TATALAKSANA DERMATITIS

DENGAN INFEKSI SEKUNDER

DI LAYANAN PRIMER

ANDI ANWAR ARSYAD

 DERMATITIS
– Peradangan kulit (epidermis dan dermis)
sebagai respon terhadap faktor eksogen dan
atau faktor endogen
– Efloresensi Polimorfik
– Gatal
– Residif dan kronis
 NOMENKLATUR

– ETIOLOGI
– MORFOLOGI
– BENTUK
– LOKALISASI
– STADIUM

3 12/8/2017
 TATA LAKSANA
– KAUSA
– SIMPTOMATIK
– LESI
– KOMPLIKASI
– SISTEMIK
(Kortikosteroid, Anti Histamin, Antibiotik)
– TOPIKAL
(Kortikosteroid, Antibiotik, Emolien)
4 12/8/2017
INFEKSI SEKUNDER

• S. Aureus
• Streptokokus β-hemolitik Grup A

5 8 December 2017 Footer text here if required

TATALAKSANA INFEKSI SEKUNDER

NON MEDIKAMENTOSA
• Mandi
• Faktor Komorbid
MEDIKAMENTOSA
• Topikal
• Sistemik

6 8 December 2017 Footer text here if required

TOPIKAL

• Lesi madidans kompres terbuka dengan Nacl

0,9%
• Bila banyak pus atau krusta dapat dilakukan
kompres terbuka dengan permanganas kalikus
1/5000 dilakukan 3 kali sehari masing@ ½-1 jam
selama keadaan akut
• Bila tidak tertutup pus atau krusta salep atau
krim asam fusidat 2%, mupirosin, gentamycin

7 8 December 2017 Footer text here if required

SISTEMIK

Lini Pertama
•Amoksisilin dan asam klaulanat dewasa
3x250-500 mg/hari, anak-anak 25 mg/kgBB
/hari dalam 3 dosis
Lini Kedua
•Eritromisin dewasa 4x250-500 mg/hari,
anak 20-50 mg/kgBB/hari terbagi 4 dosis
•Klindamisin 15mg/kg/BB/hari terbagi 3
dosis
8 8 December 2017 Footer text here if required
SMART Steroid Use
S trength (potency)
M easure (FTU)
A ppropriate use
R eactions (adverse)
T herapeutic index
Strength (Potency)
 Assessment of steroid potency
2014 US Atopic Dermatitis guidelines state:
“Comparative trials of topical corticosteroids (TCSs) are limited
in duration and scope, and as a result, there are no clinical data
to support one or a few specific agents as being more efficacious
than others”1

Consequently, steroids are classified into groups according to strength

or “potency”, based on vasoconstriction assays rather than
comparative trials1−4
This provides a useful but imperfect method for predicting clinical
effectiveness5, which is widely referred to in all major international
treatment guidelines1−3

1. Eichenfield L, et al. J Am Acad Dermatol 2014; 71:116–132; 2. Ring J, et al. J Eur Acad Dermatol Venereol 2012; 26:1045–1060;
3. Rubel D, et al. J Dermatol 2013; 40:160-171. 4. Narkar Y. Pharm Res 2010; 27:2590–2601;
5. Ference JD, Last AR. Am Fam Physician 2009; 79:135–140
 Potency classification systems
– Different countries use different types of classification to categorise the different TCSs1–5;
often referred to as “steroid potency ladders”

Hig
h

US1 EU2 Japan3 Other4,5

Potency

I IV Strongest Very potent/ super

II potent
Very strong
III III
IV Strong Potent
V II Medium
VI Moderate
Low VII I Weak
Mild

1. Eichenfield L, et al. J Am Acad Dermatol.2014; 71:116–132; 2. Ring J, et al. J Eur Acad Dermatol Venereol 2012; 26:1045–1060; 3. Haruko H. Asian Med J 2001; 44:142–147;
4. Rubel D, et al. J Dermatol 2013; 40:160–171; 5. Dermnet NZ. Topical Steroids. http://dermnetnz.org/treatments/topical-steroids.html. Accessed July 2014
 US steroid potency ladder*1 Common
brand names2
Hig Very high potency
h I Clobetasol propionate 0.05% (Cream, ointment, solution) Dermovate
Halobetasol propionate 0.05% (Cream, ointment)
High potency
II Diflorasone diacetate 0.05% (Cream)
Mometasone furoate 0.1% (Ointment)
Medium potency
III Betamethasone valerate 0.1% (Cream, foam, lotion, ointment)
Desoximetasone 0.05% (Cream)
IV
Potency

Fluocinolone acetonide 0.025% (Cream, ointment)

