elevated ALT level, impotence and decreased sperms 2. Corticosteroid (glucocorticoid) Corticosteroids have been widely used in dermatology in the recent 40 years, and have a wide range of ind ications 1)Mechanism of corticosteroids a. Immunosuppression Corticosteroids can inhibit antigen presentation, lymphocytic proliferation and cytokine secretion. Moreover, they will also decrease complement and antibody level. Therefore immunity of the body will be suppressed b. Anti-inflammation Corticosteroids can suppress neutrophil function, stabilize lysosomal membrane decrease pro-inflammatory cytokine secretion and inhibit fibroblastic DNA synthesis c. Anti-toxin and anti-shock High dosage of corticosteroids will improve microcirculation and cardiac function. prevent platelet aggregation and decrease myocardial oxygen depletion d Anti-neoplasm Corticosteroids can decrease DNa synthesis and mitosis of lymphocytes, and can also inhibit proliferation of fibroblasts and epithelial cells. Therefore, corticosteroids have anti-neoplasm effect 2) Indications Corticosteroids are mainly administered for the treatment of drug eruption Steven-Johnson syndrome, acute urticaria, allergic shock, severe contact dermatitis systemic lupus erythematosus(SLE), dermatomyositis, pemphigus, pemphigoid and allergic cutaneous vasculitis etc Those commonly used corticosteroids are listed in Table Table commonly used corticosteroids coricoteroid Anti-inflammato Equivalent Dose for ry effect dosage(mg) adults(mg/d) Hydrocortisone 100-400iv Moderate Methylprednisol 16-40 20-80iv 8-40 High Dexamethasone 30 0.75 5-9po, betamethasone 0.6 3)Usage of corticosteroids in dermatology a Short term therapy Drug eruption, acute allergic reaction and severe contact dermatitis are ind ications of short term therapy. The medicine is usually administered intravenously, and the dosage will be decreased within short period after the improvement of symptoms b Mid-term therapy This method is suitable for recurrent skin diseases such as allergic purpura, generalized eczema, special-type psoriasis, and erythema multiforme etc. The drug is usually administered orally, the dose being tapered gradually within 2-3 months until the drug is
elevated ALT level, impotence and decreased sperms. 2. Corticosteroid (glucocorticoid) Corticosteroids have been widely used in dermatology in the recent 40 years, and have a wide range of indications. 1) Mechanism of corticosteroids a. Immunosuppression Corticosteroids can inhibit antigen presentation, lymphocytic proliferation and cytokine secretion. Moreover, they will also decrease complement and antibody level. Therefore, immunity of the body will be suppressed. b. Anti-inflammation Corticosteroids can suppress neutrophil function, stabilize lysosomal membrane, decrease pro-inflammatory cytokine secretion and inhibit fibroblastic DNA synthesis. c. Anti-toxin and anti-shock High dosage of corticosteroids will improve microcirculation and cardiac function, prevent platelet aggregation and decrease myocardial oxygen depletion. d. Anti-neoplasm Corticosteroids can decrease DNA synthesis and mitosis of lymphocytes, and can also inhibit proliferation of fibroblasts and epithelial cells. Therefore, corticosteroids have anti-neoplasm effect. 2) Indications Corticosteroids are mainly administered for the treatment of drug eruption, Steven-Johnson syndrome, acute urticaria, allergic shock, severe contact dermatitis, systemic lupus erythematosus (SLE), dermatomyositis, pemphigus, pemphigoid and allergic cutaneous vasculitis etc. Those commonly used corticosteroids are listed in Table . Table commonly used corticosteroids potency coricoteroid Anti-inflammato ry effect Equivalent dosage (mg) Dose for adults(mg/d) Mild Hydrocortisone 1 20 100-400 i.v Moderate Prednisone 3.5 5 10-60 po Methylprednisolo ne 5 4 16-40 po, 20-80 i.v Triamicinolone 5 4 8-40 po High