Lloydy’s (Chloe’s edition 2012) PDF

Lloydy’s (Chloe’s edition 2012), Some Updates in June 2021 by Ali Ashour 5-Minute OTC Consult for Trainee Pharmacists © Michael Lloyd 2012, Updated; Ali Ashour June 2021 1 DERMATOLOGY...

Lloydy’s (Chloe’s edition 2012), Some Updates in June 2021 by Ali Ashour 5-Minute OTC Consult for Trainee Pharmacists © Michael Lloyd 2012, Updated; Ali Ashour June 2021 1 DERMATOLOGY PAEDIATRICS WOMEN’S HEALTH Head Lice 3 Teething 24 Period pain (primary dysmenorrhoea) 43 Scabies 4 Febrile Convulsions/Fever in Children 25 PMS 44 Eczema/Dermatitis 5 Gastroenteritis & Dehydration 25 Cystitis 44 Psoriasis 6 Colic 26 Vaginal Thrush 45 Fungal skin infections (Athlete’s foot, tinea, jock itch) Cradle Cap 26 7 Nappy rash 27 PREGNANCY/BREASTFEEDING Nail infection 7 Nutrition & General Health advice during Pregnancy Acne 8 EYE DISORDERS 46 Chickenpox 9 Dry Eye Syndrome 28 Back pain in pregnancy 47 Corns/calluses 9 Viral Conjunctivitis 28 Constipation 47 Bacterial Conjunctivitis 29 Reflux 47 Warts 10 Allergic Conjunctivitis 30 Nocturnal muscle cramps in legs 48 Dandruff 11 Stye 30 Pruritis in Pregnancy 48 Sunscreen/Sunburn 12 Chalazion 31 Breast & Nipple Thrush 48 Hair loss 12 Contact Lens Care 31 Problems with lactation 48 Hydrocortisone Topical Cream 13 Blepharitis 31 Mastitis 48 Shingles 13 Red Eyes 32 Morning Sickness 49 German Measles (Rubella) 14 Vasoconstrictor eye drops 33 Measles 14 Antihistamine eye drops 33 PAIN Ocular lubricants 33 Musculoskeletal pain 50 ORAL HEALTH Insect bites 50 Cold Sores 15 EAR, NOSE & THROAT Headache 51 Dry Mouth (Xerostomia) 15 Ear Ache 35 Bruising 52 Aphthous (mouth) ulcers 16 Ear Wax 35 Tennis elbow 52 Gingivitis 17 Otitis Externa 36 Oral thrush 17 Allergic rhinitis 36 MISCELLANEOUS Toothache 18 Sore Throat 37 Nicotine Replacement Therapy 53 Oral Hygiene 18 Intranasal Decongestants 38 Orlistat 55 Nasal corticosteroids 38 Emergency Contraception 56 GASTROENTEROLOGY & GENITOURINARY Nasal antihistamines 38 Travel Health 57 Haemorrhoids 19 Sleep 59 Heartburn 20 RESPIRATORY Antihistamines 60 Diarrhoea and Vomiting 21 Cough 39 Motion Sickness 21 Cold and Flu 41 Constipation 22 Asthma inhalers 42 Irritable bowel 23 Threadworm © Michael Lloyd 2012, Updated; Ali Ashour June 2021 2 CONSIDERATIONS WITH APPLICTION TO THE SKIN ONSET 1. Wash hands before and after - rapid onset 2. Cover the affected area (if occlusion permitted) - what were you doing differently – washing powder, 3. Skin damage (burns, eczema) – increased kindergarten, preceding overseas travel? penetration 4. Scale and crust (psoriasis) = reduced penetration LOCATION 5. Children have higher SA-weight ratio 6. Elderly have frail, thin skin - Pityriasis versicolor (trunk) 7. Creams generally contain more additives than - Tinea/fungi (jock/nappy, feet, scalp) ointments and can cause sensitisation (lanolin, - Atopic dermatitis (flexures, extensors + possible fragrance, PEG, hydroxbenzoates) fungal involvement) - Viral (mouth, eyes) LABEL 8 PHOTOSENSITISATION - Warts (hands, feet, elbows, knees) Triclosan, coal tar derivatives, methoxsalen, retinoids, - Chickenpox (trunk early then spreads) sulfonamides, amiodarone, griseofulvin, NSAID, - Shingles/varicella zoster (trunk) phenothiazines, quinolones, St John’s Wort, tetracyclines, - Molloscum contagiosum (red, hard, raised thiazides TAKING A DERMATOLOGICAL HX (“my skin is itchy”) papules, harmless) - Impetigo (honey coloured, need Abx, kids can’t go SYMPTOMS to school) - Itchy, hot, red - Psoriasis (knees, scalp, elbows) - infected - Scabies (all over, especially in finger webs and - RASH? flexures, with no rash on skin, only scratch marks) - crusted or weeping AGGRAVATING FACTORS CHARACTERISTICS - pet, food, pollen - vesicles - washing detergent - pustules - sun - satellite lesions - chemical, swimming pool - following nerve - sweat HOW LONG RELIEVING FACTORS - change in appearance since onset? - cool compress - spread? - warm bath © Michael Lloyd 2012, Updated; Ali Ashour June 2021 3 Patient Problem Treatment Children (ok in…) Pregnancy Lactation Other DERMATOLOGY Head Lice Quellada lotion (permethrin 1%) (obsolete) Not < 2 B2 Safe Lice Self Care Preferred - Don’t use lice Apply to clean, damp hair after washing & towel drying. products for Leave in for 10 minutes, rinse out prevention! (not with shampoo, don’t rewash for 2 days) - Check head for lice and comb with a fine-tooth comb to remove dead lice. weekly after cure - After use, soak Itch (rash): back of scalp, neck No hairdryer post tx (towel dry) otherwise it can inactivate chemicals. combs in container and behind ears. Itch not always Repeat wet combing every 2 days in between treatment. of boiling water for a present – check for signs of Make sure lice have been killed (not resistant) – try KP24 if lice alive day post tx. minute dandruff, psoriasis, seborrheic - Clean sheets and dermatitis. Repeat treatment 7 days after to kill newly hatched lice. clothes in hot water, sun dry Egg shells (nits): white specks S: burning, itch, redness, swelling - Place items that stuck to hair near the scalp Check and treat other family members if infected can’t be washed in Itch may continue up to 1-week post