CORTICOSTEROID & ANTIHISTAMINEDr. Nelva K. Jusuf, SpKK(K)

CORTICOSTEROID

In Corticosteroid, we have 5 topics :WhatWhyWhenWhereHow

W H A T

CORTICOSTEROID

Is regulatory hormone synthesized from a cholesterol core in adrenal gland at the cortex.

W H Y

CORTICOSTEROIDS applied for dermatology due to effects :Anti inflammationAnti allergy Vasoconstrictor Immunosuppressive Anti mitotic / anti proliferate

W H E N

Absolute Indications

Pemphigus SLE (Systemic Lupus Erithematous)Severe SJS (Stevens Johnson Syndrome) : TEN (toxic epidermal necrolized)ERYTHRODERMA

W H E NRelative Indications Bullous pemphigoid Allergic urticaria Erythroderma Nodosum erythema Mutliform erythemaSevere dermatitis DLE (Discoid Lupus Erythematosus)

W H E NTOPICAL CORTISCOTEROIDPotency : Weak, medium, potent , highly potent INDICATIONS : very large HIGHLY RESPONSIVE : Atopic dermatitis Seborrheic dermatitis Contact dermatitisNumularis dermatitis

W H E NMEDIUM RESPONSIVE : PsoriasisDLE Lichen planus

FORMS : cream, ointment, fatty ointment, lotion, spray

W H E N

INTRA LESION CORTICOSTEROID INDICATIONS :Keloid Hyper tropic scar Alopesia areata Chronic Lichen simplexCystic acne Granuloma anulare

W H E R E TOPICAL CORTICOSTEROID

Folds area, babys face weak potent (if given high potency CS systemic effect side effect on the skin increasing

H O WCORTICOSTEROID DOSE RULESFirst, find the therapy dose re-evaluation period of therapy (depend on the disease & individuals)If improvement (+) tapering off maintanance dose after few days if no improvement dose increased until improvedSingle dose every morning side effect larger than divided dose

H O WTo prevent side effect alternate day doseTo decrease dose & shorten CS therapy can be given at the same time with MTX, AZT, Cyclosporin (STEROID SPARRING EFFECT)Treatment shouldn't be stopped suddenly rebound phenomenon Side effects appear depend on dose, period of therapy & types of CS.

AGENTAnti inflammation potencyEquivalent dose (mg)Na RetentionPotent Short acting :HydrocortisoneCortisone 10,82025++++Intermediate acting PrednisonePrednisoloneMethyl PrednisoloneTriamcinolone 3,54555544++--Long acting :ParamethasoneBetamethasoneDexamethasone 10253020,600,75---

DAILY INITIAL DOSE SYSTEMIC CORTICOSTEROID ON ADULTS IN VARIES DERMATOSES DISEASES :DermatitisMild drug eruptionSevere SJS & TEN Erythroderma Leprosy reactionDLEBullous pemphigoidPemphigus vulgarisPemphigus foliaseousPemphigus erythematousPsoriasis pustulosaDOSE : Prednisone 4 x 5 mg/3 x 10 mgPrednisone 3 x 10 mg/4 x 10 mgDexamethasone 6 x 5 ,gPrednisone 3 x 10 mgPrednisone 3 x 10 mgPrednisone 3 x 10 mgPrednisone 40 80 mgPrednisone 60 150 mgPrednisone 3 x 20 mgPrednisone 3 x 20 mgPrednisone 4 x 10 mg

SIDE EFFECT PREVENTIONHigh protein diet, low salt diet Anabolic CSKCl 3 x 500 mg/day if K deficiencyACTH : Synachten depo1 mg (100 IU) once in 4 weeks AntibioticAntacid

Side effect control of systemic CS Patient name : ..age :.gender : F/MDiagnosis:..Start having high dose CS : Facemoon face ( )Skinhirsutism ( ), atrophy ( ), striae atrophise ( ),dermatosis acneformis ( ), purpura ( ), teleangiectase ( )

Eyeposterior subcapsular cataract ( ),glaucoma( )Muscles atrophy ( ). Fibrosis ( ), myopathy waist/shoulder ( )

5.Digestive gastric juice hypersecretion ( ), pancreatitis ( ),changing gastric protection ( )regional ileitis ( ), ulcus pepticum/perforation ( ), ulcerative colitis ( ),

6. CNS changing personality :euphoria ( ), insomnia ( ), nervous ( ), psychosis ( ), irritable ( ), eating increased( ),paranoid ( ), suicidal tendancy ( ), hyperkinesias ( )7. Skeletons osteoporosis ( ), fracture ( ), vertebrae compression ( ), scoliosis ( ), long bone fracture ( )

