Podiatrists may have many needs for compounded medications:
Onychomycosis – nail fungus
Commercial products to treat onychomycosis include griseoflulvin, itraconazole, Terbinafine and circlopirox 8% nail lacquer (Penlac). Griseofulvin has reported poor cure rates and requires 10 – 18 months of use. Oral therapy with itraconazole and Terbinafine also present problems with drug interactions and liver toxicity. A patient with compromised liver function or a GERD patient on a PPI will not be a candidate for oral itraconazole. For patients who cannot use antifungals, Penlac is the only commercial topical treatment available. However, Penlac reportedly has only a 14% cure rate after several months of use. Having a compounded prescription medication may overcome these problems and avoid the need for extensive liver monitoring. We can dissolve an antifungal in dimethylsulfoxide (DMSO) that has superior nail penetration and it is able to deliver an antifungal to the site of infection. Examples of antifungals that can be compounded in DMSO are azole antifungals and terbinafine.
- Itraconazole 1%/Ibuprofen 2% in DMSO nail polish
- Itraconazole 1%/Undecylenic Acid 17% in Tea Tree Oil-DMSO nail polish
- Itraconazole 1%/Undecylenic Acid 17%/Salicylic Acid 10% in Tea Tree Oil-DMSO nail polish
- Ketoconazole/Tea Tree Oil/DMSO Antifungal Solution
- Terbinafine 1.67% Topical Solution
The classic treatment for warts is salicylic acid used topically. There are some unique treatments for warts that can be prepared by a compounding pharmacist involving the drugs Cimetidine, trichloroacetic acid, and 5-fluorouracial. Cimetidine at doses of 40mg/kg orally has been used to treat recalcitrant multiple warts.
- Cimetidine 5%/DDG 0.2%/Tea Tree Oil 10%/Ibuprofen 2% transdermal
- Salicylic Acid 40% Ointment
- Salicylic Acid Compound Collodion
- Salicylic Acid 28% Polymeric Substrate
- Trichloroacetic Acid 2%/Salicylic Acid 60%
Non-Surgical Nail Removal
There is a compounded preparation that will allow for non-surgical nail removal that may be required for non-dermatophytic fungal infections.
- Urea 40% ointment
There are numerous medications that are commercially available to treat diabetic neuropathy and help return sensitization. Some of the drugs used to treat diabetic neuropathy are amitriptyline, baclofen, ketamine, gabapentin, and clonidine. Diabetic patients can benefit from topical combinations of these medications that are not commercially available. Combinations of topical medications have the advantage of fewer adverse effects as well as using one medication rather than several.
- Baclofen 5%/Ketoprofen 10%/Lidocaine 5%/Gabapentin 5% transdermal
- Ketamine 10%/Gabapentin 6%/Clonidine 0.2%/Lidocaine 2% transdermal
- Ketamine 10%/Gabapentin 6%/Clonidine 0.2%/Nidedipine 2% transdermal
- Gabapentin 6%/Clonidine 0.2% transdermal
- Clonidine 0.2%/Gabapentin 6%/Ketamine 10% transdermal
Hyperhidrosis of the Feet and Foot Odor
Many of the commercial products prepared for hyperhidrosis feet contain the drugs aluminum, atropine or scopolamine, formaldehyde, methenamine and glycopyrrolate. Methenamine is a pro-drug that is converted to the active drug formaldehyde. Aluminum chlorohydrate is a common ingredient found in many over-the-counter antiperspirants.
- Methenamine 5% Clear Lotion/Gel
- Methenamine 5% Deodorant Stick
- Methenamine 5%/Benzalkonium Chloride 2%
- Aluminum Chlorohydrate 5% and 10% Topical Antiperspirant Cream
- Aluminum Chlorohydrate 5% Topical Powder
- Aluminum Chlorohydrate 7.7% Topical Paste
- Formaldehyde Roll-on Deodorant
- Glycopyrrolate 0.25%/Tea Tree Oil 2.5% Deodorant/Antipersirant
Inflammation and Pain
Most topicals for inflammation and pain due to sprains and strains can be made from various NSAIDs in PLO containing ketoprofen. Of all the medications used topically in podiatry, NSAIDs probably have the most clinical data behind their use. The NSAIDs can be combined with a muscle relaxer or topical anesthetic if desired.
- Ketoprofen 10%/Cyclobenzaprine 1-2% transdermal
- Ketoprofen 10%/Lidocaine 5%/Bupivacaine 2% transdermal
Wound Healing and Circulation Improvement
Nifedipine has been used in concentrations of 0.2% to 10% PLO gel in an effort to enhance circulation in areas of ischemia. Higher concentrations are used by pharmacists, but the lower doses are a better starting point due to the hypotensive properties of this drug. The same vaso-dialation properties that make it work well orally in diseases such as hypertension, angina pectoris, and Raynaud’s syndrome could also make it work well as an agent to rub on areas around diabetic ulcers and in ischemic areas to aid in blood flow. Transdermal nifedipine PLO should be dispensed in an amber bag because of its light sensitivity. The patient should be monitored for decreased blood pressure while using the preparation, and the wound should be monitored for signs of healing (skin becoming more pink, vascularized and skin dryness around the wound. For more diabetic formulations, click here.
- Nifedipine 4-16% transdermal
- Pentoxifylline 5% Lipoderm
Additional preparations for Podiatrists:
- Decubitus ulcers
- Transdermal anti-inflammatory agents
- Treating calluses
- Skin softeners & moisturizers
- Transdermal treatments for neuropathy
- Keratinolytic agents
- Wound Care
- Plantar fasciitis (Heel Spurs)
- Anti-fungal foot powders
- Muscle & joint pain