Outline. Learning Objectives. Hydrocortisone. Hydrocortisone. Too Much Fun in the Sun and Other Outdoor Dermatologic Dangers

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1 TOO MUCH FUN IN THE SUN AND OTHER OUTDOOR DERMATOLOGIC DANGERS OTC Recommendations for Sunburn, Heat Rash, Plant Dermatitis, and Insect Bites Kimberly Cauthon, PharmD, CGP Feik School of Pharmacy University of the Incarnate Word Too Much Fun in the Sun and Other Outdoor Dermatologic Dangers is accredited by ACPE for pharmacists, ACPE L01 P, and technicians, ACPE L01 T, for 1.5 contact hours. Kimberly Cauthon has no financial or other conflicts of interest in relation to this program. Texas Pharmacy Association 2014 Conference & Expo 2 Learning Objectives 1. Recognize the signs and symptoms of plant dermatitis, insect bites, sunburn, and heat rash. 2. Determine if a patient is an appropriate OTC candidate for treatment of plant dermatitis, insect bites, sunburn, and heat rash. 3. Recommend the appropriate OTC treatment for plant dermatitis, insect bites, sunburn, and heat rash. 4. Counsel patients on the following OTC products: topical hydrocortisone, topical anesthetics, topical diphenhydramine, and topical antipruritics. Outline 1. OTC topical medications Hydrocortisone Anesthetics Diphenhydramine Antipruritics/Counterirritants Skin Protectants 2. Dermatologic terminology and pictures 3. Medical conditions and treatment Plant dermatitis Insect bites & stings Sunburn Heat Rash 3 4 Hydrocortisone Only topical corticosteroid available OTC Strengths: 0.5% & 1% Mechanism of Action (MOA) Act early in the inflammatory pathway by preventing initial release of arachidonic acid which prevents the formation of prostaglandins Purpose Antipruritic Suppresses development of edema, capillary dilation, swelling, tenderness Hydrocortisone Directions: Apply 3 4 x/daily Do not apply to infected skin Apply a thin layer Can apply everywhere except eyes and eyelids Not recommended OTC for children < 2 years of age 5 6 1

2 Onset Improves pruritus and rash in 1 2 days Systemic absorption is 1% Local and systemic adverse effects rare but could occur with long term use Not common with OTC strength Not common in short term use Hydrocortisone Absorption dependent upon thickness of the stratum corneum A mild topical steroid that works on the face may achieve little on the palm A potent steroid may quickly cause side effects on the face Examples of absorption Eyelids 30% Face 7% Armpit 4% Forearm 1% Palm 0.1% Sole 0.05% Hydrocortisone Tachyphylaxis could occur after long term use Local adverse effects from chronic topical steroid use Striae s/dermatitis/corticosteroids.html Purpura and atrophy corticosteroids.html Atrophy and telengectasi Topical Anesthetics Topical Anesthetics OTC Active ingredients Benzocaine 5 20% Pramoxine 0.5 1% Dibucaine 1% Lidocaine 0.5 5% Phenol 0.5% to 1.5% MOA Produces a loss of sensation by causing a reversible blockade of conduction of nerve impulses at the site of application Purpose in skin conditions Relieve pain and itching Numbs the skin Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, 9 10 Topical Anesthetics Directions Use no longer than 7 days Do not use with an occlusive dressing Use low concentration on skin surface that is not intact due to concerns about absorption Not recommended OTC for children < 2 years of age Phenol not recommended in children or pregnant women Onset of action is rapid Duration is 15 to 45 minutes What is the maximum frequency topical anesthetics should be applied per day? a) 4 b) 6 c) 8 d) Unlimited use Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR,

3 What is the maximum frequency topical anesthetics should be applied per day? a) 4 b) 6 c) 8 d) Unlimited use Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, Topical Anesthetics Adverse effects Hypersensitivity reactions: allergic contact dermatitis Systemic absorption: Applying large amounts have resulted in a number of deaths especially if covered with a barrier Lightheadedness, dizzy, anxious, vomiting, abnormal sensation, seizures, arrhythmias Methemoglobinemia Signs and symptoms may include pale, gray or bluish skin, shortness of breath, fatigue, confusion, rapid heart rate and lightheadedness Most reports in children Which OTC topical anesthetic has the most risk of hypersensitivity reactions? a) Pramoxine b) Benzocaine c) Lidocaine Which OTC topical anesthetic has the most risk of hypersensitivity reactions? a) Pramoxine b) Benzocaine c) Lidocaine Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, Which OTC topical anesthetic has the most risk of systemic toxicity? Which OTC topical anesthetic has the most risk of systemic toxicity? a) Pramoxine b) Benzocaine c) Lidocaine a) Pramoxine b) Benzocaine c) Lidocaine Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR,