Dexamethasone 30 0.75 1.5-9 po, 5-10 i.v betamethasone 30 0.6 1-6 po 3) Usage of corticosteroids in dermatology a. Short term therapy Drug eruption, acute allergic reaction and severe contact dermatitis are indications of short term therapy. The medicine is usually administered intravenously, and the dosage will be decreased within short period after the improvement of symptoms. b. Mid-term therapy This method is suitable for recurrent skin diseases such as allergic purpura, generalized eczema, special-type psoriasis, and erythema multiforme etc. The drug is usually administered orally, the dose being tapered gradually within 2-3 months until the drug is
completely discontinued C. Long term therapy This method is suitable for chronic, systemic involved skin diseases such as SLE dermatomyositis, pemphigus, pemphigoid and systemic vasculitis etc. Sufficient dose of corticosteroids must be administered as early as possible, and intravenous administration is required for severe cases. Dosage should be tapered gradually until the disease is kept under control, and long term maintenance therapy(normally 5-7.5mg/d of prednisone)is d. Pulsed therapy This is usually used in extremely severe cases such as allergic shock, laryngeal edema, severe Sle with renal or CNS(central nervous system) involvement and severe pemphigus etc. Usually 0.5-1.0g of methyl prednisolone is administered intravenously within 3-10 hours per day for 3-5 days. Electrolyte level and ECG should be kept under e. Intralesional injection Usually 0.3-1.0ml of 1% triamcinolone suspension is injected into the lesion of alopecia areata, lichen planus, keloid, prurigo nodularis and DLE etc, once every 1 or 2 weeks for 5 times. Overt injection is to be avoided for fear of cutaneous atrophy, hemorrhage and ulcer 4)Side effects Long term side effects include infection, hypertension, diabetes, gastric hemorrhage, osteoporosis, cataract, hirsutism and striae distense etc. Close follow up is necessary 3. Antibiotics I)Penicillin Penicillin is effective against Gram positive bacterial and treponemal infection, such as erysipelas, syphilis, gonorrhea, erysipeloid, anthrax and yaws etc. Skin test is required before administration for fear of allergic shock. Allergy to penicillin is contraindication 2)Cephalosporin Cephalexin, cephrad ine, cephazolin, cefuroxime, ceftazid ime and ceftriaxone all belong to the big family of cephalosporin, and they can be classified into 3 generations Ceftriaxone is effective against gonorrhea(acute simple gonorrhea, 0.25g i. m once, complicated gonorrhea, 0. 25g i m ad for 10 days). Cross-sensitivity is likely to occur in those allergic to penicillin 3)Tetracycline Doxycycline(100mg bid PO)and minocycline(50-100mg bid PO)are most commonly used tetracycline for the treatment of acne and nongonococcal urethritis. Major sid effects include dizziness and hyperpigmentation. Long term usage is not recommended for children 4)Macrolides Ao The major macrolides include erythromycin(0. 5g qid PO), roxythromycin(0. 15g bid D), clarithromycin and azithromycin(0. 5g gd PO). They are effective against gonorrhea non-gonococcal urethritis, chancroid and erythrasma 4. Anti-viral drugs 1)Acyclovir(0. 2g q4h Po), valaciclovir(0.3g bid PO), famciclovir(0. 25g tid PO)and ganciclovir(5mg/kg bid intravenous drip) are major antiviral drugs that are effective against herpes simplex, herpes zoster and genital herpes, since they can inhibit dNA
