Topical Therapy

Therapy for atopic dermatitis is multi-faceted and encompasses restoring the skin barrier function, using anti-inflammatory medications (topical or systemic), identifying and eliminating triggers, and secondary prevention. The skin barrier in AD is faulty with a decrease in the amount of and an abnormal ratio between skin lipids (most notably ceramide), which leads to increased transepidermal water loss (Chamlin et al., 2001; Darsow et al., 2005). Genetic mutations of the epidermal barrier protein filaggrin are a predisposing factor for AD (Palmer et al., 2006; Weidinger et al., 2006). Emollients are regarded as a standard of care in preventing and treating AD. When used as a moisturizing regimen in conjunction with steroids, emollients enhance the anti-inflammatory affect of topical steroids resulting in a steroid-sparing phenomenon (Hanifin et al., 2004; Hanifin et al., 1998). It is recommended that emollients be applied at least twice daily and immediately after bathing (Darsow et al., 2005).

Since their development over 50 years ago, topical corticosteroids have served as the first line of therapy for AD and this recommendation remains in the most up-to-date position of the European Academy of Dermatology and Venereology (Darsow et al., 2005). Topical steroids are anti-inflammatory medications and are classified according to their vasoconstrictor assays, with the most potent topical steroids in Class 1 and the least potent in Class 7 (see Table 4 ). Longer duration of therapy and more potent topical steroids have a higher potential for adverse effects. The amount of absorption of a topical steroid is influenced by the surface area of the skin, thickness of the skin (epidermis), the type of vehicle, drug concentration, and the presence of absence of occlusive dressings. Class 1 to 5 topical steroids should be avoided in areas of thinner skin, including the eyelids, face, mucous membranes, genitalia, and intertriginous areas, as these areas have increased likelihood of transepidermal corticosteroid absorption (Leung et al., 2004). In contrast, potent topical steroids may be needed on the palms and soles as the epidermis in these areas is much thicker (Brazzini & Pimpinelli, 2002). Children have a low body volume to skin surface area ratio, which allows for a greater absorption of corticosteroids leading to a higher potential for adverse affects. As a result, higher-potency steroids should be avoided in children (Paller et al., 2005). Local adverse effects of topical steroids include striae, skin atrophy, telangiectasias, perioral dermatitis, erythema, acne, glaucoma, and cataracts. Potential systemic adverse effects include growth suppression, suppression of the hypothalamic-pituitary-adrenal axis, and osteoporosis, and are most likely to occur with the use of high-potency steroids (Brazzini & Pimpinelli, 2002; Paller et al., 2005).

Benefits of topical steroids include a low-cost, wide variety of preparations, and proven clinical effectiveness (Leung et al., 2004). Topical steroids are available in a wide variety of vehicles including creams, lotions, ointments, solutions, gels, and foams. In general, ointments are more potent than creams because of superior ability to hydrate the stratum corneum (the top layer of the epidermis) which enhances absorption (Brazzini & Pimpinelli, 2002; Leung et al., 2004). Selection of a vehicle can also be based on the body area to which the medications will be applied. For example, ointments on hairy areas of the body can be messy, so foams and lotions are preferred. Sometimes in severe disease, occlusive dressings may be employed. Occlusive dressings have the advantage of increasing the penetration of a steroid and making therapy more effective, but they also increase the risk of side effects; therefore, they should not be used for prolonged periods of time (Brazzini & Pimpinelli, 2002).