4 Topical Antihistamines Diphenhydramine 0.5 to 2% Purpose Relieve pain and pruritus Anesthetic effect and relieve pain and itching by depressing cutaneous receptors Directions Use 3 4x/day; no longer than 7 days Not recommended OTC for children < 2 years of age Onset and duration not clearly defined Works quickly and not long duration Topical Antihistamines Adverse reactions Can cause hypersensitivity reactions; contact dermatitis Risk increases when used after 3 4 weeks Systemic absorption rare but can occur in young children and when used for a long time J Drugs Dermatol. 2010; 9(8): Antipruritics/Counterirritants Active ingredient examples Camphor 0.1% to 3% Menthol <1% MOA Produce a less severe pain to counteract a more severe pain Analgesic by depressing cutaneous receptors Purpose Relieves itching and pruritus and pain J Am Acad Dermatol. 2007; 57:873 8 Postgrad Med. 2013; 125 (4 Suppl 1): 7 18 Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. Antipruritics/Counterirritants Directions Use 3 4x/day; no longer than 7 days Not recommended in children less than 2 years of age Onset quick and duration short Adverse reactions Can cause burning if applied to an open lesion Camphor is toxic when ingested Nausea, vomiting, headache, dizziness, delirium, convulsions, coma Not recommended by American Academy of Pediatrics Pediatrics. 1994; 94(1): What are the active ingredients in these products? OTC Product Active ingredient(s) Topical Class Cortizone Hydrocortisone 0.5%, 1% Steroid Cortaid Hydrocortisone 0.5%, 1% Steroid Lanacane Aerosol spray Benzocaine 20% Anesthetic Allegra Intensive Relief Diphenhydramine 2% Allantoin 0.5% Dermoplast Benzocaine 20% Menthol 0.5% Sarna Lotion Camphor 0.5% Menthol 0.5% Antihistamine Protectant Anesthetic Antipruritic Antipruritics Sarna Sensitive Anti itch Pramoxine 1% Anesthetic Aveeno Anti itch Pramoxine 1% Calamine 3% Camphor 0.3% Gold Bond Maximum Relief Menthol 1% Pramoxine 1% Chigarid Camphor 2.8% Phenol 2% Anesthetic Protectant Antipruritic Antipruritic Anesthetic Antipruritic Anesthetic

5 Zinc oxide 1 25% Calamine 1 25% Skin Protectants Reduce inflammation and irritation Absorb fluids from weeping lesions Apply prn Medication Delivery Choice Vehicle Ointment Cream Lotion Aerosols Gels Solutions Uses Most potent delivery system Most effective in penetrating the skin Dry or closed lesions Greasy Can be rubbed in and disappears Less greasy Oozing lesions or blisters Less potent than ointments Less potent than creams Alcohol based sprays can irritate the skin Sprays do not require touching the skin to apply Used for hairy areas Shorter duration of affect Have a drying effect Handbook of Nonprescription Drugs. 17th ed Application of Topical Creams 30 grams covers the body with a thin layer Calculation 30 grams x (% of body needing medication) = amount necessary per application X days supply = Amount Example 30 grams x 10% = 3 grams 3 grams x 7 days supply = 21 grams Body Surface Area (BSA) For Adult: Back of hand is 1% BSA Application of Topical Products Another example for determining quantity Amount of topical medication needed for TID for 1 week Part of Body Cream or ointment (g) Lotion, Solution, or Gel (ml) Face Both hands Scalp Both arms or both legs Trunk Derm Terminology Which term describes these lesions? 1. Macule 2. Patch 3. Papule 4. Vesicle 5. Bulla 6. Pustule Handbook of Nonprescription Drugs. 17th ed

6 Derm Terminology Which term describes these lesions? 1. Macule 2. Patch 3. Papule 4. Vesicle 5. Bulla 6. Pustule Match the picture with the disease a) Heat rash b) Plant dermatitis c) Sunburn d) Insect bites Derm Pictures Websites Websites CDC Public Health Image Library American Academy of Dermatology Dermatology Information System (British) Medline Plus (Patient information and images) Dermatology information (New Zealand) Address a to z PLANT DERMATITIS 33 What percentage of people are sensitive to urushiol? a) 20% b) 40% c) 60% d) 100% What percentage of people are sensitive to urushiol? a) 20% b) 40% c) 60% d) 100% Pharmacy Today. May 2014: 30. Pharmacy Today. May 2014:

