Download handling complaints in the community pharmacy part 1

5/31/2013
HANDLING COMPLAINTS IN THE
COMMUNITY PHARMACY PART 1:
DERMATOLOGY
Lynda Uzonwune PharmD
Community Pharmacy Resident
Medica Pharmacy/Sullivan University
June 8th, 2013
DISCLOSURE STATEMENT AND CPE

Lynda Uzonwune, PharmD does not have any type of affiliation, including
financial in relation to this CPE activity
LEARNING OBJECTIVES
Discuss selected common skin conditions
Recognize clinical signs and symptoms of common dermatological
conditions
 Identify goals of treatment
 Discuss OTC treatment options
 Explain circumstances when a patient could be referred to a pharmacist


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INTRODUCTION
The skin is the largest organ of the
body
 It is composed of 3 main layers

Epidermis
Dermis
 Hypodermis


FUNCTIONS OF THE SKIN






Protection against injury
Regulation of body temperature
Prevention of dehydration
Sense organ
Immune functions
Vitamin D production and absorption
SKIN DISORDERS
Patients with skin disorders typically present with some type of
rash, pruritus or erythema
 Since a lot of skin care products are sold OTC in pharmacies,
pharmacists are usually one of the first health care professionals
patients refer to for skin care recommendation
 Knowledge of clinical presentation of various skin disorders and
products to treat the symptoms will help pharmacists in giving the
right recommendation to patients

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MANAGING SKIN CONDITIONS

Before treatment recommendations, pharmacist should:

Assess the problematic area of the skin if possible



Patient might need referral if:
 Eye and genitalia involvement (contact dermatitis)
 Superimposed infection
 Blood or pus at lesion sites
Obtain a general medical and allergy history
Conduct a thorough patient interview regarding signs and symptoms
CONTACT DERMATITIS
Accounts for 5.7 million physician visits per year
More than 3,700 substances have been identified as contact allergens
 Slightly more in females due to increased exposure to irritants from
jewelry and cosmetics
 Two primary types:




Irritant contact dermatitis (ICD) is an inflammatory reaction of the skin caused by
exposure to an irritant.
Allergic contact dermatitis (ACD) is an immunologic reaction of the skin caused by
exposure to an antigen
IRRITANT CONTACT DERMATITIS
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IRRITANT CONTACT DERMATITIS




Common on exposed skin surfaces (hands and forearms) of individuals who work
in environments requiring frequent hand washing, food handling or repeated
contact with irritants.
Caused by direct damage to the epidermal cells by direct absorption of irritant
through the cell membrane or release of cytokines due to chemical exposure
Prolonged skin exposure may increase severity
Common causes include:




Urine/Feces
Detergents
Hand sanitizers,
Acids and alkalis
IRRITANT CONTACT DERMATITIS

Clinical presentation






Inflamed, red skin
Rash accompanied by itching, stinging and
burning
Usually limited to the hands and forearms
Initial symptoms may progress to ulcers and
localized necrosis
Dermatitis resolves in several days when
patient avoids further contact with irritant
Chronic exposure to irritant propagates
symptoms may progress to fissures, scales
and hyperpigmentation and
hypopigmentation
IRRITANT CONTACT DERMATITIS

Goals of treatment



Removal of offending irritants
Relieve inflammation, dermal tenderness and irritation
Treatment
Apply emollients liberally to affected areas
Cool tap water compress or aluminum acetate (Burrows solution)
compress for 20 minutes 4-6 X daily
 Sedating oral antihistamine (night time itching)


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CASE 1

Helen is a food service worker
that asks for your advice about
a rash she has on her hands.
She recently cleaned the
kitchen at work with a
professional grade cleaner.
She thinks she may be
“allergic” to bleach. Is she a
candidate for self-care and
what will you recommend?
CASE 1
Helen is a candidate for self-care since there are no other
complication with this rash and rash is localized to her hands
 Recommendation:

A.
B.
C.
D.
E.
Continue using cleaner, rash will resolve on its own
Avoid using cleaners or wear protective glove if necessary
Apply emollient or hypoallergenic moisturizer to rash
B and C
A and C
DIAPER DERMATITIS (DIAPER RASH)
Contact dermatitis usually caused by exposure to urine and feces
The skin of the perineal region in an infant is about one-half to one-third
the thickness of adult skin
 Decreased skin barrier capabilities make the infant skin more susceptible
to irritation, absorption of chemicals and opportunistic microbes.
 Tight fitting, stiff or rough diapers contribute to mechanical friction of the
skin
 Occlusive plastic or rubberized covers or pants contribute to occlusion
 Urine and fecal bacteria contribute to skin breakdown


