Common Skin Disorders for the Community Pharmacist PDF

COMMON SKIN DISORDERS: A GUIDE FOR THE COMMUNITY PHARMACIST Dr. Kimberley Begley Can you help me?… OBJECTIVES REVIEW COMMON SKIN DISORDERS ENCOUNTERED BY COMMUNITY PHARMACISTS IDENTIFY APPROPRIATE TREATMENTS FOR COMMON SKIN DISORDERS UNDERSTAND KEY POINTS AND PATIENT COUNSELING POINTS FOR...

COMMON SKIN DISORDERS: A GUIDE FOR THE COMMUNITY PHARMACIST Dr. Kimberley Begley Can you help me?… OBJECTIVES REVIEW COMMON SKIN DISORDERS ENCOUNTERED BY COMMUNITY PHARMACISTS IDENTIFY APPROPRIATE TREATMENTS FOR COMMON SKIN DISORDERS UNDERSTAND KEY POINTS AND PATIENT COUNSELING POINTS FOR SKIN DISORDER TREATMENTS Xerosis (Dry Skin) ▪ Dry skin is caused by a decrease in water retention by the stratum corneum and is characterized by roughness, scaling, inflammation, and itching. ▪ Dry skin has become a major focus for pharmacists as the size of the aging population increases. Weather Causes of Dry Heat Skin Hot baths and showers Harsh soaps and detergents Other skin conditions Symptoms of Dry Skin ▪ Skin tightness ▪ Skin that feels and looks rough ▪ Itching (pruritus) ▪ Faking, scaling or peeling skin ▪ Fine lines or cracks ▪ Gray, ashy skin ▪ Redness ▪ Deep cracks that may bleed Treatment of Dry Skin Nonprescription Dry Skin Products Trade Name Primary Ingredients Petrolatum-Containing Products Petrolatum; mineral oil; ceresin wax; wool wax alcohol; Absorbase Ointment potassium sorbate AmLactin Cream/Lotion Ammonium lactate 12% Aquaphor Ointment Petrolatum 41%; water Cetaphil Cream Petrolatum; glycerin Sodium cocoyl isethionate; stearic acid; sodium Cetaphil Gentle Cleansing Bar tallousate; PEG-20; petrolatum Eucerin Cream Petrolatum; mineral oil; mineral wax; wool wax alcohol Petrolatum; mineral oil; dimethicone; cetearyl alcohol; Jergens Ultra Healing Lotion cetyl alcohol; glycerin Moisturel Cream/Lotion Petrolatum; dimethicone; cetyl alcohol; glycerin White petrolatum; mineral oil; dimethicone; glyceryl Vaseline Intensive Care Lotion stearate; cetyl alcohol; glycerin Treatment of Dry Skin Nonprescription Dry Skin Products Trade Name Primary Ingredients Ceramide Containing Products Glycerin; ceramide 1, 3, 6, and 11; hyaluronic acid; CeraVe Moisturizing Lotion dimethicone; petrolatum, potassium phosphate Eucerin Professional Repair Concentrated Ceramide 3; glycerin; urea Lotion Urea-Containing Products Carmol 10 Lotion Urea 10% Carmol 20 Cream Urea 20% Lac-Hydrin Five Lotion Urea 5% Counterirritants Camphor 0.5%; menthol 0.5%; carbomer 940; cetyl Sarna Anti-Itch Lotion alcohol; DMDM hydantoin; glyceryl stearate; petrolatum Treatment of Dry Skin Nonprescription Dry Skin Products Trade Name Primary Ingredients Miscellaneous Emollients Cetaphil Gentle Skin Cleanser Liquid Cetyl alcohol; stearyl alcohol; PEG Glycerin; petrolatum; cetyl alcohol; aloe; cetearyl Gold Bond Ultimate Healing Lotion alcohol; propylene glycol; glyceryl stearate Mineral oil; lanolin oil; glyceryl stearate; propylene Keri Original Dry Skin Lotion glycol Cetyl alcohol; glycerin; mineral oil; PEG-40; emulsifying Lubriderm Advanced Therapy Lotion wax; vitamin E Mineral oil; petrolatum; sorbitol; lanolin; lanolin alcohol; Lubriderm Daily Moisturizing Lotion triethanolamine Neutrogena Body Oil Isopropyl myristate; sesame oil Neutrogena Soap TEA-stearate; triethanolamine; glycerin Glycerin; mineral oil; isopropyl palmitate; vitamin E; Nivea Body Lotion lanolin alcohol Purpose Gentle Cleansing Bar Sodium tallowate; sodium cocoate; glycerin; BHT Nondrug Measures to Prevent Dry Skin Patient Instructions and Counseling ▪ Avoid triggers ▪ Avoid excessive bathing ▪ Take sponge baths on other days using warm water ▪ Pat dry after bathing or showering ▪ Drink plenty of water daily ▪ Moisturizer should be generously applied 3–4 times daily ▪ Moisturizers should be applied within 3 minutes after bathing ▪ Initial improvement should be seen within 24 hours ▪ Avoid caffeine, spices, and alcohol, because they can contribute to dehydration ▪ Keep the room humidity higher than normal Atopic Dermatitis (Eczema) ▪ Atopic dermatitis is an inflammatory condition of the epidermis and dermis that is characterized by episodic flares and periods of remission. ▪ More than 30 million people in the U.S. have some form of the condition. ▪ Fifty percent of patients are diagnosed within the first year of life, with as many as 85% presenting before the age of 5 years. ▪ Prevalence of atopic dermatitis worldwide is increasing. ▪ Many patients with atopic dermatitis do not seek medical care.  