completely discontinued. c. Long term therapy This method is suitable for chronic, systemic involved skin diseases such as SLE, dermatomyositis, pemphigus, pemphigoid and systemic vasculitis etc. Sufficient dose of corticosteroids must be administered as early as possible, and intravenous administration is required for severe cases. Dosage should be tapered gradually until the disease is kept under control, and long term maintenance therapy (normally 5-7.5mg/d of prednisone) is necessary. d. Pulsed therapy This is usually used in extremely severe cases such as allergic shock, laryngeal edema, severe SLE with renal or CNS (central nervous system) involvement and severe pemphigus etc. Usually 0.5-1.0g of methyl prednisolone is administered intravenously within 3-10 hours per day for 3-5 days. Electrolyte level and ECG should be kept under close observation. e. Intralesional injection Usually 0.3-1.0ml of 1% triamicinolone suspension is injected into the lesion of alopecia areata, lichen planus, keloid, prurigo nodularis and DLE etc, once every 1 or 2 weeks for 5 times. Overt injection is to be avoided for fear of cutaneous atrophy, hemorrhage and ulcer. 4) Side effects Long term side effects include infection, hypertension, diabetes, gastric hemorrhage, osteoporosis, cataract, hirsutism and striae distense etc. Close follow up is necessary. 3. Antibiotics 1) Penicillin Penicillin is effective against Gram positive bacterial and treponemal infection, such as erysipelas, syphilis, gonorrhea, erysipeloid, anthrax and yaws etc. Skin test is required before administration for fear of allergic shock. Allergy to penicillin is contraindication. 2) Cephalosporin Cephalexin, cephradine, cephazolin, cefuroxime, ceftazidime and ceftriaxone all belong to the big family of cephalosporin, and they can be classified into 3 generations. Ceftriaxone is effective against gonorrhea (acute simple gonorrhea, 0.25g i.m once; complicated gonorrhea, 0.25g i.m qd for 10 days). Cross-sensitivity is likely to occur in those allergic to penicillin. 3) Tetracycline Doxycycline (100mg bid PO) and minocycline (50-100mg bid PO)are most commonly used tetracycline for the treatment of acne and nongonococcal urethritis. Major side effects include dizziness and hyperpigmentation. Long term usage is not recommended for children. 4) Macrolides The major macrolides include erythromycin (0.5g qid PO), roxythromycin (0.15g bid PO), clarithromycin and azithromycin (0.5g qd PO). They are effective against gonorrhea, non-gonococcal urethritis, chancroid and erythrasma. 4. Anti-viral drugs 1) Acyclovir (0.2g q4h PO), valaciclovir(0.3g bid PO), famciclovir (0.25g tid PO) and ganciclovir (5mg/kg bid intravenous drip) are major antiviral drugs that are effective against herpes simplex, herpes zoster and genital herpes, since they can inhibit DNA
synthesis of herpes virus. Ganciclovir is more effective against megavirus. These drugs are usually administered for 5-10 days until viral infection is under control. Side effects include phlebitis and transient elevated serum creat inine level 2)Interferon Interferon is both anti-viral. anti-tumor and immunomodulant. Interferon a. b and re used for the treatment of viral infection and tumor. 106-107 u of interferon is usually injected intramuscularly every day or every 2 days, and can also be locally injected. Side effects include fever, flu- like symptoms and renal injury 5. Antifungal drugs 1)Amphotericin Amphotericin B can bind with ergosterol on the cell membrane of fungus, creating pores on the membrane. This will lead to the exudation of cytoplasm and eventually the death of fungus. Amphotericin B can kill or suppress a wide range of fungi such as cryptococcus, monilia and sporothrix etc, but has hardly any effect on dermatophytes. It is only intravenously administered, the maximum dose being 0.1g-1.0g/kg per day Liposome encapsulated amphotericin b will increase both efficacy and safety of this med icine 2)Itraconazole effect. It can be used in the treatment of sporotrichosis, candidiasis, aspergillosis any ing Itraconazole is of high anti-fungal activity, wide anti-fungal spectrum and long lasti superficial fungal infection. The dosage is 100-200mg per day for adults. Pulsed therapy is recommended for onychomycosis: 200mg Bid for 1 week every month for adults