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DIAPER DERMATITIS

Clinical presentation
Erythematous, wet-looking
patches and lesions
 Rashes may appear dusky
maroon or purplish on darker
skin
 Occurs on skin spaces covered
by the diaper
 Untreated or infected diaper
dermatitis can progress to skin
ulceration

DIAPER DERMATITIS

Goals of Therapy





FDA-Approved Skin Protectants
Relieve Symptoms
Eliminate diaper rash
Prevent infection
Prevent recurrences
Treatment



Application of skin protectants with
each diaper change
Skin protectants serve as physical
barriers while allowing for body’s
normal healing process
FDA approved skin protectant
products cannot contain
antimicrobials, topical analgesics
and antifungals
Allantoin
Kaolin
Calamine
Lanolin
Cocoa butter
Mineral oil
Cod liver oil
Petrolatum
Colloidal oatmeal
Topical cornstarch
Dimethecone
White petrolatum
Glycerin
Zinc acetate
Hard fat
Zinc carbonate
Zinc oxide
SELECTED NON-PRESCRIPTION PRODUCTS
Product
Primary ingredients
A +D zinc oxide ointment
Zinc oxide 10%; dimethicone
Vitacilina Bebe Diaper
Rash Ointment
Petroleum 34.6%; zinc oxide 30%; allantoin 1%
Flanders Buttocks
Ointment
White Petrolatum 66.2%; zinc oxide 13.4%(castor oil,
mineral oil; Peruvian balsam
Boudreaux's Butt Paste
Zinc oxide 16% (Peruvian balsam, boric acid, castor oil,
mineral oil, petrolatum)
Lansinoh Diaper Rash
Ointment
Dimethicone 5%, lanolin 15.5%, zinc oxide 5.5%
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DIAPER DERMATITIS

Best treatment – PREVENTION
More frequent diaper changes
Reduce of mechanical irritation and trauma to the inguinal and perineal
skin
 Avoid baby wipes that contain contain alcohol, perfumes, soap, or other
ingredients that can burn, sting or cause contact dermatitis


CASE 2
Susan is a customer who takes her 6 month old son to a reputable
daycare center while she works during the day. She has noticed
reddened, wet-looking rashes localized within her son’s diaper
region. She wants to use an OTC product she ordered online
containing the active products – dimethicone, benzocaine and zinc
oxide. What will you recommend?
A. Recommend that Susan starts using this product as the above
active ingredients are the best for skin care
B. Recommend that Susan gets another product without benzocaine
C. Recommend she talks to the daycare center about changing her
son’s diaper more frequently
D. A and B
E. B and C

ALLERGIC CONTACT DERMATITIS
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ALLERGIC CONTACT DERMATITIS (ACD)





Accounts for 10% to 20% of contact dermatitis cases
Caused by sensitization of T-cells on skin contact with allergen and release of
inflammatory mediators
Type IV delayed hypersensitivity reaction
Poison ivy (Toxicodendron genus) is the most common cause of ACD in the
United States
Other common causes:




Nickel
Latex
Fragrances
Benzocaine
ALLERGIC CONTACT DERMATITIS (ACD)

Clinical presentation





Intense itching, redness and streaky
rash
Papules, small vesicles and large bullae
Inflamed, swollen skin
Occurs anywhere the antigen contacts
the body
Secondary infections might occur from
open skin as a result of scratching
POISON IVY, OAK AND SUMAC
Urushiol is the oleoresin in
plants of the genus
Toxicodendron
 Causes urushiol-induced
allergic dermatitis
 80% of the U.S population is
estimated to be sensitive to
urushiol

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POISON IVY, OAK AND SUMAC
Vesicles and bullae may be
linear or broader in occurrence
depending on how urushiol is
transferred to skin
 Urushiol is transferred from
objects and fingers to other
body surfaces

POISON IVY, OAK AND SUMAC

Goals of treatment
Removal of offending agent
Relieve inflammation, itching and excessive scratching
 Relieve accumulation of debris arising from oozing, crusting and scaling
of vesicle fluids