Fluticasone propionate 0.05% (Cream)
Fluticasone propionate 0.005% (Ointment)
Mometasone furoate 0.1% (Cream)

Lower-medium potency
V Hydrocortisone butyrate 0.1% (Cream, ointment, solution)
Hydrocortisone valerate 0.2% (Cream, ointment)
Low potency
Desonide 0.05% (Cream, gel, foam, ointment)
VI Fluocinolone acetonide 0.1% (Cream, solution)
Lowest potency
VII Hydrocortisone 0.25%, 0.5%, 1% (Cream, lotion, ointment, solution)
Low
Hydrocortisone acetate 0.5%–1% (Cream, ointment)
*Includes representative preparations and not all available agents
The potency of steroids may vary depending on the concentration of the active ingredient and/or
the delivery vehicle
*Includes representative preparations and not all available agents

1. Eichenfield L, et al. J Am Acad Dermatol 2014; 71:116–132;

2. Drugs.com: Topical Steroids. http://www.drugs.com/drug-class/topical-steroids.html. Accessed November 2014.
Choosing a TCS

Potency

– Patient age
– Disease type
– Disease severity
– Location
– Expected duration of treatment

MR Warner, C Camisa, Topical Corticosteroids, Comprehensive Dermatologic Therapy SE Wolverton ed., Saunders Elsevier 2nd edition 2007
 Consideration for choosing potency of TCS

Type of Extent of Duration of Use in State of

Potency Location
dermatosis dermatosis use pedia epidermis
I
Not for face,
Superpotent Avoid extensive Avoid use in Thick, lichenified
Resistant to Short term, 2-3 axillae,
e.g. application (>50 under 12 or hypertrophic
II to V weeks submammary,
Clobetasol gm/week years old skin
groin
propionate
Not for face,
Avoid extensive Avoid use in Thick, lichenified
Short term, 2-3 axillae,
II & III application (>50 under 12 or hypertrophic
Severe weeks submammary,
High gm/week years old skin
groin

Avoid
Avoid extended extended use
Short term Safer for short
use of >1-2 of >1-2
IV & V treatment of Trunk and term use on this
Moderate weeks in weeks in
Intermediate extensive extremities skin, less effective
infants and infants and
dermatosis on think skin
children children

Face, axillae,
Best if long Thin skin; not
Vi & VII Steroid Preferred for large groin & other Infants and
term treatment effective for thicker
Low sensitive areas moist occluded children
needed skin
areas

MR Warner, C Camisa, Topical Corticosteroids, Comprehensive Dermatologic Therapy SE Wolverton ed., Saunders Elsevier 2nd edition 2007
Steroid responsive dermatoses

Group Steroid responsive dermatoses

Dermatitis Atopic dermatitis, lichen simplex chronicus, prurigo, seborrheic
dermatitis, nummular eczema, cumulative insult dermatitis, allergic
contact dermatitis, pompholyx
Papulosquamous Psoriasis, lichen planus
Pigmentary Vitiligo
Vesiculo-bullous Bullous pemphigoid, pemphigus foliaceus, cicatricial pemphigoid
Auto-immune Lupus erythematous, dermatomyositis, morphea
Others Lichen sclerosis et atrophicus, alopecia areata, keloid, pyoderma
gangrenosum, insect bite reactions, early stage of cutaneous T-cell
lymphoma, polymorphic eruption of pregnancy

SK Rathi, P D’Souza. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J of
16
Dermatology, 2012; 57(4)
Measurement
Measuring Dose of Topical Corticosteroids1,2

Fingertip Unit (FTU): 0.5 g of ointment or cream

The distance of first phalanx of the fingertip

Face Chest
Arm& Leg & Chest
& (Back
Hand Foot (Front)
Neck )
3-12
Month
s

Age1-3

Age 3-6

Age 6-10
Face & 1 1 1 Leg 1 Chest Chest
Neck Arm Hand Foot (Front) (Back)

Above age 10
(Including
Adults)

1. Long CC, et al. Br J Dermatol 1998;138:293-296. 2.Bewley A et al. Br J Dermatol 2008;158:917-920

 Regional Differences in Steroid Absorption

Hengge et al, J Am Acad Dermatol. 2006 Jan;54(1):1-15

 Location of the body
Clinical considerations when using TCS they are used

TCS absorption rates vary per body part

Lower potency
corticosteroids 1,2

Super-potent
corticosteroids are
mainly used for Mid- and higher-potency
corticosteroids used as
stubborn, an initial therapy in
cutaneous plaques adults, excluding face,
or lesions on the groin and axillary areas1,2

palms, soles, and/or

scalp1,2

1. Uva L, et al. Int J Endocrinol 2012; 2012:561018; 2. Ference JD, Last AR. Am Fam Physician. 2009; 79: 135−40
Clinical considerations when using TCS
The st corneum acts as a depot for TCS