Headache, nausea, gastrointestinal d iscomfort and aLt elevation are side effects of this med icine 3)Fluconazole Fluconazole can cross the blood-brain barrier, and be administered either orally or intravenously. It is effective against cand idiasis, cryptococcosis, blastomycosis and aspergillosis etc. Fluconazole can also be used to treat superficial mycosis(50mg qd PO) and onychomycosis(150mg qw PO). Side effects include gastrointestinal discomfort hepatic dysfunction and leucopenia etc 4) Terbinafine Terbinafine can kill or inhibit fungus by inhibiting squalene and cycloxygenase on the cell membrane, and is effective against tinea unguium and dermatophytes. However terbinafine has no effect on yeast and monilia. The dosage is 250mg per day and is determined accord ing to body weight for children 6. Retinoids There are altogether 3 generations of retinoids, which can regulate the growth and differentiation of epithelial cells I) The first generation They are natural metabolic products of retinoids. Isotretinoin(0. 5mg/kg per day )and retimid-ester(1. 2-2.0mg/kg per day) are commonly used for cystic acne, Darier's disease icthyosis and palmoplantar keratosis etc. Side effects include hyperglyceridemia, hypercalcemia, skin dryness and teratogenesis etc 2) The second generation Mono-aromatic retinoids belong to this generation. Etretinate(0.75-1mg/kg per day) and etratin(50-75mg /d)are commonly used for severe psoriasis, pityriasis rubra
synthesis of herpes virus. Ganciclovir is more effective against megavirus. These drugs are usually administered for 5-10 days until viral infection is under control. Side effects include phlebitis and transient elevated serum creatinine level. 2) Interferon Interferon is both anti-viral, anti-tumor and immunomodulant. Interferon α,β and γ are used for the treatment of viral infection and tumor. 106 –107 U of interferon is usually injected intramuscularly every day or every 2 days, and can also be locally injected. Side effects include fever, flu-like symptoms and renal injury. 5. Antifungal drugs 1) Amphotericin B Amphotericin B can bind with ergosterol on the cell membrane of fungus, creating pores on the membrane. This will lead to the exudation of cytoplasm and eventually the death of fungus. Amphotericin B can kill or suppress a wide range of fungi such as cryptococcus, monilia and sporothrix etc, but has hardly any effect on dermatophytes. It is only intravenously administered, the maximum dose being 0.1g-1.0g/kg per day. Liposome encapsulated amphotericin B will increase both efficacy and safety of this medicine. 2) Itraconazole Itraconazole is of high anti-fungal activity, wide anti-fungal spectrum and long lasting effect. It can be used in the treatment of sporotrichosis, candidiasis, aspergillosis and superficial fungal infection. The dosage is 100-200mg per day for adults. Pulsed therapy is recommended for onychomycosis: 200mg Bid for 1 week every month for adults. Headache, nausea, gastrointestinal discomfort and ALT elevation are side effects of this medicine. 3) Fluconazole Fluconazole can cross the blood-brain barrier, and be administered either orally or intravenously. It is effective against candidiasis, cryptococcosis, blastomycosis and aspergillosis etc. Fluconazole can also be used to treat superficial mycosis (50mg qd PO) and onychomycosis (150mg qw PO). Side effects include gastrointestinal discomfort, hepatic dysfunction and leucopenia etc. 4) Terbinafine Terbinafine can kill or inhibit fungus by inhibiting squalene and cycloxygenase on the cell membrane, and is effective against tinea unguium and dermatophytes. However, terbinafine has no effect on yeast and monilia. The dosage is 250mg per day and is determined according to body weight for children. 6. Retinoids There are altogether 3 generations of retinoids, which can regulate the growth and differentiation of epithelial cells. 1) The first generation They are natural metabolic products of retinoids. Isotretinoin (0.5mg/kg per day) and retimid-ester (1.2-2.0mg/kg per day) are commonly used for cystic acne, Darier’s disease, icthyosis and palmoplantar keratosis etc. Side effects include hyperglyceridemia, hypercalcemia, skin dryness and teratogenesis etc. 2) The second generation Mono-aromatic retinoids belong to this generation. Etretinate (0.75-1mg/kg per day) and etratin (50-75mg /d) are commonly used for severe psoriasis, pityriasis rubra
