Over the Counter Dermatology Bonnie T. Mackool, MD, MSPH Assistant Professor of Dermatology, Harvard Medical School Massachusetts General Hospital Disclosures

Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose. Seinfeld:

• “Saving Lives? She’s one step above working at the Clinique Counter.”

• George: Quote from The Slicer (S09E07) Dermatology Related Aisles (all):

Acne, Cosmetics (Beauty), Personal Care, Diet and Nutrition, baby and Child, Vitamins, Sexual wellness Steroid Acne

HC ointment 1 % x 7 days

Side Effects of Topical Glucocorticoids Topical Side Effects Systemic Side Effects • Atrophy (sheen) • Sodium Retention • Telangiectases • Hyperglycemia • Striae • CHF • Acne (perioral dermatitis) • Femoral Head Necrosis • Worsening cutaneous fungal • Cataracts infection • Glaucoma • Tachyphylaxis • Hypokalemia(digoxin toxicity) • Adrenal suppression • Growth retardation Acne Treatment with OTC Products

• Benzoyl Peroxides (creams, gels, washes) • Topical Vitamin A (adapalene) • Salicylic acid (washes, creams, pads) • Antibiotic: sulphur Acne

Inflammatory Papules Open Comedones Closed Comedones Post Inflammatory Hyperpigmentation Benzoyl Peroxides

Properties Side Effects • Anti-bacterial • Dryness • Lotions, gels • Irritation • Decrease bacterial • Bleach clothing with contact resistance with topical antibiotic (compared to topical antibiotic alone) Topical Retinoids: Adapalene OTC Other Retinoids Requiring Prescription: Tretinoin and Tazarotene

Properties Side Effects • Comedolytic • Irritant effect • Cream, gel, solution • Sun sensitivity Topical Antibiotic

Sulphur 10 percent Salicylic acid

Washes, creams, pads Side effects; irritation, dryness Think about absorption effects.

Reading the Labels Potential Irritants or Allergens

Contact Dermatitis Cover Up Anti-Acne Potential irritants and allergens Australian Tea Tree Oil, Salicylic Acid, Aloe, Witch Hazel, Chamomile, Lavender, Tea Tree Oil Wintergreen Lice

Dimethicone (Nix) Wide use in Europe Flammable Psoriasis

Coal Tar: anti-itch, anti-inflammatory, anti-pruritic Forms: ointments, gels, shampoos, lotions Salicylic Acid (creams – 3%; shampoo) Potential Side Effects of Topical Tar

• Irritation • Sensitivity to the sun • Shampoos – discoloration of blond, light, or gray hair Salicylic Acid Used to Treat Psoriasis

3% cream Salicylic Acid

• OTC preparations wart preps methyl salicylate = Oil of Wintergreen (muscle creams) Chinese herbal skin treatments • Prescription medications Salicylate Percentages

• Acne: 2-6% • Keratolytic agents: 2-6% • Warts: 15-40% Salicylic Acid

• 79 year-old man with renal • 72 yo man with ESR failure – 10% sal acid in – 2-5% sal acid for 6 days triamcinolone cream • Unconsciousness 80% BSA x3 weeks • Refractory hypo-glycemia

Maurer: Arch Derm: 1994 Unbound Salicylate Penetrates Cells More Readily

• Highly protein bound medications may increase unbound salicylate • Uremia increases unbound salicylate Increase Risk of Toxicity from Salicylates

• Valproic acid – highly protein bound • Sulfonylurea – “ “ • Aspirin • Liver failure • uremia • Hypoalbuminemia • Child (large BSA to wt) Chronic Salicylate Toxicity

• Lethargy • Confusion • Hallucinations • Seizures • coma Topical OTC Salicylic Acid Muscle Cream

• 17 yo woman – track team member • Died in sleep of cardiac arrest April 2007 • Toxic salicylate levels • Used OTC muscle creams • May have taken oral ASA concurrently Issues: Are We Informed?