eradication. airtight bag for 2 Lice: darkish sesame seed like weeks KP 24 lotion (maldison 0.5%) Not < 2 No No - Children can be sent Must actually see live lice before Apply 20-40mL to dry hair, leave in overnight, wash out in the back to school after treatment! morning and comb out dead lice. first treatment. Check what they’ve used before - To protect against lice did it work? - Don’t share hats, Banlice (pyrethrin & piperonyl butoxide) Not < 2 No No hairbrushes, combs, How often do you have to treat Apply to dry hair, leave in for 10 mins, wash out with normal shampoo, pillow your child for head lice? remove lice and eggs with fine tooth comb. - carry out weekly checks - keep long hair tied Hedrin (dimeticone 4%) OK A Safe back Refer Apply to dry hair, allow to dry naturally, apply it from the scalp to the tip. - Cost is prohibitive wash out with shampoo at least 8 hours after. Repeat the treatment after - OTC treatment failure (itch 7 days. Avoid “natural” alternatives present 10 days post tx) due For Hedrin 15 you can leave it in for 15 minutes only. (Moov eucalyptus oil 11%) to incorrect application or in pregnancy as may resistance to chemical contain essential oils which - Pregnancy (mother’s choice, are contraindicated. In children < 2 better Permethrin at B2, get Dr opinion for risk-benefit) Wet combing preferred when < - - **Shampoos not as good - < 2 years old Apply conditioner to dry hair from tip to root. Comb with a fine-tooth comb from 2 as diluted by water to - Swollen glands, scalp to tip in sections. subtherapeutic conc weeping/crusty rash? Infectn 1. Use for DIAGNOSIS. Wipe on white paper, see if live lice are present (darkish sesame seed like) 2. Use AFTER CHEMICAL TX to remove the unhatched nits (eggs) and dead lice. Repeat each section at least TWICE. Repeat every 2 days until no head lice seen for 10 consecutive days. 3. Use for TREATMENT alone if don’t want to use chemical © Michael Lloyd 2012, Updated; Ali Ashour June 2021 4 Scabies 1. Lyclear (permethrin 5%) cream Scabies Self Care - Try not to scratch 2. Eurax (crotamiton 10%) once daily – for itch (max 5 days, not full body of infant), Cat B2 - Stop spreading: the infected person and 3. Dermaveen Colloid Oatmeal Bath Oil – for bath those who have been in contact Mite infestation. 4. Polaramine (dexchlorpheniramine 2mg) – for night-time itch & sedation need to be treated at Intense ITCHING, which is worse same time and stay at night and after bathing. 5. Dermaid (hydrocortisone 1%) – for intense itch and inflammation if not relieved by other tx away from school Scratching of the skin can lead to until both treatments changes in its appearance. 6. Dermaveen Moisturising Cream done - Notify the school Commonly effects web space of Refer 6 months) drying of clothing armpits, buttocks and genital and bedding area. Dose: 1-2 tubes for adults. Treat neck, face - Seal hats, sot toys ½ tube for children 5-12. and scalp etc in plastic bad for May cause rash around the ¼ tube 1-5 years 7 days midriff, underarms, inside of thighs and around ankles. Shower and dry thoroughly. Apply to whole body starting from the neck down Scabies treatments may (include neck, face and scalp when treating children 3 weeks post tx Apply with a new paint brush. Same counselling as Lyclear equal quantity of o infected skin (weeping yellow water for children discharge) S: stinging, burning, dermatitis under 12 years of o treatment failure (do a patch test first, quite irritating) age, and with 3 o unclear diagnosis parts of water for o severe and extensive symptoms babies o itchy papules on elbows, knees and sacral region, symmetrical (dermatitis herpetiformis) o crusted scabies © Michael Lloyd 2012, Updated; Ali Ashour June 2021 5 Eczema/Dermatitis 1.SOAP SUBSTITUTES (avoid irritants) Eczema Self Care 2. EMOLLIENT THERAPY (maintain skin integrity, hydrate skin, help with itch) - identify cause & avoid irritant (SOAP, jewellery, detergents, After applying corticosteroid an emollient can be applied to the same area 30 mins later. Once food, sand, dust, rough symptoms are controlled with steroid patient can revert back to emollient therapy alone (to clothes, calamine lotion, prevent relapse). Frequent application is important. extremes in heat etc) - Red, itchy rash (itch variable from day to day - bathe and shower less depending on stress, heat, night time, etc) a) Dermaveen (colloidal oatmeal, paraffin oil) Shower & Bath Oil frequently - Dry, scaly Bath 10-15mins once a day  QID when flare-ups occur - lukewarm water, not hot - Hot skin Bath oils may make surfaces slippery, careful when you get out of bath. - pat dry carefully - Papules, blisters - avoid scratching (cool area, - Weeping b) Dermeze (50% WSP, 50% liquid paraffin) MOISTURISE, cover itchy - Poorly defined edge Dermaveen (colloidal oatmeal) Eczema Cream - patient won’t tolerate such a thick emollient skin with a wet towel/shirt - Can become thickened, dry, cracked if chronic Apply QID (best after shower/bath when skin damp/warm) (mild form of Wet Wrap - Discoid (disc like ring worn but no central clearing) Creams & Ointments are MORE effective than lotions. Use lotion when eczema is mild Therapy 