Treatment for Urushiol Exposure

Rule of 9's: Estimate Body Surface Area

• The rule of 9's is used to estimate the percentage of total body surface area (TBSA) affected by burns.
• In adults each arm is 9%, the head 9%, the anterior trunk 18%, posterior trunk 18%, each leg 18%, and the perineum 1%.

Zanfel™™

• Zanfel™ removes urushiol by binding with it to create an aggregated cluster, which can then be washed away with water.
• It can be used at any time after exposure.
• It can be applied on any external body area, including the face and genitals.
• It is safe for use by children and pregnant or nursing women.
• The cost is $33 per 1 oz.

Tecnu™ Extreme Medicated Poison Ivy Scrub

• It is a medicated scrub to treat poison ivy.
• Wet the affected area, apply the desired amount, rub gently for 15 seconds, rinse with cool water, and towel dry.
• Use within 8 hours post-exposure to remove urushiol before a rash begins.
• The cost is $12 per 4 oz.

Tecnu Original Outdoor Skin Cleanser™™

• This cleanser is used to remove urushiol.
• Apply to dry skin, rub vigorously for 2 minutes, then rinse with cool water or wipe off with a cloth.
• It can be used within 8 hours post-exposure.
• It removes any oil from objects and pet fur.
• The cost is $12 per 12 oz.

Allergic Contact Dermatitis

• Itching can be treated with 1st generation oral antihistamines.
• Weeping can be treated with astringents like witch hazel and aluminum acetate.
• Inflammation can be treated with topical hydrocortisone.
• Topical anesthetics, antihistamines, or antibiotics should be avoided - i.e. neomycin.

Topical Steroids Potency Chart

• Topical steroids are classified by potency.
  • Class 1 is super potent.
  • Class 2 is potent.
  • Class 3 is upper mid.

Diaper Dermatitis - Causes

• Diaper dermatitis is a skin irritation on the bottom.
• A 30 y/o mother approaches the counter with her 3-month-old son in her arms; the son has had a rash on his bottom since the previous night, she says it is the first time it has occurred.
• Her sister watched him yesterday, is inexperienced, and changed the diaper only 3 times.
• The rash is bright red and shiny - it is just on his bottom.

Plans for Treatment

• The treatment goals are to relieve symptoms, rid the patient of the dermatitis, prevent secondary infection, and prevent recurrences.

Diaper Dermatitis - Exclusion for Self-Treatment

• Lesions present for more than 7 days are an exclusion
• Lesions present after 7 days of appropriate care are an exclusion
• A secondary infection is an exclusion
• Lesions caused by another disease state are an exclusion
• Dermatitis outside the diaper region is an exclusion
• Possibly associated with a UTI is an exclusion
• Presence of broken skin is an exclusion
• Onion-skin-like presentation or presence of bullae, oozing, blood, or pus is an exclusion
• Chronic/frequent lesions present are an exclusion
• Altered vitals or behavioral changes are an exclusion
• Comorbid conditions are an exclusion symptom

Diaper Dermatitis - Non-Drug Measures

• Change the diaper frequently.
• Flush skin with plain water at diaper changes.
• Allow skin to dry before re-diapering.
• Use a reusable cloth diaper instead.

Diaper Dermatitis - Drug Measures

• Apply hydrocortisone cream at each diaper change.
• Apply zinc oxide cream at each diaper change.
• Apply miconazole cream at each diaper change.
• Apply triple antibiotic ointment at each diaper change.

Diaper Dermatitis - Exclusions for Self-Treatment

• Exclusions include lesions present for >7 days, lack of improvement in 7 days despite appropriate care, secondary infection, or lesions caused by another disease state.
• Exclusions also include diaper dermatitis outside the diaper region, possibly associated with a UTI, presence of broken skin, onion-skin-like appearance, bullae, oozing, vesicles, blood, pus, chronic/frequent lesions, constitutional symptoms, significant behavioral changes, and comorbid conditions.

Diaper Dermatitis - Treatment

• A person with reddened, maroon, or purplish skin under the diaper area may be affected.
• Affected skin may also appear shiny or wet.

Diaper Dermatitis - Assess

• Assess the history, duration and extent of dermatitis.
• Ask about other symptoms, including behavioral changes.
• Ask about attempts to treat the dermatitis.

ABCDE Mnemonic for Tx Diaper Dermatitis

• Air = allow diaper area skin to air dry frequently; allow diaper-free time.
• Barrier = apply a barrier skin protectant liberally to the diaper area with each diaper change to prevent and treat diaper dermatitis.
• Cleansing = gently cleanse the diaper area with a soft cloth, warm water, or a baby wipe when stool is present.
• Diaper = change the diaper frequently or every 2 hours, and as soon as soiled as possible. Use absorbent disposable diapers if affordable for the parent.
• Education = educate parents/caregivers about non-pharmacologic diaper hygiene practices and pharmacotherapy, verifying understanding to ensure adherence.

Diaper Dermatitis - Treatment Products

• Zinc oxide such as Desitin can be difficult to clean off.
• Calamine lotion is absorptive, antiseptic, and antipruritic.
• Petroleum is an emollient.
• Corn starch is absorbent, warn of inhalation.
• Talc is a lubricant, warn of inhalation.

Desitin™ - Zinc Oxide Products

• Original is 13% zinc oxide at $5.27/4 oz.
• Max Strength is 40% zinc oxide at $5.39/4 oz.

A+D™ - Lanolin (15.5%), Petrolatum (53.4%)

• Original is $4.59/4 oz.
• Zinc Oxide Cream: Dimethicone (1%), Zinc Oxide (10%) $4.59/4 oz.