POISON IVY, OAK AND SUMAC: PREVENTION

Ivy Block (bentoquatam)


FDA approved topical barrier lotion
Believed to physically prevent urushiol from being absorbed
Hydropel
Hollister Moisture Barrier Cream
 Stokogard Outdoor Cream



All three reduced dermatitis severity by 48%, 52%, and 59%, respectively
during a comprehensive study
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POISON IVY, OAK AND SUMAC: TREATMENT

Urushiol Removal


Wash contaminated areas with mild soap
and water
Commercial cleansing products



Tecnu
 Grindelia Robusta 3x (homeopathic, anti-itch agent)
 Believed to bind and inactivate urushiol
Zanfel
 Ethoxylate and sodium lauryl sarcosinate
(detergent)
 Acts similarly to soap
 May be beneficial up to 6 days after exposure
There is no significant difference in efficacy between
use of commercial cleansing agents, oil removing compounds
(Goop) and use of soap and water
POISON IVY, OAK AND SUMAC: TREATMENT

Itching

Oral antihistamines
Cetirizine, Benadryl, chlorpheniramine etc.
Anti-itch and sedative properties
Once daily dosing
 Topical products containing antihistamines, anesthetics or antibiotics are NOT
recommended (sensitizers)




Calamine Lotion




Astringent with soothing properties
Leaves visible pink film after on application
Refer patient to PCP if needed > 7 days and if condition is not improving
Colloidal oatmeal baths
POISON IVY, OAK AND SUMAC: TREATMENT

Oozing Vesicles

Aluminum acetate (Burrow's solution)
Used as astringent compress and baths for vasoconstriction and reduction of blood
flow in inflamed tissue
Low cell permeability
 Softens and removes crusts from oozing lesions
 Mild anti-itch properties



Dosing
Solution to be diluted 1:40 with water before use
Soak affected area for 15-20 minutes, 2 – 4 times daily
 May also apply washcloths soaked in solution on affected area for 20 -30 minutes



Colloidal baths
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MYTH VERSUS FACT
Which of the following statements on urushiol contamination is
TRUE:
A. Poison ivy rash spreads when the liquid from the vesicles contacts
unaffected skin
B. Vigorous scrubbing of affected skin with household bleach removes
urushiol
C. Urushiol can no longer be removed once it enters skin and
attaches to tissue proteins
D. Isopropyl alcohol and hand sanitizers are recommended to remove
urushiol antigen
PRICKLY HEAT
PRICKLY HEAT (HEAT RASH)
Can occur at any age in anyone
who has active sweat glands
 Results from blocked or
clogged sweat glands

Sweat glands unable to secrete
sweat
 Dilation and rupture of
epidermal sweat pores
 Associated with hot, humid
weather and occlusive clothing

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PRICKLY HEAT

Clinical presentation
Pinpoint size, raised lesions
Prickly heat lesions may appear
in small numbers clustered
together or spread over the
occluded area on a pink to red
field
 Common sites for prickly heat
dermatitis: axillae, chest, upper
back, back of the neck,
abdomen, and inguinal area


PRICKLY HEAT

Goals of Therapy
Keeping skin dry
Promote healing
 Soothe discomfort caused by lesions


PRICKLY HEAT: TREATMENT

Treatment

Topical antihistamines

Colloidal oatmeal
Topical cornstarch and talc








Ointments are more occlusive than cream
Apply twice daily
Topical cornstarch has absorbent properties
Talc functions as a lubricant
Powders can clog pores if used in excess
Apply daily after bathing
Hydrocortisone




Use if <10% of skin area involved
Apply twice daily and as needed
Self treatment using hydrocortisone should not go beyond 7 days. Do not use
hydrocortisone for more than seven days
Hydrocortisone ointment is more occlusive than cream
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CASE 3

John is an athlete who started noticing some pinpoint rashes on
his upper back and the back of his neck starting 4 days ago. The
rashes get itchy and uncomfortable sometimes. Is he a candidate
for self-care? What can you recommend?
DRY SKIN
DRY SKIN



Occurs due to decreased water
retention in the stratum corneum
Naturally occurring with
advancing age
Could occur secondary to
prolonged detergent use,
malnutrition, or physical damage
to the stratum corneum or habits
that increase skin dryness –
excessive use of soap and
prolonged use of hot water for
bathing
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DRY SKIN

