CORTICOSTEROID & ANTIHISTAMINE

Dr. Nelva K. Jusuf, SpKK(K)

CORTICOSTEROID

In Corticosteroid, we have 5 topics :

What Why When Where How

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

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

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

WHEN
Relative Indications
Bullous pemphigoid Allergic urticaria Erythroderma Nodosum erythema Mutliform erythema Severe dermatitis DLE (Discoid Lupus Erythematosus)

WHEN
TOPICAL CORTISCOTEROID
Potency : Weak, medium, potent , highly potent

INDICATIONS : very large HIGHLY RESPONSIVE :

Atopic dermatitis Seborrheic dermatitis Contact dermatitis Numularis dermatitis

WHEN
MEDIUM RESPONSIVE :
Psoriasis DLE Lichen planus

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

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

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

HOW
CORTICOSTEROID DOSE RULES
First, 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 improved Single dose every morning side effect larger than divided dose

HOW
To prevent side effect alternate day dose To 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.

AGENT
Short acting : Hydrocortisone Cortisone
Intermediate acting Prednisone Prednisolone Methyl Prednisolone Triamcinolone
Long acting : Paramethasone Betamethasone Dexamethasone

Anti inflammation potency 1 0,8

3,5 4 5 5

Equivalent dose (mg)

Na Retention Potent
++ ++
+ + -

20 25
5 5 4 4

10 25 30

2 0,60 0,75

DAILY INITIAL DOSE SYSTEMIC CORTICOSTEROID

ON ADULTS IN VARIES DERMATOSES

DISEASES :
Dermatitis Mild drug eruption Severe SJS & TEN Erythroderma Leprosy reaction DLE Bullous pemphigoid Pemphigus vulgaris Pemphigus foliaseous Pemphigus erythematous Psoriasis pustulosa

DOSE :
Prednisone 4 x 5 mg/3 x 10 mg Prednisone 3 x 10 mg/4 x 10 mg Dexamethasone 6 x 5 ,g Prednisone 3 x 10 mg Prednisone 3 x 10 mg Prednisone 3 x 10 mg Prednisone 40 80 mg Prednisone 60 150 mg Prednisone 3 x 20 mg Prednisone 3 x 20 mg Prednisone 4 x 10 mg

SIDE EFFECT PREVENTION

High protein diet, low salt diet Anabolic CS KCl 3 x 500 mg/day if K deficiency ACTH :
Synachten depo 1 mg (100 IU) once in 4 weeks

Antibiotic Antacid

Side effect control of systemic CS

Patient name : ..age :.gender : F/M Diagnosis:.. Start having high dose CS : 1. Face moon face ( ) 2. Skin hirsutism ( ), atrophy ( ), striae atrophise ( ), dermatosis acneformis ( ), purpura ( ), teleangiectase ( )
3. Eye posterior subcapsular cataract ( ), glaucoma( ) atrophy ( ). Fibrosis ( ), myopathy waist/shoulder ( )

4.

Muscles

5.Digestive

gastric juice hypersecretion ( ), pancreatitis ( ), changing gastric protection ( ) regional ileitis ( ), ulcus pepticum/ perforation ( ), ulcerative colitis ( ),
changing personality : euphoria ( ), insomnia ( ), nervous ( ), psychosis ( ), irritable ( ), eating increased( ),paranoid ( ), suicidal tendancy ( ), hyperkinesias ( ) osteoporosis ( ), fracture ( ), vertebrae compression ( ), scoliosis ( ), long bone fracture ( )

6. CNS

7. Skeletons

8. Blood
9. Blood vessel 10. Adrenal cortex 11.Protein, carbohydrate, fat metabolism 12.Electrolyte

13.Immune system

increased : hemoglobin ( ), erythrocyte ( ) leukocyte ( ), lymphocyte ( ) blood pressure increased ( ) atrophy ( ), stress irresistible ( ) protein loss ( ), hyper lipidemia ( ), blood sugar increased ( ),obesity ( ), buffalo hump ( ), fatty liver ( ) Na/water retention ( ), Kalium loss ( ), asthenia ( ), paralysis ( ), tetany ( ), cardiac arrhythmia ( ) decreased 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 dilation Diffuse and wide spread flare secondary to arteriolar dilation A 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 headache Increased secretion of exocrine glands causing stimulation of gastric juice Stimulation of nerve endings leading to pain and itch Smooth 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.

ANTIHISTAMINE
HISTAMINE 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 , shock Skin : itching, erythema, edema, and maculopapular lesion

ANTIHISTAMINE
Beside 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

ANTIHISTAMINE
Indication :
Antihistamine H1 allergic symptoms due to released of histamine

Topical :
Effective as analgetic on mucous and elimiate skin itchness

ANTIHISTAMINE
New antihistamines :
Doesnt cause sedation

Side effect :
CNS ANS Digestive tract Blood

ANTIHISTAMINE
Toxicity
Insomnia, tremor, nervous, convulsion

Drugs interaction
If taken with depressant group medicine in the same time, can cause potentiation effect and antihistamine antagonist characterized with guanetidin (anti hyper tension)

THE END
GOOD LUCK FOR YOUR POST TEST