Clinical Pharmacy PDF

Skin Condition Problems Introduction Objective: ACNE Clinical Pharmacy...

Skin Condition Problems Introduction Objective: ACNE Clinical Pharmacy ❑Acne (or acne vulgaris) involves blockage or Skin Condition Problems(2) 1. Acne. inflammation of the hair follicles and 2. Fungal infection. accompanying sebaceous gland. QASEM HAMZA MERZA ❑An estimated 95% of all adolescents will 3. Cold sores. experience some degree of acne and most PHD.IN CLINICAL PHARMACY self-treat. 4. Scabies. OCTOBER, 2024 ❑Mild-to-moderateacne often responds well to correctly used OTC treatments. SIGNIFICANCE OF QUESTIONS AND ANSWERS Age Description Age ❑ Hormonal changes during puberty, especially the ❑ Onset is usually at puberty and acne can persist for For patients in whom acne begins later than the production of androgens, are involved in the causation of anything from a few months to several years until teenage years, other causes should be acne in teenagers. considered, ❑ Increased keratin and sebum production are important the late teens or early 20s. ❑ Including hyperandrogenism in women, contributory factors; the increased amount of keratin ❑ Acne is extremely rare in young children and leads to blockages of the follicles and the formation of babies, and any such cases should be referred for ❑ drug therapy (such as combined hormonal microcomedones. investigation, since an androgen-secreting contraception) ❑ A microcomedone can develop into (hormone-producing) tumour may be responsible. ❑ and occupational factors. Oils and greases used a non-inflammatory lesion (comedone), which may be ❑Sometimes, acne is seen later in life. at work can precipitate acne, and it would be worth open (blackhead) or closed (whitehead), asking about this. or into an inflammatory lesion (papule, pustule or nodule) Severity Severity ❑ Mild acne predominantly consists of non-inflammatory ❑ Comedones may be open or closed. Description ❑ The plug of keratin, which is at the entrance to the comedones. Severity ❑ Moderate acne consists of a mixture of non- follicle in a comedone, is initially white (a whitehead), ❑ Scarring can result from these deep lesions, ❑ It is thought that excess sebum causes an overgrowth of bacteria, particularly Cutibacterium acnes (previously inflammatory comedones and inflammatory papules later becoming darker coloured because of the although sometimes superficial lesions can also known as Propionibacterium acnes), and pustules. accumulation of melanin (a blackhead). cause scarring. ❑ which sets off an inflammatory reaction and is involved in the development of inflammatory lesions. ❑ Severe acne is characterised by the presence of ❑ If the acne is particularly inflamed, cystic or ❑ In severe acne the inflammatory reaction is more ❑ Acne can thus be non-inflammatory or inflammatory in widespread nodules and cysts, as well as a nodular with a risk of scarring, referral to the GP nature. pronounced; nodules (deep pustular lesions) and preponderance of inflammatory papules and pustules. for alternative forms of treatment, such as topical cysts may occur, which may be red and tender. or systemic antibiotics, is needed. Affected areas Affected areas ❑ Rosacea is a chronic, inflammatory skin condition that is ❑Acne principally affects sometimes confused with acne. ❑ It occurs in young and middle-aged the face, ❑ adults and sometimes in older people the upper back and shoulders (50%) ❑ Only the face is affected. and the chest (15%). ❑ Rosacea has characteristic features of These are all areas with large numbers of reddening, papules and pustules. sebaceous glands. It may be associated with recurrent episodes of facial flushing telangiectasia (broken capillaries).  Duration ❑ The information gained here should be considered in Medication Medication conjunction with facts about medication (prescribed or ❑You should establish any treatment tried ❑Acne can sometimes be drug-induced. OTC) tried already and other medicines being taken. already and its method of use. Lithium, ❑ Persistence with daily treatment over several months Inappropriate use of medication for phenytoin example , and the progestogens levonorgestrel and is usually required for beneficial effect. for example, infrequent application norethisterone (e.g. in the combined oral ❑ Acne of long duration where several OTC preparations or short duration of use, contraceptive pill) may be culprits. have been correctly used without success warrants could affect the chances of success ❑If acne is suspected as a result of drug referral. therapy, patients should be advised to discuss this with their doctor. Treatment timescale MANAGEMENT Benzoyl peroxide When to refer ❑ OTC treatment may be recommended for mild- ❑ Benzoyl peroxide has both antibacterial and