Topical Medicaments Research Articles

Allergic contact dermatitis from selected topical medicaments: A brief review

Adverse cutaneous reactions, some of which are allergic in origin and of variable severity, occur from systemic administration of medicaments, and others result from contact sensitivity from their topical use. Allergic contact dermatitis (ACD) to topically applied medicaments, excipients or active ingredients, is encountered frequently in clinical practice and should be suspected in all at-risk individuals. Although about one-third of all cases of ACD are initiated or perpetuated by prescribed or non-prescribed topical preparations, the problem usually remains underappreciated. The prevalence of hypersensitivity to these allergens varies across regions and periods of time depending on the personal habits and health-seeking behavior of an individual, the interest of the clinician in the field of contact dermatitis, and the types of cases studied. Often promoted by social media influencers as a remedy for all dermatological problems or cosmetics, the use of several home remedies and other over-the-counter anti-aging and cosmetic products has increased exponentially in recent years. We, herein, briefly review some of the commonly used products potentially causing ACD.

Allergic contact dermatitis caused by topical corticosteroids: A review for clinicoepidemiological presentation, evaluation, and management aspects

Dermatitis medicamentosa or contact dermatitis to topically applied medicaments, active ingredients or excipients, is encountered frequently in clinical practice and should be suspected in patients showing resistance to treatment despite adequate therapy and in patients, who complain of intolerance to a particular treatment. Topical corticosteroids are prescribed mostly in dermatology for their anti-inflammatory, antiproliferative, and immunosuppressive actions to treat various inflammatory dermatoses. These may act as allergens and produce immunoglobulin E-mediated immediate hypersensitivity (anaphylaxis, urticaria, angioedema, bronchospasm, vomiting, and cardiovascular collapse) or T-cell-mediated allergic contact dermatitis (ACD). Although it occurs less often and is not life threatening, ACD negatively impacts the quality of life by worsening preexisting dermatitis. The prevalence of hypersensitivity to these allergens varies across regions and periods of time depending on the clinical practice, prescribing habits, and types of cases studied. Over-the-counter availability of corticosteroids in multiple formulations in recent years may further compound the problem due to their indiscriminate and extensive use. Although about one-third of all cases of contact dermatitis are initiated or perpetuated by topical medicaments, the occurrence of contact dermatitis due to corticosteroids remains undersuspected. This is perhaps due to their anti-inflammatory and immunosuppressive properties that make it difficult to doubt and prove contact sensitivity that may be from a corticosteroid itself or to the additives and vehicles in the formulation. Patch testing can help identify the culprit agents in ACD but early diagnosis depends on clinical suspicion. Sensitization in contact dermatitis exhibits cross-reactivity patterns based on corticosteroid structure. Clinicoepidemiological presentation, evaluation, and management aspects of contact hypersensitivity reactions to corticosteroids are reviewed.

Efficacy of Clobetasol Propionate (0.05%), Amlexanox (5%), and Triamcinolone Acetonide (0.1%) in the Treatment of Oral Lichen Planus.

This study aimed to compare the efficiencies of 0.05% clobetasol propionate, 0.1% triamcinolone acetonide, and 5% amlexanox in the management of oral lichen planus (OLP). A total of 120 patients diagnosed with oral lichen planus were equally divided into three groups and treated with 0.05% clobetasol propionate (group A), 0.1% triamcinolone acetonide (group B), and 5% amlexanox (group C) topical medicaments. The patients were evaluated for pain using the visual analog scale (VAS) and erosive lesion. There was a statistically significant decrease in the VAS pain scale score from day 1 to day 15 in all of the tested groups. There was also a reduction in the erosive area on the right and left buccal mucosa on the 15th day with all three tested drugs. Triamcinolone acetonide (0.1%) was effective in reducing the erosive lesions on buccal mucosa when compared with 0.05% clobetasol propionate and 5% amlexanox. Clobetasol propionate, triamcinolone acetonide, and amlexanox were effective in treating OLP patients.

Efficacy of Aloe Vera, Amlexanox (5%), and Triamcinolone Acetonide (0.1%) in the Management of Oral Lichen Planus.