Symptoms of Atopic Dermatitis ▪ Pruritis ▪ Erythema ▪ Papules or vesicles may be present ▪ Plaques and scales may form Treatment of Atopic Dermatitis ▪ Corticosteroids are the standard of care for atopic dermatitis when nonprescription anti-inflammatory therapy is warranted during acute flare-ups Key Points for Atopic Dermatitis and Dry Skin ▪ Most patients with mild–moderate atopic dermatitis or dry skin are candidates for self-treatment. ▪ Question patients presenting with dry or eczematous skin lesions about new or changes in exposure to soaps, detergents, fragrances, chemicals, irritants, temperature extremes, allergens, and other triggers; ▪ Counsel patients with dry skin disorders to take brief baths, use tepid water, pat dry, and apply moisturizers within 3 minutes of completing the bath or shower. ▪ Advise patients to use mild skin cleansers and to apply copious quantities of moisturizers 3–4 times daily. ▪ Contact their primary care provider if symptoms worsen or do not improve within 7 days. Contact Dermatitis ▪Inflammation, redness, itching, burning, stinging, and vesicle and pustule formation on dermal areas exposed to irritant or antigenic agents. ▪Classification ◦ Irritant contact dermatitis ◦ Allergic contact dermatitis Exclusion Criteria for Self-Treatment of Contact Dermatitis Treatment of Contact Dermatitis Treatment of Contact Dermatitis ▪ Hydrocortisone (0.5% and 1%) is the most effective nonprescription topical therapy for treating symptoms of mild–moderate allergic contact dermatitis that do not involve edema or extensive areas of the skin. Treatment of Contact Dermatitis ▪ Apply aluminum acetate compresses to areas with Nonprescription vesicles, bullae, and/or weeping lesions as follows: ▪ Mix a pre-packaged tablet or packet of aluminum acetate with a Medications pint of cool tap water, wet a cloth with the solution, and apply the compress to rash areas. ▪ Apply compresses for 20–30 minutes at least 4–6 times a day or as needed. ▪ Use colloidal oatmeal baths or soaks to soothe and cleanse areas of the rash and to reduce itching: ▪ Sprinkle a 30-g packet fast-running bath water and mix the water to avoid lumping of the oatmeal. ▪ Soak for 15–20 minutes in the oatmeal bath at least twice a day. ▪ Pat skin dry rather than wiping it. ▪ Oatmeal baths can leave the tub slippery and can clog the drain. ▪ Use a sedating oral antihistamine, such as diphenhydramine or doxylamine, for nighttime sedation. ▪ Using nonprescription medications for dermatitis longer than 7 days. Urushiol-Induced Allergic Contact Dermatitis ▪ In the United States, four species of Toxicodendron plants belonging to the family Anacardiaceae (Northern or Western poison ivy, Eastern and Western poison oak, and poison sumac) cause dermatoses on exposure. ▪ Urushiol-induced dermatitis, however, is often linear and/or occurs over a broad area, because urushiol may be transferred to other parts of the body from the hands or inanimate objects. ▪ Presents with papules, small vesicles, and/or bullae over inflamed, swollen skin. Significant itching is a prominent feature. Chronic forms of can present with lichenification. Presentation of Urushiol-Induced Allergic Contact Dermatitis ▪ Symptoms occur only where contact was made with urushiol. o Begins within a few hours to several days (generally within 24–48 hours). ▪ The individual may incur inadvertent repeated exposure. Treatment Goals The goals of self-treating are: (1) to remove and avoid further contact with the offending agent; (2) to treat the inflammation; (3) to relieve itching and prevent excessive scratching; (4) to relieve the accumulation of debris from oozing, crusting, and scaling of the vesicle fluids; and (5) to prevent secondary