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This patient has several conditions that warrant careful treat-ment. Hypertension is eminently treatable; the steps described in Chapter 11 are appropriate and effective in the elderly as well as in young patients. Patient education is critical in combating his reluctance to take his medications. Alzheimer’s disease may respond to one of the anticholinesterase agents (donepezil, rivastigmine, galantamine). Alternatively, memantine may be tried. Unfortunately, age-related macular degeneration (the most likely cause of his visual difficulties) is not readily treated, but the “wet” (neovascular) variety may respond well to one of the drugs currently available (bevacizumab, ranibizumab, pegaptanib). However, these therapies are expensive.
Dirk B. Robertson, MD & Howard I. Maibach, MD
A 43-year-old woman presents with a complaint of worsen-ing rosacea. She initially responded to once-daily topical metronidazole 0.75% gel with excellent clearing of the papulopustular component of her acne rosacea. Recently, she has noted increasing persistent facial erythema. What therapeutic options are available?
Diseases of the skin offer special opportunities to the clinician. In particular, the topical administration route is especially appropriate for skin diseases, although some dermatologic diseases respond as well or better to drugs administered systemically.
The general pharmacokinetic principles governing the use of drugs applied to the skin are the same as those involved in other routes of administration (see Chapters 1 and 3). Although often depicted as a simple three-layered structure, human skin is a complex series of diffusion barriers (Figure 61–1). Quantitation of the flux of drugs and drug vehicles through these barriers is the basis for pharmacokinetic analysis of dermatologic therapy, and techniques for making such measurements are rapidly increasing in number and sensitivity.
Major variables that determine pharmacologic response to drugs applied to the skin include the following: 1.
Regional variation in drug penetration: For example, the scrotum, face, axilla, and scalp are far more permeable than the forearm and may require less drug for equivalent effect.
2.
Concentration gradient: Increasing the concentration gradient increases the mass of drug transferred per unit time, just as in the case of diffusion across other barriers (see Chapter 1). Thus, resistance to topical corticosteroids can sometimes be overcome by use of higher concentrations of drug.
3.