and trade show - wild apricot · 2013-09-21 · and trade show “be the critical link ......

KPhA’s 133rd Annual Meeting

and Trade Show

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DermatologySeptember 21, 2013

Emily Prohaska, Pharm.D.

KPhA’s 133rd Annual Meeting and Trade Show“Be the Critical Link”

DoubleTree by Hilton HotelOverland Park, Kansas

Disclosures

• Dr. Prohaska has no disclosures to report.

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Learning Objectives

1. Identify the presentation of common dermatologic conditions based on physical description or appearance.

2. Select safe and effective over-the-counter and/or prescription products to treat common dermatologic conditions.

3. Assess patient-specific information such as age and concurrent disease states to determine if the patient may effectively self-treat or needs to be referred to another healthcare provider.

4. Recognize when patients should initiate, switch, or modify treatment regimens for topical or oral pharmacologic agents.

5. Develop an appropriate treatment plan for a given patient case, including pharmacologic and non-pharmacologic therapy.

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Getting Started

Skin Structure

6

www.aocd.org/?page=SkinFacts

Types of Skin Lesions

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http://www.faqs.org/health/Body-by-Design-V1/The-Integumentary-System-Ailments-what-can-go-wrong-with-the-integumentary-system.html

Estimating Body Surface Area

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http://www.mdcalc.com/parkland-formula-for-burns http://vitualis.wordpress.com/2007/02/26/the-fingertip-unit-of-topical-steroids/

Structured Assessment:

QuEST-SCHOLAR MAC• Provider consultation▫ Quickly and accurately assess the patient▫ Establish that the patient is an appropriate self-care candidate▫ Suggest appropriate self-care strategies▫ Talk with the patient

• Gather information from the patient▫ Symptoms: What are the main and associated/related symptoms?▫ Characteristics: What are the symptoms like?▫ History: What has been done so far? Has this ever happened and what was successful?▫ Onset: When did this particular problem start?▫ Location: Where is the problem?▫ Aggravating factors: What makes it worse?▫ Remitting factors: What makes it better?

▫ Medications: prescription and nonprescription medications, natural products, and trade-name and generic products

▫ Allergies: medication and other types of allergies▫ Conditions: other medical conditions

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Irritant and Allergic Contact

Dermatitis

Patient Case 1

• John is an 18-year-old male who returned today from a camping trip with his fraternity brothers. He presents to the pharmacy with linear streaks of vesicles on his calves and ankles. He also states that his groin is involved and notes, “Don’t ask.” He believes the rash is due to poison ivy and wants to know if he can purchase something over the counter or if he needs to go to an urgent care clinic. He has exercise-induced asthma and uses albuterol PRN, but does not regularly take any other medications. Which of the following is the best treatment course to recommend for John?A. Self treat; hydrocortisone 1% ointment, aaa TIDB. Refer to provider; methylprednisolone 4 mg dosepak, tud x 6

daysC. Refer to provider; prednisone 10 mg, taper x 21 daysD. Refer to provider; triamcinolone 0.1% cream, aaa BID

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Overview• Irritant Contact Dermatitis (ICD)▫ Caused by exposure to an irritant

� Chemicals, solvents, detergents

▫ Can occur within minutes—weeks

▫ More likely to occur in persons with a history of atopic dermatitis

• Allergic Contact Dermatitis (ACD)▫ Caused by exposure to an allergen

� Most commonly urushiol

� May also be caused by metals, fragrances, cosmetics

▫ Re-exposure to allergen leads to allergic reaction

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Symptoms• Inflammation• Erythemous rash or bumps• Formation of vesicles or pustules• Itching• Pain or tenderness• Urushiol-Induced ▫ Itching and erythema progressing to blisters or bullae▫ Crusting occurs after several days

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ICD vs. ACD

Feature/

CharacteristicACD ICD

LocationExposed areas, often the hands

Usually the hands

Symptoms Primarily pruritusBurning, stinging, pruritis, pain

BordersDistinct lines and borders

Less distinct

Time to symptom development after exposure

Days Minutes to hours

Mechanism of symptom development

Immune reactionDirect damage to exposed tissues

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Clinical Presentation—ICD

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Images taken from: http://www.mayoclinic.com/health/dermatitis/DS00543&slide=4http://emedicine.medscape.com/article/1049353-overview

http://www.skinsight.com/images/dx/webAdult/irritantContactDermatitis_34209_med.jpg

Clinical Presentation—ACD

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Images taken from:: http://www.mayoclinic.com/health/dermatitis/DS00543&slide=2http://www.drreddy.com/ivyrash1.jpg

http://www.consultantlive.com/skin-diseases/content/article/10162/1658680?pageNumber=3http://images.suite101.com/724220_com_allergic_c.jpg

Self-Treatment Exclusions• < 2 years of age

• > 25% involvement of body surface area

• Swelling of eyes, body, or extremities

• Discomfort in genital region due to itching, redness, swelling, or irritation

• Involvement of mucous membranes of mouth, eyes, nose, or anus

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Non-Pharmacologic Therapies• Wash exposed areas with water and cleanse with mild soap as soon as possible

• Wear protective clothing or gloves to limit exposure

▫ Change often to avoid skin occlusion

• Practice good handwashing technique

• Cool or lukewarm showers to relieve itching

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Non-Prescription Pharmacologic Therapy• Mild dermatitis▫ Shake lotion containing calamine, menthol, and/or phenol � Apply every 4 hours as needed

