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Basics of medical therapy—systemic medication, other treatments, monitoring and scoring systems
Medical treatments for skin disease are increasingly focussed on systemic therapy, especially in secondary care. Biologic drugs are being developed to target specific pathways in the pathogenetic mechanisms of several skin diseases. Biologics are discussed in Chapter 61 .
When to select systemic therapy
Systemic treatments are used when topical treatment is ineffective, or for serious skin diseases and infections when a topical approach would be inappropriate. Details of the main classes of systemic drugs used for skin disease are summarised in Table 13.1 .
Table 13.1
An overview of systemic therapy
| Group | Drug | Indications |
|---|---|---|
| Corticosteroids | Prednisolone usually | Bullous disorders, connective tissue disease, vasculitis |
| Cytotoxics | Methotrexate | Psoriasis, sarcoidosis, eczema |
| Hydroxycarbamide | Psoriasis | |
| Biologics | Etanercept, infliximab, adalimumab, ustekinumab and many others | Psoriasis and atopic eczema unresponsive to other systemic agents, off-licence use in other diseases (p. 133) |
| Immunosuppressants | Ciclosporin | Psoriasis, atopic eczema, pyoderma gangrenosum |
| Gold | Bullous disorders, lupus erythematosus | |
| Azathioprine, mycophenolate mofetil | Bullous disorders, chronic actinic dermatitis, atopic eczema | |
| Retinoids | Acitretin | Psoriasis, other keratinization disorders |
| Isotretinoin | Acne | |
| Alitretinoin | Hand dermatitis | |
| Antifungals | Griseofulvin, terbinafine | Fungal infection |
| Ketoconazole | Fungal infection ( Candida albicans too) | |
| Itraconazole, fluconazole | Fungal infection, candidiasis | |
| Antibiotics | Various | Skin sepsis, acne, rosacea |
| Antivirals | Aciclovir, valaciclovir | Herpes simplex, herpes zoster |
| Famciclovir | Herpes zoster, genital herpes simplex | |
| Antihistamines | H1 blockers | Urticaria, eczema |
| Antiandrogens | Cyproterone acetate | Acne (females only) |
| Antimalarials | Hydroxychloroquine | Lupus erythematosus, porphyria cutanea tarda |
| Antileprotic | Dapsone | Dermatitis herpetiformis, leprosy, vasculitis |
Systemic steroids
The major indications for the use of systemic steroids in skin diseases are for severe conditions such as the blistering disorders, pemphigus and pemphigoid, and for severe involvement by vasculitis, systemic lupus erythematosus, sarcoidosis and some other conditions. Increasingly, the use of the rather non-specific immunosuppressive effect of corticosteroids is being supplanted by biologic drugs that have a more targeted effect or a better safety profile.
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