anti- ❖A patient with mild-to- Moderate acne that to-moderate acne. comedone actions ❑Severe acne has not responded to treatment within 8 The general aims of therapy are ❑ is the first-line OTC treatment for inflammatory and to remove follicular plugs so that sebum can ❑Failed medication weeks should be referred to the doctor. non-inflammatory acne. escape and ❑Suspected drug-induced acne ❑ Anti-inflammatory action occurs at all strengths. to reduce the number of bacteria on the skin. ❑Considerable distress The most useful formulations are lotions, ❑ Its keratolytic action increases the turnover of skin creams and gels. cells, helping the skin to peel. Regular application can ❑ A non-comedogenic Moisturiser can help if the result in improvement for most people with acne of all skin becomes dry as a result of treatment. severities. Benzoyl peroxide Benzoyl peroxide Benzoyl peroxide Advice on using benzoyl peroxide Benzoyl peroxide Advice on using benzoyl peroxide: ❑ At first, benzoyl peroxide is very likely to produce ❑ Gels can be helpful for people with oily skin, and creams for Advice on using benzoyl peroxide: Advice on using benzoyl peroxide reddening and soreness of the skin, and patients ❑ If irritant effects are severe and persist despite low those with dry skin. ❑ Benzoyl peroxide increases the risk of sunburn. should be warned of this. strength and short exposure time, use of the product ❑ Washing the skin with a mild soap or cleansing product, Avoidance of sunlight is not always possible, so the rinsed off with water and allowed to dry fully before applying patient should use an appropriate sunscreen or protect ❑ Reddening and soreness can be minimised by should be discontinued. treated skin on the chest and back by wearing a t-shirt. beginning with the lowest strength preparation ❑ Application is once or twice a day (once daily is benzoyl peroxide, can help by reducing the amount of sebum ❑ Wash off the application of benzoyl peroxide after 15 usually sufficient) thereafter. on the skin. ❑ Occasionally, sensitisation to benzoyl peroxide may occur min initially, and increase exposure in increments of 15 ❑ Treatment should start with a 2.5% or 5% product. ❑ Facial washes containing benzoyl peroxide should not be after a period of use. The skin becomes reddened, min until the drug can be tolerated for 2 h or more. used while the patient is using another topical benzoyl inflamed and sore, and treatment should be discontinued. After 2 or 3 weeks, a higher strength preparation, such as that of 10%, may be introduced. peroxide preparation. Benzoyl peroxide ❑Other keratolytics Antiseptic agents Cosmeceuticals Advice on using benzoyl peroxide Other keratolytics include salicylic acid and Skin washes and soaps containing antiseptic Cosmeceuticals are intermediate products ❑ Allergic contact dermatitis occurs in 1 in 500 users and potassium hydroxyquinoline sulfate. They are second- agents, such as between licensed preparations containing should be suspected if the eyes become itchy and swollen. line treatments. chlorhexidine, ❑ Warning should be given that benzoyl peroxide can bleach medications and cosmetics. Preparations ❑Nicotinamide Are available. Such products may be useful clothing and bedding. If it is applied at night, white sheets and marketed for acne include those containing Topical nicotinamide gel has a mild anti-inflammatory pillowcases are best used and patients can be advised to in acne by degreasing the skin and reducing ceramides and retinols. There is insufficient action and is applied twice daily. wear an old t-shirt or shirt to minimise damage to good There is limited evidence of effectiveness. the skin flora. There is limited evidence of evidence to support or refute their use. clothes. Side effects may include skin dryness and/or irritation. effectiveness. ❑ Contact between benzoyl peroxide and the eyes, mouth and Several weeks’ treatment may be needed to see the full effects. other mucous membranes should be avoided.  SIGNIFICANCE OF QUESTIONS AND ANSWERS COMMON FUNGAL INFECTIONS ❑ Athlete’s foot ❑Duration (tinea pedis) is a superficial fungal skin infection of the feet and ❑Appearance ❑Duration toes. ❑Severity Considered together with its severity, a long-standing It is very common, and at any one time, around 15–25% of people condition may need referral. ❑Broken skin are likely to have athlete’s foot. ❑Soreness ❑Appearance The fungus that causes the disease thrives in warm, moist Athlete’s foot usually presents as itchy, flaky skin in the conditions. ❑Secondary infection web spaces between the toes. The spaces between the toes can provide a good growth ❑Location The flakes or scales of skin become white and macerated and begin to peel off. environment. ❑Previous history The skin