15-60mins) -avoid over-warm clothes or Exogenous – contact with external agents eg. c) Dermaveen (colloidal oatmeal) Cleansing Bar temperature in the home allergic contact dermatitis, photoallergy dermatitis - keep fingernails short Other options: - relaxation, stress Mx, Endogenous – internal predisposition eg. - QV range (liquid paraffin, glycerol, WSP) exercise, healthy diet seborrhoeic dermatitis, atopic eczema, varicose - Hamiltons (urea, liquid paraffin, glycerol) - don’t overheat (X electric eczema blanket, use fans) - soft, cotton clothes (no CONTACT DERMATITIS 3. CORTICOSTEROIDS (manage flares and extreme itch/inflammation) synthetics) - Occurs at site of contact but can spread and reactivate at previously exposed sites When moisturers don’t provide enough relief. Use least potent to bring eczema under control. Strength, - Lesions appear rapidly within 6-12 hours amt, frequency depends on age, area, disease extent. of contact a) Dermaid (hydrocortisone 1%) Cream 1. Allergic (jewellery, perfume, plant, pets, Apply BD for 7 days to face, body, groin, flexures during “flare ups” medicines, latex, nuts/food) Apply before emollient, after bathing. Can occlude with cotton socks and gloves and light wet wraps (max 60 mins) if desired. Once inflammation has subsided, frequency of application can 2. Irritant (water, detergents, soap, chemical, be reduced. Avoid prolonged use (refer after 7 days if treating in pharmacy)! friction) “FTU application” – distance from tip of adult finger to first crease covers an area twice the size of an adult flat hand! ATOPIC S: skin atrophy, stretch marks, secondary infection, stinging, acne, hypopigmentation, systemic - history of eczema, asthma, hayfever? (fluid retention) Cat A, safe in breastfeeding, children > 2 yrs (but okay in baby if small area) Sites vary with age: - Infants: face & nappy area b) Sigmacort (hydrocortisone 1%) Ointment – for really dry areas - Child/adults: elbows, knees, hands, feet flexures c) Eumovate (clobetasone 0.05%) Cream Refer d) Hydrozole (hydrocortisone 1%, clotrimazole 1%) – if suspected fungal infection - children < 2 in need of corticosteroids (but if mild we could even treat a baby) - secondary bacterial or fungal infections (Abx) 4. ANTIHISTAMINES (for itch at night) - patch testing for allergens - treatment of warts & molluscum a) Polaramine (dexchlorpheniramine 2mg) contagiosum is difficult in eczema Max QID prn - widespread & severe Cat A, >6yrs - Lloyd © Michael herpes simplex 2012, Updated;  000 Ali Ashour June 2021 - urticaria (red itchy rash but blanches when 6 pressed – need antihistamines and oral corticosteroids) Psoriasis 1. Dermeze (50% WSP, 50% liquid paraffin) Refer cases of suspected but Apply regularly and liberally to plaques and affected skin to optimise skin hydration. Soothing. For external use undiagnosed psoriasis. only. Best if applied after a shower. Safe in everyone. Tar, dithranol and salicylic acid PLAQUE can be irritating on the skin and Skin cell turnover in 4 days OR if patient won’t tolerate oily Dermeze should not be used in acute instead of 35. Well defined, red inflammatory psoriasis, on the papules coalescing to QV Cream (glycerol, light liquid paraffin, WSP) face or in the flexures. erythematous plaques. Red plaques often covered by a 2. QV Bath Oil (soap substitute) – avoids exacerbation by soaps/detergents Psoriasis Self Care silvery scale. Pinpoint bleeding if - Discuss with patient that it’s a plaques removed. Symmetrical! 3. Pinetarsol (wood tar) or Dermaveen Colloidal Oatmeal for bath chornic condition and will Not normally itchy.Pitting nails. 10 minutes QID for flare require long term tx - Stress mx, exercise Can occur anywhere on the body 4. Psor-Asist (salicylic acid 2%, coal tar 5%, sulfur 3% - Avoid trauma (scratching, but often appear on the extensor Apply BD – to soften and lift scale, plus anti-inflammatory/itch. sunburn), frequent use of areas such as the elbows, knees Avoid face and flexures. soaps and detergents, and or the trunk or scalp, in the S: local irritation, staining of skin & clothes, photosensitivity (avoid exposure to direct sunlight) alcoholic beverages. flexors (perianal, submammary or C: salicylate allergy, unstable/inflammatory psoriasis - Sunlight exposure may axillary regions) - sites of skin Safe in pregnancy and children. improve psoriasis trauma. OR for scalp psoriasis Two peaks of onset – 20s and late 50s. Ionil T Shampoo (salicylic acid 2%, coal tar solution 5%, alcohol 13%) or Ionil T Plus Shampoo (coal tar solution 1%) SCALP Use as a shampoo TWICE a week apply to wet hair for 5 mins, rinse and repeat. Scalp redness, inflammation, scaling. Redness extends beyond 5. Dermaid (hydrocortisone 1%) – for flare hair margin. Hairloss more likely fungal (tinea capitis). 