Medico-Marketing Manual

Transcription

1 Medico-Marketing Manual

2 INDEX SR. NO. TOPIC PAGE NO. 1 Role of Skin 2 2 Skin Infections 3 3 Skin Inflammation 8 4 Mixed Skin Infections 9 5 Mexaderm + Microemulsion Cream 12 6 Comparison Microemulsion Cream & Ordinary Cream 13 7 Terbinafine Role in Mexaderm Ofloxacin & Ornidazole Role in Mexaderm Corticosteroids Clobetasol Propionate Role in Mexaderm Comparison Mexaderm + and Other Preparations Mexaderm+ - Indications, Dosage, Key Discussion Points Mexaderm+ - Major Competitors Derma Market Categories, Segment, Top Brands Oflo + Orni +Terbi + Clobeta - Market Size, Growth etc Top Competitor Brands - Market Size, Volume, Value & Growth Mexaderm+ - Our Objective Our Strategy Mexaderm+ Marketing / Inputogram & Visit Plan Indications - Glossary 29-36

3 1. What is the role of skin? The skin is the largest organ of the human body which protects the body and internal organs. Some of the major functions (role) of the skin are as below: Barrier function Protects from environmental changes, external hazards & microorganisms Prevention from excessive water loss & gain (TEWL) Protection from UV rays Regulation of body temperature Sensation -Touch, Pain and Pressure Excretion of toxic substances through sweat Storage of water fats and Glucose Synthesis of vitamin D 2. How skin protects the body? The skin works as waterproof cushion to protect the body because of keratin which is a fibrous protein present in the epidermis. The cells in the epidermis are tightly connected to each other, thus microorganisms or other external material, environmental hazards and allergens cannot easily pass through them. Moreover, epidermis is covered with a thin protective film called as Skin s acid Mantle which is acidic in nature (ph 5.5 to 6) and does not allow the microorganisms to grow. Skin and hair provides protection from UV rays and guards against sunburn by secreting melanin. The skin sweats to excrete wastes and toxic substance and regulates body temperature. The skin prevents dehydration by controlling the level of perspiration. As long as the skin is intact and healthy, external hazards like, dirt, allergens & microorganisms cannot enter in to the skin. If the skin has breaks, cuts, injured or has a blister or splinter in it, then microorganisms and other external hazards can easily enter into the body and may cause an infection or skin disease. 3. What is a skin infection? Micro-organisms such as bacteria, fungi, viruses and others that can cause infections are all around us i.e. in the air, water, soil and food, as well as in the bodies of animals and other people. Infection 1

4 occurs when these microorganisms overcome the body's natural defense (immune) system, enter in to the body, attach to the cells, grow and multiply. These microorganisms (bacteria, fungi, virus and others) are also present on our skin. The skin blocks these microorganisms and protects itself and the body through its natural defense mechanism. The skin infections can be caused by the invasion & proliferation of a wide variety of microorganisms. If the skin is oily, dry with rashes, scaly or itching & irritation, or comes in contact with chemicals or allergens, it gets damaged with cracks and the microorganisms get favorable conditions to grow. They get proliferated and cause skin infections. These infections can spread on the skin and inside the skin and may also enter the bloodstream. 4. What are the symptoms of skin infections? The symptoms of skin infection generally start with itching & irritation, inflammation (pain, heat, redness & swelling), rashes, change in colour & texture of the infected area of skin. Sores, blisters and lesions (flat, elevated or depressed) can also be the symptoms of skin infections. These symptoms may vary depending on the type of infections (bacterial, fungal, viral or others). The Skin infections can be localized or widespread (on large areas of the skin & inside the skin) and can also enter the bloodstream causing systemic infections. 5. What are the different types of skin infections? There are various types of skin infections based on the causative microorganisms i.e. Bacteria, Fungi, and Virus etc. involved in it. The type of skin infection always depends on the cause e.g. Folliculitis is a skin infection caused by a bacteria Staphylococcus aureus. 2