▫ Hydrocortisone cream or ointment� Apply 3-4 times daily for up to 7 days

▫ Sodium bicarbonate paste, soaks, compresses� Apply directly to rash for 20-30 minutes as needed

▫ Oral antihistamines� Use at bedtime to relieve itching

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Non-Prescription Pharmacologic Therapy• Moderate-severe dermatitis

▫ Aluminum acetate solution

� Add 1 tablet or package to 1 pint cool water

� Soak 15-30 minutes tid or apply compresses PRN

▫ Colloidal oatmeal baths

� One packet (30 grams) per tubful

� Soak 15-20 minutes once or twice daily

• Severe dermatitis

▫ Requires referral to provider

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Urushiol-Specific Non-Prescription

Pharmacologic Treatments• Tecnu® Outdoor Skin Cleanser

▫ Use as soon as possible after exposure

▫ Cleanse for at least 2 minutes

• IvyBlock® (bentoquatam)

▫ FDA-approved organoclay to protect against poison ivy/oak/sumac exposure

▫ Apply at least 15 minutes before exposure, reapply every 4 hours

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Prescription Pharmacologic Therapy

• Topical corticosteroids▫ High potency agents (eg, clobetasol)

• Oral corticosteroids (ACD)▫ Useful when face or groin is involved and topical agents cannot be used

• Injectable corticosteroids (ACD)▫ For patients who cannot tolerate or comply with other routes

• Systemic antibiotics for secondary infection▫ Target Gram-positive coverage

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Topical Corticosteroids:

Very/Super High Potency

Drug NameBrand Name(s)®

Vehicle Strength Generic

Betamethasone dipropionate, augmented

Diprolene G, L, O 0.05% Yes

ClobetasolClobex*, Cormax, Olux, Temovate

C, F, G, L, O, Sh, So, Sp

0.05% Yes*

Diflorasonediacetate

Apexicon,Psorcon

O 0.05% Yes

Fluocinonide Vanos C 0.1% No

Flurandrenolide Cordran T 4 mcg/cm2 No

Halobetasol Ultravate C, O 0.05% Yes

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C=Cream; F=Foam; G=Gel; L=Lotion; O=Ointment; Sh=Shampoo; So=Solution; Sp=Spray; T=Tape*: Preparation not available as a generic product


High Potency

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Drug Name Brand Name(s)® Vehicle Strength(s) Generic

Amcinonide Amcort; Cyclocort C, L, O 0.1% Yes

Betamethasone dipropionate

Diprolene; Diprosone C, L, O 0.05% Yes

Desoximetasone Topicort C, G^, O0.25%, 0.05%^

Yes

Diflorasonediacetate

ApexiCon, Florone C, O 0.05% Yes

Fluocinonide Lidex C, G, O, So 0.05% Yes

Halcinonide Halog C, O 0.1% No

Triamcinolone acetonide

Kenalog; Triderm C, O 0.5% Yes

C=Cream; G=Gel; L=Lotion; O=Ointment; So=Solution^: Vehicle supplied as indicated strength


Medium Potency

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Vehicle Strength(s) Generic

Betamethasone valerate

Luxiq C, F^, L, O0.01%; 0.12%^

No

Clocortolonepivalate

Cloderm C 0.1% No

Desoximetasone Topicort C 0.05% Yes

Fluocinolone Synalar C, O 0.025% Yes

Fluocinonide Lidex C, G, O, So 0.05% Yes

Fluticasone propionate

Cutivate C, O^, L0.005%^; 0.05%

Yes

C=Cream; F=Foam; G=Gel; L=Lotion; O=Ointment; So=Solution^: Vehicle supplied as indicated strength


Medium Potency (cont’d)

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Hydrocortisone butyrate

Locoid C, L, O, So 0.1% Yes

Hydrocortisone valerate

Westcort C, O 0.2% Yes

Mometasone Elocon C, L, O, So 0.1% Yes

Prednicarbate Dermatop C, O 0.1% Yes

Triamcinolone acetonide

Kenalog C, L, O, Sp^0.147%^; 0.025%; 0.1%

Yes

C=Cream; G=Gel; L=Lotion; O=Ointment; So=Solution; Sp=Spray^: Vehicle supplied as indicated strength


Low Potency

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Alcometasonedipropionate

Aclovate C, O 0.05% Yes

DesonideDesonate, DesOwen, Verdeso*

C, F, G, L, O 0.05% Yes*

Fluocinoloneacetonide

Capex, Derma-Smoothe/FS

C, Oi, Sh, So 0.01% Yes

HydrocortisoneCortaid, Cortizone, U-cort

C, O, L^0.5%, 1%, 2.5%^

Yes

C=Cream; G=Gel; L=Lotion; O=Ointment; Oi=Oil; So=Solution; Sp=Spray*: Preparation not available as a generic product^: Vehicle supplied as indicated strength

Oral Corticosteroid Comparison

DrugEquivalent

DoseDuration of

ActionMineralocorticoid

Activity

Cortisone 25 mg Short ++

Dexamethasone 0.75 mg Long No

Hydrocortisone 20 mg Short ++

Methylprednisolone 4 mg Intermediate No

Prednisolone 5 mgIntermediate(12 – 24 hours)

+

Prednisone 5 mgIntermediate(12 – 24 hours)

+

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Counseling Points• Treatment involves identifying the causative agent

• Avoid use of topical “caine-type” anesthetics, topical antihistamines, and topical antibiotics

• Urushiol can remain active for long periods of time on inanimate objects or pet fur