The choice of a topical steroid should be tailored to each patient based on the potency, vehicle, lesion location, patient age, season, environment, socioeconomic class, prior medication(s), the presence or absence of infection, and patient preferences. Currently, it is recommended that the least-potent topical steroid be used (along with a good skin care regimen) to achieve the maximum benefit; then tapered, discontinued, or changed to less-potent topical steroid (Paller et al., 2005). Optimally, topical steroids should be used for only a few weeks in a continuous fashion and then used intermittently (for example, twice a week) (Hanifin et al., 2004; Paller et al., 2005). It is preferable for low-potency steroids to be used in maintenance therapy and mid to high-potency steroids to be used to treat flares (Leung et al., 2004). Pruritus can serve as a marker in evaluating a treatment response, and tapering of the steroid should not be attempted until pruritus has disappeared. Tapering of the topical steroid should be done gradually to avoid a flare (Darsow et al., 2005). Multiple large reviews have shown that once-a-day application of an appropriately selected topical steroid is as effective as twice-daily application (Green, Colquitt, Kirby, & Davidson, 2005; Hanifin et al., 2004). In children with mild-to-moderate AD, the use of intermittent, short cycles of potent steroids is safe and equivalent in effectiveness to the long-term use of weaker topical steroids (Hanifin et al., 2004).

In exact years, topical calcineurin inhibitors have become available for treating atopic dermatitis. These medications also have anti-inflammatory affects, but do not contain steroids. The two medications offered are pimecrolimus and tacrolimus, and both are approved to treat patients over age 2 (Darsow et al., 2005). Both medications decrease the extent, severity, and symptoms of AD (Hanifin et al., 2004). Pimecrolimus (Elidil^®) is effective in treating mild-to-moderate forms of AD and is available in a 1% cream. Tacrolimus (Protopic^®) is used in treating moderate-to-severe AD and is available in 0.03% and 0.1% ointments (Hanifin et al., 2004). The 0.1% tacrolimus ointment is indicated for patients older than 16 years of age (Paller, 2004). All topical calcineurin inhibitors are applied twice a day and can be used along with topical corticosteroids. Some clinicians may choose to initiate treatment of atopic dermatitis with topical corticosteroids and make a transition to topical calcineurin inhibitors when the extent of the inflammation is reduced. Others have layered these products together by applying the steroid first, applying the topical calcineurin inhibitor 30 minutes later, and decreasing the potency of the steroid or eliminate it all together once clinical improvement is seen (Paller et al., 2005).

Studies have shown that tacrolimus 0.1% is either equal to or more efficacious than a Class 5 corticosteroid in treating AD, and tacrolimus 0.03% is more efficacious than a low-potency steroid, but not as efficacious as a mid-potency topical steroid (Beck, 2005). Studies comparing tacrolimus and pimecrolimus demonstrated that 0.1% tacrolimus is more efficacious than pimecrolimus; 0.03% tacrolimus has equal efficacy to 1% pimecrolimus in mild disease; and 0.03% tacrolimus is better than 1% pimecrolimus in decreasing the itch associated with AD (Paller et al., 2005). Tacrolimus has a faster onset of action as compared to pimecrolimus, with improvement in symptoms during the first week of therapy (Paller, 2004).

Both of these medications were proven safe and effective (up to 1 year in all and 4 years in tacrolimus 0.1%) in numerous trials (Chapman et al., 2005; Darsow et al., 2005; Hanifin et al., 2005; Koo et al., 2005; Leung et al., 2004; Paller, 2004; Paller et al., 2005). These medications do not have the side effect profile of topical steroids, and therefore can be used in areas where the epidermis is thinner such as the eyelids, face, mucous membranes, genitalia, and intertriginous areas, without the risk of skin atrophy and striae. The most frequent side effect is burning at the application site (which may be more frequent in tacrolimus); however, this symptom often improves with time and usage (Abramovits, 2005; Darsow et al., 2005). Other local side effects include itching and erythema (Chapman et al., 2005). In noncomparative trials, the incidence of cutaneous viral infections such as herpes simplex, eczema herpeticum, molluscum, varicella zoster, and warts is slightly increased in patients treated with topical calcineurin inhibitors (Hanifin et al., 2005; Koo et al., 2005). Additional side effects include flu-like symptoms, allergic reactions, asthma, cough, fever, otitis media, and headache (Hanifin et al., 2005; Koo et al., 2005).

