Skin Care as an Adjunct Treatment for Skin Disease

C.B. Lynde; J.N. Kraft, MD; C.W. Lynde, MD, FRCPC
Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Introduction

A good skin care regimen including both prescription and non-prescription treatments for multiple dermatological conditions is very important. Many skin disorders can be caused by a primary dermatological condition but one should remember systemic diseases and drugs prescribed for other conditions can also cause skin problems. Daily skin care is a key component of management for many skin diseases. It is important to educate patients about behavioral changes they can make on a daily basis, in addition to prescribed therapy.

Dry Skin

• Atopic dermatitis
• Asteatotic dermatitis
• Ichthyoses
• Irritant contact dermatitis
• Acne vulgaris
• Rosacea
• Retinoid-induced irritant dermatitis
• Psoriasis
• Cosmetic therapies & procedures

• Renal failure
• Diabetes
• Hypothyroidism
• Malnutrition

• Systemic retinoids (e.g., isotretinoin [Accutane^®])
• Epidermal growth factor receptor inhibitors (e.g., cetuximab [Erbitux^®])
• Radiation therapy, chemotherapy

Patient education

• Learn how to recognize flares and
• treat early

Bathing

• Baths are recommended more than showers, lukewarm water, 5-10 minutes, once or twice daily.
• Use a mild cleansing product (e.g., Cetaphil^® Cleanser, Toleriane^® Cleanser).
• Add emulsifying oil (e.g., Keri® Bath Oil).

Laundry

• Mild detergents with no fragrance
• No bleach or fabric softener

Skin care

• Use mild cleansing agents.
• Apply moisturizer 3-5 minutes after bathing.
• Avoid light lotions; use products rich in essential fatty acids, and those formulated with appropriate combination of humectants, emollients, and occlusives.

• Avoid rough fabrics, chlorine, solvents, and stress.

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Itchy Skin

Localized

• Atopic dermatitis
• Urticaria
• Insect bites
• Lichen planus
• Lichen simplex chronicus
• Psoriasis

Generalized

• Winter itch
• Infestations (e.g., lice, scabies)
• Pruritus of senescent skin

• Renal failure
• Hepatic disease (obstructive biliary disease)
• Endocrine/metabolic (hyper/hypothyroidism, diabetes, gout)
• Neurologic (multiple sclerosis, post-herpes zoster, depression, peripheral nerve injuries)
• Neoplastic (leukemia, lymphoma, multiple myeloma, internal malignant tumors)
• Hematologic (hemochromatosis, iron deficiency anemia)
• Infectious (HIV, hepatitis C)

• Opiates
• ASA
• Drug reactions (exanthematous eruptions, fixed drug eruptions, urticaria/ angioedema) to antibiotics, antihypertensives, cholesterol lowering agents, etc.
• Radiation therapy, chemotherapy

• See management for Dry Skin above.
• Consider allergy testing to determine sensitivity.

• Decrease alcohol intake.
• Reduce stress.
• Avoid irritants, e.g., no harsh fabrics, harsh soaps, solvents, chlorine.
• Rinse detergents from clothing.
• Use bath oil or baking soda.
• Apply moisturizer regularly after washing.
• Refresh with cool water compresses or cooled moisturizers

• Menthol 1% and/or camphor 1/4%-1/2% in aqueous cream (keep refrigerated)
• Combination products with menthol, colloidal oatmeal and shea butter (compounding not necessary).

• Antihistamine

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Photosensitivity

• Polymorphous light eruption
• Actinic prurigo
• Solar urticaria
• Brachioradial pruritus

• Systemic Lupus Erythematosus
• Porphyrias
• HIV

• Doxycycline, minocycline, tetracycline
• NSAIDs
• Trimethoprim-sulfamethoxazole
• Thaizide diuretics
• ACE inhibitors
• Antimalarials
• Coal tar and its derivatives
• Chlorpromazine
• Procainamide
• Vitamin A acid derivatives (e.g., isotretinoin [Accutane^®], topical retinoic acid [Retin-A®])
• Skin depigmenting agents (e.g., hydroquinone, kojic acid)

• Sun avoidance
• Protective clothing
• Barrier protection with minimum SPF 30 broad spectrum sunscreens
• Antihistamines q.h.s.