• Resolution of CD will occur in one to three weeks with or without treatment

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Atopic Dermatitis

Overview• Part of the atopic triad

• Chronic, relapsing skin disorder

▫ Most commonly develops before age 5

▫ Stratum corneum contains less moisture than normal skin

• Caused by genetic and environmental factors

▫ Irritants, allergens, climate

• Can affect any area of the body

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Symptoms

• Papules and vesicles

• Intense itching

• Redness and chapping of the skin

• Crusting and scaling may also occur

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Clinical Presentation

33

Images taken from: http://www.mayoclinic.com/health/medical/IM02939, http://www.webmd.com/skin-problems-and-treatments/slideshow-common-adult-skin-problems, http://www.nlm.nih.gov/medlineplus/ency/imagepages/2407.htm, http://www.skinsight.com/images/dx/webAdult/atopicDermatitisEczema_8506_lg.jpg,

http://www.nlm.nih.gov/medlineplus/ency/imagepages/2390.htm, http://www.mayoclinic.com/health/medical/IM02942

Self-Treatment Exclusions

• Involvement of large body surface areas

• < 2 years of age

• Secondary skin infection

• Severe condition with intense itching

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Non-Pharmacologic Therapy

• Identify triggers• Limit exposure to exacerbating factors• Avoid occlusive clothing and irritating fabrics• Keep nails trimmed short and clean• Bathe or shower every other day in lukewarm water• Apply cool water compresses for oozing or weeping lesions

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Non-Prescription Therapies

• Bath products▫ Bath oils▫ Oatmeal products▫ Cleansers

• Emollients and Moisturizers▫ Lotions, creams, ointments

• Humectants▫ Glycerin, polyethylene glycol

• Keratolytics▫ Urea, alpha-hydroxy acids, allantoin

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Non-Prescription Therapies• Astringents

▫ Aluminum acetate

� Dilute before use

� Soak 2-4 times daily for 15-30 minutes

� Apply wet compresses as needed

▫ Witch hazel

• Topical corticosteroid

▫ Hydrocortisone

� Apply 3-4 times daily for up to 7 days

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Non-Prescription Therapies• Antipruritics

▫ Topical anesthetics

� Pramoxine, Lidocaine, Benzocaine

� Apply 3-4 times daily

▫ Topical antihistamines

� Diphenhydramine

� Apply 3-4 times daily

▫ Counterirritants

� Camphor and menthol

� Avoid in pediatric patients

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Prescription Therapy

• Topical corticosteroids▫ Daily application as beneficial as multiple daily applications▫ Mild dermatitis: low potency▫ Moderate – severe dermatitis: medium potency

• Topical calcineurin inhibitors▫ Tacrolimus (Protopic®) cream BID

� 0.03% for ages 2 to 15� 0.1% for patients > 15 years old

▫ Pimecrolimus (Elidel®) 1% cream BID• Oral corticosteroids▫ Adults and adolescents: taper x 7 days for acute exacerbations

• Cyclosporine 3 to 5 mg/kg/day▫ Very severe cases only

• Oral or topical antibiotics for secondary infections

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Counseling Points• Relief can occur in 1-2 days when treated appropriately

• There is no cure

• Exacerbations are likely

• Avoid use of potent corticosteroids in skin folds and on the face; consider topical calcineurininhibitors in these cases

• Consider chronic topical corticosteroids for those with frequent exacerbations

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Urticaria

Patient Case 2

• Jessica is a 27 year-old female who developed hives after receiving iodine contrast dye prior to an MRI last week. She was treated with steroids and anitihistamines at the hospital, but presents to your pharmacy today concerned that the lesions have improved but not completely gone away and are still very itchy. Her current medications include topiramate 25 mg qday for migraine prevention and sumatriptan 100 mg as needed for acute migraines. She asks for your advice as to what she should do. Which of the following is the best recommendation for Jessica?A. Self treat; loratadine 10 mg qdayB. Self treat; loratadine 40 mg qdayC. Self treat; loratadine 10 mg qday + famotidine 10 mg BIDD. Refer to provider; prednisone 50 mg qday x 3 days

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Overview

• Also known as hives

• Many causes, including allergy, cold, heat, or medication

• Can be acute or chronic

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Symptoms

• Well defined wheals or plaques

• May be paler in center

• Can be swollen/raised or flat

• Highly pruritic

▫ Worsening at night

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Images taken from:: http://www.webmd.com/skin-problems-and-treatments/picture-of-hives-urticariahttp://www.mayoclinic.com/health/medical/IM01519

https://ufhealth.org/hives

Self-treatment Exclusions

• Signs of angioedema

▫ Swelling of lips, throat, tongue

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Non-Pharmacologic Therapy• Identification and removal of trigger exposure

Pharmacologic Therapy:

Non-Sedating Antihistamines

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Drug NameBrand Name®

Vehicle Strength Generic Typical Dose OTC

Certirazine ZyrtecCh, Li^, T

5mg10mg1mg/mL^5mg/mL^

YesUp to 40mg qday

Yes

Fexofenadine Allegra Li*^, T60mg 180mg30mg/mL^

Yes*Up to 720mg qday

Yes

Loratadine ClaritinCh, Li^, T

5mg10mg5mg/mL^

YesUp to 40 mg qday

Yes

Ch=Chewable; Li=Liquid; T=Tablet^: Vehicle supplied as indicated strength*: Preparation not available as a generic product