6. Refer to dermatologist – for steroids, dithranol, calcitriol, PUVA DDx: eczema, seborrhoeic Other options: dermatitis, and tinea. Atopic Keratolytics Ok Ok Ok eczema occurs on the flexor Salicylic acid and sulphur are used to lift and soften thick scale in psoriases. aspects of the limbs rather than E.g. salicylic acid 2% to 10% in sorbolene cream, emulsifying ointment or white the extensor aspects, as in soft paraffin psoriasis. Coal Tar - - - Tars are anti-inflammatory and antipruritic. Although considered first-line therapy, use is limited by patient acceptability due to colour and smell. E.g. PolyTar Liquid LPC 2% to 10% cream or ointment topically, apply twice daily salicylic acid 2-4% can be included in coal tar preparation Dithranol Avoid Avoid Avoid Antiproliferative effect on psoriatic skin; useful in thick plaque psoriasis. dithranol 0.1% to 2% with salicylic acid 2$ to 5% (to prevent oxidation of dithranol and remove scale) in yellow soft paraffin, apply topically to lesions each day then wash off 10-30 minutes later with lukewarm water © Michael Lloyd 2012, Updated; Ali Ashour June 2021 7 Fungal skin infections 1. Lamisil (terbinafine 1%) cream Tinea Self Care (Athlete’s foot, tinea, jock itch) OR Fungus thrives in warm, moist conditions  good Canesten (clotrimazole 1%) cream – if pregnant or 60yrs. 5. close bottle tightly severe/resistant fungal Causes; 6. allow 3-5mins for nails to dry nail infections refer to - Athlete’s Foot (initial 7. clean spatula and neck of bottle with same cleaning pad the Dr for systemic oral skin infection)? 8- be careful not to let lacquer contact skin treatment or removal of - Immunocompromised, nail. diabetes? S: local itch and redness - Poor peripheral circulation? Wear gloves for treatment. - Pitting of nails Don’t use cosmetic nail polish, artificial nails or occlusive dressings during (PSORIASIS) treatment. - Trauma? Refer - Involves entire nail matrix (only helps superficial or distal) - OTC tx failure - Suspected poor compliance - $$$$$ © Michael Lloyd 2012, Updated; Ali Ashour June 2021 9 Acne 1. Cetaphil Oily Skin Cleanser (oil free) – BD Acne Self Care 2. Benzac (benzyl peroxide 2.5, 5%) cream Gradual improvement over time with treatment, 3. Cetaphil Moisturising Lotion – BD usually within 8-12 Cetaphil is good because it’s “non-comedogenic” – doesn’t cause white and blackheads to form! weeks after beginning Hormone stimulated inflammatory therapy. skin condition – of the sebaceous glands. P. acnes growth 1-Benzac (benzoyl peroxide 2.5,5,10%) Gel (alternative Oxy Cream 5%) Refer young Ok Ok Cleanse face each night (infection). - antibacterial activity and is mildly comedolytic children < 12 with Cetaphil. Avoid oily cleansers (Clearasil). Mild acne is confined to face with Before applying, wash affected area with Cetaphil Oily Skin Cleanser with warm open (blackheads) and closed water; gently pat dry. Wash hands after application Do not squeeze or pick (whiteheads) comedones. Only the acne lesions mild inflammation. Shall not Apply Benzac ONCE a day initially, increasing to TWICE a day. (pimples). cause scarring Begin treatment with lower strengths (2.5%) then change to 5% after 4 weeks if tolerated and acne resistant. Avoid wearing heavy oil based makeup and Refer: Can bleach hair, clothing and bedding. Avoid contact with eyes, mouth and other mucous fragrances and clean o moderate or severe acne membranes. makeup off thoroughly (widespread involving back and each night. chest, very inflamed, painful, “Acne Flare” - can cause skin irritation including reddening and soreness, especially at scarring risk) beginning of treatment. Skin drying, peeling, feeling of warmth. Keep hair tied up so it’s o failed medication not oily on your face Usually takes between 8-12 weeks of treatment to experience benefit. – be patient. o drug-induced: lithium COC, phenytoin, azathioprine, Inactivates topical tretinoin; apply 12-24 hours apart. Exercise regularly and androgens, haloperidol, eat a healthy diet with rifampicin Azclear(azelaic acid 15%) gel B1 – no Data lots of fresh food and o very young 25 water. This will improve data lacking adults general health and be Apply BD morning and night. o occupational acne reflected in the skin o inflammation of skin follicles condition. Less irritating than benzoyl peroxide but may cause hypopigmentation, use with plus flushing of cheeks and caution in patients with dark complexions. central face (ROSACEA) UV light can be helpful – - treat with Finacea Same instructions as Benzac (except no bleaching) acne usually gets better o associated hirsutism, during summer overweight, menstrual irregularity (PCOS) o perioral dermatitis Self-Care Card:. Acne © Michael Lloyd 2012, Updated; Ali Ashour June 2021 10 Chickenpox 1. Paracetamol for fever. Pt infectious from 48 hours before 2. Solugel (amorphous hydrogel = propylene glycol, sodium chloride) appearance of rash until applied liberally every 2 hours to lesions provides a soothing effect and the all lesions have accelerates healing – place in fridge crusted. Crops of “teardrop” vesicles on erythematous bases. Starts with 3. Pinetarsol (wood tar 2.3%) or Dermaveen Colloidal Oatmeal Bath Oil Incubation time (time small red lumps (papules) → fluid for bathing (emollient, antipruritic, and anti-inflammatory). Take care not between contact and containing blisters (vesicles) → to slip when stepping out of bath. development of rash) is rupture, forming crusted spots. usually ~2 weeks. 