8. Blood increased : hemoglobin ( ), erythrocyte ( )leukocyte ( ), lymphocyte ( )9. Blood vesselblood pressure increased ( )10. Adrenal cortexatrophy ( ), stress irresistible ( )11.Protein, protein loss ( ), hyper lipidemia ( ), blood carbohydrate, sugar increased ( ),obesity ( ), buffalo fat metabolism hump ( ), fatty liver ( )12.Electrolyte Na/water retention ( ), Kalium loss ( ), asthenia ( ), paralysis ( ), tetany ( ), cardiac arrhythmia ( )13.Immune systemdecreased of immune, high risk to infection ( ), TB reactivation ( ),herpes simplex ( ), malignancy ( ), etc ( )

ANTIHISTAMINE HISTAMINE : Is a bio active amin with low molecular weight found mainly in human on the mast cell of the tissue and basophile in blood.

ANTIHISTAMINE Histamine stimulated smooth muscles and had an intense vasopressor effect. Histamine was isolated from liver and lung tissue and skin by physical stimuli. Histamine is distributed widely throughout the animal kingdom and is found in venom, noxious secretions, bacteria and plants. Most mamalian tissue contains histamin with the highies concentrationss found in lungs, skin and intestinal mucousa.

ANTIHISTAMINE HISTAMINE :Is synthesized by decarboxylation of the amino acid histidine. Can be liberated from storage by numerous factors. When liberated, a reaction known as the triple response results.Erythema appears due to capillary dilationDiffuse and wide spread flare secondary to arteriolar dilationA wheal appears at the injury site due to exudation of fluid through the altered vascular wall

ANTIHISTAMINE HISTAMINE :Other effects of histamine on the body include :Dilation of cerebral vessels leading to a headacheIncreased secretion of exocrine glands causing stimulation of gastric juiceStimulation of nerve endings leading to pain and itchSmooth muscle contraction, which can cause broncho constriction Dilatation and increased permeability of capillaries leading to loss of plasma and decreased blood pressure, which can cause increases in heart rate and cardiac output.

ANTIHISTAMINEHISTAMINE This situation causes variety clinical manifestation, depend on individual organ target and species, such as :Respiratory tract : bronchus obstruction and larynx edema Gastro intestinal tract : nausea, vomit, and diarrhea Cardiovascular tract :hypo tension , shockSkin: itching, erythema, edema, and maculopapular lesion

ANTIHISTAMINEBeside histamine, when the degranulation of the mast cell and / or basophile applied, also released another pharmacologic substances called histamine like substance : SRS A (Slow reacting substance anaphylaxis)ECF A (Eosinophile chemotactic factor anaphylaxis)Serotonin ( 5 hydroxytryptamine)PAF (Platelet activating factor) Heparin (6)

ANTIHISTAMINE

Is an ethyl amine substance ( - CH2 CH2 N ) (also found in histamine)Half part of ethyl amine : linear chain or half-ring form.

Antihistamine doesnt resist to the release of histamine, but it competes with histamine to reach H1 effectors in receptor cell, and quickly reversible attached. The attachment with receptor can be re-released soon due to its short acting occupying period needs repeated dose to keep the concentrate high to compete with histamine in the receptor places.And eventually the number of antihistamine will be reduced due to metabolism and elimination.

ANTIHISTAMINE

Antihistamine is quickly absorbed, parenteral, more or less 15 minutes, per oral + - 30 mins and reaching the top after 1 2 hours with indurance 3 6 hours, but there is also the slow released form.

CLASSIFICATION Antihistamine H1 divided into 7 groups according to the connection with ethyl amine : Ethanol amine : bromodiphen hydramine, carbinoxamine, clemastine, difenhidrinate.Ethylendiamine : tripelenamine, antazoline.Alkylamine : chlorphenyramine, brompheniramine.Piperazine : hydroxycin

CLASSIFICATION

Phenotiazin : prometazine Piperidine : ciproheptadine Miscellanous : astemizole, terfenadine, mebhidroline

ANTIHISTAMINEIndication :Antihistamine H1 allergic symptoms due to released of histamine Topical :Effective as analgetic on mucous and elimiate skin itchness

ANTIHISTAMINENew antihistamines : Doesnt cause sedationSide effect :CNS ANS Digestive tractBlood

ANTIHISTAMINE

Toxicity Insomnia, tremor, nervous, convulsionDrugs interactionIf taken with depressant group medicine in the same time, can cause potentiation effect and antihistamine antagonist characterized with guanetidin (anti hyper tension)

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