5 Some common types of skin infections are as below: Bacterial Infections P. Acne, Folliculitis, Carbuncles, Furuncles, Boils, Impetigo etc. Fungal Infections (Ringworm/Tinea) T. corporis, T. cruris, T. unguium, T. pedis etc. Yeast (Candida) Infections T. versicolor, Oral thrush, Vaginal candidiasis Viral Infections Rubella, Herpes zoster, HPV (human papilloma virus) etc. Skin infestation These are caused by the organisms which stay and grow on the skin or within the skin. E.g. Sarcoptes scabiei which causes scabies. Others are roundworm infestation and Lice infestation etc. Mixed Skin Infections In mixed skin infections the primary infection may be caused by bacteria or fungus and on that secondary infection develops. The itchy skin with oozing, breaking out with rashes, hives (like bee hives) and eczema can also be the examples of infected skin. Some skin infections can be minor, temporary and easily treated, while others can be very serious and may develop into mixed infections. 6. Which are the microorganisms responsible for skin infection? Skin infections can be mainly caused by the microorganisms like bacteria, fungi and viruses. The most common causative pathogens are as below: Bacteria - Staphylococcus aureus, Streptococcus pyogenes, Propionibacterium etc. Fungi Tricophyton rubrum, Microsporum canis, Epidermophyton floccosum, Candida albicans etc. Virus Herpes zoster, Rubella, Vericella, HPV etc. 7. How infections occur on the skin? Skin infections can be caused by the invasion, growth and proliferation of a wide variety of microorganisms like bacteria, fungi, viruses, germs and others. These microorganisms are normally present on the skin and in the body. They can enter in to the skin & proliferate if they get the favorable conditions to grow such as rashes, breaks & cuts, burns, oily skin, hormonal changes or if the skin s or body s immunity is down etc. These microorganisms may have uncontrolled growth, thus can spread on the skin and inside the skin to cause severe infections. These infections can also enter / spread in to the bloodstream and may lead to systemic infections. 8. What is a fungal infection of the skin? The fungal infections are caused by the fungi which are the plants (microorganisms) without stems, roots or leaves. They do not have Chlorophyll (hence can t survive on their own) therefore they grow as Parasites (obtaining nutrients from living organisms) and Saprophytes (obtaining nutrients from dead organic material). 3

6 The fungi are classified as DYM (Dermatophyte Yeast Mold) which is based on their parasite or saprophyte properties: Dermatophytes: Fungi, which produce disease of the skin, hair and nail. These fungi grow as saprophytes on keratin. There are three genera of dermatophytes which are Tricophyton, Microsporum and Epidermophyton. Yeasts: Single celled eukaryotic (cells having nucleus) fungi that produce disease of the skin and its appendages (hair & nail) and especially where the mucous membrane is present e.g. Oral candidiasis (thrush), Vaginal Candidiasis, Tinea Versicolor etc. Mold and other fungi: These are multicellular fungi that produce extremely superficial fungal infection. Mold infections generally originate from soil. E.g. Fusarium species, Aspergillus species, Alternaria species etc. (Toe nail infection is the common example). Fungi (fungus) invade and grow in dead keratin. Keratin is a protein that makes up the skin, hair and nails. There are several different types of fungal infections. They are divided into different groups depending on the type of fungus involved. The symptoms and presence of a fungal skin infection depends on the type of fungus that has caused it and also depends on the affected area of the skin / body. Fungal skin infection causes skin rashes that are red, scaly and itchy or may produce fine scales similar to dry skin. The fungal infection can be localized (limited to one area of skin) or widespread (can spread to other parts of the body/skin). Typical fungal infection known as Ringworm infection because of ring shape (here no worm is involved in the infection) 4

