OTC Medicines: Ear Wax

• The lecture is about OTC Medicines (2)

Learning Outcomes

• The ability to respond to symptoms
• The ability to recognise the causes, signs, and symptoms of common minor ailments
• Know when to treat and when to refer patients
• Recognise and understand red flag symptoms
• Understand common OTC products and doses

Ear Wax

• Earwax is a normal physiological substance in the ear canal
• The wax helps remove skin debris from the ear canal
• Aids in cleaning, lubricating, and protecting the lining of the ear canal
• Possesses antibacterial properties
• It is usually soft and works its way out of the ear, but excessive build-up of hard earwax can develop
• Cotton wool buds should never be inserted into the ear to clean, as this can push the wax further in and damage the eardrum

Ear Wax Symptoms

• Temporary deafness
• Discomfort
• A sensation that the ear is blocked
• Symptoms should appear gradually

Ear Wax Referral Symptoms

• Dizziness/tinnitus
• Fever or general malaise
• Foreign body in the ear canal
• OTC medication failure
• Pain

Ear Wax OTC Treatment

• Cerumenolytics
• Oil-based ear drops
• Peroxide-based ear drops
• Water-based ear drops

Ear Wax General Advice

• Warn patients that instilling ear drops may cause temporary hearing loss, discomfort, dizziness, and skin irritation
• Some ear wax treatments contain arachis oil and/or almond oil, so checking for a nut allergy is essential
• If the issue is recurrent, the patient should see their GP for examination
• Other treatments include irrigation of the ear or syringing/suctioning of the wax

Ear Wax OTC Treatment Details

• Cerumenolytics soften hardened cerumen for easier removal
• Examples include Cerumol, hydrogen peroxide, urea, sodium bicarbonate, and olive oil
• Prescribe ear drops for 3-5 days initially to soften wax
• Instruct the patient to pour a few drops into the affected ear, lie with the affected ear uppermost when putting in drops, and stay in this position for 2-3 minutes

Mouth Ulcers: Causes

• Trauma to the inside of the mouth or tongue, such as biting the cheek while chewing food
• Ill-fitting dentures causing ulceration
• Ulcers preceding the start of the menstrual period
• Stress and emotional factors
• Food allergies
• The cause can remain unclear

Mouth Ulcers: Symptoms

• Minor aphthous ulcers are most common, typically 2-10 mm in diameter, round or oval, and cause discomfort but eating is not affected
• Major aphthous ulcers are usually over 10 mm, round or oval, cause prolonged & painful ulceration, and eating may become difficult
• Herpetiform ulcers are least common where pinhead-sized coalesce to form irregular shape as they enlarge and may be very painful

Mouth Ulcers: Referral Symptoms

• Painless ulcers that should be referred
• Ulcers lasting more than 14 days
• More than 10 ulcers present
• An ulcer greater than 1cm in diameter
• Signs of systemic illness
• Children under 10

Mouth Ulcers: OTC Treatment

• Chlorhexidine mouthwash
• Anaesthetic or analgesic gels
• Orabase protective paste
• Hydrocortisone muco-adhesive buccal tablet

Mouth Ulcers: OTC Treatment

• Local anaesthetics like lidocaine (Anbesol range, Calgel) provide short duration of action with no known interactions and limited side effects
• Local analgesics like choline salicylate (Bonjela) are licensed from 16 years+ with different licensing for teething and junior versions

Mouth Ulcers: Chlorhexidine Mouthwash

• Reduces duration and severity of ulceration
• Prevents secondary bacterial infection
• Regular use can stain teeth brown
• Should be used twice a day for 1 min and continue for 48 hours after symptoms resolve

Mouth Ulcers: Orabase Protective Gel

• Contains gelatin, pectin, and carmellose paste
• sticks and works by protecting the ulcer from further abrasion
• Does not contain pain relieving agents

Mouth Ulcers: Hydrocortisone Muco-adhesive Buccal Tablet

• Acts locally on the ulcer to reduce inflammation and pain
• Thought to shorten healing time but evidence is weak
• For use by adults and children over 12.
• Tablet is held in close proximity to the ulcer until dissolved and one tablet is used four times a day
• The tablet should not be sucked but dissolved in contact with the ulcer, though it can be difficult when the ulcer is in an inaccessible spot