Darier's disease and skin tumor etc. Side effects are similar to those of first generation but less 3) The third generation Poly-aromatic retinoids belong to the third generation. Arotinoid(0.03mg qd po at supper)is an example and can be used to treat psoriasis, ichthyosis and Darier's disease etc. The maintenance dosage is 0. 03mg every other day 7. Immunosuppressant Immunosuppressants include a variety of drugs, such as cyclophosphamide, azathioprine, methotrexate, cyclosporin and tacrolimus etc. Side effects such as gastrointestinal discomfort, liability to infection, inhibition of bone marrow, hepatic injury, sterility and teratogenesis are obvious. Therefore blood test and liver function are to be kept under surveilland 1)Cyclophosphamide(ctx) CTX can be used for the treatment of systemic lupus erythematosus(SLE), pemphigus re CTX has strong suppressive effect on b cells and thereby humoral immun ity. Therefo matomyositis, vasculitis and mycosis fungoides(MF)etc 50mg/ oral administration and 100-200mg god for intravenous administration. Patients are advised to drink a large amount of water after taking this med icine in order to avoid toxicity to bladder 2)Azathioprine(AZP) AZP(100mg/d)has powerful inhibitory effect on T cells, and is used for treating pemphigus, bullous pemphigoid, SLE and dermatomyositis etc. Hepatic and renal function should be kept under close observation 3)Methotrexate(MTX As an antagonist of folic acid, MTX will suppress the growth of lymphocyte and epithelial cells. MTX can be administered orally (2.5mg q 12h for 3 times per week intramuscularly or intravenously (7.5mg-25mg every 7-10days). The indications of thi medicine include psoriasis, pemphigus, pityriasis rubra, Behcet disease and MF etc 4)Cyclosporin(CSA) Selectively acting upon T cells, CSA(3-10mg/kg per day ) is effective against autoimmune diseases such as psoriasis, pemphigus, bullous pemphigoid, alopecia totalis and atopic dermatitis(AD)etc. Side effects include renal toxicity, hypertension and headache etc 5)Tacrolimus A calcineurin inhibitor. tacrolimus has similar mechanism to that of csa. but of much more efficacy. Belonging to the macrolide family, tacrolimus(0. 15mg/kg Bid PO; or 0.075-0. Img/kg per day intravenously) is effective against recalcitrant psoriasis, pyoderma gangrenosa and dystrophic epidermolysis bullosa etc. Side effects are similar to that of CSA, but much less. Topical tacrolimus is effective against various skin disease such as dermatitis, eczema and psoriasis etc 8. Miscellar 1)Chloroquine and Hydroxy chloroquine Both drugs can decrease sensitivity of skin to ultraviolet and stabilize lysosomal membrane Chloroquine(250-500mg/d)and Hydroxy chloroquine(. 2-0.4g/d)are effective against SLE, polymorphous actinic eruption, porphyria and lichen planus etc Side effects include gastrointestinal discomfort, leucopenia, retinal injury, renal and