7 Plant Dermatitis Urushiol is the active antigen found in the plant oil of poison ivy, oak, and sumac Enters skin within 10 minutes of contact Poison ivy, oak, and sumac all found in Texas Once a person has been sensitized by contact with these oils, subsequent exposure produces a contact dermatitis Rash may appear 2 48 hours after exposure (few hours to several days) West J Med. 1999; 171: Plant Dermatitis Signs & Symptoms (general order of appearance) Pruritus Erythema Vesicles, papules *Do not contain antigenic material Linear grouping of vesicles Ooze and weep Cutis. 1996; 58: Plant Dermatitis Treatment Recommendation A 31 year old male went hiking 2 days ago Vesicles and papules on his lower legs and knees Pruritus, erythema Vesicles are not open and there is no weeping Current treatment is washed the area and wet compresses Rash started yesterday 10% BSA NKDA Which of the following would you recommend to treat his pruritus? 1. Topical benzocaine 2. Topical hydrocortisone 3. Topical diphenhydramine 4. Refer for further evaluation Which of the following would you recommend to treat his pruritus? Plant Dermatitis Need for Referral 1. Topical Benzocaine 2. Topical Hydrocortisone 3. Topical Diphenhydramine Avoid due to the potential to cause allergic contact dermatitis Topical steroids are first line treatment for allergic contact dermatitis per the American Academy of Allergy, Asthma, and Immunology (AAAAI) practice parameters Most effective when started early or before the vesicles form More potent steroids usually recommended Antihistamines generally ineffective for relief of pruritus from allergic contact dermatitis per AAAAI Avoid due to the potential to cause allergic contact dermatitis Am Fam Physician. 2010; 82(3): Ann Allergy Asthma Immunol. 2006; 96 (3 Suppl 2): S1 S38 < 2 y/o Dermatitis present > 2 weeks Involvement of > 1/4 of BSA Presence of numerous bullae Extreme itching, irritation or severe vesicle and bulla formation Swelling of the body or extremities Signs of infection Soft yellow scab, pus Fever Swollen eyes or eyelids swollen shut Discomfort in genitalia from itching, redness, swelling or irritation Involvement and/or itching of mucous membranes of mouth, eyes, nose or anus Impairment of daily activities Failure of self management after 7 days

8 Plant Dermatitis Treatment Plant Dermatitis Treatment Dermatitis will resolve in 5 21 days with or without treatment Non drug treatment Wet compresses Cool water Tepid showers Colloidal Oatmeal Bath For weeping and dry Soothe and cleanse areas Prevent dryness from astringents Example: Aveeno Sprinkle cup into fast running bath water Soak minutes BID Pat skin dry rather than wiping Colloidal Oatmeal Topicals Oral antihistamine Help with sleeping Reaction is not histamine mediated Am Fam Physician. 2010; 82(3): Ann Allergy Asthma Immunol. 2006; 96 (3 Suppl 2): S1 S Plant Dermatitis Treatment Recommendation The patient s rash has not spread but is now oozing and weeping. He would like something to help dry out the rash. What do you recommend? 1. Topical calamine 2. Topical menthol 3. Topical pramoxine Plant Dermatitis Wet Type Treatment Recommendation 1. Topical calamine 2. Topical menthol 3. Topical pramoxine Can help to cool and dry oozing lesions but not much evidence per AAAAI Few adverse effects Not recommended in open lesions due to burning Avoid due to the potential to cause allergic contact dermatitis Ann Allergy Asthma Immunol. 2006; 96 (3 Suppl 2): S1 S38 West J Med. 1991; 171: a to z/diseases and treatments/m p/poison ivy/tips Astringents OTC Active Ingredients Aluminum acetate Example: Domeboro MOA Protein precipitants Reduce inflammation by vasoconstriction Cool and dry the skin by evaporation Purpose Retard oozing, weeping, or bleeding lesions Astringents Directions Mix a prepackaged tablet or solution with 16 oz of cool tap water Wet cloth with the solution and apply the compress to the rash areas Apply or soak 15 to 30 minutes 3 x/day Onset within the day Adverse effects: drying, contracting of skin Use no more than a week because it can cause skin damage (tissue necrosis) Very minimal systemic absorption