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Psoriasis

• Post streptococcal infection Therapeutic Causes
• Beta blockers
• Lithium
• Corticosteroid rebound phenomenon
• Antimalarials
• Interferon
• NSAIDs Adjunctive Treatment
• Moisturizers
• Antihistamines
• Sunburn avoidance
• Avoidance of drugs that exacerbate the condition

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Scaly Scalp

• Psoriasis
• Seborrheic dermatitis
• Dandruff

• Salicylic acid 1%-4% +/- olive oil (never use if patient has seborrheic dermatitis as it promotes growth of causative yeast), mineral oil
• Shampoos containing selenium sulphide, zinc pyrithione, tar
• Tar (e.g., 10%-20% coal tar solution; liquor carbonis detergent in a topical steroid ointment)

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Pimples/Acne

• Acne vulgaris

• Hyperandrogen states (e.g., polycystic ovarian syndrome)
• Menstruation hormonal factors
• NB: foods are not an aggravating factor

• Cosmetic products containing lipids and cocoa butter
• Heavy oils, greases, and tars
• Topical drugs containing tars, ointments, and corticosteroids
• Corticosteroids
• Androgens
• Halogens (e.g., systemic dioxin poisoning causing chloracne)
• Lithium
• Antituberculosis drugs (e.g., isoniazid)
• Antiepileptics (e.g., carbamazepine, phenytoin)
• Some formulations of oral contraceptives

• Daily facial washes and cleansers specially formulated for oily skin
• Low dose benzoyl peroxide washes
• Non-comedogenic moisturizing lotion

• Eyes: saline drops
• Nose: petroleum jelly ointment
• Lips: lip balm
• Dry skin: daily moisturizers

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Rosacea

• Niacin

• Avoid aggravating factors that induce flushing/ telangiectasia development: spicy food, alcohol, hot drinks, and heat-inducing activities.
• Warn patients not to apply potent topical corticosteroids to the face.
• Medical therapies help to resolve pustulation, papulation, and erythema, but have a minimal effect on the suppression of flushing and established telangiectasia.
• Some laser therapies can be effective.
• Cosmetic camouflage (e.g., Cover FX^®) may be especially helpful for females.
• Methylsulfonylmethane + silymarin (Rosacure^®) helps minimize appearance of erythema.

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Clinical Pearls

Providing patient education along with adjunctive therapies can help reduce frustration and improve patient compliance.

• Use simple skin care regimen, e.g., mild washes and daily facial moisturizer.

Sunscreen

• Apply broad spectrum, photostable formulation with SPF
• 30 before going out in the sun.
• Reapply frequently.
• A fairly thick application is needed for effectiveness.

Tar and its derivatives

• Stains fabrics yellow.
• Apply at night along the grain of hair growth to avoid folliculitis.
• Use old sheets to reduce concern about staining.
• Turns white hair a straw color.
• Patients with white hair should be warned to use on scalp with caution.

Benzoyl peroxide

• Bleaches fabrics. To minimize:
• Use a white towel to dry face after use.
• Avoid contact with fabrics until skin is dry.
• Use at night to avoid bleaching good clothing.

Antihistamines

• Caution patient regarding drowsiness and consider recommending non-drowsy antihistamine (e.g., cetirizine [ReactineR], desloratadine [AeriusR] during the day).

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Conclusion

Pharmacists can play a key role in helping patients with skin concerns by recognizing causes of common skin symptoms and recommending therapy to patients. They can counsel patients on behavioral strategies to help reduce disease severity and recurrence, and help patients choose products well-matched for a given skin condition. When counseling patients, a reactive approach to their concerns is appropriate, but a proactive approach is superior as this provides the best possible care.

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