In March of 2005, the U.S. Food and Drug Administration (FDA) issued a Public Health Advisory concerning a potential increased risk of cancer associated with topical tacrolimus and pimecrolimus. The advisory was based on animal studies and a small number of case reports of skin cancer and lymphoma in adults and children treated with topical calcineurin inhibitors. The FDA made recommendations on the use of topical calcineurin inhibitors to health care providers, patients, and caregivers, as follows (see Table 5 ). Pimecrolimus and tacrolimus should be used only as second-line agents for short-term and intermittent treatment of atopic dermatitis in patients unresponsive to, or intolerant, of other treatments. Avoid the use of pimecrolimus and tacrolimus in children younger than 2 years of age. The effect of pimecrolimus and tacrolimus on the developing immune system in infants and children is not known. In clinical studies, infants and children younger than 2 years old treated with pimecrolimus had a higher rate of upper-respiratory infections than did those treated with placebo cream. Use pimecrolimus and tacrolimus only for short periods of time, not continuously. The long-term safety of pimecrolimus and tacrolimus are unknown. Children and adults with weakened or compromised immune system should not use pimecrolimus and tacrolimus. Use the minimal amount of pimecrolimus and tacrolimus needed to control the patient symptoms. In animals, increasing the dose resulted in higher rates of cancer. The FDA will be requiring a black box warning to be placed on these medications and the development of a medication guide for tacrolimus and pimecrolimus (FDA, 2005).

The American Academy of Dermatology (AAD) issued a statement in response to the FDA that it was disappointed that the FDA took this action, despite the lack of data proving proper topical use of pimecrolimus and tacrolimus is dangerous to people (AAD, 2005). The chance of systemic exposure of these medications has been studied in various trials and shown to be minimal and transient and not associated with an increase in adverse effects (Beck, 2005). Prospective clinical studies of topical calcineurin inhibitors have not shown an increase risk of lymphoma, lymphoproliferative disease, or skin cancers (Beck, 2005). Taking into consideration that systemically administered (oral) calcineurin inhibitors, cyclosporine, and tacrolimus have demonstrated an increased risk of lymphoproliferative diseases and skin cancers in transplant patients (Beck, 2005; Darsow et al., 2005; FDA, 2005), additional long-term studies of 10 years or more will be needed to determine the safety profile of topically administered calcineurin inhibitors (FDA, 2005).

Other topical treatments for AD include coal tar, doxepin, and topical sodium cromoglicate (Hanifin et al., 2004; Stainer et al., 2005; Williams, 2005). Coal tar and coal tar derivatives have been used for decades to treat AD and have efficacy similar to a Class 7 steroid (Williams, 2005). These medications exhibit antipruritic and anti-inflammatory effects and should only be used in chronic lesions of atopic dermatitis (Leung & Bieber, 2003). Coal tar can be used as monotherapy or in combination with topical steroids. Photosensitivity and folliculitis may result from coal tar (Leung & Bieber, 2003), but the major drawback is the odor and dark color which stains clothes (Correale et al., 1999). These cosmetic disadvantages generally lead to issues with compliance (Hanifin et al., 2004). Doxepin is a topical antihistamine that is able to decrease the pruritus associated with AD within 48 hours (Williams, 2005). Concerns over its potential for cutaneous sensitization and the side effect of sedation may limit its use (Leung et al., 2004). Studies in the past regarding the effectiveness of topical cromoglicate in treating AD are inconsistent. Cromoglicate acts to prevent or reduce the release of inflammatory and chemotaxic mediators from mast cells. A exact randomized trial demonstrated that the application of cromoglicate lotion (in addition to a treatment plan of topical steroids and emollients) can Improve symptoms and severity of skin lesions and decrease steroid use in children with AD as compared to the lotion vehicle. Erythema and burning at the site of application are the most common side effects of topically applied cromoglicate (Stainer et al., 2005).

