to access the PubMed abstract.
J Am Acad Dermatol. 2000;43:503-507
Childhood molluscum contagiosum: experience with cantharidin therapy in 300 patients.
Click here to access the PubMed abstract.
Squaric Acid Dibutylester (SADBE) for Cutaneous Warts in Children
Warts are a common paediatric 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.
Click here to access the PubMed abstract.
Pediatr Dermatol. 2000 Jul-Aug;17(4):315-8
Use of squaric acid dibutylester (SADBE) for cutaneous warts in children.
Click here to access the PubMed abstract.
J Am Acad Dermatol. 1999 Oct;41(4):595-9
Contact immunotherapy with squaric acid dibutylester for the treatment of recalcitrant warts.
Click here to access the PubMed abstract.
Rosacea
Clin Exp Dermatol 2003 Jan;28(1):61-3
Topical application of NADH for the treatment of rosacea and contact dermatitis.
Click here to access the PubMed abstract of this article.
Scarring and Keloids
Br J Plast Surg 1998 Sep;51(6):462-9
Topical tamoxifen--a potential therapeutic regime in treating excessive dermal scarring?
Click here to access the PubMed abstract of this article.
Topical Anesthetics
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 contain 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 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. Click here to access the PubMed abstract of this article.
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
Sun Protection/Photoaged Skin/Wrinkles
Cosmeceuticals for Anti-Aging
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 antiaging and anti-inflammatory effects. Topical bleaching agents such as hydroquinone, kojic acid and azelaic acid can 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.
Puizina-Ivić N, Mirić L, Carija A, Karlica D, Marasović D.
Click here to access the PubMed abstract of this article.
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 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.
Robinson LR, Fitzgerald NC, Doughty DG, Dawes NC, Berge CA, Bissett DL. Click here to access the PubMed abstract of this article.
Anti-Wrinkle Efficacy of Adenosine-Containing Preparations
A blind, randomized, placebo-controlled study evaluated formulations containing adenosine to reduce periorbital lines (“crow’s feet”) and glabellar frown lines (wrinkles that appear between the eyebrows). Improvements were evidenced after 3 weeks of product application and were steadily confirmed after 2 months, despite severe climatic conditions and independently of the analysis technique that was used with the FOITS data. Adenosine-containing cream also significantly improved glabellar frowns. This study demonstrates the potential beneficial effects of adenosine-containing products on crow's feet and glabellar facial wrinkles.
Int J Cosmet Sci. 2006 Dec;28(6):447-51.
Evaluation of anti-wrinkle efficacy of adenosine-containing products using the FOITS technique.
Abella ML.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
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
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
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. Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
Topical application of 0.01% estradiol and 0.3% estriol markedly improved elasticity and firmness of the skin, substantially decreased pore sizes, increased skin moisture, and decreased wrinkle depth.
Eur J Obstet Gynecol Reprod Biol. 2007 Feb;130(2):202-5.
Effects of topical estradiol on the facial skin collagen of postmenopausal women under oral hormone therapy: a pilot study.
Click here to access the PubMed abstract of this article.
Int J Dermatol. 1996 Sep;35(9):669-74.
Treatment of skin aging with topical estrogens.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
Am J Clin Dermatol. 2005;6(1):39-47.
The role of dimethylaminoethanol in cosmetic dermatology.
Click here to access the PubMed abstract of this article.
Antioxidants such as vitamins E and C, coenzyme Q10, alpha-lipoic acid, glutathione, and others can reduce signs of aging.
Acta Dermatovenerol Alp Panonica Adriat. 2008 Jun;17(2):47-54.
Skin aging.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
Int J Dermatol 2005 Mar;44(3):197-202.
Moisturizing effects of topical nicotinamide on atopic dry skin.
Click here to access the PubMed abstract of this article.
J Cosmet Dermatol 2004 Apr;3(2):88-93
Nicotinic acid/niacinamide and the skin.
Click here to access the PubMed abstract of this article.
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 anti-aging 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 photoageing of facial skin.
Click here to access the PubMed abstract of this article.
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 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 was 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. Exp Dermatol. 2004;13 Suppl 4:36-40 Skin aging and sex hormones in women -- clinical perspectives for intervention by hormone replacement therapy.
Click here to access the PubMed abstract of this article.
Exp Dermatol. 2006 Feb;15(2):83-94
Biology of estrogens in skin: implications for skin aging.
Click here to access the PubMed abstract of this article.
Eur J Obstet Gynecol Reprod Biol. 2006 Jun 22
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.
Click here to access the PubMed abstract of this article.
Fertil Steril. 2005 Aug;84(2):285-8
Long-term effects of hormone therapy on skin rigidity and wrinkles.
Click here to access the PubMed abstract of this article.