9 Plant Dermatitis (Closed lesions) Treatment Beneficial Topical hydrocortisone Topical antipruritics/ counterirritants Protectants Colloidal oatmeal Non Beneficial or Harmful Topicalantihistamines Topical anesthetics Topical antibiotics Plant Dermatitis (Open lesions) Treatment Beneficial Aluminum acetate Topical hydrocortisone cream Skin protectants Colloidal oatmeal Non Beneficial or Harmful Ointments Topical antihistamines Topical anesthetics Topical counterirritants Ann Allergy Asthma Immunol. 2006; 96 (3 Suppl 2): S1 S38. Ann Allergy Asthma Immunol. 2006; 96 (3 Suppl 2): S1 S38. Pharmacy Today. May 2014: True or False? INSECT BITES & STINGS Chiggers burrow and reside beneath the top layer of skin and should be eradicated by suffocation for proper symptom relief. 52 False Chiggers burrow and reside beneath the top layer of skin and should be eradicated by suffocation for proper symptom relief. Chigger larvae attach to the skin Secrete a digestive fluid that causes skin to disintegrate Skin eruptions usually occur after the chigger has detached from the skin Insect Bites vs. Insect Stings Bites Nonvenomous Mosquitoes Ticks Chiggers Most are local Pruritus, erythema, papules Stings Venomous and contain allergenic proteins Bees Wasps Yellow Jackets Hornets Fire ants Pain, pruritus, and irritation Buff W, Powell PH. Insect bites and stings and pediculosis. In: Krinsky DL, Berardi RR, Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. US Pharm. 2007; 32(6):

10 Insect Bites & Stings Need for Referral Hypersensitivity to bites or stings resulting in systemic symptoms away from bite or sting site Hives, excessive swelling, dizziness, weakness, N/V, SOB < 2 years of age History of tick bite and systemic effects indicating possible infection Lyme Disease Signs of secondary infection of bite area Previous severe reaction to insect stings Insect Bite Treatment A 17 year old male has chigger bites on his lower legs. Intense pruritus Been present since yesterday Took a Benadryl last night NKDA Which of the following would you recommend to treat his pruritus? 1. Topical counterirritant 2. Topical hydrocortisone 3. Topical diphenhydramine 4. 1 and 2 5. All of the above Buff W, Powell PH. Insect bites and stings and pediculosis. In: Krinsky DL, Berardi RR, Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. US Pharm. 2007; 32(6): Which of the following would you recommend to treat his pruritus? Lack of evidence based medicine 1. Topical Counterirritant Most review articles and texts recommend their use No evidence that it is ineffective Would avoid in children since there are more options 2. Topical Hydrocortisone Most review articles and texts recommend use No evidence that it is ineffective 3. Topical Diphenhydramine No evidence to support its use Only evidence available shows it does not work Buff W, Powell PH. Insect bites and stings and pediculosis. In: Krinsky DL, Berardi RR, Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. US Pharm. 2007; 32(6): Am Fam Physician. 2013; 88 (12): J Drugs Dermatol. 2010; 9(8): Insect Stings Treatment 1.Remove stinger (don t squeeze it) 2.Wash area 3.Apply ice or a cold pack to slow absorption, reduce pain and swelling x 10 minutes 4.Can use same drug tx as insect bites If pain not relieved by topical, consider oral analgesic Jelly Fish Treatment Remove tentacles with a stick (not fingers) Bathe area in sea water Pour vinegar or 4 6% acetic acid on sting ASAP for 30 seconds Bathe in hot water Topical or oral analgesic Topical steroid Cochrane Database Syst Rev. 2013; 12: CD Hawaii Med J. 2011; 70(10):

11 Insect Bites & Stings Treatment Beneficial Topical hydrocortisone Topical anesthetics Topical counterirritants Skin protectants Non Beneficial or Harmful Topical antihistamines SUNBURN US Pharm. 2007;32(6): Dermatology. 2001;202: What percentage of children and teens get a sunburn each year? 50% 75% 90% 100% What percentage of children and teens get a sunburn each year? 50% 75% 90% 100% Sunburn Peripheral vasodilation in the epidermis from UVB light Inflammatory reaction Prostaglandins Leukocytes after 24 hours Erythema peaks at hours Develops 3 5 hours after sun exposure Symptoms include tenderness, pain, and itching Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association, Sunburn Treatment Recommendation A 16 year old female has a painful sunburn after visiting South Padre Island beach today She did not wear sunscreen Her skin is tender to the touch and she would like something to help with the pain No vesicles or peeling Located on her arms, back, upper chest, and shoulders NKDA