skin infections. Nonpharmacological Therapy Prevent and Protect Removal of Urushiol ◦ Urushiol quickly binds to skin, but it is readily degraded in the presence of water. ◦ Washing exposed areas with mild soap and water reduces the risk of transfer and the severity of the rash. ◦ Once urushiol has entered the skin and attached to tissue proteins, the antigenic process and reaction begins. ◦ Good handwashing, including meticulous cleansing under or clipping of the fingernails, is necessary to avoid contaminating additional skin surfaces. ◦ Anitgen removal methods such as vigorous scrubbing of contaminated skin with a harsh soap or household bleach, or the use of isopropyl alcohol, hand sanitizers, and other cleansers and organic solvents are not recommended. Guidelines for Products that Remove Urushiol Key Points for Poison Ivy/Oak/Sumac Dermatitis ◦ The most important initial treatment is removing the resin from the skin. ◦ Treatment of localized, pruritic rash consists of a topical application of hydrocortisone cream, compresses, or baths. Zanfel is also recommended to treat localized rash, because it may be used for relief anytime a rash develops. Weeping vesicles or bullae may be treated with aluminum acetate compresses. ◦ Severe cases may require systemic corticosteroids to relieve symptoms. Key Points for Contact Dermatitis ▪ Once exposed to an irritant or antigen, the patient should shower with mild soap and water or apply large volumes of cool water. ▪ Contact dermatitis may begin as localized streaks or patches of highly pruritic rash that, with time, may become more numerous or coalesce into larger plaques on exposed dermal areas. ▪ Patients should be referred for further evaluation if there is involvement of the face, genitalia, or anus; signs of infection; considerable edema anywhere on the body; or extensive lesions covering a large portion of the body. ▪ Treatment of localized, pruritic rash consists of a topical application of hydrocortisone cream, compresses, or baths. Weeping vesicles or bullae may be treated with aluminum acetate compresses. Scaly Dermatoses (Dandruff) ▪Dandruff is a chronic, noninflammatory scalp condition resulting in excessive scaling of the scalp epidermis. ▪Scaling and pruritus occur, causing white flakes to accumulate on the scalp. ▪Routine shampooing with mild hypoallergenic shampoo is essential. Algorithm and Exclusion for Self-Treatment of Dandruff Treatment of Dandruff Cytostatic Agents ▪ Pyrithione Zinc [ZPT] (0.3–2%): Products include Denorex, Head and Shoulders, X- Seb T, and Zincon. Pyrithione zinc has an antifungal effect and reduces cell turnover rate. ▪ Selenium sulfide 1%: Products include Head and Shoulders Clinical Strength Shampoo and Selsun Blue Medicated Formula. Selenium sulfide reduces the cell rate turnover and inhibits growth of P. ovale. ▪ Coal tar: Products include Denorex and Neutrogena-T. Coal tar reduces the number and size of epidermal cells. ▪ Patients should be counseled that contact time with cytostatic agents is very important for effectiveness. Advise patients to rub shampoo in well and leave it in up to 5 minutes before rinsing it out. Treatment of Dandruff Keratolytic agents ▪ Salicylic acid (1.8–3%): Products include Ionil, Neutrogena, Scalpicin, and Sebucare. Its keratolytic action removes dandruff scales. ▪ Sulfur (2–5%): Products include Sulfoam, Sul-Ray, and Exsel. Sulfur possibly exerts an antifungal effect. Sulfur is usually found in combination with salicylic acid. ▪ Combination of sulfur and salicylic acid: Products include Meted and Sebulex. Treatment of Dandruff Antifungals ▪ Ketoconazole (1%) shampoo (Nizoral A-D) This shampoo is intended to kill dandruff-causing fungi that live on your scalp. It's available over-the- counter or by prescription. [2% is a prescription] ▪ Ciclopirox 1% shampoo (Loprox) This is prescription. Key Points for Dandruff ▪ Use a medicated shampoo containing pyrithione zinc, selenium sulfide, or ketoconazole. Zinc pyrithione (in Head and Shoulders) and selenium sulfide (in Selsun Blue) are effective in treating dandruff. ▪ Coal tar products can be used; however, they