This research assessed the efficiencies of aloe vera, 0.1% triamcinolone acetonide, and 5% amlexanox in the management of OLP. A total of 120 participants diagnosed with oral lichen planus (OLP) were equally divided into three groups and treated with: aloe vera, (Group A), 0.1% triamcinolone acetonide (Group B), and 5% amlexanox (Group C) topical medicaments. The patients were evaluated for pain, using the visual analogue scale (VAS). They were also evaluated for ulcerative lesion type and erosive area on days 1, 7, and 15 of the study. There was a statistically considerable decrease in the VAS pain scale score, reduction in the erosive area on buccal mucosa, and healing of ulcer from day 1st to 15th day with all three tested drugs. All drugs used in this study; aloe vera, triamcinolone acetonide, and amlexanox were effective in treating OLP patients.

Allergic contact dermatitis from propylene glycol: A case series from Australia.

Propylene glycol (PG) is used in a variety of cosmetics, food and pharmaceuticals. PG is a known sensitizer but also irritating when patch tested (PT). The aims were to investigate the frequency of contact sensitization to PG and to identify cases of allergic contact dermatitis (ACD). A retrospective study was performed on patients PT at the Skin Health Institute (SHI), Victoria, Australia to PG 5% pet. and PG 10% aq. between 1 January 2005 and 31 December 2020. In all, 6761 patients were PT to PG and 21 (0.31%) reacted. Of those 21 individuals, 9 (42.9%) had a relevant reaction. 75% of relevant positive reactions were in patients PT to PG 10% aq. The most common source of PG exposure was topical medicaments (77.8% of relevant reactions) and moisturizers, with the largest group being topical corticosteroids. Contact sensitization to PG in the patch test population remains uncommon, although it is possible that testing with concentrations of 5%-10% PG did not identify all reactions. Topical corticosteroids were the most important cause. Patients with suspected contact dermatitis to topical corticosteroids should be PT to PG.

A Clinical Approach to Hirsutism

Hirsutism is a condition of hyper androgenism, which is defined as androgen- dependent excessive male- pattern hair growth, affects approximately 10% of women with or without complex underlying pathology. It is a physiological phenomenon if it occurs with a familial history and is considered as a serious condition if it is due to various metabolic and genetic causes along with androgen secreting tumors. Hence an apt treatment is only possible after a proper diagnosis. In our classics, there is no direct term for hirsutism is mentioned. But we can decipher relative aspects from multiple references regarding hair and hair growth. Even though, based on the Dushya involvement it can be considered as a condition of Kapha Pradhana Tridosha Kopa. Hence based on a proper diagnosis through an apt diagnostic technique Abhyantara (internal) as well as Bahya (external) Chikitsa (treatment) like depilation techniques, use of Lepa (topical medicaments), oil etc.

Evaluation, complications and treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a disease which commonly affects people of all ages and significantly impacts the quality of life. The clinical symptoms of CRS, which is defined by a chronic inflammation of the sinonasal mucosa, include persistent rhinorrhoea, nasal congestion, sinus pressure, and a diminished sense of smell that lasts longer than 12 weeks. CRS can be categorized into two groups: CRS with nasal polyps and CRS without nasal polyps. Inflammatory, environmental, and host factors are responsible for causing CRS although the mechanism is debatable. Diagnostic examination including anterior rhinoscopy, endoscopy or radiography, ideally from sinus computed tomography, can aid in confirmational diagnosis of CRS. The objective of the treatment is to improve mucociliary clearance, nasal drainage and outflow, reduce local infection and inflammation, and facilitate topical medicament access. Nasal saline irrigation and intranasal corticosteroid sprays are the first-line treatments. Antibiotics may be helpful for patients who have symptoms of a superimposed, acute active sinus infection. Endoscopic sinus surgery may be useful if medical therapy is ineffective. Referrals to otolaryngologists should be made for patients who are not responding to first-line medical therapy. CRS if not treated timely can further lead to complications including development of various diseases such as asthma breathing issues, smell disorders and certain bacterial and fungal infections. Effective treatment of the CRS is hence needed. The purpose of this research is to review the available information about evaluation, complications and treatment of CRS.