7 9. What are the types of fungal infections? Fungal infections are broadly classified in to following two types, Dermatophytes (Tinea - Ringworm) infections also called as dermatophytosis Yeast (Candida) infections Ringworm or Tinea (fungal) infections are known by the different names on the basis of location of infected sites. Few of them are given below: Tinea capitis: (Ring worm of scalp) - Caused most often by dermatophyte, tricophyton, and microsporum. Scaly red lesions in which hair appears lusterless or dull. Tinea corporis: (Ring worm of the chest and uppe body) -Most commonly caused by trichophyton and microsporum species. Tinea cruris: (Ring worm of the groin) - Caused by epidermophyton species. Tinea unguium: (Ring worm of the nail) - Caused by T. rubrum (Onycomycosis). Tinea barbae: (Ring worm of the beard also known as Barber s itch) - Mostly caused by Trichophyton species. Restricted to area of beard i.e. face, or neck in males. Tinea manuum: (Ring worm of the hand ) -Mostly caused by Trichophyton species affects palm and areas between the fingers Tinea pedies: ( ring worm of the foot / Athlete s foot ) - Caused by Trichophyton species and Epidermophyton floccosum The fungal infections of the skin which are caused by the yeast (candida) are called candidiasis which generally affects mucous membrane & keratinous structure. The common examples are, Intertrigo It is caused by the species Candida albicans, which develops rashes between the skin folds. The most common areas affected include larger skin-fold areas e.g. armpits, under the breasts, genital area and abdomen etc. Pityriasis versicolor (Tinea versicolor) Infection caused by yeast Malassezia. It is also called as Pityriasis versicolor. It causes a pink brown or red colour patches on skin. It usually occurs on back, upper arms and torso. Thrush (Candida albicans) - C. albicans is a common fungus that often lives in the mouth, stomach, skin and vagina. Usually it doesn't cause any problems. However, if the person is unwell, pregnant, taking antibiotics or having diabetes, the yeast can multiply and cause the symptoms of thrush. It looks like small white patch that leaves a red mark if rubbed. In women, vaginal thrush can cause itchiness and a white discharge. Note - Details of the above infections are given on last (glossary) page. 5

8 10. What is a bacterial infection of the skin? Certain bacteria commonly live on the skin without causing any harm. However, these bacteria can cause skin infections when the skin becomes excessively dry or oily. These bacteria enter the body through cuts, open wounds, or other breaks, also when we scratch the skin. Bacterial infections are the alteration of the normal skin into infected area/site that occurs when harmful form of bacteria grows in number and proliferates on the skin and in body. They range from mild to severe. Symptoms of bacterial infection may include redness, swelling, pain, or pus. Some common bacteria that cause skin infections are Staphylococcus aureus and Streptococcus pyogenes. 11. What are the types of bacterial infections? Types of Bacterial skin infection are Primary and Secondary bacterial infections. It depends on the invasion and severity of bacterial infection. Usually scratching (nails) also causes bacterial infections or worsens the infections. Some bacteria invade normal skin, broken skin from eczema/dermatitis or wounds (causing wound infection). Bacteria may also sometimes result in rashes. The major bacterial infections of the skin are Cellulitis, Boils, Impetigo, Acne, Folliculitis, Carbunculosis & Furunculosis etc. Some of the common bacterial infections of skin are given below: Carbuncles - A carbuncle is a red, swollen, and painful cluster of boils that are connected to each other under the skin. Staph Infection - The infection often begins with a little cut, which gets infected with bacteria. These staph infections range from a simple boil to antibiotic-resistant infections to flesh-eating infections. Cellulitis - Cellulitis is a common infection of the skin and the soft tissues underneath. It happens when bacteria enter a break in the skin and spread. Impetigo - Impetigo is a highly contagious bacterial skin infection. It can appear anywhere on the body but usually attacks exposed areas. It looks like a bee hive in appearance. Boils - A boil is a skin infection that starts in a hair follicle or oil gland. At first, the skin turns red in the area of the infection, and a tender lump develops. After four to seven days, the lump starts turning white as pus collects under the skin. 6

9 Pilonidal Cyst and Abscess - A pilonidal cyst occurs at the bottom of the tailbone (coccyx) and can become infected and filled with pus. Once infected, the technical term is pilonidal abscess. Note Details of the above indications are given on glossary (last) page. 12. What is anaerobic infection? Anaerobic infections are common infections caused by anaerobic bacteria (bacteria that do not need oxygen to live). These bacteria are naturally occurring and plentiful in and on the body. They don t cause infection in their natural state; but these anaerobes cause infection after an injury or trauma to the body, or under favorable conditions. These anaerobes also cause infections when the body s immunity (self-defense) is compromised where they get the favorable condition to grow and multiply in number. Anaerobic infections are often caused when deep tissues inside the body become injured and/or exposed. This can be by injury, trauma, or surgery. Anaerobic infections could be severe skin infections hence they are often difficult to treat. The most common example is acne caused by anaerobe i.e. Propionibacterium acne, that naturally exist in our body / skin. 13. What is skin inflammation; how does it occur? The word inflammation came from Latin i.e."inflammo = I set alight, I ignite. Inflammation is the body's immune response to an injury, invasion or insult. It is body s defense mechanism i.e. the body's attempt of self-protection to remove harmful stimuli and begin the healing process. Inflammation is characterized by pain, heat (temp.), redness and swelling (PTRS). The inflammation of skin is called dermatitis (Derma = Skin & itis = Inflammation). If the skin is exposed to triggering factors, such as UV Rays, irritants (e.g. Soaps or fragrances etc.) or allergens, the cells in the skin produce a variety of inflammatory responses. It is the localized physical condition in which part of the skin becomes reddened, swollen, hot and often painful. Skin inflammation (dermatitis) is of various type e.g. Atopic dermatitis, Contact dermatitis, Nummular dermatitis and Seborrheic dermatitis etc. Skin inflammation can be characterized in 2 types Acute (rapid onset and quickly becomes severe) and Chronic (this means long-term inflammation, which can last for several months and even years). 7