4. Phenergan (promethazine, 10-25 mg n for kids >6) or Areas commonly affected: Vallergan(Trimeprazine) at night to avoid night time scratching. Kids can return to school Trunk, face and scalp. when lesions have Can occur on mucous scabbed over, temp is membranes. Keep child well hydrated even if doesn’t want to eat (prodromal symptom). normal and sense of Keep skin cool, cold compresses to reduce itching. well-being returned. Prodromal symptoms: Cut child’s nails short (scratching increases the risk of secondary bacterial Fever, malaise, anorexia, infection and scaring). Spread by respiratory headache Anti-itch creams (e.g. Paraderm, Eurax) may be useful. droplets, direct contact with varicella vesicles. Symptomatic treatment (self- AVOID limiting, usually clears in 7-14 - calamine lotion as dries out skin causing further irritation and Self-Care Card: days) and good hygiene to avoid resultant scaring when itched Chicken Pox secondary infection. - moisturisers (trap heat) - hydrocortisone X Corns/calluses 1. Scholl Corn Cushioning Pads Corn/callus Self Care Treatment should be aimed at relieving pressure – can use circular corn pad or other forms of padding to relieve friction and absorb pressure. Encourage pts to wear open shoes such as PLUS thongs and sandals. White or yellowish thickened areas of skin which Duofilm Gel (salicylic acid 27%) 2 weeks. see “warts” Correct fitting shoes. occur on pressure areas - top of toes and along the side of feet (bony prominences of the feet) – Shielding, padding, due to BAD FOOTWEAR! Pain relieved when 2. Scholl Corn/Callus Removal Pads (salicylic acid 40% discs + cushioning pads) moleskin, gel inserts remove shoe (cf pain remains when remove - slow-release disc system plus cushioning pad for protection shoe with plantar wart). - feet should be clean and dry MUST address the Hard and circular-shaped with a polished core. - remove medicated disc from backing, place adhesive surface of disc over corn and cover with pad underlying issue to No “black dots/spots” - layers of white keratin - repeat daily for max 2 weeks resolve the problem & when pared. P: diabetes, PVD, salicylate allergy, not on broken, inflamed skin, not if 50 y.o. Will stain skin brown but will fade after treatment complete  change colour or shape  bleed/itch without provocation (skin cancer)  Raised lesions with central dimple (molluscum contagiosum) Offer no treatment first – self-limiting condition, options available may damage sin and cause scarring. Do you still want to treat? o Duct Tape Occlusion Therapy Alternative method: Easiest and least expensive. Cover wart with waterproof tape (e.g. duct tape) and leave on for 6 days, then soak, pare with pumice stone/emery board, leave overnight then reapply tape cyclically for 8 cycles © Michael Lloyd 2012, Updated; Ali Ashour June 2021 12 Dandruff Treatment for Dandruff and Seborrhoeic dermatitis is the same (except different in newborn = cradle cap). Dandruff Self Care - Shampoo hair daily 1. Head and Shoulders - treatment, followed by prophylaxis once a week if you have an oily scalp OR if severe (and not pregnant or taking warfarin) - Wash hair after Hyperproliferative skin condition exercise Nizoral 1% (2% if has already tried 1%) - Limit use of hair (increased sin cell turnover) – yeast infection. products 2. Dermaveen Hypoallergienic Shampoo & Conditioner - Leave-in conditioner Shampooing on a daily basis with a mild, hypoallergenic, non-medicated shampoo helps prevent dandruff. Ensure to if your scalp is dry White, oily flakes or scales on a thoroughly wash out shampoo. (but avoid alcohol in dry, itchy scalp. Won’t be red. Confined to scalp. Common in products, they dry puberty. More common in winter. Nizoral (ketoconazole 1%, 2%) Ok B3 Ok out skin) Visible dead cells (flakes) can - Relaxation and often be seen on the patient’s Apply to wet scalp, lather, then leave for 5 minutes; repeat and rinse thoroughly. stress Mx, healthy clothing. Use twice a week until treated (4-week course), then once every week for food, exercise prevention. Treatments are either antifungal Bathe eyes in cold water if affected by shampoo. note: no evidence for or cytostatic (reduces rate of cell S: scalp irritation, hair discolouration coal tar shampoos in the turnover). C: WARFARIN? treatment of dandruff. DDx: Dandruff should improve - Seborrhoeic Head and Shoulders (zinc pyrithione 0.5%) Ok Ok Ok within 1 – 2 weeks of beginning treatment. dermatitis Apply to wet hair, lather, then leave for 5 minutes; repeat and rinse thoroughly. (scales are yellowish Use twice weekly until treated then once a week for prophylaxis. May need to rotate and greasy, some therapies, especially in inflammation, reddening *Antifungal and cytostatic seborrhoic dermatitis! and crusting; typically affects centre of face, eyebrows, nasolabial folds and midchest, Selsun Blue® (selenium sulphide 1%) >5 Ok; avoid Ok often associated Self-Care Card: 1st blepharitis and otitis Dandruff Lather into wet hair for 5 mins, repeat and rinse thoroughly; initially twice weekly, trimester externa) – treated same then as necessary way as dandruff S: may stain jewellery and alter the colour of hair dyes, skin irritation - Psoriasis (silver scale)? P: avoid if patient has inflamed or broken skin. - Contact dermatitis (use of new hair products?) Pityriasis Versicolor (body) Refer: o Treatment resistant dandruff 1- Selsun Gold 2.5% - leave on overnight, repeat for 10 days treatment. (after 12-week trial) Hypopigmentation may persist until adequate sun exposure. o Signs of infection (patches of hair loss indicate tinea capitis) OR o Scalp is red, bleeding, inflamed, painful (contact dermatitis, 2- Pevaryl (econazole) 1% foaming liquid – apply to wet body, leave on seborrhoeic dermatitis, overnight, for 3 consecutive nights (rinse off in morning). psoriasis, sunburn) © Michael Lloyd 2012, Updated; Ali Ashour June 2021 13 Sunscreen/Sunburn Hamilton QUADBLOCK, Sensitive Skin or Toddlers Milk SLIP - use an SPF 30+ broad-spectrum, water resistant sunscreen, titanium dioxide and zinc oxide SLOP Prevention is better than treatment. ‫الوقاية خير من العالج‬ (physical agents for reflection) SLAP - apply liberally to clean, dry skin 30 mins before going outside SEEK - reapply sunscreen every 2 hours, more often if swimming or playing sport SLIDE SPF 30+ has greatest protection. - can use Toddlers Milk in > 12 months (7mm, inflammation and oozing, to be transferred to a doctor or hospital, apply an amorphous hydrogel (Solugel) and cover this with a change in sensation (itch, irritation), irregular border, non-adherent inert dressing (Melolin). If inflamed use Allevyn Ag (silver dressing). Once the burn asymmetric is obviously in the healing phase, change Fixomull (adhesive fixation sheet) 1. Paracetamol 2. Solugel® (propylene glycol, sodium chloride); Apply liberally prn and cover with Melolin non-adherent dressing. Store in fridge for extra relief and cooling effect on application. (a clear hydrogel which helps autolytic debridement and soothes) 3. SOOV Burn Spray® (cetrimide, lignocaine, phenoxyethanol) Hold the bottle 10 cm from the affected area and spray until skin is wet. Self-Care Card: For treating the face, spray onto fingers and then apply gently. Apply QID. Sense in the Sun 4. Cover large areas with a wet T-shirt. Moist wound management Self-Care Clean an acute wound with sterile 0.9% sodium chloride vials. If the wound is contaminated, use Betadine 1% Solution (povidone-iodine) for 4 mins then wash off. - Don’t use gauze - Don’t need to Stop bleeding by pressure or the application of Algisite M (alginate dressing), or both. reapply Betadine - Keep it moist (don’t Close a laceration or deep cut with steri-strips air-dry to form scab, and if it becomes too Dress with Tegaderm with Pad (island film permeable dressing), either waterproof or not. Change every 5 days, or sooner if exudate extends towards edges of island. wet there is infection risk) If necessary, support this with Tubifast (retention bandage) Dermatix (silocone gel) for scar reduction. © Michael Lloyd 2012, Updated; Ali Ashour June 2021 14 Hair loss Hair loss self care 1. Regaine (minoxidil) 2% or 5% Response is best when many thin, miniature hairs still remain Apply 1 mL BD to area where hair regrowth/stabilisation before starting treatment. No benefit is seen where there is no is required. Apply to clean, dry scalp and allow to dry visible hair. naturally (avoid hairdryer). Do not wash hair for 4 hours. Male-pattern baldness (androgenic alopecia) is the most common Noticeable hair growth occurs by 3–4 months with maximal form of hair loss presenting in pharmacy. Continuous treatment is required to maintain response. response after 12 months of continuous treatment (discontinue Response may not be seen until about 4 months of treatment if no response by 6 months). Thinning of the hair and a frontal receding hairline; often treatment. accompanied with hair loss at the crown (moreso in women). Wash hands well after application. Benefit of treatment is lost within 6–12 months of stopping. Hereditary (family history)? Do not wear a wig, scarf or hat for at least 1 hour after application as this may increase the amount absorbed Skin on scalp is easily burned – wear hat - Itch, redness, well circumscribed round patches of through the skin causing unwanted effects. alopecia that’s scaly with black dots on scalp as a result of Side effects may include mild dermatitis or unwanted hair Avoid overuse of damaging hair products, irons infected hairs = tinea capitis (fungal) growth above eyebrows and on cheeks. - Silvery scale, thickened (psoriasis) Exercise, diet, fluids, stress Mx S: irritation, redness, low BP, facial hair growth Refer P: BLOOD PRESSURE problems (antihypertensive) - < 18yrs X Cat C, not if 65yrs - Sudden onset Self-Care Card: - Suspected iron deficiency Male Pattern Hair Loss - Diabetes, hypothyroidism 2. Zinc & Iron – if deficiency is the cause - Medicine: antineoplastics, anticoagulants, lithium, COC, retinoids, colchicine, carbimazole - Impulsive desire to twist and pull hair (trichotillomania) - Failure of OTC treatment. © Michael Lloyd 2012, Updated; Ali Ashour June 2021 15 Hydrocortisone Topical >2 unless under Ok Ok Topical hydrocortisone Cream Hydrocortisone cream 0.5% or 1% (Dermaid®, Sigmacort®, Cortic-DC®) supervision of should not be used S2 0.5% pharmacist where the cause of the S3 1% (30g or less) Apply thin layer to affected area 1-3 