Sedating Antihistamines

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Vehicle Strength GenericTypical Dose

OTC

ChlorpeniramineChlor-Trimeton

Li^, T, X^

4mg, 12mg^2mg/5mL^

Yes4mgQID

Yes

Clemastine Tavist Li^, T1.34mg,2.68mg0.67mg/5mL^

Yes1.34mgQID

Yes

Diphenhydramine BenadrylCh*, Li, T

12.5mg, 25mg12.5mg/5mL

Yes25mg QID

Yes*

Hydroxyzine Atarax Li^, T10mg, 25mg, 50mg, 100mg, 10mg/5mL^

Yes25mgQID

No

Ch=Chewable; Li=Liquid; T=Tablet ; X=Extended release^: Vehicle supplied as indicated strength*: Preparation not available as a generic product


H2 Antagonists

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OTC

Famotidine PepcidT, Ch*, Li^

10mg, 20mg, 10mg/mL^

Yes10mg BID

Yes*

Nizatadine Axid Li, Cp, T150 mg, 300 mg15 mg/mL~

Yes150 mg BID

Yes~

Ranitidine Zantac T75mg, 150mg, 300mg~

Yes150mg BID

Yes~

Ch=Chewable; Cp=Capsule; Li=Liquid; T=Tablet^: Vehicle supplied as indicated strength*: Preparation not available as a generic product~: Strength not available OTC

Pharmacologic Therapy - Refractory

• Add-on therapy options – chronic urticaria or failed initial therapy

▫ H2 antagonists

� Add-on to H1 antagonists therapy

▫ Corticosteroid burst

� Prednisone 50mg x 3d

� Follow burst therapy with H1 antagonists

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Counseling Points

• Most cases will resolve spontaneously

• Initial selection of product should depend on patient schedule and ability to dose medication

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Sunburn

Overview

• Acute inflammatory response to UV radiation

▫ Transient, self-limiting

• Classified as first degree and second degree

• Ranges in severity from mild erythema to severe blistering

• Can be worsened by photosensitizing drugs

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Common Photosensitizing Medications

▫ Diuretics (especially thiazide-type)

� Chlorthalidone, furosemide, HCTZ

▫ Sulfonamides

� Sulfadiazine, sulfamethoxazole, sulfasalazine

▫ Sulfonylureas

� Glimepiride, glipizide

▫ Tetracyclines

� Doxycycline, minocycline, tetracycline

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Symptoms

• Erythema of exposed skin

▫ Occurs 3-5 hours after exposure

▫ Begins healing after 12-24 hours

• Blistering of exposed skin

• Increased sensitivity of skin to mechanical pressure

• Severe sunburn can lead to fever, chills, nausea/ vomiting, and shock

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Images taken from: http://www.medicinenet.com/image-collection/acute_sunburn_picture/picture.htmhttp://www.uptodate.com/contents/image?imageKey=DERM%2F73224~DERM%2F59991~DERM%2F52112~DE

RM%2F88081&topicKey=DERM%2F6624&rank=1~68&source=see_link&search=sunburn&utdPopup=true


• < 6 months of age

• Severe systemic symptoms

▫ Nausea

▫ Fever

▫ Headache

▫ Extreme pain

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• PREVENTION is key!• Cover exposed skin• Sunscreen, sunscreen, sunscreen▫ FDA updated labeling regulations December 2012� Broad spectrum and SPF>15 = Protection against UVA and UVB rays, may protect against skin cancer and early skin aging

� Water resistance = length of time you get full SPF benefits during exposure to water or sweat (40 or 80 minutes)

▫ Reapply sunscreen q2h

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• No therapies shown to decrease healing time

• Cold compresses

• Aloe-vera based gels

• Emollients

• Cover ruptured blisters with bandages

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Pharmacologic Therapy

• Ibuprofen 400-800mg q4-6h

• Topical antimicrobials

▫ Mupirocin 2%

▫ Silver sulfadiazine

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Counseling Points

• Photosensitizing medications

• New sunscreen labeling

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Patient Case 3

• Amy is a 16-year-old female presenting to the pharmacy today with her mother. They are concerned because Amy’s acne has gotten progressively worse over the summer. Amy is especially worried about how she will look in her upcoming pictures at the homecoming dance next month. She has been using OTC salicylic acid 2% twice daily with minimal improvement. You can see a mixture of comedones and pustules on her face, and you estimate that there are about 50 total lesions present. Amy is otherwise healthy and takes only a daily multivitamin. Which of the following would be the best recommendation for Amy?A. Self treat; add benzoyl peroxide 5% aaa BIDB. Refer to provider; tretinoin 0.025% aaa qHSC. Refer to provider; spironolactone 50 mg qday + tretinoin 0.025% aaa

qHSD. Refer to provider; doxycycline 100 mg BID + tretinoin 0.025% aaa

qHS + benzoyl peroxide 5% aaa BID

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Overview

• Most common in adolescents but may persist in up to 40% of adults• Multifactorial underlying pathophysiology▫ Follicular hyperproliferation and abnormal desquamation▫ Androgenic hormonal triggers▫ Increased sebum production▫ Propionibacterium acnes (P. acnes) proliferation▫ Inflammation

• Exacerbated by cosmetics, environment, local irritation, medications, stress

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Medication-Related Causes

• P.I.M.P.L.E.S.

▫ Phenytoin

▫ Isoniazid

▫ Moisturizers

▫ Phenobarbital

▫ Lithium

▫ Ethionamide

▫ Steroids

• Also azathioprine, cyclophosphamide, rifampin

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Precursor Acne Lesions

66

Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: the American

Pharmacists Association; 2009.