10 14. What is mixed skin infection? Mixed skin infection is an infection by several microorganisms where numerous combinations of bacteria, fungi and viruses may be involved. It is commonly seen in abscesses, injuries and infections of wounds, burns and cuts. Mixed skin infection is also known as secondary fungal infection involved with bacteria or secondary bacterial infection involved with fungi. E.g. Superinfected eczematous skin condition. 15. How mixed skin infection develops? Mixed skin infections can be caused by numerous aerobic & anaerobic bacteria and development of fungi (Tinea & Candida) on the same. The mixed skin infections are also called as Secondary fungal or secondary bacterial infection where the presence of both either fungi or bacteria may be involved along with redness, inflammation and irritation. Mixed skin infections could be developed in prolonged bacterial (aerobic & anaerobic) infections with the growth of fungi (Tinea & Candida) as well as during prolonged fungal infections with the growth of bacteria. Mixed skin infections can also develop in cases of cuts, wounds and burns where first bacteria (aerobic & anaerobic) and later fungi (Tinea or Candida) could be involved along with inflammation. Progression of Mixed Skin Infections Skin Primary Fungal Infection Becomes Eczematized Oozing, Weeping, Itching, Scaling Secondary Bacterial Infection Complicated Skin Lesions Skin Primary Bacterial Infection Becomes Eczematized Oozing, Weeping, Itching, Scaling Secondary Fungal infection Complicated Skin Lesions Skin Cut, Wounds, Burns Secondary Bacterial Infections Becomes Eczematized Attracts Fungal Infection Complicated Skin Lesions 16. Which are the types of mixed skin infections? The mixed skin infection is the infection where numerous bacterial as well as fungal species are involved. Types of mixed skin infection are often decided as per the severity of the symptoms and the invasion of the pathogen at the affected area. Following are the types of mixed skin infections. 8

11 Fungal infections developed into secondary infection after the invasion of bacteria Secondary bacterial infections developed after the invasion of fungi Infections developed in cases of cuts, wounds and burns where both bacteria (aerobic and anaerobic) and fungi are involved. Superinfected Eczematous conditions 17. Which are the treatment options available for Mixed Skin Infection? The commonly used treatments for mixed skin infections are given below: Topical anti-fungal Imidazoles (Clotrimazole, Miconazole, Fluconazole etc.), Allylamines (Terbinafine, Naftifine etc.) Topical anti-bacterial - Wide range viz. Aminoglycosides (Kanamycin, Tobramycin, Gentamicin, Neomycin etc.), Lincosamides (Licomycin & Clindamycin), Macrolides (Erythromycin, Azithromycin etc.), Fluroquinolones (Nadifloxacin, Ofloxacin etc.) Corticosteroids Super potent (Clobetasol, Halobetasol), Very Potent (Betamethasone, Beclomethasone), Moderate (Mometasone, Fluticasone) & Mild (Hydrocortisone, Fluocinolone) Combination of a steroid with anti-fungal Combination of a steroid with anti-bacterial Anti-fungal, anti-bacterial and steroid combination for treatment of Mixed Skin Infections that are caused by the bacteria and, or fungi (Secondary colonization) The symptomatic inflammatory dermatophytosis with erythema, pruritus, and burning could be treated by using synergistic combinations such as antibacterial, antifungal and, or antiinflammatory. 18. What are the drawbacks of available combinations / treatments? Recurrence is a very common problem in the treatment of mixed skin infections because of the presence of anaerobic bacteria which could not be properly treated with available triple combinations. This is because they do not contain antibacterial that works against anaerobic bacteria; hence they are not much effective in treatment of mixed skin infections. 9

