Indications for Different Types of Ointments
The most appropriate ointment formulation should be selected based on the specific skin condition, affected body area, and desired therapeutic effect, with ointments being preferred for very dry skin conditions due to their superior occlusive properties and even spreading compared to creams, lotions, and solutions. 1
General Principles of Topical Therapy
- Ointments spread more evenly on the skin compared to creams, lotions, and solutions, making them more effective for delivering consistent medication doses across the treated area 1
- The fingertip unit (FTU) combined with the "Rule of Hand" is the most frequently used measurement for accurate application of external agents 2
- For adequate coverage, 200-400g of emollient is typically needed weekly for dry skin conditions 3
- Topical agents should be applied in a downward direction to avoid folliculitis 3
Emollients and Moisturizers
- Emollients are first-line therapy for dry skin conditions and should be applied 3-8 times daily 3
- Different formulations are appropriate for different conditions:
- Lotions (e.g., Eucerin intensive, E45 Lotion): Suitable for hairy areas and when minimal greasiness is desired 3, 4
- Creams/gels (e.g., Diprobase cream, Doublebase gel): Provide moderate moisturization and are cosmetically acceptable 3, 4
- Ointments (e.g., White soft paraffin, emulsifying ointment): Most effective for very dry skin conditions due to their occlusive properties 3, 4
- In a randomized controlled trial comparing emollient types for childhood eczema, there was no significant difference in effectiveness between lotions, creams, gels, and ointments, though satisfaction was highest for lotions and gels 4
Topical Corticosteroids
- Indicated for inflammatory skin conditions with different potencies based on severity and location 5, 3
- Potency selection guidelines:
- Mild corticosteroids (e.g., Hydrocortisone 1%): For mild inflammatory conditions, facial application, and children 5, 3
- Moderate potency (e.g., Eumovate): For moderate inflammatory conditions 5, 3
- Potent/very potent (e.g., Betnovate, Dermovate): For severe inflammatory conditions on thick skin areas 5, 3
- Application technique: Apply thinly once or twice daily to affected areas, using ointment formulations for dry skin and creams for weeping areas 5, 3
- For maintenance therapy in atopic dermatitis, intermittent use of medium potency topical corticosteroids (2 times/week) is recommended to reduce disease flares and relapse 5
Specialized Ointments for Specific Conditions
Pruritus Management
- For generalized pruritus without visible skin signs (GPUO), the following are recommended:
- For pruritus in elderly skin:
- Topical crotamiton cream, capsaicin, and calamine lotion are not recommended for generalized pruritus of unknown origin 5
Rosacea Management
- A phenotype-led approach is recommended for rosacea treatment:
- Multiple cutaneous features of rosacea can be treated with more than one agent simultaneously 5
Actinic Keratosis Management
- 5% 5-FU cream used twice daily for 3 weeks is effective at reducing actinic keratoses on the face and back of hands by about 70% for up to 12 months 5
- 3% diclofenac in 2.5% hyaluronic gel is moderately effective for mild actinic keratoses when used for 60-90 days 5
- Topical tretinoin cream shows dose-dependent response with 0.3% ointment clearing 55% of actinic keratoses versus 35% with 0.1% concentration 5
Dermatitis from EGFR Inhibitors
- For grade 1 rash: Continue EGFR-TKI therapy and apply emollients regularly 5
- For grade 2 rash: Intensify moisturizing and apply topical steroids (1-2.5% hydrocortisone or eumovate ointment to the face; betnovate, elocon or dermovate ointment to the body) for 2-3 weeks 5
- For grade 3 rash: Temporarily interrupt EGFR-TKI therapy and manage with oral antibiotics and topical corticosteroids 5
Immune Checkpoint Inhibitor-Related Dermatologic Toxicities
- For grade 1 maculopapular rash (covering <10% BSA):
- Continue immunotherapy
- Apply class I topical corticosteroid (clobetasol propionate, halobetasol propionate, betamethasone dipropionate cream or ointment) for body; Class V/VI corticosteroid for face 5
- For grade 2 rash (covering 10-30% BSA):
- Continue immunotherapy with dermatology referral
- Apply topical corticosteroids as in grade 1 5
- For grade 3 rash (covering >30% BSA):
- Hold immunotherapy and obtain same-day dermatology consultation
- Apply topical corticosteroids and initiate systemic corticosteroids 5
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
- For oral mucosal involvement:
- Apply white soft paraffin ointment to the lips every 2 hours during acute illness
- Use a potent topical corticosteroid mouthwash four times daily 5
- For urogenital involvement:
- Apply white soft paraffin ointment to the urogenital skin and mucosae every 4 hours
- Use a potent topical corticosteroid ointment once daily to involved, non-eroded surfaces 5
Common Pitfalls to Avoid
- Underuse of emollients leading to inadequate skin care 3
- Overuse of potent steroids causing skin atrophy and systemic effects 5, 3
- Using creams instead of ointments for very dry skin conditions 3, 1
- Discontinuing treatment too early, leading to recurrence of skin conditions 3
- Using topical antibiotics as monotherapy, which increases the risk of resistance 3
- Failure to recognize that ointments provide more even medication distribution compared to creams and solutions 1