may be dry and scaly or moist and weeping The problem is more common in men than in women and ❑Medication responds well to OTC treatment. ❑Location ❑Previous history ❑ Severity Classically, the toes are involved, the web space between Many people get recurrent athlete’s foot. Ask ❑ Medication Athlete’s foot is usually a mild fungal infection causing the fourth and fifth toes being the most commonly affected. about previous bouts and about the action taken. Establish the identity of any treatment and the method itching. the infection may spread to the sole of the foot and to the The skin may then become inflamed and sore. Any patient with diabetes who presents with of use. sides and upper surface in some cases. Once the skin is broken, there is the potential for athlete’s foot is best referred to the doctor. Treatment failure may occur simply because it was not When other areas of the foot are involved, it can be secondary bacterial infection to develop. People with diabetes may have impaired continued for sufficiently long enough. confused with allergic dermatitis. If there are indications of bacterial involvement, such as circulation or nerve supply to the feet and are if an appropriate antifungal product has been used If the toenails appear to be involved, referral to the GP weeping, pus or yellow crusts, then referral to the doctor correctly without remission of symptoms,the patient is surgery may be necessary depending on how many more prone to secondary infections in addition to is needed. best referred to the Doctor. toenails are affected and severity. poorer healing of open wounds. When to refer Treatment timescale MANAGEMENT advice Most cases of athlete’s foot are minor in nature and ❑Severe, affecting other parts of the foot If athlete’s foot has not responded to can be treated effectively by providing advice and People with fungal infection of the foot should be treatment within 2 weeks, patients should with OTC products. advised on measures to reduce the risk of ❑Signs of bacterial infection transmission ❑Unresponsive to appropriate treatment see their doctor. not scratching affected skin ❑Patients with diabetes not going barefoot in public places) ❑Involvement of toenails good foot hygiene ❖ keeping feet cool and dry, ❖ wearing cotton socks and ❖ washing socks regularly. Topical preparations ❑ Many OTC topical preparations are available for the ❑ Imidazoles (e.g. clotrimazole, miconazole) treatment of athlete’s foot. ❑ Terbinafine and ketoconazole have a 1-week Topical imidazoles can be used to treat many topical fungal ❑ Terbinafine (adults only) allylamines (e.g. terbinafine), infections, including athlete’s foot. Terbinafine is available in cream, spray and gel treatment period, which some patients may prefer. imidazoles (e.g. clotrimazole, miconazole, econazole, They have a wide spectrum of action and some have been formulations for patients 16 years of age and older, and Pharmacists should instruct patients on how to use the ketoconazole and bifonazole), shown to have both antifungal and some antibacterial treatment correctly and on other measures that can help to also in solution form activities. undecenoic acid and prevent recurrence Regular application of the recommended that terbinafine is better than the azoles in preventing Formulations include creams, powders and sprays. tolnaftate. product to clean, dry feet is essential, and treatment must Miconazole, clotrimazole and ketoconazole have recurrence ❑ All are more effective than placebo. be continued after symptoms have gone to ensure occasionally been reported to cause mild irritation of the skin. Terbinafine can cause redness, itching and stinging of eradication of the fungus. Ketoconazole is for adults only. ❑ terbinafine was more effective in preventing recurrence the skin; contact with the eyes should be avoided. (‘sustained cure’).  Topical corticosteroids and combination product Topical corticosteroids and combination product ❑Undecenoates (e.g. zinc undecylenate, undecylenate acid, methyl undecylenate Hydrocortisone may be sold OTC for allergic and ❑ Tolnaftate and propyl undecylenate) irritant dermatitis, insect bites orstings and mild- Some combination products containing Tolnaftate is available in powder, cream, aerosol and sometimes formulated with zinc salt to give to-moderate eczema. hydrocortisone together with an antifungal solution formulations additional astringent properties. Clobetasone skin preparations can be sold OTC is effective against athlete’s foot. agent are available OTC for use in athlete’s foot There is some limited evidence that it is more for eczema and dermatitis. and candidal intertrigo.