12 19. What is the better option for the treatment of mixed skin infections? Generally the combination of topical steroid and antifungal drugs are used for the treatment of dermatophytosis. Also the combination of an antifungal & corticosteroid, anti-bacterial & corticosteroid or anti-bacterial, antifungal & corticosteroids could be used. The steroids provide rapid symptomatic relief and control the inflammation while the antifungal drug eradicates the causative fungal organism; an anti-bacterial provides the complete control over secondary bacterial infections. The combination of powerful antifungal and a potent corticosteroid along with antibacterial that can cover both aerobic and anaerobic (bacterial) infections could be the better option for the treatment of mixed skin infections to avoid recurrence. 20. Which innovative brand Glowderma is launching for the treatment of Mixed skin infection? Glowderma is launching Mexaderm+ Microemulsion Cream which is an innovative combination with a difference, for the treatment of Mixed Skin Infections. 10

13 21. What are the ingredients of Mexaderm+ Cream? Composition: Ofloxacin Ornidazole Terbinafine Hydrochloride 0.75% w/w, 2.00% w/w, 1.00% w/w Clobetasol propionate 0.05% w/w In a Microemulsion cream base. q. s. 22. What is the innovation in Mexaderm+ Cream? Mexaderm+ Cream is prepared in a special Microemulsion Cream Technology. Microemulsion is a potential drug delivery system for more than one medicine simultaneously. It is a novel vehicle used for delivery of actives which can enhance drug absorption with reduced systemic side effects. Microemulsion technology is used to form the ultrafine particles of the drug that increases the transdermal penetration of actives. Microemulsion enhances drug targeting without a simultaneous increase in systemic absorption. 23. What are the advantages of microemulsion cream technology in Mexaderm+ Cream over ordinary cream preparations? The microemulsion cream technology has following advantages, Microemulsion technology enhances absorption & penetration of the active drug in the Stratum Corneum Improves efficacy of the drug Gives faster results Minimizes side effects 11

14 Penetration of Mexaderm+ Microemulsion Cream Microemulsion Cream Microemulsion cream has ultrafine globules with particle size of 10 nm to 50 nm (Human skin pore size is 50 nm to 100 nm) Prepared with an instant transparent system using soluble active ingredients and incorporated in a cream base. Offers enhanced absorption & penetration of the actives in the SC Ensures better bioavailability of the actives hence faster action Remains stable in all climatic conditions Offers reservoir effect in the skin that prevents recurrence Ensures faster results Minimal side effects Ordinary Creams Ordinary creams / normal skin care creams has average particle size is 100 nm to 1000 nm These are the emulsion of oil & water in approximately equal proportions with active ingredients dispersed in it. Has inadequate absorption and penetration in the SC Poor bioavailability of the actives hence slower action Stability of the ordinary creams is a concern during climatic changes No proper reservoir effect hence increased risk of recurrence Slower results Causes side effect like redness and irritation of the skin at applied area 12

15 24. What is Terbinafine Hydrochloride? Terbinafine Hydrochloride is an allylamine anti-fungal having a broad spectrum activity against fungal pathogens of the skin, hair and nails, including dermatophytes such as Trichophyton, Microsporum, Epidermophyton floccosum, and yeasts of the genera Candida. Terbinafine is fungicidal against dermatophytes, moulds and some dimorphic fungi. {Dimorphic fungi = A long filamentous fungi} At room temperature it grows as a mold; at body temperature it grows as yeast. 25. What is the mode of action of Terbinafine? The cell membranes of fungi are vital for their survival. They keep unwanted substances from entering the cells and stop the contents of the cells from leaking out. The main substance which helps to maintain the cell wall intact is Ergosterol. Terbinafine causes inhibition of enzyme squalene epoxidase that leads to excess accumulation of squalene, which has been shown to result in the fungicidal effect. Excess accumulation of squalene is fungicidal (kills the fungi) Deficiency of Ergosterol is fungistatic (Stops growth of fungi) Essential for fungal survival & growth 13