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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In the following study, the effects of topical 0.01% estradiol and 0.3% estriol compounds were measured in preclimacteric women with skin aging symptoms. After treatment for 6 months, elasticity and firmness of the skin had markedly improved; wrinkle depth and pore sizes had decreased by 61 to 100%; skin moisture had increased; and wrinkle depth decreased significantly.
Int J Dermatol 1996 Sep;35(9):669-74
Treatment of skin aging with topical estrogens.
Click here to access the PubMed abstract of this article.
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.
Click here to access the PubMed abstract of this article.
Pruritus
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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Hydroxyethyl Starch-Induced Pruritus Relieved by Menthol/Camphor Lotion
Hydroxyethyl starch (HES) is a key component of many colloid volume expanders used in hypovolemic shock and otologic disease. Pruritus is a common side effect. Although classically refractory to treatment with corticosteroids and antihistamines, some benefit has been achieved with topical capsaicin, ultraviolet light therapy, and oral naltrexone.
A man with severe symptoms and refractory course was treated with a topical lotion containing 0.5% camphor and 0.5% menthol, which was dramatically successful. A randomised, double-blind, placebo-controlled trial showed a combination of menthol and phenol to be beneficial in mustard-gas induced pruritis.
J Am Acad Dermatol. 2008 Jul;59(1):151-3.
Hydroxyethyl starch-induced pruritus relieved by a combination of menthol and camphor.
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Singapore Med J 2007;48:392-5.
Phenol and menthol in the treatment of chronic skin lesions following mustard gas exposure.
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Naltrexone for Post-Burn Pruritus and Severe Generalized Pruritus in Biliary Atresia
“Severe pruritus is one of the many complications that burn survivors endure as a consequence of healing or healed burn or donor site wounds, [and] continues to be a clinical challenge that is inadequately addressed by traditional therapies. The success of naltrexone, an opioid antagonist, in treating pruritus in other patient populations, supported the concept that it may also be effective in burn survivors.” Opioid antagonists have been shown to suppress pruritus in patients with chronic cholestasis, uremia, atopic dermatitis, and chloroquine-induced itching.
“Naltrexone is a well-tolerated medication with little adverse effects [and] may be an effective adjuvant treatment in the management of cholestatic pruritus in the pediatric population.”
Two studies used a topical formulation of 1% naltrexone (or placebo) for 2 weeks to treat patients with localized and generalized atopic dermatitis with severe itching. More than 70% of the patients using the 1% naltrexone cream experienced a significant reduction of pruritus. The cream containing naltrexone had an overall 29.4% better effect than placebo.
Burns. 2008 Sep;34(6):797-802. Epub 2008 Mar 5.
Naltrexone for the management of post-burn pruritus: A preliminary report.
LaSalle L, Rachelska G, Nedelec B.
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Pediatr Dermatol. 2008 May-Jun;25(3):403-4.
The use of naltrexone in the management of severe generalized pruritus in biliary atresia: report of a case.
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J Am Acad Dermatol. 2007 Jun;56(6):979-88
Treatment of pruritus with topically applied opiate receptor antagonist.
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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 Am Acad Dermatol. 2007 Jun;56(6):979-88
Treatment of pruritus with topically applied opiate receptor antagonist.
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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.
Click here to access the PubMed abstract of this article.
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 Click here to access the PubMed abstract of this article.
Psoriasis
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. Epub 2009 Dec 17.
No increased risk of cancer after coal tar treatment in patients with psoriasis or eczema.
Roelofzen JH, Aben KK, Oldenhof UT, Coenraads PJ, Alkemade HA, van de Kerkhof PC, van der Valk PG, Kiemeney LA.
Click here to access the PubMed abstract of this article.
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?
Schwartz JR, Rocchetta H, Asawanonda P, Luo F, Thomas JH.
Click here to access the PubMed abstract of this article.
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.
Feldman SR, Yentzer BA.
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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. Click here to access the PubMed abstract of this article.
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.
Carroll CL, Clarke J, Camacho F, Balkrishnan R, Feldman SR.
"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.
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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.
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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 psoriais--a case report.
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Vitiligo
Treatment Options for Vitiligo
Pseudocatalase Cream
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.
Examples of Compounded Medications
The following list is just a few of the preparations that we can compound for dermatology. We work together with prescriber and patient to solve problems, and 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
- Ivermectin - oral or topical
- 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
Click here to access the PubMed abstract
J Pathol 2000 Aug;191(4):407-16
Melanocytes are not absent in lesional skin of long duration vitiligo.
Click here to access the PubMed abstract.
J Investig Dermatol Symp Proc 1999 Sep;4(1):91-6
In vivo and in vitro evidence for hydrogen peroxide (H2O2) 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
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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