times daily (0.5%) or 1-2 times daily (1%). /doctor skin condition is S4 1% 50g unknown. In particular, should not be used Temporary relief of symptoms where a viral or bacterial associated with acute and cause is suspected. chronic corticosteroid responsive conditions including minor skin irritations, itching and rashes due to eczema, dermatitis, contact Should not be applied to dermatitis (such as rashes due to broken skin. cosmetics and jewellery), psoriasis, anogenital pruritus and sunburn. Where skin is dry, Used any other cream/ointment? should apply an Have acne, cold sore, chicken emollient first to the pox, or shingles? entire area of dry skin Unsure if rash is infected? before the application of For an infant? Nappy rash? topical hydrocortisone to Rash on the face? the targeted area(s). Have diabetes or arthritis? Pregnant or breastfeeding? Already used for 7 days or more? Recurrent problem? Skin broken? Dry skin? Shingles Drug Treatment: Aciclovir, Famciclovir (250mg q8h for 7/7), Valiciclovir – within 72hrs (reduces pain, viral shedding, duration of rash If child affected – refer! (Herpes Zoster) & ophthalmic complications) – Tm: 7 days Reactivation of varicella-zoster Non-drug Treatment: Line of vesicles running up nerve! - bathe lesions in saline TDS to soothe and remove the crusts. - rest & fluids. -Antiviral tx should be initiated in - cover lesions with non-adherent dressing (Melolin). the 1st 72hrs of attack. - Analgesia for pain (aspirin/ paracetamol/ paracetamol extend) others: prednisolone & amitriptyline (Chickenpoxshingles) - Solugel Smx: Zostrix (capsaicin 0.025%) for post-herpetic neuralgia - prodromal general malaise - TDS - QID (headache, fever, sore throat etc) - don’t apply to broken or irritated skin, eyes, mucous membranes - blistering rash – us trunk, back - see doctor if neuralgia persists after 14-day trial (along a nerve) - burning on application more with infrequent use - extreme pain - rub in thoroughly, excess wiped with tissue - lesions erupt over a week & - wash hands with soap wear gloves if burning heal within 2 weeks © Michael Lloyd 2012, Updated; Ali Ashour June 2021 16 German Measles (Rubella) Presentation NOT as common due to vaccination Rubella Virus Infectious: 7 days BEFORE rash until 7 days after Vaccination available Treatment: SMx: - fluids & rest *blotchy flat rash (cf chickenpox - fever: paracetamol which is rased) Problem for pregnant women  defects in unborn child (hearing, eye defects, * pink on face/neck/body mental speech etc) * tender glands Measles (Rubeola) Prodrome: Parmyxovirus - fever, runny nose, mailaise, reduce appetite & Koplik’s spots in mouth (24- HIGHLY CONTAGIOUS!!! 48hrs before the appearance of a rash) Vaccine available Rash: RARE in Aust - non-itchy, starts behind ears, spreads to trunk & extremities in 24hrs, blotchy flat Smx: rash & coincides with high fever * initially ‘cold’ Smx Recovery: * incubation  prodrome  Rash - cough for 1-3 weeks  Recovery Treatment: - rest & fluids - fever: paracetamol - VACCINE effective if given within 48-72hrs for treatment. - Check all family members Pregnancy: risk miscarriage or premature labour © Michael Lloyd 2012, Updated; Ali Ashour June 2021 17 Patient Problem Treatment Children Pregnancy Lactation Other (ok in…) ORAL HEALTH Cold Sores 1. If patient presents at ONSET OF PRODROME (tingle, burn, itch) Cold Sores Self Care Zovirax (aciclovir 5%) cream OR -use sunscreen (sun can Famvir (famciclovir 3 x 500mg) tablets (unless really mild, immunocompromised, 24hr after symptom onset) (PawPaw) to prevent drying Weeping – spreads Virasolve (idoxuridine 0.5%, lignocaine) out and cracking which can Crust over – healing (week) lead to 2o infection 3. Then in both situations 1. and 2. if required you can give: -avoid contact *HSV infectious from tingle stage PLUS -don’t touch eyes after until blisters have healed (most Compede (hydrocolloid) patch touching coldsore outbreaks last 14 days from – minimises risk of bacterial infection, stops spread, creates moist environment to help healing -use separate towel to dry prodrome to healing). Spread by - can be worn from the first sign of a cold sore until the lesion has been healed hands after applying and avoid kissing and contact (very - apply every 8 hours (can be left on overnight) touching eyes. contagious). Lies dormant for life of - can be given to a pregnant woman even though you are going to refer her! - relaxation, healthy eating, host. PLUS exercise, stress Mx Curasept (chlorhexidine 0.2%) mouthwash - avoid triggers (stress, sun, - Itchy, painful PLUS cracked lips, trauma) - Unilateral (ANGULAR PawPaw lip ointment – prevent cracking CHELITIS is Bilateral, PLUS common in denture Panadol (paracetamol 500mg) – pain wearers, braces, excess of PLUS saliva, and crooked teeth. Famvir (famciclovir 3 x 500mg) tablets to have on hand for next outbreak (if recurrent) use antifungal or antibacterial according to Zovirax (aciclovir 5%) cream Refer ok ok the cause for tx) Apply at first sign of lesion 5 times a day for 5 days (every 4 hrs while awake) > 12yrs This will only reduce the time it takes your cold sore to heal Refer: by a few days (you will still