In the highly complex CIMA curriculum, the Management Level is yet another challenge: one that must be overcome. In order to assist you in surpassing this challenge, Wisdom, the pioneer CIMA institute in Sri Lanka, offers you the best possible lecture panel. Consisting of a group of diverse individuals with the most relevant and exciting corporate experience under their belts, they will ensure that coursing through the Management Level to the Strategic Level is no difficult task.

Performance Management
Performance Management, the performance pillar subject of the Management Level, is an area where both your theoretical skills and numerical skills get tested. Hasitha Premaratne, Wisdoms' highly popular lecturer for Performance Management will make sure that you are not at a loss when it comes to either of these skills.

Heading the finance function at Brandix Lanka (Pvt) Ltd, Hasitha's diverse and colourful corporate experience in areas such as capital markets, economics, finance and management adds flavour to his classes. He has produced over 12 Sri Lankan prize winners during his lecturing career of 10 years, while also having received the prestigious CIMA 'Tutor of the Year' Award for 2009. His academic and professional qualifications include an MBA in International Finance and a BSc in Computer Science, along with associate membership of the Chartered Institute of Management Accountants and the Society of Certified Management Accountants and also fellow membership of the Association of Chartered Certified Accountants.

Enterprise Management
Enterprise Management, with a greater focus on the business and its competitive environment, requires students to gain a thorough understanding of the theoretical aspects and also to apply them in typical company related scenarios. Lectures for Enterprise Management are carried out by Tharindu Amaresekere, a young and vibrant lecturer who has received much praise and acclaim from his students over the past 6 years.

Tharindu bears many academic and professional qualifications, which include a Bachelor's Degree in computing. He is also the only EM lecturer in Sri Lanka to hold a Master's Degree in Project Management, a vital component of the EM syllabus. He is currently studying for his MBA specialising in Marketing from the University of Colombo and CIM Diploma in Marketing.

Currently employed as a brand consultant for an international web solutions organisation, Tharindu's combined local and international experience renders him the perfect lecturer for a theory related subject in the likes of EM, where building the link between theory and practicality will never lose importance. His keenness on practising Corporate Stimulus Teaching, where theory is aligned with real world companies, has won him a large fan club among CIMA students. He also provides individual focus for improvement of writing skills, which will assist in presenting your arguments in a succinct and comprehensive manner.

Financial Management
For Financial Management, Wisdom presents two individuals with well respected financial and teaching skills. Mallik de Silva, who has found much favour among his students as a friendly and approachable person, has over 15 years lecturing experience. Currently serving as the Group Finance Manager at Richard Pieris and Company PLC, he counts diverse and versatile exposure in many multinational organisations. An associate member of the Institute of Chartered Accountants of Sri Lanka and a fellow member of the Chartered Institute of Management Accountants UK, he also possesses an MSc in Financial Management.

Akalanka Saparamadu, who joins Mallik at Financial Management, is a CIMA passed finalist who has also completed his Bachelor of Business Administration (Finance Special) degree with a First Class from the University of Colombo. At present, he is a Chartered Financial Analyst (CFA) - Level 3 candidate. Akalanka is presently employed at HSBC Sri Lanka as an Account Relationship Manager.
Together the duo has produced many prize winners and consistently maintained above average pass rates. Their combined efforts in teaching will expose you to a novel experience in finance.

In addition to the stimulating back up received from the lecture panel, Wisdom also provides you with a balanced environment where extra-curricular activities are promoted without disturbing academic activities. Thus, your CIMA studies are bound to be a combination of fun and success. When you are being presented with such a great opportunity to be coached under the best quality lecture panel for CIMA, would you want to say 'no'? Join Wisdom and experience a refreshing CIMA journey. Classes for Management Level began on June 4 2011.