• Systemic Absorption • Drug Interactions – Medication – Topical with Systemic – Host (athlete) • Methyl salicylate and ASA • dehydration – Ex: Methyl salicylate and coumadin • sweating Topical Agents May Cause Death Absorption: Some Factors

Host factors Other factors • Skin thickness (age, prior • Heat medication) • Occlusion • Location • Moisture • Integrity of epidermis • Vehicle and concentration (i.e., erosion) • Stratum corneum thickness • Kidney/Liver function 40-Year-Old Man

• Scar changing • Donor site • Allergy to bacitracin • 4 mm punch biopsy performed of nodule • Polymyxin antibiotic applied

Diaphoretic, Light Headed, Dyspneic

• Hypotensive • Recumbent edematous, throat hx: allergy to bacitracin = became tightened Transferred to ED

• Did well • Benign biopsy result Severe Allergic Reactions to Topicals Include Anaphylaxis

• Co-sensitization can occur between: bacitracin and neomycin bacitracin and polymyxin

• Erroneous assumption that side effect was local and minor Anaphylaxis

• Bacitracin – anaphylaxis • Neomycin – anaphylaxis, ototoxicity (wound irrigation, topical ) • Polymyxin – anaphylaxis • Chlorhexidine solution Topical Iodine

Metabolic acidosis Hypothyroidism Hyperthyroidism Topical iodine

Metabolic acidosis Hypothyroidism Hyperthyroidism Topical Iodine

• Metabolic acidosis - systemic absorption with depth and extent of burns • Extensive 2nd and 3rd degree burns • Iodine ointment q 6 hrs x 7 days

Lavell KJ et a;. Iodine absorption in burned patients treated topically with povidone-iodine. Clinical Pharm and Thera. 1975;17:355-63. Thyrotoxicosis from Povidone Iodine 10%

Sternal Wound Irrigations Intra-vaginal (23 yo) pre-op • 28 treatments in 45 days • 3 treatments in 4 days • Thyrotoxic within a few weeks • Thyrotoxic within 17 days of • Tot serum + inorganic iodine 49.5 treatment 1 • Tot serum + inorganic iodine 12.5 • (normal: 0 – 2 microgr/dl)

Rajatanavin R et al, Am J Med;77;378 1984

Topical Iodine: Caution

• Pre-existing thyroid disease • Premature infants • Low birth weight full term infants • Individuals with large BSA usage • Burn victims • Lack of epidermal integrity Adverse effect of topical methylsalicylate ointment on warfarin anticoagulation: an unrecognized potential hazard

Yip AS, Chow Wh, Cheung KL. Postgrad Med J:1190:66:367-9. 11 Patients from Anticoagulation Clinic

• Admitted based on abnormally high INR and h/o topical methylsalicylate ointment usage • Examined for bleeding • Labs included blood salicylate level Results

• 11/11 abnormally elevated INR • All had positive blood level for salicylate • 2-4 grams of topical methylsalicylate ointment x 2 weeks • 1 GI bleed (endoscopy negative), 2 diffuse bruises Warfarin Augmentation by Salicylate

• Salicylate may displace warfarin from protein bindings sites • Salicylate may depress prothrombin formation by the liver Herbal medicines may account for important drug interactions CYP 3A4 induction Acute Transplant Rejection Due to Saint John’s Wort

• 2 cardiac transplant patients • Initiated Saint John’s wort • Developed rejection • Saint John’s wort decreases cyclosporine levels • Induces CYP 3A4 ______

– Ruschitska F. Lancet 2000:355:548-9. Seinfeld:

• “Dermatologists. Skin doesn’t need a doctor.”

• Jerry: Quote from The Slicer (S09E07) Dermatology Related Aisles: Acne, Cosmetics(Beauty), Personal Care, Diet and Nutrition, baby and Child, Vitamins, Sexual wellness Over the Counter Dermatology Bonnie T. Mackool, MD, MSPH Assistant Professor of Dermatology, Harvard Medical School Massachusetts General Hospital