Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 1 5/31/2013 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 2 5/31/2013 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 3 5/31/2013 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) 4 5/31/2013 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 5 5/31/2013 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% 6 5/31/2013 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 7 5/31/2013 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 8 5/31/2013 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 9 5/31/2013 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 10 5/31/2013 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 11 5/31/2013 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 12 5/31/2013 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 13 5/31/2013 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 14 5/31/2013 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 15 5/31/2013 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 16 5/31/2013 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 17 5/31/2013 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% 18 5/31/2013 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 19 5/31/2013 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 20 5/31/2013 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 21 5/31/2013 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 22