Change is inevitable, but it is important to keep an eye out for the constants. You as students are gearing towards CIMA's syllabus change, thinking which subjects to do next and maybe of the best combination of subjects to take up this session. Whilst you are preparing for this change, we at Imperial College, armed with vast experience, an exceptional faculty and outstanding facilities are ready to guide you through this new hurdle. Whilst change is inevitable, Imperial College remains constant with providing students the best defence.

Imperial College is the longest established Business School in Sri Lanka and a premier CIMA tuition provider. Imperial College's history exceeds 20 years, dating back to 1985 when it was founded as CBS, which was a pioneer in CIMA education in Sri Lanka. Through our long standing history we have witnessed 5 syllabus changes and continual growth. Year on year we have been commended for producing students who are 'employable', and we have a reputation for instilling in our students, the right tools, knowledge, competencies and skill set needed to significantly contribute to the management of organizations.

Imperial college provides you with an ideal stepping stone to tackle this syllabus change successfully with the immense support of a prominent panel of lecturers who believe in a holistic approach to learning. To put it simply, they believe in going beyond the principles and theory to giving you a wider view of the subject, by bringing in the immense corporate experience they possess into the classroom. Hence you get first-hand information on applying the principles you learn in the real business world. The team at imperial College for the Operational and Management Levels include 3 outstanding lecturers, who head each pillar. More importantly these are lecturers who have coached many students to be high -flyers not only in Sri Lanka but also in South East Asia and India.

Students are assured of a comprehensive syllabus coverage one month ahead of examinations. It is essential that students are thorough with key principles of the syllabus and our lecturers are committed to patiently guiding you through them. Further, Students are provided with examination type mock papers that are marked and one to one feedback provided. In addition to receiving quality tuition, revision also plays an essential role for test success. Students at Imperial College benefit from a comprehensive revision plan which comprises of approximately 20 hours per subject.

During this revision lecturers lead students through significant areas of the syllabus that examiners find important in addition to practicing several past examination questions and past papers. Imperial College also fosters an open student faculty relationship enabling students to approach every lecturer for additional support. Students also stand to gain with the provision of extra question practice classes to ensure thorough knowledge of the subject and test preparedness.

Receiving the best support during your studies is of paramount importance; In addition to getting just that, we also advise students on the best combination of subjects to take enabling them to maximise their potential and capabilities. The ultimate result lies on one's ability to secure employment. We train, guide and mold students not only to be ready for employment, but we also take the extra step towards assisting our students with finding the right job that best suits their capabilities. Isn't this an ideal situation for you?

As a student of Imperial College, you stand the best chance of gaining from an advantage of studying with the most established Business School in Sri Lanka, having the most experience with successfully managing syllabus changes. Wouldn't it be great for you to feel at ease whilst embarking on change?
We've seen though 5 syllabus changes successfully and are ready to tackle number 6! Are you ready to write your success story with us?

For more information on CIMA at Imperial College , visit us at No. 3, St. Kilda's Lane, Colombo 3, or call us on 0773 918 777 or 011 4 51 52 53.

©2006-2023, BILL4TIME. ALL RIGHTS RESERVED.National Law Review, Volume XIII, Number 206

• Inventory management software grants visibility into your stock, helping you maintain optimal amounts to continue fulfilling orders without holding too much of a given item.
• Inventory management software automates critical tasks and reduces the chance of human errors, especially through integrations with key systems like accounting software and point-of-sale solutions.
• Your industry and business operations will dictate the inventory management software features you’ll need.
• This article is for business owners who want improved methods for tracking, maintaining and ordering stock while automating crucial tasks.

Effective inventory management is vital for any business that stocks goods or raw materials. While inventory management was historically a manual process, modern technology has eliminated the need for a labor-intensive and error-prone manual inventory management system. Today, inventory management software is available to streamline the process, reduce errors and help businesses optimize how they maintain and order the products they sell.

We’ll examine inventory management software and share how to choose the right solution to streamline your business operations. 

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