have limited efficacy. ▪ Keratolytic shampoos also can be used but require longer treatment periods. ▪ Massage the medicated shampoo into the scalp and leave on the hair for 3–5 minutes before rinsing. Repeated rinsing (2–3 times) after the desired contact time is suggested. Use the shampoo daily for 1 week; then use it 2–3 times weekly for 2–3 weeks, and thereafter once weekly or every other week to control the disorder. Fungal Skin Infections (Tinea) Classification ▪ Tinea pedis (“athlete’s foot”)* ▪ Tinea cruris (“jock itch”)* ▪ Tinea corporis (ringworm of the skin)* ▪ Tinea capitis (ringworm of the scalp) ▪ Tinea unguium (onychomycosis: fungal infection of toenails and fingernails) * = May self-treat initially with OTC agent Presentation Ringworm Athlete’s Foot Algorithm and Exclusion for Self- Treatment of a Fungal Skin Infection  Trade Name Ingredient Indications for Use Directions for Use Desenex For adults and children For jock itch and ringworm, For athlete’s foot, apply Miconazole 2% Antifungal Powder older than 2 years of age apply twice daily for 2 weeks twice daily for 4 weeks Lotrimin AF Jock For athlete’s foot and For adults and children For jock itch, apply Itch Antifungal Miconazole 2% ringworm, apply twice daily older than 2 years of age twice daily for 2 weeks Powder Spray for 4 weeks For athlete’s foot and Micatin Antifungal For adults and children 2 For jock itch, apply Miconazole 2% ringworm, apply twice daily Cream years of age and older twice daily for 2 weeks for 4 weeks For athlete’s foot and Lotrimin AF Jock Clotrimazole For adults and children 2 For jock itch, apply ringworm, apply twice daily Itch Cream 1% years of age and older daily for 2 weeks for 4 weeks For athlete’s foot, apply For jock itch and Lotrimin Ultra Jock For adults and children Butenafine 1% twice daily for 1 week, or ringworm, apply once Itch Cream 12 years and older once daily for 4 weeks daily for 2 weeks For athlete’s foot between For jock itch and Lamisil AT (cream, For adults and children Terbinafine 1% the toes, apply twice daily ringworm, apply once spray) 12 years and older for 1 week daily for 1 week For athlete’s foot and For jock itch, apply Tinactin Athlete’s For adults and children 2 Tolnaftate 1% ringworm, apply daily for 4 daily for 2 weeks Foot Cream years of age and older weeks For athlete’s foot and For prevention, spray 1– Tinactin Powder For adults and children 2 Key Points for Fungal Skin Infections ▪ Tinea corporis, tinea cruris, and tinea pedis can be treated with nonprescription drugs. Clotrimazole, miconazole nitrate, terbinafine hydrochloride, butenafine hydrochloride, tolnaftate, and undecylenic acid are efficacious for this purpose. ▪ The effectiveness of topical antifungals will be limited unless the patient eliminates other predisposing factors to tinea infections. ▪ Powder dosage forms should be reserved only for extremely mild conditions or as adjunctive therapy. Because solutions and creams can spread beyond the affected area, they should be used sparingly. ▪ Topical antifungals should be used once or twice daily (morning and night), depending on the indication. Treatment should be continued for 1–4 weeks, depending on the symptoms and the type of fungal infection. ▪ The only antifungal currently approved for prevention of athlete’s foot is tolnaftate. Patient Instruction and Counseling ▪ Because fungi thrive in warm, moist environments, patients should be encouraged to wear loose-fitting garments (preferably cotton or moisture-wicking material). ▪ Socks should be cotton or have similar moisture-wicking properties. ▪ Dry the areas likely to be infected (groin, feet, etc.) thoroughly before covering with clothes. ▪ Avoid walking barefoot (particularly in high-risk areas such as dorm or gym showers) and sharing garments. Acne Vulgaris (Acne) ▪Acne is an inflammatory disorder of the pilosebaceous glands that occurs most commonly during puberty. ▪Classification ◦ Mild: Primarily noninflammatory lesions (open and closed comedones), relatively few superficial inflammatory lesions, and no scarring ◦ Moderate: Multiple papules (inflammatory and