Noninflammatory Acne Lesions

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Inflammatory Acne Lesions

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Symptoms and Classification

• Mild

▫ < 20 comedones; < 15 inflammatory lesions; < 30 total lesions

• Moderate

▫ 20 – 100 comedones; 15 – 50 inflammatory lesions; 30 – 125 total lesions

• Severe

▫ > 5 cysts; > 100 comedones; > 50 inflammatory lesions; > 125 total lesions

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Images taken from: http://www.webmd.com/skin-problems-and-treatments/acne/ss/slideshow-acne-dictionary


• Moderate-severe acne

• Possible rosacea

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• Identify and avoid exacerbating factors

• Avoid touching face

• Washing face with mild soaps or cleansers BID

• UV exposure

• Hydration

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Treatment Algorithm for Acne

Mild

• First line: TR + TA• Alternatives: TR + TA; TR or AA or SA• Maintenance: TR

Moderate

• First line: OA + TR + BPO• Alternatives: OI (nodular); OA + TR + BPO/AA• Maintenance: TR + BPO

Severe

• OI• High-dose OA + TR + BPO – or – High-dose OAAn + TR + TA• Maintenance: TR + BPO

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AA=azelaic acid; BPO=benzoyl peroxide; OA=oral antibiotic; OAAn=oral antiandrogenic; OI=oral isotretinoin; SA=salicylic acid; TA=topical antimicrobial; TR=topical retinoid

Pharmacologic Therapy: Retinoids

74

Drug Name

Brand Name(s)®

Vehicle Strength(s) GenericTypical Dose

Adapelene Differin C, G^, L 0.1%, 0.3%^* Yes* qHS

Isotretinoin

Absorica, Amnesteem,Claravis, Myorisan, Zenatane

Cap10, 20, 30, 40 mg

No

0.5 – 1 mg/kg/dayin 1 to 2 divided doses

Tazarotene Tazorac C, G 0.05%, 1% No qHS

Tretinoin

Atralin, Renova,Retin-A, Tretin-X

C, G

0.01%, 0.025%, 0.0375%, 0.04%, 0.05%, 0.1%

Yes qHS

C=Cream; Cp=Capsule; G=Gel; L=Lotion^: Vehicle supplied as indicated strength*: Preparation not available as a generic product


Topical Antimicrobials

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Benzoyl Peroxide

Oscion, PanOxyl

C, G, L, Pl

2.5%, 5%,10%

Yes BID

ClindamycinCleocin, ClindaGel

F, G, L, Pl, So

1% Yes qday – BID

Dapsone Aczone G 5% No BID

ErythromycinAkne-Mycin, Ery

G, Pl, So 2% Yes BID

SulfacetamideKlaron, Ovace

L, Su, W 10% Yes BID

C=Cream; G=Gel; L=Lotion; Pl=Pledget; So=Solution; Su=Suspension; W=Wash

Phamacologic Therapy: Oral Antibiotics

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DoxycyclineDoryx,Monodox*, Vibramycin

Cp, T; TX

50, 75, 100, 150, 200 mg

Yes* qday – BID

Erythromycin Ery-tabs T 500 mg Yes BID

MinocyclineMinocin, Solodyn

Cp, T, TX^

Cp: 50, 75, 100 mgT: 45^, 50, 55*^, 65*^, 80*^, 90^, 100, 105*^, 115*^, 135 mg^

Yes qday – BID

SMZ-TMP Bactrim DS T 800/160 mg Yes qday – BID

Cp=Capsule; T=Tablet; TX=Extended-release tablet*: Preparation not available as a generic product^: Vehicle supplied as indicated strength

Phamacologic Therapy: Misc.

77



Azelaic acidAzelex, Finacea

C, G 15%, 20% No BID

Combination oral contraceptives

Various T Various Yes qday

Salicylic Acid OTC

Neutrogena, Stridex, others

C, F, G, Pl

2% Yes qday – BID

Spironolactone Aldactone T25, 50, 100 mg

Yes25 to 200 mg in 1 to 2 divided doses

C=Cream; F=Foam; G=Gel; Pl=Pledget; T=Tablet


Combination Products

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BPO –Adapalene

Epiduo G 2.5% - 1% No qHS

BPO –Clindamycin

Benzaclin G 5% - 1% Yes BID

BPO –Clindamycin

Acanya*, Duac

G 2.5% - 1.2% Yes* qday

BPO –Erythromycin

Benzamycin G 5% - 3% Yes BID

Clindamycin-Tretinoin

Veltin;Ziana

G1.2% -0.025%

No qHS

BPO=Benzoyl Peroxide; G=Gel*: Preparation not available as a generic product

Counseling Points

• Product selection• Realistic expectations: treatments may take up to 12 weeks to improve symptoms• Adverse reactions▫ Photosensitivity: BPO, dapsone, retinoids, tetracyclines▫ Bleaching with BPO▫ Skin hypopigmentation with azelaic acid

• Tazotarotene and isotretinoin are pregnancy category X• Avoid tetracyclines in children < 9 years old

79

Insect Bites

Overview

• Reactions caused by bites from many species of insects

• Rarely dangerous, but highly irritating to the patient

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Symptoms

• Mosquito Bites• Chigger Bites▫ Hardened, red papule▫ Intense itching▫ Generally found near collars, waistbands, sleeves