Warts and Verrucas: Causes

• Cutaneous warts are small, rough growths caused by infection of skin cells with certain strains of human papillomavirus (HPV)
• A verruca (also known as a plantar wart) is a wart on the sole of the foot

Warts and Verrucas: Symptoms

• Can appear anywhere on the skin but most commonly on the hands and feet
• More common in children with peak incidence at 12-16 years old
• Warts appear as raised fleshy lesions on the skin with a roughened surface (most common type resembles a cauliflower) and appearance can vary based on location
• Verrucas occur on weight-bearing areas of the sole and heel, have different appearance from warts pressure from the body's weight pushes the lesion inwards, sometimes producing pain when weight is applied during walking

Warts and Verrucas: Referral Symptoms

• Changed appearance of lesions (size and colour)
• Bleeding, itching, genital warts, facial warts
• Immunocompromised patients

Warts and Verrucas: OTC Treatment

• Once immunity to the infecting virus is sufficiently high, the lesions will disappear (6 months-2 years)
• Many patients and parents prefer active treatment using acids or cryotherapy

Warts and Verrucas: General Advice

• Correct use is required to break down hard skin and to prevent damage to surrounding healthy skin
• Continuous application of the selected preparation for several weeks or months is needed, and it is important to explain this
• OTC wart products CANNOT be used on the face or skin folds, moles or birthmarks, or lesions with red edges, or unusual colour, open wounds, irritated skin or any area that appears to be infected

Warts and Verrucas: Acid Treatments

• Acid treatments contain salicylic acid and lactic acid which act by softening and destroying the lesion by chemically burning, thus mechanically removing affected tissue
• Forms: gels/paints/plasters/applied once a day
• Prior soaking of the affected hand or foot in warm water for 5–10 min helps soften and hydrate the skin, increasing action of salicylic acid
• Main risk is causing chemical burns and irritation to healthy skin so it is pertinent to use petroleum jelly to prevent contact with healthy skin
• Application of the liquid or gel using an applicator will help to confine the substance to the lesion itself

Warts and Verrucas: Cryotherapy

• Dimethyl ether propane can be used to freeze warts and is available in an application system for home use for adults and children over 4
• There is little evidence from which to judge its effectiveness in home use rather than when applied by a doctor (doctors usually use liquid nitrogen which freezes to a much lower temperature)
• Should not be used by people with diabetes or by pregnant women

Conjunctivitis: Causes

• Describes inflammation of the conjunctiva, a membrane covering the anterior white part of the eye and the inside of the eyelids, where it can become inflamed due to infection, allergy or irritation
• Infection can be caused by either viruses or bacteria where viral conjunctivitis is most common and does not require treatment
• Allergic conjunctivitis can be seasonal or associated with allergic rhinitis symptoms

Conjunctivitis: Symptoms

• Viral conjunctivitis is often accompanied by other signs of viral respiratory tract infection, such as cough and cold
• Main symptoms: redness or 'pinkness', uncomfortable gritty sensation, and discharge
• Sticky and purulent discharge indicative of bacterial infection whereas watery discharge = viral infection
• Only one eye may be affected initially, but symptoms usually spread to the 2nd eye

Conjunctivitis: Referral Symptoms

• Clouding of the cornea
• Associated vomiting
• Possible foreign body in the eye
• Irregular pupil shape
• Photophobia
• Eye pain
• Changes in vision
• Bacterial conjunctivitis that shows no improvement within 48hrs of treatment

Conjunctivitis: OTC Treatment

• No specific OTC preparations are available for viral conjunctivitis
• Symptoms may be eased by bathing the eyelids to remove any discharge and using lubricant eye drops
• Bacterial conjunctivitis can be treated using Chloramphenicol
• Allergic conjunctivitis can be treated using antihistamines or Sodium Cromoglicate

Conjunctivitis: General Advice

• Viral and bacterial causes are highly contagious
• The patient will remain infectious until the redness and weeping resolve (usually in 10–12 days)
• Self-help and hygiene measures: Bathe the eyelids with lukewarm water to remove any discharge/ Use tissues to wipe the eyes and throw away immediately/ Wash hands regularly and avoid sharing pillows and towels
• Contact lenses should not be worn, and new lenses should be used after infection has cleared