Clinical presentation
Roughness
Scaling
 Loss of flexibility
 Fissures
 Inflammation, and pruritus

picture from www.acner.com

DRY SKIN

Goals of therapy



Restore skin hydration,
Restore the skin's normal barrier function
Treatment
Take baths with oil 2-3 times per week
Apply lotion within 3 minutes of bath/shower to trap moisture
 Corticosteroid ointment for inflammation and erythema
 Use of emollients and moisturizers


FUNGAL SKIN INFECTIONS
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FUNGAL SKIN INFECTIONS
Approximately 10% to 20% of the U.S population suffer from a
tinea infection at any one time
 They are often referred to as ringworm
 Usually superficial, involving skin, hair and nails
 Heat, moisture and break in skin along with other factors increase
infection risk

TYPES OF FUNGAL INFECTIONS
Tinea corporis (ringworm)
Tinea capitis
 Tinea unguium
 Tinea pedis (athlete's foot)
 Tinea cruris (jock itch)


ALWAYS refer patient to their MD for cases of tinea unguium and tinea
capitis
CLINICAL PRESENTATION

Tinea corporis
Usually begin as small circular,
erythematous, scaly areas
 Lesions often spread
peripherally
 Borders may contain vesicles or
pustules

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CLINICAL PRESENTATION

Tinea capitis
Scaling of scalp
Dull, gray and breaking hair in
infected area
 Pustules and weeping lesions
may be present
 Black spots might develop on
scalp following hair loss


CLINICAL PRESENTATION

Tinea unguium
Affected area gradually lose
their normal shiny luster
Thick, rough, yellowing and
opaque nails
 Nail becomes friable with time
and might separate from nail
bed


CLINICAL PRESENTATION

Tinea pedis (athlete's foot)
Malodorous feet
Stinging sensation on feet
accompanied by itching
 Fissuring, scaling or maceration
of interdigital spaces
 Usually affects lateral toe webs
(between 4th&5th or 3rd & 4th
toes)
 Soles of feet might also be
affected


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CLINICAL PRESENTATION

Tinea cruris (Jock itch)
Lesions with well-demarcated,
elevated margins than central
areas
 Erythema and fine scaling
usually present.
 Usually occurs bilaterally with
itching
 More common in men



Lesions usually spare penis and
scrotum
Usually occurs on the medial
upper thighs and pubic area
TREATMENT

Safe, effective and available products for tinea pedis, tinea cruris and tinea corporis
Tolnaftate
Clotrimazole 1% and miconazole nitrate 2%
 Terbinafine HCL
 Butenafine HCL


TREATMENT

Tolnaftate 1%


FDA approved for prevention and treatment of tinea infections
Treatment standard for many years

Mechanism

Dosing




Exact mechanism unknown
Possibly distorts the hyphae and stunts fungal mycelial growth
Twice daily topical application for up 2 to 4 weeks (4 to 6 weeks for
interdigital tinea pedis
Side effects


Mild stinging on application
Some relapse of superficial fungal infections has occurred after therapy
discontinuation
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TREATMENT
Drug
Clotrimazole 1%
Miconazole Nitrate 2%
Mechanism
Imidazole derivative; acts by
inhibiting the biosynthesis of
ergosterol and other sterols –
damages fungal cell wall
membrane and altering
permeability
Imidazole derivative; acts by
inhibiting ergosterol synthesis.
Also affects triglyceride and
fatty acid synthesis to increase
amount of reactive oxygen
species within fungal cell
Dosing
Topical application twice daily
for up to 4 weeks
Topical application twice daily
for up to 4 weeks
Side Effects
Mild skin irritation, burning and Mild skin irritation, burning and
stinging
stinging
TREATMENT
Drug
Terbinafine HCL 1%
Butenafine Hydrochloride
1%
Mechanism
Synthetic allylamine derivative;
inhibits biosynthesis of
ergosterol through squalene
epoxidase inhibition
Synthetic benzylamine; inhibits
biosynthesis of ergosterol
through squalene epoxidase
inhibition
Dosing
Twice daily topical application
for 1 to 2 weeks or once daily
application for 4 weeks
Twice daily topical application
for 1 to 2 weeks or once daily
application for 4 weeks
Side effects
Irritation, itching and dryness
Irritation, itching and dryness
TREATMENT