Boudreaux's Butt Paste™

• Original is 16% zinc oxide at $7.39/4 oz.
• Max Strength is 40% zinc oxide at $7.39/4 oz.
• Natural: 16% zinc oxide, Aloe Vera, and Beeswax is $7.79/4 oz.

Triple Paste™™™

• Zinc Oxide 12.8% at $9.99/3oz

Honest Company ™

• Zinc Oxide (14%) at $9.49/2.5oz

Insect Bites and Stings

• A 27 y/o patient enters the pharmacy with numerous bites on her leg.
• She seeks a recommendation for the itching.
• The likely cause of these itchy welts are mosquito bites.

Insect Bites and Stings - Plan - Pharmacological

• The best recommendation to relieve the itch is 3-4 times daily for no more than 7 days of Lidocaine topical.
• Apply Diphenhydramine cream twice daily for no more than 5 days.
• Spray DEET 30% every 6-8 hours.
• Apply 1% hydrocortisone ointment 3-4 times daily for no more than 5 days.

Insect Bites and Stings

• Counsel patients to cover skin with clothing. Cuff clothing around ankles/wrists/neck.
• Counsel patients to avoid swamps, dense woods and brush, keep pets free of pests, remove standing water, and limit time outside at night.
• Counsel patients to use barriers and apply insect repellent.

Insect Bites and Stings - Plan - DEET Use

• DEET is useful against mosquitoes, fleas, and ticks.
• It releases a vapor that discourages insects.
• Apply every 4-8 hours.
• Less than 30% is preferred for children, though do not use under 2 months of age.
• 10%-35% is adequate adult protection.
• Over 20% is needed for tick prevention.
• Apply to hands then apply to face.
• Safe in women who are pregnant or breast feeding
• Do not use under clothing or over cuts/wounds.
• Apply sunscreen first, then DEET.
• Wash it off before bed! Wash clothes
• It may melt plastic.

Insect Bites and Stings - Pharmacological Tx

• Follow-up: Arrange time for follow-up and assess patient outcomes.
• If symptoms are not resolved after 7 days, or if they worsen, then refer the patient.
• Educate on signs of infection.
• Apply all medications 3-4 times daily for no longer than 7 days.

Insect Bites and Stings - Pharmacological Tx Options

• Topical anesthetics, such as benzocaine, pramoxine, benzyl alcohol, lidocaine, dibucaine, and phenol, provide reversible nerve blockade and lose sensation. Consider this a first-line therapy if no allergy exists.
• Hydrocortisone 1% is capable of vasoconstriction, thus reducing inflammation and pruritis.
• Topical antihistamines, such as diphenhydramine (0.5%-2%), have an anesthetic effect.
• Topical counterirritants, such as camphor (0.1%-3%) and menthol (0.1%-1%), have an anesthetic effect.
• Skin Protectants Zinc Oxide, Titanium Dioxide, Calamine protect skin, reduce inflammation and irritation.

Insect Bites and Stings - Exercises

• A rash that looks like a bullseye is a tell-tale sign of Lyme's disease.
• To safely remove an observed tick, grab it with tweezers close to the surface of the skin and pull straight out.

Pediculosis

• There are 3 types of lice; head lice is Pediculus humanus capitis, body lice is Pediculus humanus corporis, and pubic lice is Phthirus pubis.

Treatment Goals: Pediculosis

• The goals are to rid the infested patient of lice by killing adult and nymph lice, and removing nits from the patient's hair.

Non-Pharmacologic Therapies: Pediculosis

• Wash hairbrushes, combs, and toys in HOT water.
• Use HOT water to wash the clothes, bedding, and towels.
• Dry on the hottest dryer setting.
• Seal things that cannot be washed in plastic bags for the length of the louse's life cycle (2 weeks).
• Avoid close physical contact.
• Vacuum living areas thoroughly and regularly.

Additional Non-Pharmacologic Therapies: Pediculosis

• Visually inspect hair and scalp.
• Use a nit comb properly.
• Part hair into segments and comb the hair in each segment.

Medications for Lice

• Pediculicide kills lice aka nymphs and adults.
• Ovicide kills lice eggs aka nits.
• All topical lice agents have pediculicidal activity, but all do not have complete ovicidal activity.
• Due to life cycle of a louse, retreatment with most topical lice products is necessary.
• Retreatment at day 9 is optimal.

Generic Drug Names for Lice

• 1st line treatment for over two years of age is Pyrethrins/piperonyl- $11.00
• 1st line for Permethrin 1% - $7.00 for patients over 2 months.
• 2nd line treatment is $225.00 for patient over 6 years old for resistance.
• Spinosad suspension is $256.00 for patients over six months old.
• Ivermectin lotion 0.5% is third line, $252.00 must be over 6 months.

Pharmacologic Therapies: Pyrethrin Application

• Apply a sufficient quantity to wet the dry hair and scalp.
• Allow the treatment to remain for 10 minutes.
• Work the shampoo into a lather and then rinse thoroughly.
• Use a nit comb to remove dead lice and eggs as described previously.

Pharmacologic Therapies: Permethrin

• Shampoo with regular shampoo, rinse, and towel dry hair.
• Apply sufficient cream rinse to wet hair and scalp.
• Allow the treatment to remain for 10 minutes; then rinse and towel dry.
• Use a nit comb as described previously.

Lice - When Seeing a Doctor

• Hypersensitivity to chrysanthemums, ragweed, or pediculicide ingredients, presence of secondary skin infection, and lice found on eyelids or eyebrows are exclusion criteria.
• Consider patients <2 years old using pyrethrins, <2 months old using permethrins, , active tumors, or resistant cases for medical referral.

Treatment Failure: Pediculosis

• When lice persist despite treatment, consider misdiagnosis, lack of ovicidal or residual killing properties, inadequate treatment or application, resistance, or lack of adherence.