noninflammatory) on the face and trunk and minimal scarring ◦ Severe: Advanced form, with inflammatory lesions that can lead to scarring Treatment of Acne Proper Skin Care First-Line Therapy ▪ Proper skin care is essential ▪ Mild: Benzoyl peroxide (BPO), topical retinoid, or topical for all stages of therapy, combination therapy including twice-daily use of ▪ Moderate: BPO with combination a gentle cleanser. therapy (topical antibiotic and ▪ Improvement in skin may topical retinoid), oral antibiotic, or take 1–2 months, and side both effects (dry, flaky skin) may ▪ Severe: Oral antibiotic plus topical appear before benefits. combination therapy (with BPO), or oral isotretinoin Antimicrobial Therapy Prescription and Nonprescription Patient Instructions and Counseling ▪ Clinically visible improvements should occur by the third week of therapy. Benzoyl ▪ Maximum efficacy can be expected after Peroxide approximately 8–12 weeks of use. ▪ Continuous use is normally required to maintain clinical response. ▪ Avoid unnecessary sun exposure, and use sunscreen. Adverse Effects ▪ These agents may cause redness, dryness, burning, itching, peeling, and swelling. ▪ They may bleach hair or dyed fabrics (pillowcases, towels, clothing). Patient Instructions and Counseling ▪ Do not use astringents, drying agents, abrasive scrubs, or harsh soaps concurrently. ▪ Apply every other night for the first 2 weeks to adjust to drying effect. Retinoids ▪ Apply nightly after 2 weeks. ▪ Expect that skin may take up to 2–3 months to improve. ▪ Use sunscreen on face daily and especially before sun exposure because of increased sensitivity. Adverse Drug Effects ▪ These agents may irritate skin and cause redness, dryness, and scaling. ▪ Tazarotene is the most irritating retinoid. ▪ Adapalene (now available without a prescription in the 0.1% gel formulation) appears to be least irritating and is preferred for sensitive skin. 0.3% is prescription strength. Patient Instructions and Counseling ▪ It is usually applied once daily for initial therapy and can be increased to 2–3 times daily if needed. Salicylic Acid ▪ Frequency can be reduced to daily or every other day if dryness or peeling develops. Adverse Effects ▪ OTC preparations are limited to 2% maximum concentration. In 20–30% concentrations, salicylic acid can be used as a chemical peeling agent. ▪ It is irritating to the skin and often is formulated in drying hydroethanolic vehicles. Key Points for Acne ◦ Acne occurs primarily in adolescent years because of increased androgens during puberty that stimulate sebaceous glands. ◦ Benzoyl peroxide, topical retinoids (some prescription only), and topical and oral antibiotics (prescription) form the basis of therapy for mild and moderate acne. ◦ Oral isotretinoin (prescription) is the drug of choice for severe, nodulocystic acne. ◦ Isotretinoin (prescription) is contraindicated in pregnancy because of the risk of serious birth defects. Pediculosis Capitis (Head Lice) ▪ Head lice are transmitted by direct contact with the head of an infected individual or through fomites or inanimate objects. ▪ A female louse lives about one month, laying 7– 10 eggs per day. Adult lice feed on blood from the scalp and can survive > 48 hours without a host. ▪ Pruritus is the most common symptom. ▪ The flat, gray-brown adult lice are difficult to locate. Nits are more likely to be seen, indicating progression in the life cycle. ▪ Systematic combing of wet or dry hair with a nit comb (teeth 0.2 mm apart) is a better method for detecting both live lice and nits than visual inspection alone. Algorithm and Exclusion for Self-Treatment of Head Lice Treatment of Head Lice Pyrethroids (synergized pyrethrins, permethrin 1%) ▪ Pyrethrins are naturally derived from chrysanthemum extract and are neurotoxic to lice. Products are often synergized by the addition of 2– 4% piperonyl butoxide (petroleum derivative), which inhibits the breakdown of pyrethrins within the louse. Trade names for this OTC combination product include A-200, LiceMD, Licide, and RID. ▪ Permethrin (Nix) is a synthetic pyrethroid that is more effective than the naturally