Fabrication of Emulsion Loaded with Cyclosporine and Moringa Oleifera Oil Potentially for Topical Psoriasis Treatment

Psoriasis is a widespread autoimmune inflammatory dermatological disease treated with oral cyclosporine to reduce the uneasiness of psoriasis. However, systemic therapy of cyclosporine is associated with high risk of side effect that limit the usage in psoriasis treatment. Topical delivery of cyclosporine is believed could overcome cyclosporine related toxicity issues. In this study, a new carrier for topical cyclosporine was developed, which cooperated with Moringa oleifera oil (MOO) that has been reported could enhance the moisture-retaining of the skin. Both high-shear homogenizer and overhead stirrer homogenizer were utilized in formulating a cyclosporine-loaded emulsion carrier. Two emulsions were prepared at different proportions of MOO, water and surfactant (Tween80:Span80) based on the constructed ternary phase diagram. Samples with different formulation (E1 and E2) were subjected to several tests including the stability, rheological, colony and in vitro release analysis. E1 and E2 possessed good stability against phase separation for 1 month at different storage temperatures (4, 25 and 40ºC), having pH values within the range of 4 to 5 as well as showing no mould and microbial growth after been incubated on nutrient agar plate at controlled conditions. Optimized formulations were found to be non-Newtonian and followed the pseudoplastic flow behaviour. Nonetheless, E2 exhibited highest permeation of cyclosporine (80.23%) through cellulose acetate membrane via Franz diffusion cell, which correspond to controlled release and best fitted to first order kinetic behaviour (R2=0.9819). This preliminary study suggested that the formulated emulsion has a promising potential as topical medicament for psoriasis.

New onset atopic dermatitis and psoriasis in the same patients under biologic treatments: The role of systemic treatments as a possible trigger.

Atopic dermatitis (AD) and psoriasis (PsO) are among the most common diseases in the daily clinical practice. Usually, AD and PsO are reported as two diseases that cannot coexist in the same patient because this requires the activation of opposing inflammatory pathways. Anyway, some reports highlight how AD and PsO may coexist in the same patient or develop consequently. In this short report we collected 12 patients that developed new AD or PsO. Among them, eight patients (n=8; 3M:5F) with a previous diagnosis of PsO, developed subsequently an AD with a mean time of onset of 71.5months. Out of eight patients, four patients where in treatment with ustekinumab, one with ixekizumab, two with adalimumab, and one with guselkumab. All new onset AD have been treated with topical medicaments, except one case that performed dupilumab. Contrariwise, four patients with a baseline AD developed a PsO with a mean time of onset of 25 months. Two AD patients were under dupilumab treatment, while the other two patients performed only topical treatments. All patients showed an improvement of the new onset PsO with topical treatment only. This report highlights how AD and PsO are not mutually exclusive diseases. The mechanisms by which AD patients develop PsO or psoriatic patients develop AD are still not very clear; some triggers can promote these processes, such as systemic therapies. Therefore, clinicians should carefully evaluate any changes in these patients, in order to reach a correct diagnosis and carry out a relative treatment.

32765 Regional variation in percutaneous absorption in in vitro human models: A systematic review

Percutaneous absorption is of importance given its role in topical medicaments, transdermal drug systems, and dermatotoxicology. Many factors influence percutaneous absorption, including anatomical location. Hence, this study summarizes the existing data on regional variation in percutaneous absorption in in vitro human models. PubMed, Embase, and Web of Science were explored, and literature containing quantitative data on regional differences in percutaneous absorption in humans in vitro, was collected. Eight relevant articles were identified, which together, explored 15 anatomic regions. Four studies compared percutaneous absorption between scalp and abdominal skin, and all concluded that the former was more permeable. Within those 4 studies, 10 penetrants of varying physical/chemical properties were tested, suggesting that anatomical location has a greater effect on percutaneous absorption than the penetrants’ properties. Additionally, torso was less absorptive than scrotum in both studies in which these sites were compared. In conclusion, the scrotum and scalp appear to be highly vulnerable to percutaneous absorption when compared with other regions such as the abdomen. This is thought to be largely due to the high hair follicle density in these areas, allowing for greater penetration through the appendageal pathway. However, there is a paucity of conclusive data regarding the absorptivity of other anatomical locations. Experimentation testing and ranking the vulnerability of different anatomical locations is of vital importance given its relevance in decontamination and transdermal drug delivery protocols, and understanding the mechanisms and degree of these variances should aid our pharmacologic/toxicologic judgments.