Clobetasol propionate 0.05% cream

Can persist in st corneum until Day 4

Superpotent steroids are recommended for a

maximum of 2 weeks with tapering thereafter to
avoid adverse events

1. SK Rathi, P D’Souza. Rational and ethical use of topical corticosteroids based on safety and efficacy. Indian J of Dermatology, 2012; 57(4)
Appropriate Use
 r2
1
ue
se
sa
isx
TCS Formulations a
fe
u
e
e
ira
lr
n
a
– To penetrate the skin and enable appropriate delivery of the active agent, most topical drugs cf
a
e
g
td
must be administered as part of a formulation g
h
n
o
n
n
icn
– Drug effectiveness can be significantly affected by choice of vehicle due to extent of a
irio
penetration or absorption of the active agent1,2 sr
la
d
n
a
yro
e
– Vehicles that minimize absorption act to keep the drug restricted to the diseased area, thus e
o
b
e
reducing the risk of side effects associated with systemic exposure1 ib
y-h
s-
rte
rid
sl
ira
Ointments g
a
o
h
sn
h
rfa
ir
Creams e
o
e
p
o
lfre
flb
Lotions a
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a
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w
u
tfn
Gels rf
iio
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e
su
rf
Foams/shampoos ssu
a
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u
;l
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;n
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yla
-a
lyri
ti
1. Huang X, et al. J Am Acad Dermatol 2005; 53:S26–S38; 2. Ference JD & Last AR. Am Fam Physician 2009; 79:135–40; 3.
lsii
Rubel D, et al. J Dermatol 2013; 40:160–71
 Frequency of
Clinical considerations when using TCS administration

Optimal dosing schedule is minimum frequency of

application that still provides relief1

Applying too little TCS

Once- or twice-daily
can lead to a poor
application is
response and too much
recommended for most
can increase side
preparations1,2
effects1

Long-term, repeated use

of TCS can cause side
effects3,4

1. Ference JD, Last AR. Am Fam Physician. 2009;79:135−40; 2. Eichenfield L, et al. J Am Acad Dermatol. 2014;71:116–32; 3. Hengge UR, et al. J Am Acad Dermatol. 2006; 54(1):1–15;
4. Lu NZ, et al. Pharmacol Rev. 2006; 58:782–97.
Reactions (adverse)
Topical Corticosteroid Adverse Reactions

Cutaneous Systemic

– Cutaneous atrophy – Suppression HPA axis

– Striae distensae – Hyperglycemia and Diabetes

– Stellate pseudoscars – Mineralocorticoid effects

– Telangiectasia – Ocular : posterior sub-capsular cataract

– Purpura glaucoma

– Erythema; ebound erythema

– Perioral dermatitis

– Rosacea
Peri oral dermatitis
– Acne Courtesy of Dr B Arcilla Acne eruption
Courtesy of Dr R Romero
– Milia

– Masking infections

– Granuloma gluteale infantum

hypopigmentation
– Hypertrichosis striae Tinea incognito
Courtesy of Dr R Francisco
Hengge UR, et al. J Am Acad Dermatol. 2006; 54(1):1–15 Courtesy of Dr R Romero
– Photosensitisation
Clinical considerations when using TCS Side effects

TCS are well tolerated and effective in the majority of patients1

– Local side effects are more common than systemic reactions1,2

– High- and ultra-high potency TCS can be absorbed and cause

systemic side effects1

– Side effects are rare when low- to high-potency steroids are used for ≤3
months

– Except in intertriginous areas, face, neck and under occlusion1

– Most common TCS side effect is skin atrophy1

– Higher potency steroids, occlusion, thinner skin and older

patient age increase the risk of a TCS inducing atrophy1

– TCS can also cause hypopigmentation but re-pigmentation often occurs after
discontinuing steroid use1

HPA, hypothalamic-pituitary-adrenal

1. Morley KW, et al. Curr Opin Pediatr. 2012; 24:121–28; 2. Hengge UR, et al. J Am Acad Dermatol. 2006; 54:1–15;
3. Menter A, et al. J Am Acad Dermatol. 2009 Apr;60(4):643-59
 Contact Sensitization to Topical CS

➢ Prevalence of 0.2 – 6 %
➢ Seen more in non-fluorinated corticosteroids
➢ Must be differentiated from sensitization to
other constituents of the CS (e.g. parabens)