• Spider Bites – Brown Recluse▫ Spreading, ulcerated wound

• Scabies▫ Many small bites between fingers, around genitalia, and in skin folds▫ Itching worse during evening hours

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83

Scabies

Chigger bites

Mosquito bites

Brown recluse spider bite

Images taken from:: http://indianapublicmedia.org/amomentofscience/the-itchy-truth/ http://www.webmd.com/allergies/ss/slideshow-bad-bugs

http://www.webmd.com/skin-problems-and-treatments/ss/slideshow-scabies-overviewhttp://www.myhousecallmd.com/arachnophobia-the-truth-behind-spider-bites/


• <2 years of age

• Hypersensitivity to bites or swelling away from the bite area

• Fever, joint pain, or lymph node enlargement

• Signs of secondary infection of bite area

• Symptoms persisting >7 days

• Signs of necrosis

84

Non-pharmacologic Therapy

• Insect avoidance▫ Cover skin with clothing

• Insect repellents▫ DEET most effective� Products containing 7%-100% DEET available� Use <30% DEET for children

▫ Picaridin▫ Citronella, lemon eucalyptus oil, soybean oil also effective

• Cold packs on bite area to reduce swelling

85

Pharmacologic Therapy

• Hydrocortisone

• Topical diphenhydramine

▫ May cause contact dermatitis

• Local anesthetics

▫ May cause contact dermatitis

▫ Caution in patients with known or suspected hypersensitivity to benzocaine

• All products: Apply to bite area TID or QID

• Can be used for up to 7 days

86

Pharmacologic Therapy - Scabies

• Can be cured with eradication

• Permethrin 5% (Elimite)

▫ Apply to entire body 1 time

▫ Leave on skin 8-14 hours then wash off

▫ May repeat in 1 week

• Ivermectin (Stromectol)

▫ Less effective than permethrin

▫ Single oral dose, repeated in 14 days

• Do not use hydrocortisone – may worsen scabies

87

Counseling Points

• Insect bites

▫ Avoidance and repellant is the best solution

▫ Bites should resolve in 3-4 days

• Scabies

▫ Complete coverage with premethrin can help achieve eradication

� Counsel patient to cover head to toe, including palms, soles of feet, under finger and toe nails, and around scalp line

88

Pediculosis

Patient Case 4

• Christina is a 35-year-old female who presents to the pharmacy today asking for advice regarding her son, Eric. Eric is 8 and recently started back to school. He was treated 2 days ago with OTC permethrin 1% for head lice but Christina notes that she can still see “those things in his hair.” Eric is otherwise healthy and takes no medications. Christina is worried about the cost of a physician visit because she is a single mom on a limited income. Which of the following would be the best treatment to recommend for Eric?A. Self treat; nit comb, no additional medication treatmentB. Self treat; repeat permethrin 1% and comb for nitsC. Refer to provider; spinosad 0.9% x 1 applicationD. Refer to provider; SMZ-TMP 800-160 mg BID x 10 days

90

Overview

• Pediculosis capitis

▫ Head lice

• Pediculosis corporis

▫ Body lice

• Both species bite to feed on blood

• Spread by direct contact

• Potentially spread by sharing objects such as hairbrushes, hats, clothing, and towels

91

Symptoms

• Head lice

▫ Many asymptomatic

� Common in children

▫ Itching of scalp, neck, and ears

• Body lice

▫ Itchy, hyperpigmented lesions clustered in areas where clothing seams contact the skin

• Enlarged lymph nodes

• Lice and egg sacs visible in hair or on clothing

92


93

Images taken from:: http://www.healthhype.com/itchy-scalp-causes-and-treatment.htmlhttp://www.skinsight.com/infant/pediculosisCapitisHeadLice.htm

http://www.uptodate.com/contents/images/DERM/86442/Pediculosis_corpor_hyperpig.jpg?title=Pediculosis+corporis+hyperpigmentation


• <2 years of age

• Infestations involving the eyelids or eyebrows

• Pregnancy or breast-feeding

• Allergy to chrysanthemums

94

Non-pharmacologic Therapy

• Lice (nit) combs in treatment of head lice▫ Use every 2-3 days▫ Carefully comb clean hair that has detangled with hair conditioner or olive oil

• Wash all clothing, bedding, and hair brushes in soap and hot water• Vacuum furniture, carpets, and rugs• Put pillows, rugs, and stuffed animals in clothes dryer on hot setting or in an airtight bag for 2 weeks• Avoid close contact with infected individuals to prevent spread of infestation

95

Pharmacologic Therapy: Pediculicides

96

G=Gel; Li=Liquid; L=Lotion; M=Mousse; Sh=Shampoo; ^: Vehicle supplied as indicated strength

Drug Name

Brand Name®


OTC

Citric acid, cytanyl 5, isopropanol

Lycelle G -- No 1x No

Ivermectin Sklice L 0.5% No 1x No

Permethrin Nix L 1% Yes 1x Yes

Pyrethrins/ piperonylbutoxide

RID, Tisit, Pronto

Sh, L, G, M^

0.3%/3%,0.3%/4%^

No 1x Yes

Spinosad Natroba Li 0.9% Yes 1x No

Pharmacologic Therapy –

Head Lice, Misc.• Petrolatum shampoo

▫ Apply to scalp and dry with hair dryer, leave overnight, rinse in morning

▫ Requires manual removal of lice and nits

• Trimethoprim/sulfamethoxazole

▫ Use after initial treatment failure

▫ Use in combination with permethrin rinse

▫ Dosage: 800/160 mg BID x 10d

97

Counseling Points

• Lice diagnosis can be embarrassing for patients

• Students do not need to be removed from school

• Question patient regarding mum and ragweed allergies

• Help patients select an OTC head lice product based on amount of time product is required to be on hair