probably get the coldsore) o lesions affecting the inside of the mouth, EYE or genitals o large area >10cm piece or spread Virasolve (idoxuridine 0.5%, lignocaine, benzalkonium) – helps pain, antibacterial Refer B1; but Refer over face Apply thin layer at first sign of lesion hourly on 1st day then every 4 hours until lesion >12 yrs refer o recurrent, i.e., more than 3 times disappears per year o secondary infection, yellow crusts Good for MILD attacks (impetigo) o very young person (child) o painless without itch/tingling (school sores = impetigo) Betadine (povidone-iodine) coldsore ointment Refer Refer Refer o pregnant or breastfeeding Apply QID for 5 days Self-Care Card o the infection > 14 days duration Povidone iodine may dry weepy cold sores and prevent 2o infection. Cold Sores o taking immunosuppressants (skin staining) o malaise, fever o have eczema © Michael Lloyd 2012, Updated; Ali Ashour June 2021 18 Dry Mouth (Xerostomia) MANAGEMENT:  mouthwashes – bicarbonate/plain water – q2h ? Reason – elderly, drug (TCA’s,  gentle brushing of teeth with soft tooth brush anticholinergics, chemoTx, palliative-  Aamir artificial salvias – Biotene, Oralube, Oralbalance – every hour prn care? mouth breathing? diuretics?  Sugar-free lollies beta blockers? oxygen therapy  Regular drinks, adequate hydration, ice cubes, water q30h ? Severity  Vaseline to lips ? Diet  Room humidifier ? Treatments already tried  Reduce causative meds  Rx: pilocarpine eye drops to mouth (SE: sweating) Presentation: -dry cracked lips -teeth stuck to lips -dry, cracked, furrowed tongue -difficulty swallowing & speaking -sore or burning mouth - saliva that is ropy and scant © Michael Lloyd 2012, Updated; Ali Ashour June 2021 19 Aphthous (mouth) ulcers 1. SM33 Gel (lignocaine and salicylic acid) – use if pregnant (just use Orabase if breastfeeding) Ulcers Self Care OR - Mouth hygiene (brush, floss, mouthwash alcohol- Kenalog in Orabase (triamcinolone 0.1%) – if severe inflammation free) Questions? - Suck on ice White or yellowish centre + inflamed 2. Curasept (chlorhexidine) mouthwash daily - Soft toothbrush red outer edge appearing on the - Avoid irritative foods tongue margin and inside the lips 3. Panadol (paracetamol 500mg) – before eating - Well-fitting dentures and cheeks. - Orthodontic max if braces - Usually, < 1cm diameter 4. Blackmores Vitamin B2 or Iron tablets of it happens bcz of iron deficiency. - 2L water, healthy diet, - Singly or in small crops 15mg TDS for 1st week then 25mg daily exercise, sleep, relax, - Often reoccurring don’t smoke - Painful Orabase® (carmellose) forms protective mechanical barrier over ulcer(s) apply prn. Safe but Ok Ok - Traumas to mouth? refer < 10 Normally resolve within 7-14 - Stress? days - Anywhere else on body? - Change to diet? - Braces, dentures? Kenalog in Orabase (triamcinolone 0.1% in carmellose paste) No Cat C - No No Dab small amount (1cm) onto ulcer and hold until a film form. DON’T RUB IN! More common in females. Apply at night; max TDS. Use after meals. Refer S: local irritation, prolonged use can cause steroid effects o > 14 days (reduced BMD, fluid retention, growth retardation) o children 1cm (major aphthous ulcer) o associated weight loss C: salicylate sensitivity, peptic ulcer o irregular shaped o nutritional deficiency (vitB12, iron, folic acid) Curasept (chlorhexidine 0.2%) mouthwash - for prevention of secondary infection. Safe but Ok Ok o medicine induced - cytotoxics, Use 10mL rinsed in the mouth for 1 minute TDS for ulcers. Use after meals and refer < 10 Self-Care Card: NSADS, thiazides, tetracycline, separate from brushing teeth by 1 hour. Mouth Ulcers alendronate, nicorandil, anticholinergics, diuretics Even though this is a special anti-discolouration formulation; can cause STAINING of o eye involvement the teeth and tongue when used for continuous periods of time. o blisters on hands & feet (hand, foot, mouth disease) © Michael Lloyd 2012, Updated; Ali Ashour June 2021 20 Gingivitis 1. Dentist – for plaque removal Warfarin, heparin NSAIDS can cause gum bleeds Inflammation of the gums caused by 2. Curasept (chlorhexidine 0.2%) mouthwash - for prevention of secondary infection. plaque (check if it’s visible) deposits Use 10mL rinsed in the mouth for 1 minute BD for gingivitis for 10 days. Phenytoin, cyclosporine, on the teeth. Use after meals and separate from brushing teeth by 1 hour. nifedipine can cause Even though this is a special anti-discolouration formulation; can cause STAINING of the teeth and tongue when used hypertrophy Sx: bad breath, gum swelling (often for continuous periods of time painless), gum bleeding when Safe in all patients flossing or brushing Oral thrush (candidiasis) 1. Nilstat (nystatin) 100 000 units/mL Oral Drops Cherry Thrush Self Care After food. Shake well, give 1 mL QID for 6 days. Put drops under the tongue, swish in the mouth as long as possible before swallowing. - Hygiene (teeth brushing BD, Avoid taking food or drink for one hour after the dosing. floss, mouthwash) Continue for at least 48 hours after symptoms have resolved. - Clean dentures well with S: stomach upset toothbrush, soak in a small Cat A, safe in in pregnancy and babies. am