Clinical evaluation of effect of aloe Vera gel formulation for healing following gingival depigmentation

Gingival hyperpigmentation is of cosmetic concern for many individuals, particularly while smiling. Gingival depigmentation has been evolved as enchanting method for hyper pigmented gingiva. Surgical wound healing attaints an important role in the surgical field. There are various topical medicaments and antibiotics available to expedite the healing process. Out of this Aloe vera showed numerous therapeutic benefits. The objective of the study was to prepare a Aloe vera gel containing Carbopol 934 and to evaluate its efficacy on the healing following Gingival Depigmentation.Total thirty patients with gingival depigmentation were included in this double-blinded, randomized, and controlled clinical trial. The test area received an application of Aloe vera gel preparation postoperatively. Postoperative healing was assessed using HI after first, second, and third weeks following therapy by a blinded examiner.Total 48 patients were enrolled in the study and out of this 30 patients fulfilled the criteria. Test sites showed better healing compared to control sites. The healing in patients in test sites showed statically significant with gradual progress in time. However, control sites did not showed statistically significant results. Anova analysis was done and Spss v.20 was used. Results showed prepared Aloe vera gel had showed significant results towards surgical wound healing after gingival depigmentation. Keywords: Gingival Depigmentation, Aloe vera, Healing Index, Randomized Clinical trial.

Contact Allergy to Topical Medicaments, Part 2: Steroids, Immunomodulators, and Anesthetics, Oh My!

Topical drugs are used to treat a variety of cutaneous and noncutaneous conditions. Direct application to the skin can result in adverse cutaneous effects, including allergic contact dermatitis (ACD). In part 2 of this series on topical medicament ACD, we focus on corticosteroids, immunomodulators, and anesthetics.

Ayurveda multimodal treatment approach for the management of generalized plaque psoriasis: a case report

Background: Plaque psoriasis typically presents with large, oval-circular plaques over the scalp, trunk, and extensor body surface. In Ayurveda, all the skin diseases depict under the heading “Kustha” (skin diseases). Among them, “Ekakustha” (psoriasis) is further explained under the title “Kshudra Kustha” (minor skin diseases). It is characterized by the hyperproliferation of the epidermal cells resulting in plaque formation over the lesions and may get severe and progress into the pustular subtype. Aim: Plaque psoriasis is compared with Ekakushtha in Ayurveda because of its resemblance to disease condition that is described in the Ayurveda classics. The aim of this study was to treat a patient with Ayurveda multimodal treatment approach. Materials and Methods: We, herein, reported a case of a woman aged 29 years complaining about reddish lesions over the scalp, peripheral area of eyes, trunk, back, and upper and lower extremities with intense pruritus since the last 8 months. Itching leads to scaling and trickling of blood from lesions. The patient was diagnosed with generalized plaque psoriasis. This case was treated by internal as well as topical medicament with the cessation of known etiological factors. Results: A significant reduction in the symptoms within 98 days of treatment without reported relapse manifestation of previous symptoms. The scores of 18, 10, and 2 were observed before treatment, after treatment, and after follow-up period, respectively, on the symptomatic relief in signs and symptoms of Ekakushtha. The Psoriasis Area Severity Index (PASI) score was adopted as the assessment of severity of case. The PASI score is zero after the treatment and 12.2 before the treatment. The Ayurveda multimodal treatment approach gives miraculous result in this type of complex nature of psoriasis disease.

Contact Allergy to Topical Medicaments, Part 1: A Double-edged Sword.

Topical drugs are used to treat a variety of cutaneous and noncutaneous conditions. Direct application to the skin can result in adverse cutaneous effects, including allergic contact dermatitis (ACD). In this article, we review medicament ACD with a focus on acne and rosacea medications, antimicrobials, antihistamines, and topical pain preparations.

Contact Dermatitis of the Vulva

The vulvar area is a common site of both irritative and allergic contact dermatitis due to the thin skin, easily traversable by irritant and allergic substances. The purpose of this review is to provide an overview of the most frequent allergens causing contact dermatitis in this particular site. A literature search was conducted via PubMed through May 2021. Relevant English language studies are included in this review. Fragrances, preservatives, botanical products, and topical medicaments were found to be the most commonly involved allergens. Contact dermatitis is a very common occurrence that should also be considered in patients with chronic vulvar or anogenital dermatitis who do not respond to appropriate treatments.

Approach to allergic contact dermatitis caused by topical medicaments.

To provide an approach to identifying topical medicament ingredients that cause allergic contact dermatitis (ACD) and to recognizing common clinical scenarios in which these ingredients might present. A retrospective chart review was conducted of patients patch tested at the Contact Dermatitis Clinic at St Paul's Hospital in Vancouver, BC, between November 2016 and June 2019. Data from the North American Contact Dermatitis Group from 2015 to 2016 and The Ottawa Hospital patch test clinic from 2000 to 2010 were also reviewed. Topical antibiotics are the most common cause of ACD to medicaments and frequently cause cosensitization to multiple allergens. This hypersensitivity reaction is often seen following surgical procedures and should be distinguished from postoperative infection. Corticosteroid allergy is easy to miss and should be suspected in cases of corticosteroid-sensitive dermatoses that worsen despite appropriate treatment. Topical anesthetics and propylene glycol are other causes of ACD found in many prescription and over-the-counter products. Allergic contact dermatitis is easy to miss and should always be considered in cases of eczematous eruptions. A thorough drug history including all topical products-both prescription and over-the-counter-is critical. Patch testing can help identify specific allergens for the patient to avoid.