• Remind patient to retreat if live lice can still be found 7-14 days after initial treatment

98

Fungal Skin Infections

Patient Case 5

• George is a 19 year old male who recently started practicing on the wrestling team at his community college. Over the past 3 days, he has noticed a well-defined, bright red rash on both his inner thighs. He states that the rash itches significantly throughout the day but has not spread to his genitals. He has no other medical conditions and takes only loratadine as needed for allergies. Which of the following would be the most appropriate treatment option for George?A. Self treat; clotrimazole cream, aaa BID x 4 weeksB. Self treat; miconazole powder, aaa BID x 4 weeks C. Self treat; tolnaftate spray, aaa BID x 4 weeksD. Refer to provider; terbinafine 250 mg qday x 12 weeks

100

Overview• Often called ringworm

• Tinea = dermatophyte infection

▫ Named according to affected body area

� Capitis, cruris, corporis, pedis, unguium

• Children more susceptible than adults

• Associated factors: immunosuppression, poor circulation, poor nutrition and/or hygiene, skin occlusion, humid climate, contact with foreign animals

101

Symptoms

• Itching• Tinea cruris▫ Bilateral red, raised scaly patches with well-defined borders

• Tinea corporis and capitis▫ Ring-shaped lesion(s) with clear centers and scaly borders

• Tinea pedis▫ Cracked, flaking skin between the toes▫ Blisters, oozing, or crusting may be present• Tinea unguium▫ Thickened, discolored, and/or dull nails

102


103

Images taken from: http://www.mayoclinic.com/health/medical/IM00983, http://www.mayoclinic.com/health/medical/IM03573, http://www.wrongdiagnosis.com/phil/html/fungal-nail-infections/579.html,http://www.mayoclinic.com/health/medical/IM02353, http://www.webmd.com/skin-problems-and-treatments/slideshow-ringworm,

http://www.skinsight.com/images/dx/webAdult/tineaCruris_5039_med.jpg


• Involvement of nails, scalp, face, mucous membranes, or genitalia• Diabetes, systemic infection, asthma, immune deficiency• Fever• Secondary bacterial infection• Excessive and/or continuous exudation• Unsuccessful initial treatment or worsening of condition

104

Non-Pharmacologic Therapies

• Cleanse skin daily with soap and water• Keep skin clean and dry• Avoid contact with infected persons• Use separate towel or dry affected skin area last• Wear protective footwear in community areas• Tinea cruris: avoid sexual contact• Tinea pedis: allow shoes to dry thoroughly

105


Azole Antifungals

106



OTC

Clotrimazole Lotrimin C, L, O 1% Yes BID Yes

Econazole Spectazole C 1% Yes qday No

Ketoconazole Nizoral C 2% Yes qday Yes

Miconazole Monistat C 2% Yes BID Yes

Oxiconazole Oxistat C, L 1% Noqday orBID

No

C=Cream; L=Lotion; O=Ointment


Amines & Miscellaneous

107

Drug Name

Brand Name(s)®


OTC

ButenafineMentax, Lotrimin@

C 1% Noqday or BID

Yes@

CiclopiroxLoprox, Penlac

C, G, La%, Su^

0.77%^, 1% Yesqday% or BID

No

Naftifine Naftin C^, G% 1%, 2%^ Noqday% or BID

Yes

Terbinafine LamisilC@, G@, Sp@, T^

1%, 250 mg^ Yesqday or BID

Yes@

Tolnaftate TinactinC, G, P, So, Sp

1% Yes BID Yes

C=Cream; G=Gel; La=Laquer; So=Solution; Sp=Spray; T=Tablet@: Specified product available OTC%: Dosing for specified vehicle^: Vehicle supplied as indicated strength

Product Selection

• Creams, solutions

▫ Most efficient and effective

• Sprays, powders

▫ Adjunct therapy

▫ Prophylaxis

• Active ingredient(s)

▫ Check product labeling

108

Counseling Points• Check product labeling for age-specific dosing; some only for use in patients > 12 years

• OTC products must be used for 2-4 weeks to ensure complete eradication

• Wash hands after product application

• Symptomatic relief will not occur quickly

109

Summary

• Drying effects needed

▫ Solutions, gels, astringents

• Lubricating effects needed

▫ Creams, lotions, ointments

• Many common skin disorders can be effectively and appropriately self-treated

• Pharmacists can play a key role in appropriate product selection

110

Patient Case 1

• John is an 18-year-old male who returned today from a camping trip with his fraternity brothers. He presents to the pharmacy with linear streaks of vesicles on his calves and ankles. He also states that his groin is involved and notes, “Don’t ask.” He believes the rash is due to poison ivy and wants to know if he can purchase something over the counter or if he needs to go to an urgent care clinic. He has exercise-induced asthma and uses albuterol PRN, but does not regularly take any other medications. Which of the following is the best treatment course to recommend for John?A. Self treat; hydrocortisone 1% ointment, aaa TIDB. Refer to provider; methylprednisolone 4 mg dosepak, tud x 6

daysC. Refer to provider; prednisone 10 mg, taper x 21 daysD. Refer to provider; triamcinolone 0.1% cream, aaa BID