Darier’s disease and skin tumor etc. Side effects are similar to those of first generation, but less. 3) The third generation Poly-aromatic retinoids belong to the third generation. Arotinoid (0.03mg qd PO at supper) is an example and can be used to treat psoriasis, ichthyosis and Darier’s disease etc. The maintenance dosage is 0.03mg every other day. 7. Immunosuppressant Immunosuppressants include a variety of drugs, such as cyclophosphamide, azathioprine, methotrexate, cyclosporin and tacrolimus etc. Side effects such as gastrointestinal discomfort, liability to infection, inhibition of bone marrow, hepatic injury, sterility and teratogenesis are obvious. Therefore blood test and liver function are to be kept under surveillance. 1) Cyclophosphamide (CTX) CTX has strong suppressive effect on B cells and thereby humoral immunity. Therefore, CTX can be used for the treatment of systemic lupus erythematosus (SLE), pemphigus, dermatomyositis, vasculitis and mycosis fungoides (MF) etc. The dosage is 150mg/d for oral administration and 100-200mg qod for intravenous administration. Patients are advised to drink a large amount of water after taking this medicine in order to avoid toxicity to bladder. 2) Azathioprine (AZP) AZP (100mg/d) has powerful inhibitory effect on T cells, and is used for treating pemphigus, bullous pemphigoid, SLE and dermatomyositis etc. Hepatic and renal function should be kept under close observation. 3) Methotrexate (MTX) As an antagonist of folic acid, MTX will suppress the growth of lymphocyte and epithelial cells. MTX can be administered orally (2.5mg q12h for 3 times per week), intramuscularly or intravenously (7.5mg-25mg every 7-10days). The indications of this medicine include psoriasis, pemphigus, pityriasis rubra, Behcet disease and MF etc. 4) Cyclosporin (CSA) Selectively acting upon T cells, CSA (3-10mg/kg per day) is effective against autoimmune diseases such as psoriasis, pemphigus, bullous pemphigoid, alopecia totalis and atopic dermatitis (AD) etc. Side effects include renal toxicity, hypertension and headache etc. 5) Tacrolimus A calcineurin inhibitor, tacrolimus has similar mechanism to that of CSA , but of much more efficacy. Belonging to the macrolide family, tacrolimus (0.15mg/kg Bid PO; or 0.075-0.1mg/kg per day intravenously) is effective against recalcitrant psoriasis, pyoderma gangrenosa and dystrophic epidermolysis bullosa etc. Side effects are similar to that of CSA, but much less. Topical tacrolimus is effective against various skin disease such as dermatitis, eczema and psoriasis etc. 8. Miscellanous 1) Chloroquine and Hydroxy chloroquine Both drugs can decrease sensitivity of skin to ultraviolet and stabilize lysosomal membrane. Chloroquine (250 -500mg/d) and Hydroxy chloroquine (0.2-0.4g/d) are effective against SLE, polymorphous actinic eruption, porphyria and lichen planus etc. Side effects include gastrointestinal discomfort, leucopenia, retinal injury, renal and
hepatic dysfunction etc. Follow-up of retina, vision, hepatic function and renal function i required after long-term usage 2)Tripterygium wilford Tripterygium wilford ii is a kind of trad itional Chinese medicine, of immunomodulatory anti-inflammatory, anti-tumour and anti- procreation activity. Both syrup abd tablet of dermatitis(erythroderma), pemphigus, pemphigoid, psoriasis, palmoplantar pustulosis c Tripterygium wilford ii are available for the treatment of Le, dermatomyositis, exfoliative and eczema etc. Side effects include gastrointestinal discomfort, hepatic injury leucopenia, inactivity of sperms and amenorrhea 3)Intravenous immunoglobulin (IvIg High dosage of IVIg is effective against severe SLE, pemphigus, pemphigoid and dermatomyositis etc, the dosage being 0. 4g/kg per day for 3-5 days. Side effect is minimal Topical Therapy Topical therapy is very important in dermatology. Choice of appropriate agent and correct usage is necessary for the treatment of various skin diseases l. Classification of topical agents according to properties 1)Cleansing agents The major cleansing agents are saline, 3% boric acid, 1: 5000 furacilin, vegetable oil and paraffin etc, used for the removal of exudation, scales, crust, and residual medicine 2)Protective agents Commonly used protective agents include talcum powder, zinc oxide powder and calamine, with the effect of protecting skin, decreasing friction and preventing irritation. 