Conjunctivitis: Chloramphenicol

• Available as drops or ointment
• Licensed for use in children older than 2 years
• Drops: One drop every 2 hours for the first 48 hours and then reducing to four times a day for a maximum of 5 days of treatment
• Ointment: should be used three or four times a day
• Suitable for most patient groups, need to check the license
• Pregnancy: not recommended, so hygiene measures should be adopted
• Breastfeeding: only if absolutely necessary

Head Lice: Causes

• Most prevalent in 4-11 year olds and more in girls/those with long hair, but can occur at any time with no seasonal variation
• Transmitted by head to head contact but fleeting contact not sufficient
• Once transmitted lice begin to reproduce with adults living for approx. 1 month, females laying eggs at the base of a hair shaft each night and eggs hatching after 7-10 days, leaving the egg case attached to the hair

Head Lice: Symptoms

• Observation of live lice is diagnostic and can be used with wet combing
• Scalp itching
• Presence of empty eggshells which cream or white-coloured and attached to the hair shafts, but are not necessarily evidence of current infection unless live lice are also found

Head Lice: Referral symptoms

• Psoriasis, secondary Infection, allergy treatment
• Symptoms without observed live lice

Head Lice: OTC Treatment

• Wet combing
• Insecticides

Head Lice: General Advice

• Detection combing is the best way to confirm the presence of live lice
• Use a fine-toothed head lice detection comb (0.2-0.3 mm apart) and conduct Systematic combing of wet or dry hair
• A person should only be treated if a live head louse is found and all affected household members should also be treated on the same day
• Treatments are most successful if done correctly
• Children who are being treated can still attend school
• No evidence that head lice have a preference for either clean or dirty hair
• No need to treat clothing/bedding that has been in contact with lice (lice only live for 1–2 days once detached from a human head)
• Essential oil-based treatments and herbal treatments are not recommended due to the lack of good-quality evidence
• Children of primary school age should be examined regularly at home (using a detection comb) to identify infestation early

Head Lice: Wet Combing

• Inexpensive, and the kits are reusable
• Time-consuming/labour intensive but might be a drawback when treating young children or if several people are to be treated at the same time
• Cure rates are lower than other methods
• You need to buy a special fine-toothed comb to remove head lice and nits, but wet combing will be ineffective with the incorrect technique
• Instructions: - Wash hair with ordinary shampoo and use lots of conditioner - Comb the whole head of hair, using the detection comb, from the roots to the ends - When you've finished combing the hair, comb through all the hair again for a second time. - Do wet combing on days 1, 5, 9 and 13 to catch any newly hatched head lice

Head Lice: Physical Insecticides

• Now considered 'first line' as they have few adverse effects, and lice do not develop resistance to them
• Dimeticone is thought to work by coating the lice internally and externally, leads to disruption in water excretion, causing the gut of the lice to rupture
• Isopropyl myristate works by blocking the breathing system & coating the lice with a thin film of fluid
• Check directions and indications of products
• Hedrin: 6 months +
• Full Marks: 2 yrs +

Head Lice: Chemical Insecticides

• Malathion is usually reserved for second-line use as physical insecticides are more effective and do not cause resistance to develop
• Permethrin is not now generally recommended because of its short contact time and because resistance rates are high in the United Kingdom
• Malathion is available as alcoholic & aqueous lotions
• Alcohol-based formulations are not suitable for patients with asthma or eczema

Colic: Causes

• Defined for as repeated episodes of excessive and inconsolable crying in an infant who otherwise appears to be healthy and thriving
• Cause is unknown
• May affect between 1 in 20 and 1 in 5 babies
• Seems to be multifactorial and Linked to Gl disorder, where spasmodic contraction of smooth muscle causes pain and discomfort, possibly caused by allergy to cow's milk, lactose intolerance, or inadequate amounts of lactobacilli