(These help relieve itch It has antifungal, but not antibacterial, action, but evidence of efficacy is limited. effective than placebo for treating athlete’s foot. they cannot be recommended for athlete’s foot while treating infection. Treatment is limited to 7 It should be applied twice daily, Treatment should be continued for 4 weeks. because, although they reduce inflammation and days. and treatment should be continued for up to 6 weeks. might make it worse. FUNGAL NAIL INFECTIONS (ONYCHOMYCOSIS) RINGWORM (TINEA) RINGWORM (TINEA) RINGWORM (TINEA) ❑ Fungal nail infection (onychomycosis) is a common cause of ❑ Ringworm of the scalp(tinea capitis) ❑ Ringworm of the body (tinea corporis) ❑ Ringworm of the groin (tinea cruris) is most common in preadolescent children,although deformed nails. is a fungal infection that occurs as a circular presents as an itchy red area in the genital it can occur in adolescents and adults. ❑ The infection evolves slowly. lesion that gradually spreads after beginning as a region and often spreads to the inside of the ❑ No treatment other than nail trimming may be appropriate There may be associated hair loss and affected small red papule. thighs. for some people who are not bothered by the infected nail or They are usually acquired through direct contact hairs come out easily The problem is seen more in men than in women who wish to avoid the possible adverse effects of drug with an infected person or animal (forexample, Confirmation of the diagnosis is normally required treatment. dogs, cats, guinea pigs and cattle), Treatment consists of topical antifungals; the use by microscopy and culture of skin scrapings and ❑ An OTC nail lacquer containing 5% amorolfine can be used Topical imidazoles, such as miconazole, are of powder formulations can be particularly hair before treatment. Treatment is with oral for the treatment of mild infection involving one or two nails effective treatments. valuable because they absorb perspiration. antifungals. in people aged over 18 years. FUNGAL NAIL INFECTIONS SIGNIFICANCE OF QUESTIONS AND ANSWERS (ONYCHOMYCOSIS) COLD SORES ❑ Age ❑Age is usually subclinical and goes unnoticed, ❑Duration occurs in childhood. ❑ Cold sores (herpes labialis) are caused by the ❑Symptoms and appearance cold sores are most commonly seen in Refer if the infection seems severe and if walking is ❑ herpes simplex virus (HSV). ❑Location adolescents and young adults. uncomfortable or if the abnormal-looking nails are ❑ It is usually a painful, self-limiting infection of the ❑Precipitating factors causing significant psychological distress. lips, cheeks or nose ororopharyngealmucosa Following the primary attack, the virus is not Also refer where there is a predisposing condition, ❑ ❑Previous history (gingivostomatitis). completely eradicated and virus particles lie such as diabetes, peripheral circulatory problems and ❑Medication immunosuppression. ❑ HSV type 1 is the cause of cold sores in more than dormant in nerve roots. 90% of cases. ❑ Age The incidence of cold sores is slightly higher in ❖ Cases resemable cold sore women than in men. Oral cancer can sometimes present a similar appearance to ❑ Duration ❑ Symptoms and appearance a cold sore. Cancerous lesions are often painless , and their the typical picture of active primary herpes infection The symptoms of discomfort, tingling or irritation (prodromal long duration differentiates them from cold sores. The duration of the symptoms is important, as of childhood, is phase) may occur in the skin for 6–24 h before the Another cause of a painless ulcer is that of a primary oral treatment with aciclovir (acyclovir)or penciclovir is of appearance of the cold sore. chancre of syphilis. ✓ a febrile child with a painful ulcerated mouth and enlarged lymph nodes. most value if started early in the course of the infection The cold sore starts with the development of minute blisters When a cold sore occurs for the first time, it can be confused (during the prodromal phase). on top of inflamed, red, raised skin.The blisters may be filled with a small patch of impetigo. ✓ The herpetic lesions last for 3–6 days and can involve with white matter. the outer skin surface as well as the inside of the Usually the infection is resolved within 1–2 weeks. Any Impetigo is usually more widespread and has a honey- Cold sores are extremely painful and this is one of the mouth (gingivostomatitis). coloured crust.It tends to spread out to form further ‘satellite’ lesions that have persisted longer need medical critical diagnostic factors. patches and does not necessarily start close to the lips. ✓ Such patients should be referred to the doctor. referral.  ❑Location ❑Precipitating factors ❑Previous history Cold sores occur most often on the lips or sunlight, The fact that the cold sore is recurrent is face. wind, helpful diagnostically. fever (during infections, such as colds and Most sufferers experience one to three flu) attacks each year. Lesions inside the mouth or close to or and menstruation, affecting the eye need medical referral. Cold sores occur throughout the year, with rundown and local trauma to the skin. a slightly increased incidence during the Physical and emotional stress can also be winter months. triggers. When to refer Babies and young children Failure of an established sore to resolve ❑Previous history ❑Previous history ❑ Medication It is helpful to enquire what creams and lotions have Severe or worsening sore Information about the frequency and severity of Immunocompromised patients, for example, History of frequent cold sores the cold sore is helpful when recommending those undergoing cytotoxic chemotherapy or with been used so far, what was used in previous episodes Sore lasting longer than 2 weeks referral to the doctor, although the condition can and what, if anything, helped last time. usually be treated by the pharmacist. HIV, are also at risk of serious infection and Painless sore patients on chemotherapy for cancer, or drugs for HIV, In patients with atopic eczema, herpes infections should always be referred to the GP. Patients with atopic eczema should be advised to seek a medical opinion. This also Eye affected can become severe and widespread as the virus Patients who are pregnant, particularly near term, applies to people on oral corticosteroids, as they may be Uncertain diagnosis spreads in affected skin. should be advised to see the doctor or midwife. susceptible to more severe infection. Immunocompromised patient Pregnancy MANAGEMENT MANAGEMENT ❑ Aciclovir and penciclovir Aciclovir cream and penciclovir creams are antivirals that ❑Aciclovir cream ❑ Penciclovir cream ❑Patients with severe infection, or who are can be used by those aged 12 years and over immunocompromised, are usually reduce time to healing by 0.5–1 day and reduce pain can be used by adults and children is applied two hourly during waking hours prescribed oral antiviral therapy by a experienced from the lesion. should be applied four hourly during waking hours (approximately five times a day) to the (approximately eight times a day) for 4 days. doctor. Treatment should be started as soon as symptoms are affected area for 5 days. Some patients experience a transient stinging or ❑ Some patients who get frequent, severe felt and before the lesion appears. If healing is not complete, treatment can be burning sensation after applying the cream. They can be advised to use treatment as soon as they cold sores either take oral antivirals long continued for up to 5 more days. If there is a poor response, the patient should seek term (prophylaxis) or are given a supply to feel the tingling or itching that precedes the appearance if the cold sore has not resolved, medical advice advice. start at the onset of symptoms. of a cold sore. should be sought. Analgesia and bland creams Hydrocolloid gel patch PRACTICAL POINTS PRACTICAL POINTS ❑ Preventing cross infection ❑ Paracetamol or ibuprofen may help with HSV type 1 is contagious and transmitted by direct contact, ❑Use of sunscreens discomfort and pain. so advise the patients to wash their hands before and after Sunscreen creams (with sun protection ❑ Keeping the cold sore moist (e.g. with lip balm or applying treatment to the cold sore. factor [SPF] 15 or above) applied to and ❑The patch is applied as soon as symptoms white soft paraffin) will prevent the drying and To avoid transmission to the eyes people who use contact start and replaced as needed. around the lips. cracking, which can predispose to secondary lenses should take particular care so as to that lenses are bacterial infection. ❑The hydrocolloid is used for its wound- not contaminated, ❑Stress ❑ For the patient who suffers only an occasional healing properties. It is sensible not to share cutlery, towels, toothbrushes or Sources of stress could be looked at to see if cold sore, a simple cream, perhaps containing an ❑There is limited evidence of efficacy in cold face flannels or to kiss people until the cold sore has cleared changes are possible. antiseptic agent, can help to reduce discomfort sores. up.  