3)Anti-pruritic agents Itching sensation can be alleviated by topical anaesthesia and skin cooling. Common anti-pruritic agents include 5% o benzocaine 3% thymol, 1% phenol and tar Most antiseptics are topical antibiotics, used for killing or inhibiting bacteria. Common topical antiseptics include 0. 1% rivanol, 5-10% benzoic peroxide, 0.5-3% erythromycin, 1: 2000 benzalkonium bromide, fusidic acid and 2% mupirocin etc 5)Antifungal agents able to kill or suppress fungi, the frequently used anti-fungal agents are 2% miconazole 2% ketoconazole, 1% bifonazole, 1% terbinafine, nystatin, 5-10% salicylic acid, 6-12% benzoic acid and 10-30% acetic acid etc 6) Anti-viral agents Topical acyclovir and penciclovir can be used for the treatment of herpes simplex and herpes zoster. 10% podophy llo toxin is effective against condyloma acuminatun( CA)and warts. As a topical immunomodulatory agent, imiquimod is effective for the treatment of CA 7)Insecticide 5-10%sulfur, 10% crotamiton, 5% benzoic peroxide and 50% baibu(tincture)etc are used as insecticide to kill mites and lice 8)Keratoplastic Keratoplastic will normal ize horny layer of epidermis, alleviating inflammation at the
hepatic dysfunction etc. Follow-up of retina, vision, hepatic function and renal function is required after long-term usage. 2) Tripterygium wilfordii Tripterygium wilfordii is a kind of traditional Chinese medicine, of immunomodulatory, anti-inflammatory, anti-tumour and anti-procreation activity. Both syrup abd tablet of Tripterygium wilfordii are available for the treatment of LE, dermatomyositis, exfoliative dermatitis (erythroderma), pemphigus, pemphigoid, psoriasis, palmoplantar pustulosis and eczema etc. Side effects include gastrointestinal discomfort, hepatic injury, leucopenia, inactivity of sperms and amenorrhea. 3) Intravenous immunoglobulin (IVIg) High dosage of IVIg is effective against severe SLE, pemphigus, pemphigoid and dermatomyositis etc, the dosage being 0.4g/kg per day for 3-5 days. Side effect is minimal. Topical Therapy Topical therapy is very important in dermatology. Choice of appropriate agent and correct usage is necessary for the treatment of various skin diseases. 1. Classification of topical agents according to properties 1) Cleansing agents The major cleansing agents are saline, 3% boric acid, 1:5000 furacilin, vegetable oil and paraffin etc, used for the removal of exudation, scales, crust, and residual medicine on the lesions. 2) Protective agents Commonly used protective agents include talcum powder, zinc oxide powder and calamine, with the effect of protecting skin, decreasing friction and preventing irritation. 3)Anti-pruritic agents Itching sensation can be alleviated by topical anaesthesia and skin cooling. Common anti-pruritic agents include 5% benzocaine, 3% thymol, 1% phenol and tar. 4) Antiseptics Most antiseptics are topical antibiotics, used for killing or inhibiting bacteria. Common topical antiseptics include 0.1% rivanol, 5-10% benzoic peroxide, 0.5-3% erythromycin, 1:2000 benzalkonium bromide, fusidic acid and 2% mupirocin etc. 5) Antifungal agents Able to kill or suppress fungi, the frequently used anti-fungal agents are 2% miconazole, 2% ketoconazole, 1% bifonazole, 1% terbinafine, nystatin, 5-10% salicylic acid, 6-12% benzoic acid and 10-30% acetic acid etc. 6) Anti-viral agents Topical acyclovir and penciclovir can be used for the treatment of herpes simplex and herpes zoster. 10% podophyllo toxin is effective against condyloma acuminatun (CA) and warts. As a topical immunomodulatory agent, imiquimod is effective for the treatment of CA as well. 7) Insecticide 5-10%sulfur, 10% crotamiton, 5% benzoic peroxide and 50% baibu (tincture) etc are used as insecticide to kill mites and lice. 8) Keratoplastic Keratoplastic will normalize horny layer of epidermis, alleviating inflammation at the