12 Which of the following would you recommend to treat her pain and discomfort? 1. Topical counterirritant 2. Topical hydrocortisone 3. Topical diphenhydramine 4. Topical pramoxine Sunburn Treatment Recommendation No medications proven to reverse the skin damage or shorten healing time 1. Topical counterirritant 2. Topical hydrocortisone 3. Topical diphenhydramine Not recommended because they can further damage the skin Systematic review in 2008 found that topical steroids did not decrease pain Randomized, double blind trial of 20 patients treated with moderate and high intensity topical steroids found no benefit No evidence to support its use Only evidence available shows it does not work 4. Topical pramoxine Reviews state it is helpful but not long lasting Pediatr Nurs. 2008; 34(4): Am J Clin Dermatol. 2004; 5(1): Arch Dermatol. 2008;144(5): Sunburn Need for referral Sx of Heat Stroke Fever, confusion, weakness, seizures Loss of epidermis or blisters >10% BSA Non drug Cool compresses or cool bath No ice Keep well hydrated Cutis. 2000; 66: Sunburn Treatment Systemic analgesics NSAIDs preferred Decrease pain, erythema, and edema Ibuprofen mg po TID QID 4 10 mg/kg per dose Use for first 1 2 days Longer duration of action than topical anesthetics Am J Clin Dermatol. 2004; 5(1): Int J Dermatol. 1987; 26: Sunburn Alternative Treatment Sunburn Treatment Aloe vera May decrease pain by inhibiting Bradykinin Thromboxane Prostaglandins Not been approved by the FDA No evidence for efficacy Contraindications Allergies to garlic, onions, tulips Liliaceae family Br J Dermatol. 2000; 143(5): Burns. 2007; 33(6): Bernard DB. Minor burns, sunburn, and wounds. In: Krinsky DL, Berardi RR, Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association, Beneficial Oral analgesics Cold compresses and cool baths Skin protectants Topical anesthetics? Non Beneficial or Harmful Topical hydrocortisone Topical counterirritants Topical aloe vera? Pediatr Nurs. 2008; 34(4): Am J Clin Dermatol. 2004; 5(1): Arch Dermatol. 2008;144(5): Cutis. 2000; 66: Int J Dermatol. 1987; 26: The Journal of the Pharmacy Society of Wisconsin

13 HEAT RASH ALSO CALLED MILIARIA OR PRICKLY HEAT What is the incidence of prickly heat or heat rash in newborns? a) 10% b) 20% c) 40% d) 60% Cutis. 1995; 55: What is the incidence of prickly heat or heat rash in newborns? a) 10% b) 20% c) 40% d) 60% Heat Rash Can occur at any age in anyone who has active sweat glands Cause is clogged sweat glands Dilation and rupture of epidermal seat pores Acute inflammation of dermis Cutis. 1995; 55: Hagemeier NE. Diaper dermatitis and prickly heat. In: Krinsky DL, Berardi RR, Ferreri SP, et al, Eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association, Am J Sports Med. 2007; 35: Heat Rash Signs and Symptoms Pin point size macules and papules clustered together Erythema Stinging, burning or itching Common sites are axillae, chest, upper back, back of the neck, abdomen, and inguinal area Heat Rash Treatment Recommendation A 12 year old male is the catcher for his summer baseball team Stinging and itching Located on his back and upper chest Present for one day He has no other symptoms NKDA

14 Which of the following would you recommend to treat his discomfort? 1. Petrolatum 2. Topical hydrocortisone 3. Topical diphenhydramine 4. Topical counterirritant Treatment Recommendation Least amount of evidence based information 1. Petrolatum Nothing occlusive should be used Will trap moisture in the skin and skin needs to dry 2. Topical hydrocortisone 3. Topical diphenhydramine 4. Topical counterirritant Review articles recommend if non drug fails Not recommended in infants No evidence to support its use Only evidence available shows it does not work One review recommended menthol to help absorb the sweat and provide cooling Other reviews do not recommend Not recommended in children by American Academy of Pediatrics Am Fam Physician. 2008; 77: Am J Sports Med. 2007; 35: Cutis. 1995; 55: Heat Rash Need for referral Heat stroke Heat exhaustion Non drug is primary treatment Free the skin; increase air flow to the affected area Wear loose clothes and lightweight clothes Shower or change clothes immediately if clothes still wet Drink plenty of water Cool environment Am Fam Physician. 2008; 77: OTC Topical Hydrocortisone Summary Conditions Plant dermatitis (wet or dry) Insect bites and stings Heat rash Topical Anesthetics Insect bites and stings Sunburn Topical Antihistamines Topical Antipruritic or Counterirritants Plant dermatitis (dry) Insect bites and stings Levels of evidence low for the conditions. J Drugs Dermatol. 2010; 9(8): BURNING QUESTIONS?? 14