Salts of aluminum
No direct antifungal activity
Used in combination with topical antifungals for tinea pedis (athlete’s’
foot)
 Antibacterial activity in concentrations > 20%


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CASE 4

a.
b.
c.
d.
A 19 year old customer approaches your counseling counter for an
OTC recommendation. She complains that her toe nails are not as
shiny as they used to be and they also break too easily. She has
heard that there is a clear nail polish available for treating fungal
infections and wants to buy one over the counter. Your
recommendation to her is:
Penlac (ciclopirox) is only available by prescription, but she can
also apply clotrimazole 1% cream to her nails instead
Recommend that she consults a physician for further evaluation
Recommend soaking feet in Domeboro solution once a day
Recommend application of regular cosmetic nail polish for shine
CASE 4
A 19 year old customer approaches your counseling counter for an
OTC recommendation. She complains that her toe nails are not as
shiny as they used to be and they also break too easily. She has
heard that there is a clear nail polish available for treating fungal
infections and wants to buy one over the counter. Your
recommendation to her is:
a. Penlac® (ciclopirox) is only available by prescription, but she can
also apply clotrimazole 1% cream to her nails instead
b. Recommend that she consults a physician for further
evaluation
c. Recommend soaking feet in Domeboro solution once a day
d. Recommend application of regular cosmetic nail polish for shine

ACNE VULGARIS
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ACNE VULGARIS
Most common skin condition seen in dermatology practice
Acne vulgaris affects about 40-50 million Americans
 More than 85% of adolescents have acne, with the condition often
continuing into adulthood
 The nonprescription market for acne vulgaris is estimated to be
more than two to four times the size of the prescription market
 Propionbacterium acnes is involved in the pathogenesis of acne


ACNE VULGARIS

Clinical presentation
Non-inflammatory lesions
usually manifest in early stages
of puberty (open or closed
comedo)
 With progression of puberty and
age, lesions tend to appear on
chest and back
 Inflammatory lesions are
characterized as papules,
pustules, or nodules
 Patients may exhibit one or
more types of lesions

ACNE VULGARIS

Goals of therapy
Prevent new lesions
Prevent scarring
 Decrease psychological impact of acne


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TREATMENT
Drug
Benzyl Peroxide
Salicylic Acid
Mechanism
Releases active oxygen slowly.
Antibacterial action against
propionbacterium. Keratolytic –
reduces follicular hyperkeratosis
Penetrates pilosebaceous units
to produce comedolytic effect.
Keratolytic – facilitates
desquamation
Dosing
OTC concentrations = 2.5% to
10% (equal antibacterial effects)
Once or twice daily topical
applications
OTC concentrations = 0.5% to
1%
Once or twice daily topical
applications
Side effects
Mild erythema, stinging or
burning sensation, scaling
Itching, mild erythema, stinging
or burning sensation and
salicylate toxicity (rare)
TREATMENT
Drug
Sulfur
Sulfur/Resorcinol
Mechanism
Keratolytic and antibacterial
Keratolytic and antibacterial
Resorcinol enhances the effect of
sulfur
Dosing
OTC concentrations = 3% to 10% OTC concentrations = 2% to 3%
resorcinol. Once daily to three
Once daily to three times daily
times daily applications
applications
Side effects
Color, malodor and drying
effects
Drying effect
GUIDE TO ACNE PRODUCT SELECTION
Gels and solutions are the most effective acne formulations
because they are astringents and remain on skin the longest
 Creams and lotions are less irritating to the skin compared to gels
and solution
 Ointment vehicles are not used because they are occlusive and tend
to worsen acne
 Recommend starting at lowest strength of product available and
gradually increase concentration to decrease irritation

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QUESTION
Which bacteria is involved in pathogenesis of acne?
Group B streptococcus
b. Staphylococcus aureus
c. Propionbacterium acnes
d. E. coli

a.
REFERENCES
D. L Krinsky, RR Berardi, S. P Ferreri et al. Handbook of Nonprescription
Drugs: An interactive Approach to Self-Care, 17e.
 Management of common skin diseases. Pharmacist's Letter/Prescriber's
Letter 2007;23(10):231011
 R.L. Talbert, J.T. DiPiro, G.R. Matzke, L.M. Posey, B.G. Wells, G.C. Yee
(Eds), Pharmacotherapy: A Pathophysiologic Approach, 8e.
 www.cdc.gov
 www.nih.gov

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