Hengge UR, et al. J Am Acad Dermatol. 2006; 54:1–15

Therapeutic Index
 Benefit/risk ratio: The Therapeutic Index (TI)

Desired effects
Therapeutic
index1 =
Unwanted effects

• A high TI is desirable and combines high potency with a low incidence of

systemic and local adverse effects2
Potential of desired effects

30
CP BV = Betamethasone valerate
25
MA/MM/ CP = Clobetasol propionate
20 HB/PC/FP HC = Hydrocortisone
BV TA HB = Hydrocortisone butyrate
15
MM = Mometasone furoate
10 MA = Methylprednisolone aceponate
HC PC = Prednicarbate
5 TA = Triamcinolone acetonide
FP = Fluticasone propionate2
0
0 5 10 15 20
Potential adverse effects

Graph adapted from Luger TA. Eur Acad Dermatol Venereol. 2011; 25:251–8

1. Pilgrim J. www.researchreview.co.nz/getmedia/f371bddf-afcd-462e-9d2b-5f2a1f7c58c8/Advantan-Product-Review.pdf.aspx?ext=.pdf (accessed Oct 2014); 2.

Korting HC, Schöllmann C. J Eur Acad Dermatol Venereol. 2012; 26:133–40; 3. Luger TA. Eur Acad Dermatol Venereol. 2011; 25:251–8
 Clobetasol propionate vs Fluocinonide creams in psoriasis and eczema

Method
Double blind parallel comparison
Patients randomly assigned to apply either clobetasol propionate
0.05% or fluocinonide 0.05% TID for 2 weeks
Patients - 227 patients included in study:
114 patients with psoriasis
113 patients with chronic eczema

Assessment
Evaluation conducted at weekly interval of 2 weeks of treatment and 1 week post
treatment
Physicians global assessment, Signs and Symptoms, Patients evaluation

Jegasothy B, et al. Int J Dermatol 1985; 24:461–465

 Clobetasol propionate vs Fluocinonide creams in psoriasis and eczema
Results
clobetasol propionate cream (0.05%) showed superior efficacy to fluocinonide
cream (0.05%) in 114 patients with psoriasis and 113 with eczema, treated 3 times
daily over 2 weeks

Response to treatment in psoriasis Response to treatment in eczema

Clobetasol propionate
Fluocinonide ** ***
** ** NS

Jegasothy B, et al. Int J Dermatol 1985; 24:461–465

Clobetasol propionate vs Fluocinonide creams in psoriasis and eczema

Results
clobetasol propionate cream (0.05%) showed superior efficacy to
fluocinonide cream (0.05%) in 114 patients with psoriasis and 113 with
eczema, treated 3 times daily over 2 weeks
Safety
Side effects in both diseases significantly greater in fluocinonide vs
clobetasol : 12% vs 4%; p< 0.05%
Side effects : cracking, fissuring, burning drying , erythema scaling
7 clobetasol patients and 1 fluocinonide patient had morning cortisols below
5µg/dl at treatment endpoint

Jegasothy B, et al. Int J Dermatol 1985; 24:461–465

 Efficacy: Atopic dermatitis
other eczemas

Photos courtesy of Dr Bernadette Arcilla

The therapeutic efficacy of mometasone furoate cream 0.1% vs
clobetasol propionate cream 0.05% applied twice daily in chronic
eczema
Method
Open randomized third party blinded, right side-left side on patients with moderate to
severe bilateral chronic eczema on limbs.

Patients applied mometasone OD or clobetasol BID to study sites on each limb

respectively

Subjects
58 out of 60 recruited patients completed study. Patients had chronic eczema for at least
6 months (LSC, hands and feet eczema, discoid, prurigo nodularis, unclassified)

Assessment
Patients were evaluated on Day 1, 8, 15 and 22
Parameters
Erythema, induration, crusting, scaling, excoriation and pruritus scored

Goh CL et al. SMJ 1999; 40:241–245

The therapeutic efficacy of mometasone furoate cream 0.1% vs
clobetasol propionate cream 0.5% applied twice daily in chronic eczema

Results
Dermatologist assessment* Patient assessment†
(n = 58) (n = 58)

Patients (%)
Patients (%)

Clobetasol propionate
Mometasone furoate

No side effects noted on any treatment site

Clobetasol propionate has significantly greater efficacy than mometasone furoate in

moderate-to-severe chronic eczema

†
* Skin rated cleared or markedly improved ; rated as excellent or good

Goh CL et al. SMJ 1999; 40:241–245

Key considerations for all patient groups with steroid-responsive
dermatoses – think SMART