Colic: Symptoms

• Generally begins in the first few weeks after the baby is born but usually resolves by the time the baby is 3-4 months old
• Excessive and inconsolable crying, facial flushing, drawing up of the legs, clenching of the fists and arching of the back is common
• Passing wind and difficulty in passing stools might also occur
• Attacks appear to be more common in the early evening

Colic: Referral Symptoms

• Infant not thriving
• Symptoms not improving or worsening over age of 4months
• Overanxious parents – may need further support

Colic: OTC Treatment

• No good evidence for any OTC interventions but parents may still wish to try them
• Simeticone
• Lactase

Colic: General Advice

• Has the feeding technique been reviewed?
  • Underfeeding the baby can result in excessive sucking and in air being swallowed, leading to colic-like symptoms
  • If bottle feeding, the teat size of the bottle should be checked
• Important to reassure parents that colic is not their fault and that the baby will 'grow out of it'
• Check on the wellbeing of the parents, do they have a good support network
• Signpost for support to their health visitor

Simeticone: Colic OTC Treatment

• Commonly used to treat infantile colic but evidence of benefit is uncertain
• A trial of simeticone drops for 1 week could be suggested if other strategies are unsuccessful and the parents would like to try treatment
• Pharmacologically inert with no side effects, drug interactions or precautions in its use and can therefore be safely prescribed to all infants

Lactase Enzyme: Colic OTC Treatment

• Evidence of benefit is uncertain
• Some babies may have difficulty in fully digesting the lactose in milk, which can be an important factor in some babies with colic
• Colief Infant Drops helps to break down the lactose in a baby's usual milk before the baby is fed, making the milk more easily digestible
• Pharmacologically inert so no side effects, drug interactions or precautions in its use and can therefore be safely prescribed to all infants

Teething: Causes

• Teething is the process in which deciduous teeth (sometimes known as milk teeth or baby teeth) emerge through the gums causing usually mild and localized symptoms
• Most infants start teething around 6 months of age with some starting before 4 months old or after 12 months old
• A full set of milk teeth has usually emerged through the gums when the child reaches 2-3 years of age

Teething: Symptoms

• Should be suspected in an infant/child up to3 years old if alternative causes have been excluded and there are clinical features which start approx. 3-5 days before each tooth eruption
• pain, increased biting and chewing, drooling, gum-rubbing, sucking, irritability, wakefulness, ear-rubbing, facial rash, decreased appetite, disturbed sleep, and mild pyrexia
• Signs of gum swelling, redness, and tenderness on palpation just before tooth eruption

Teething: Referral Symptoms

• Exclude any alternative conditions which may cause similar symptoms, especially if the child is systemically unwell or severely distressed
• Urgent medical review if infant/child becomes systemically unwell, severely distressed, or displays prolonged symptoms

Teething: OTC Treatment

• Teething rings (non-pharmaceutical)
• Ibuprofen/paracetamol
• Lidocaine containing products

Teething: Products NOT Recommended

• Oral salicylate gels
• Homeopathic gels/powders

Teething: General Advice

• Baby's teeth should be brushed from their first appearance using a baby toothbrush
• Children should have their first dentist appointment at around 6 months old
• Consider the use of over-the-counter paracetamol and/or ibuprofen to provide symptom relief in infants three months of age or older, if self-care measures have not helped
• Self-care measures to relieve teething symptoms, gentle rubbing of the gum with a clean finger, allowing the infant to bite on a clean and cool object, cuddling and reassuring the child, wiping away excess saliva regularly to reduce the risk of facial rash

Teething: Analgesics

• e.g. ibuprofen or paracetamol can be used for infants 3 months of age or older if required
• Give either paracetamol or ibuprofen alone
• Adherence and dose must be checked
• If no response, switch analgesic if adherence and dose are appropriate
• If the child does not respond, consider alternating paracetamol and ibuprofen
• Care needs to be taken not to exceed the maximum doses of either drug in 24hrs
• Remember to use the sugar-free versions

Teething: Lidocaine

• No longer available as GSL but will be P meds
• 3rd line treatment option
• Apply a pea-sized blob of gel to a clean fingertip, spread gently onto the sore area of the gum, andrepeat the dose after 3 hours
• Do not use more than 6 times in one day (24-hour period)