SCABIES SIGNIFICANCE OF QUESTIONS AND PRACTICAL POINTS ANSWERS ❑Scabies is an intensely itchy skin infestation ❑ Eczema herpeticum ❑Age ❑Age caused by the human parasite Sarcoptes Patients with atopic eczema are very susceptible to ❑Infant, child or adult Scabies infestation can occur at any age from Scabiei. herpetic infection and show an abnormal response to the ❑Symptoms infancy onwards. ❑The itch can be severe, particularly at night virus. ❑Itching, rash it is most common between ages 10 and 19 and and scratching can lead to changes in the more often found in women than men. Patients with severe eczema should avoid contact with appearance of the skin. ❑Presence of burrows Scabies has become more frequent in the elderly anyone who has an active cold sore. ❑Scabies goes through peaks and troughs of ❑History in residential and nursing-home environments. prevalence, with a peak occurring every 15– ❑Signs of infection Refer infants and young children to the doctor if severe infection is suspected, immediate referral to the 20 years. ❑Medication scabies is suspected. doctor ❑Symptoms The scabies mite burrows down into the ❑Symptoms ❑History ❑Signs of infection skin and lives under the surface. Patients may have a rash that does not The itch of scabies can take several (6–8) weeks Scratching can lead to excoriation, A characteristic feature of scabies is that always correspond to the areas of infestation. to develop in someone who has not been secondary infections, such as impetigo, itching is worse at night and can lead to The rash may be patchy and diffuse or dense can occur. and erythematous. infested previously. loss of sleep. Commonly infested sites include the web It is more commonly found around the midriff, The scabies mite is transmitted by close personal The presence of a weeping yellow space of the fingers and toes, wrists, underarms, buttocks, inside the thighs and discharge or yellow crusts would be contact. armpits, around nipples, buttocks and the around the ankles. indications for referral genital area. ❑ Medication When to refer MANAGEMENT MANAGEMENT It is important for the pharmacist to establish whether any treatment has been tried ❑ Permethrin ❑Babies and young children ❑There is evidence from a systematic review The cream formulation is used in the treatment of scabies.. The patient should be asked about how any treatment ❑Crusted scabies of clinical trials of scabies treatments that For a single application in an adult, 30–60 g of cream (one to been used, since incorrect use can result in treatment permethrin is highly effective. two 30-g tubes) is needed. failure. ❑Scabies outbreak in institutions (schools, nursing homes) ❑The evidence for malathion is less robust. The cream is applied to the whole body and left on for 8–12 h The itch of scabies may continue for several days or even before being washed off. ❑Permethrin cream is used first line and weeks after successful treatment, malathion can be used where permethrin is If the hands are washed with soap and water within 8 h of itching has not subsided does not necessarily mean that application, cream should be reapplied to the hands. not suitable. treatment has been unsuccessful. PRACTICAL POINTS 1. The itch will continue and may become ❑ Permethrin ❑ Malathion ❑ Malathion worse in the first few days after treatment. Medical supervision is required for its use in children Malathion is effective for the treatment of scabies and The lotion should be left on for 24 h, The reason for this is thought to be the pediculosis (head lice). under 2 years and in elderly patients (aged 70 years and without bathing, after which it is washed release of allergen from dead mites. For one application in an adult, 100 ml of lotion should be over). off. Patients need to be told that the itch will not sufficient. Permethrin can itself cause itching and reddening of the Skin irritation may sometimes occur. stop straight away after treatment. The aqueous lotion should be used in scabies. skin. The lotion is applied to the whole body. It can be poured into a Medical supervision is needed for children Crotamiton cream or lotion can be used to Patients who are allergic to chrysanthemum plants may be bowl and then applied on cool, dry skin using a clean, broad under 6 months of age. relieve the symptoms. allergic to permethrin and malathion should be used paint brush or cotton wool.  PRACTICAL POINTS PRACTICAL POINTS PRACTICAL POINTS 4. The scabies mite can live only for around 2. In the past, treatment was applied after a 3. All members of the family or household should be treated, preferably on the 1 day after leaving its host and transmission hot bath. This is not necessary and same day, whether they have symptoms or not. is almost always caused by close personal there is even evidence that a hot bath may contact. However, it is possible that Because the itch of scabies increase absorption into the blood, removing reinfestation could occur from bedclothes or may take up to 8 weeks to develop, people treatment from its site of action on the skin. may be infested but symptomless. clothing and The incubation period of the scabies mite is 3 this can be prevented by washing them at a weeks, so reinfestation may minimum temperature of 60 °C after the first occur from other family or household members. treatment.