Topical corticosteroid treatment selection will be impacted by:

Clinical judgement and differential diagnosis

Age of the patient

Other medical conditions

Size of affected area and location of lesions on the body

Patient preference

Formulations available

Intended duration and frequency of treatment

When treating severe or chronic dermatoses, high-potency corticosteroids may be

necessary1–4

Choosing TCSs with enough potency to achieve a favourable clinical response may
improve patient adherence5

1. Eichenfield L, et al. J Am Acad Dermatol 2014; 71:116–113; 2. Rubel D, et al. J Dermatol 2013; 40:160–171;
3. Ference JD, Last AR. Am Fam Physician 2009; 79:135–140; 4. Hengge UR, et al. J Am Acad Dermatol 2006; 54:1-15;
5. Menter A, et al. J Am Acad Dermatol 2009; 60:643–659
Dermovate™ Product Information
Clobetasol propionate

Indication: Clobetasol propionate is a very active topical corticosteroid which is of particular value when used in
short courses for the treatment of the more resistant dermatoses such as psoriasis (excluding widespread plaque
psoriasis), recalcitrant eczema, lichen planus, discoid lupus erythematosus and other conditions which do not respond
satisfactorily to less active steroids. Dosage and Administration: Adults, Elderly and Children over 1 year: Apply
sparingly to the affected area once or twice daily until improvement occurs and discontinue when control is achieved. In
the more responsive conditions this may be within a few days. Treatment should not be continued for more than four
weeks without the patient’s condition being reviewed. Repeated short courses of DERMOVATE may be used to control
exacerbations. If continuous steroid treatment is necessary, a less potent preparation should be used.
Contraindication: The following conditions should not be treated with DERMOVATE: Untreated cutaneous
infections, Rosacea, Acne vulgaris, Pruritus without inflammation, Perianal and genital pruritus and Perioral dermatitis.
DERMOVATE is contraindicated in dermatoses in children under one year of age, including dermatitis. Warnings
and Precautions: DERMOVATE should be used with caution in patients with a history of local hypersensitivity to
corticosteroids or to any of the excipients in the preparation. Children: In infants and children under 12 years of age,
long-term continuous topical corticosteroid therapy should be avoided where possible, as adrenal suppression can
occur. Children are more susceptible to develop atrophic changes with the use of topical corticosteroids. If
DERMOVATE is required for use in children, it is recommended that the treatment should be limited to only a few days
and reviewed weekly. Pregnancy and Lactation: There are limited data from the use of DERMOVATE in pregnant
women. Topical administration of corticosteroids to pregnant animals can cause abnormalities of foetal development.
Adverse Reactions: Skin and Subcutaneous Tissue Disorders: Common: Pruritus, local skin burning /skin pain;
Uncommon: Skin atrophy*, striae*, telangiectasias*; Very rare: Skin thinning*, skin wrinkling*, skin dryness*,
pigmentation changes*, hypertrichosis, exacerbation of underlying symptoms, allergic contact dermatitis/dermatitis,
pustular psoriasis, erythema, rash, urticaria, acne.

*Skin features secondary to local and/or systemic effects of hypothalamic-pituitary adrenal (HPA) axis suppression.
Abbreviated PI based on GDS12/IPI05

Before prescribing, please consult to PI which is available upon request

Adverse Events yang terjadi, harus dilaporkan kepada GSK Indonesia di nomer telpon 08118438228 atau email ke yqq68540@gsk.com
 GSK Indonesia
Menara Standard Chartered 35th floor
Jl. Prof. Dr. Satrio No. 164, Jakarta 12930, Indonesia
Tel. (62-21) 2553 2350 Fax. (62-21) 2553 2360
ID/CPP/0009/16 • Approval Date: 19/08/16 • Expiration Date: 19/08/18

Thank you

For Healthcare Professionals Use Only

CURICULUM VITAE

Nama : dr. Andi Anwar Arsyad, SpKK, Mkes

TTL : Watampone, 16 oktober 1981
Alamat : Jl. Awang Long No 48 Bontang
Status : Menikah, 2 anak
Riw. Pendidikan : S1 FK UNHAS lulus
2005
PPDS, IKKK FK
UNHAS Lulus 2013
Pelatihan Internasional :
1. ICAD 2012 Bangkok
2. APEOD 2013 YOGYAKARTA
3. Dubai Derma 2014
4. WCD Vancouver 2015
5. APALSM Jakarta 2016
6. EADV 2017, Geneva
Pelatihan Nasional :
1. PIT PERDOSKI
2. KONAS PERDOSKI
3. SIMPO dan WS lokal lainnya