111

Patient Case 2

• Jessica is a 27 year-old female who developed hives after receiving iodine contrast dye prior to an MRI last week. She was treated with steroids and anitihistamines at the hospital, but presents to your pharmacy today concerned that the lesions have improved but not completely gone away and are still very itchy. Her current medications include topiramate 25 mg qday for migraine prevention and sumatriptan 100 mg as needed for acute migraines. She asks for your advice as to what she should do. Which of the following is the best recommendation for Jessica?A. Self treat; loratadine 10 mg qdayB. Self treat; loratadine 40 mg qdayC. Self treat; loratadine 10 mg qday + famotidine 10 mg BIDD. Refer to provider; prednisone 50 mg qday x 3 days

112

Patient Case 3

• Amy is a 16-year-old female presenting to the pharmacy today with her mother. They are concerned because Amy’s acne has gotten progressively worse over the summer. Amy is especially worried about how she will look in her upcoming pictures at the homecoming dance next month. She has been using OTC salicylic acid 2% twice daily with minimal improvement. You can see a mixture of comedones and pustules on her face, and you estimate that there are about 50 total lesions present. Amy is otherwise healthy and takes only a daily multivitamin. Which of the following would be the best recommendation for Amy?A. Self treat; add benzoyl peroxide 5% aaa BIDB. Refer to provider; tretinoin 0.025% aaa qHSC. Refer to provider; spironolactone 50 mg qday + tretinoin 0.025% aaa

qHSD. Refer to provider; doxycycline 100 mg BID + tretinoin 0.025% aaa

qHS + benzoyl peroxide 5% aaa BID

113

Patient Case 4

• Christina is a 35-year-old female who presents to the pharmacy today asking for advice regarding her son, Eric. Eric is 8 and recently started back to school. He was treated 2 days ago with OTC permethrin 1% for head lice but Christina notes that she can still see “those things in his hair.” Eric is otherwise healthy and takes no medications. Christina is worried about the cost of a physician visit because she is a single mom on a limited income. Which of the following would be the best treatment to recommend for Eric?A. Self treat; nit comb, no additional medication treatmentB. Self treat; repeat permethrin 1% and comb for nitsC. Refer to provider; spinosad 0.9% x 1 applicationD. Refer to provider; SMZ-TMP 800-160 mg BID x 10 days

114

Patient Case 5

• George is a 19 year old male who recently started practicing on the wrestling team at his community college. Over the past 3 days, he has noticed a well-defined, bright red rash on both his inner thighs. He states that the rash itches significantly throughout the day but has not spread to his genitals. He has no other medical conditions and takes only loratadine as needed for allergies. Which of the following would be the most appropriate treatment option for George?A. Self treat; clotrimazole cream, aaa BID x 4 weeksB. Self treat; miconazole powder, aaa BID x 4 weeks C. Self treat; tolnaftate spray, aaa BID x 4 weeksD. Refer to provider; terbinafine 250 mg qday x 12 weeks

115

Acknowledgements

• Amanda Applegate, Pharm.D.

116

References1. Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: the American Pharmacists Association; 2009.

2. Lexi-Comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; 2013.3. Longyhore DS. Dermatology and HEENT. ACCP Updates in Therapeutics 2013: The Ambulatory Care pharmacy Preparatory Review and Recertification Course. ACCP: 2013. 1-253-302.

4. Mayoclinic.com. Dermatitis. http://www.mayoclinic.com/health/dermatitis/DS00543&slide=4. Updated 24 April 2010.

5. Hogan D. Contact dermatitis, irritant. http://emedicine.medscape.com/article/1049353-overview. Updated 16 October 2009.

6. Hogan D. Contact dermatitis, allergic. http://emedicine.medscape.com/article/1049216-overview. Updated 3 June 2010.

7. Usatine R & Riojas M. Diagnosis and management of contact dermatitis. American family Physician. 2010; 82(3): 249-55.

8. Mayoclinic.com. Atopic dermatitis (eczema). http://www.mayoclinic.com/health/eczema/DS00986. Updated 22 August 2009.

9. NIAMS. Atopic dermatitis. http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis/default.asp. Updated May 2009.

10. Weston WL & Howe W. Treatment of atopic dermatitis (eczema). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

11. PL Detail-Document, Comparison of Topical Corticosteroids. Pharmacist’s Letter/Prescriber’s Letter. September 2012

12. Using oral corticosteroids: a toolbox. Pharmacist's Letter/Prescriber's Letter 2010;26(5):260507.13. Bingham CO. New onset urticaria. In UpToDate, Sani S; Callen J (ed), UpToDate, Waltham, MA 2013. 14. FDA.gov. FDA sheds light on sunscreens. http://www.fda.gov/forconsumers/consumerupdates/ucm258416.htm . Updated 20 August 2013.

15. Young AR; Tewari A. Sunburn. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA 2013. 16. Graber E. Treatment of acne vulgaris. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.17. PL Detail-Document, Pharmacotherapy of Acne. Pharmacist’s Letter/Prescriber’s Letter. August 2013.18. Goldstein AO & Goldstein BG. Pediculosis capitis. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA 2013. 19. Goldstein AO & Goldstein BG. Pediculosis corporis. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA 2013. 20. Goldstein AO & Goldstein BG. Dermatophyte (tinea) infections. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.

21. Topical treatment of superficial fungal infections. Pharmacist's Letter/Prescriber's Letter 2009;(8):250806.

Questions?Emily Prohaska, [email protected]

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