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A. Bathing

Soap should be used only in the axillae and groin and on the feet by persons with dry or inflamed skin. Soaking in water for 10–15 minutes before applying topical corticosteroids or emollient enhances their efficacy (Soak and Smear).

B. Topical Therapy

Nondermatologists should become familiar with a representative agent in each category for each indication (eg, topical corticosteroid, topical retinoid, etc).

1. Corticosteroids

Topical corticosteroid creams, lotions, ointments, gels, foams, and sprays are presented in Table 6–2. Topical corticosteroids are divided into classes based on potency. Agents within the same class are equivalent therapies; however, prices of topical corticosteroids vary dramatically. For a given agent, higher lipophilicity (greasiness) corresponds with increased potency; ie, triamcinolone 0.1% ointment is more potent than triamcinolone 0.1% cream which in turn is more potent than triamcinolone 0.1% lotion. The potency of a topical corticosteroid may be dramatically increased by occlusion (covering with a water-impermeable barrier) for at least 4 hours. Depending on the location of the skin condition, gloves, plastic wrap, moist pajamas covered by dry pajamas (wet wraps), or plastic occlusive suits for patients can be used. Caution should be used in applying topical corticosteroids to areas of thin skin (face, genitals, skin folds). Topical corticosteroid use on the eyelids may result in glaucoma or cataracts. One may estimate the amount of topical corticosteroid needed by using the “rule of nines” (as in burn evaluation; see Figure 37–2). Approximately 20–30 g is needed to cover the entire body surface of an adult. Systemic absorption does occur with topical corticosteroids, but adrenal suppression, diabetes mellitus, hypertension, osteoporosis, and other complications of systemic corticosteroids are rare (eFigure 6–1).

Table 6–2.Useful topical dermatologic therapeutic agents.1

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