Aluminium contact allergy without vaccination granulomas: A systematic review and meta-analysis.

Aluminium contact allergy is mainly seen as granulomas following immunization with aluminium-adsorbed vaccines and contact allergy following epicutaneous exposure may be overlooked. To investigate the prevalence of aluminium allergy confirmed by patch testing, with no association with vaccination granulomas, and explore whether epicutaneous exposure to aluminium can contribute to allergic contact dermatitis. Two authors independently searched PubMed and MEDLINE (OVID) for case studies on contact allergy to aluminium proven by patch testing. Age-stratified meta-analyses to calculate the pooled prevalence were performed. Twenty-five studies describing a total of 73 cases were included in the review. Seven studies were suitable for meta-analyses. The prevalence of aluminium contact allergy was 5.61% (95% confidence interval [CI] 0.12%-11.08%) for children and 0.36% (95% CI 0.04%-0.67%) for adults. The studies described a variety of epicutaneous exposures, where metallic aluminium, topical medicaments, and deodorants were the main sources. Aluminium sensitization without a known exposure source was described in 10 of the 25 articles. The prevalence of aluminium contact allergy in the general public may be higher than expected and not solely related to vaccination granulomas. However, the clinical relevance is rare if not related to granulomas.

Application of silver diamine fluoride as part of the Atraumatic Restorative Technique

Dentistry is an evolving profession that has been significantly impacted by the COVID-19 pandemic. Greater consideration must be taken with treatment planning to minimise aerosol generating procedures (AGPs) as well as working in the patient's best interest to provide the best quality of dental care. Silver diamine fluoride (SDF) is an effective non-invasive treatment option and is applied as a topical medicament on tooth cavities to arrest dental caries. Currently there is limited use of this substance across dental practices in the UK, however the prospect of SDF being introduced is becoming increasingly likely due to the COVID-19 pandemic.

Comparative evaluation of steroid sensitivity in various dermatoses with control group through histopathological examination and patch testing

Background: Topical corticosteroids are widely used for treating various dermatoses. People have been self-medicating them for fungal infections, pigmentary disorders, and for many other dermatoses. This overzealous and irrational use of corticosteroid makes individuals susceptible for its adverse effects. Aim: The aim of this study was to evaluate steroid sensitivity in various dermatoses. Materials and Methods: Patch testing with Indian standard series and corticosteroid series was performed in sixty subjects where thirty patients were cases and thirty were controls. Histopathological examination and As it is (ASIS) were done only for the case group. Patches were applied on the back for 48 h and reading was done on day 2, day 4, and day 7 according to the International Contact Dermatitis Research group grading. Results: The maximum cases were in the age group of 20–30 years (33.3%) while 31–40 years was the most common age range (50%) among controls. Among the case group, 60% were male and 40% were female. Maximum patients affected in the case group were homemakers (36.7%) followed by laborers (13.3%). The case group showed 16.7% positive patch test reactions while none were positive in the control group. Thiomersal was positive in 13.3% of cases and neomycin in 3.3% of cases. ASIS was negative in all cases. Thiomersal is commonly used as a preservative in topical medicaments, cosmetics, and vaccines. Conclusions: Steroid sensitivity is hard to diagnose clinically, thereby causing difficulty in managing such cases. Patch test is a noninvasive gold standard procedure without major adverse effects and helps in treating the dermatoses with appropriate class of corticosteroid by avoiding the suspected allergen.

Mixed occupational and iatrogenic allergic contact dermatitis in a hairdresser

Allergic contact dermatitis (ACD) is a common occupational disease. Hairdressers and beauticians are at increased risk of occupational chronic hand eczema. We present a case of mixed occupational, non-occupational and iatrogenic ACD in a hairdresser which illustrates that delayed diagnosis can result in high morbidity, and unnecessary treatment and cost. A hairdresser with chronic hand and facial eczema failed medical management with topical steroids and dupilumab. Patch testing revealed contact allergy to multiple occupational exposures, home exposures and topical medicaments.