derived pyrethrins. Topical pyrethroids are first-line therapies and should be used before other topical therapies unless the patient cannot tolerate therapy or resistance develops. Directions for Use ▪ Wash hair with conditioner-free shampoo, rinse with water, and towel dry before application. Apply enough product to fully saturate hair, scalp, and neck. Leave on for 10 minutes, then rinse off with warm water. Use a lice-nit comb to remove dead lice and nits following rinsing. Repeat treatment in 7–10 days, if indicated. Patient Instructions and Counseling ▪ Determine it treatment is needed for all family members. ▪ Avoid contact with the eyes, mouth, and nose. ▪ Do not use on irritated or inflamed scalp. Adverse Drug Effects ▪ Adverse effects include irritation, erythema, and itching. Nondrug Measures for Treating Head Lice Infestation Key Points for Head Lice ◦ Head lice is a common condition caused by infestation of Pediculus humanus capitis and occurs most commonly in children during school months. ◦ Permethrin (Nix) is the nonprescription agent of choice for treatment. Warts (Verruca) ▪Warts result from a localized infection of the human papillomavirus on the skin. ▪Self-treatment for warts with over-the-counter agents is not recommended for diabetic patients because of reduced sensation in their feet. Classification ▪Common warts (verruca vulgaris) occur on the fingers, hands, and knees. ▪Plantar warts (verruca plantaris) occur on the soles of the feet. Treatment Principles and Goals Warts can be eliminated by the following: ▪Direct application of caustics (e.g., salicylic acid) ▪Freezing (cryotherapy) with liquid nitrogen or with dimethyl ether and propane ▪Surgery Algorithm and Exclusion for Self-Treatment for Warts Treatment of Warts Salicylic Acid Patient Instructions OTC salicylic acid products include the following: ▪ Use topical salicylic acid preparations on a daily basis until the wart is removed. ▪ Salicylic acid 17% in flexible collodion ▪ Use special care in washing hands before vehicle: Compound W gel and liquid, Dr. and after treatment, and use a separate Scholl’s Clear Away Fast-Acting Liquid towel for drying other parts of the body. ▪ Salicylic acid 40% embedded in pads or ▪ Do not use salicylic acid on irritated, discs: Compound W One Step Pads, Dr. broken, or infected skin. Scholl’s Clear Away Medicated Discs ▪ If the wart remains after 12 weeks of continuous treatment, see a dermatologist or podiatrist. ▪ Salicylic acid products are contraindicated in patients with diabetes and other patients with poor circulation. Patient Instructions and Counseling for Salicylic Acid Treatment of Warts Cryotherapy ▪ Dimethyl ether and propane are FDA approved for OTC removal of common warts and plantar warts. ▪ Cryotherapy irritation leads the host to produce an immune response against the causative virus (similar to liquid nitrogen, which can be administered only by a health care provider). After about 10 days, the frozen skin and wart fall off, revealing newly formed skin underneath. Cryotherapy products include the following: ▪ Dimethyl ether and propane: Dr. Scholl’s Freeze Away Wart Remover and Wartner Cryogenic Wart Removal System are approved for removal of common warts. ▪ Dimethyl ether, propane, and isobutane: Compound W Freeze Off is approved for removal of common warts and plantar warts. Patient Instructions ▪ Place the applicator in the spray can, which becomes very cold (-55°C). ▪ After the applicator is saturated, hold it on the wart for a product-specific time period to freeze the wart (20 seconds for Wartner; 40 seconds for Compound W). ▪ The process may be repeated after 10 days as many as three or four times for persistent warts. Patient Instructions and Counseling for Cryotherapy Key Points for Warts ◦ Warts result from a localized infection of the human papillomavirus on the skin. ◦ They can be removed by surgery, cryotherapy, or application of caustics (e.g., salicylic acid). ◦ Self-treatment for warts with over-the-counter agents is not recommended for diabetic patients because of reduced sensation in their feet. Questions? [email protected]