16 26. How Terbinafine is superior to other antifungals? Terbinafine Terbinafine is an Allylamine antifungal Terbinafine is a fungicidal even at low dosage Inhibits enzyme squalene epoxidase that leads to excess accumulation of squalene, which results in death of the fungus i.e. fungicidal effect Terbinafine has the reservoir effects in to the skin after application, hence no recurrence Duration of therapy is less Better efficacy and better patient compliance Miconazole, Clotrimazole & Fluconazole These all are the imadizole derivatives Azoles are fungi-static in nature with low dosage Inhibits the fungal cytochrome P450 enzyme (α-demethylase) responsible for converting lanosterol to ergosterol. This leads to accumulation of peroxides resulting in the inhibition of fungal growth i.e. fungistatic effect May have the chances of recurrence after discontinuation of treatment Require long-term applications Less convenient for the patients because of repeated applications required 27. What is Ofloxacin? Ofloxacin is a synthetic broad-spectrum antibiotic belongs to fluroquinolone group of antibacterials. Ofloxacin is active against both Gram-positive and Gram-negative bacteria. 28. What is the mode of action of Ofloxacin? The Ofloxacin inhibits the bacterial enzymes required for their DNA replication, transcription, repair and recombination to prevent the proliferation of bacteria. Ofloxacin cures the infection by killing the bacteria hence is bactericidal in nature. 29. How Ofloxacin helps in treating mixed skin infections? Ofloxacin is effective against both Gram-positive and Gram-negative bacteria. Ofloxacin also shows good activity against staphylococcus aureus and various strains which are majorly responsible for skin infections. Therefore, Ofloxacin helps to prevent the development of secondary infections and acts against the bacterial infections of the skin. 14

17 30. How Ofloxacin is superior to other topical antibacterial like Gentamicin and Neomycin? Ofloxacin A synthetic 2 nd Generation antibacterial belongs to the class of Fluroquinolone Inhibits the synthesis of DNA gyrase enzyme Broad spectrum antibacterial, effective against both Gram +ve & Gram ve Bacteria Can be used in all types of secondary bacterial or mixed infections Used in both dry and wet type of skin infections Safe on long term use and does not cause skin sensitivity Very effective treatment with less chances of bacterial resistance even after long term use Gentamicin / Neomycin Aminoglycoside class of antibacterial Acts on 30s subunit of ribosomes (RNA) Only effective against Gram - ve Bacteria & Partially effective against Gram +ve Bacteria Only can be used to treat minor skin infections Only can be used in limited and dry types of skin infections Both of them exhibits some toxic effects in many people having allergic reactions Develop resistance to certain bacterial species after long term use 31. What is Ornidazole? Ornidazole is broad spectrum antibacterial belongs to the class of 5-Nitro-imidazole derivative. Ornidazole is used for treatment and prophylaxis of anaerobic infections. It has broad spectrum bactericidal action against anaerobic bacteria. Ornidazole is known to interact with the DNA of anaerobes resulting in the destruction of their DNA structure; it inhibits the protein synthesis causing cell death in susceptible microorganisms. 32. What is the role (mode of action) of Ornidazole in mixed skin infections? Mixed skin infections have some anaerobic bacteria involved. These anaerobes are single-celled living organisms which reside in our skin in low oxygen environment, without causing any harm. But the moment they get the favorable conditions (like cracks in the skin, deep seated wounds, cuts and burns, weak immunity etc.) they grow & multiply in number causing infection. Ornidazole enters into the cells of these anaerobes by diffusion. Nitro group of Ornidazole is reduced by the proteins present in these anaerobes to reactive nitro radical, which applies cytotoxic action by damaging their DNA and other critical biomolecules. Hence the DNA structure of the anaerobes destabilizes, their DNA strand breaks resulting in the cell death of anaerobes. Ornidazole inhibits the DNA structure of anaerobes (involved in mixed skin infections) and selectively blocks their cell functions, resulting in their cell death. 15

18 33. Which are the steroids available for the treatment of skin infection & inflammation? Corticosteroids are the steroid hormones that are either produced by the body or prepared synthetically. Corticosteroids can reduce inflammation (redness and swelling), suppress the immune system and narrow the blood vessels in the skin. Their main purpose is to reduce skin inflammation and irritation. There are various topical corticosteroids available in different strengths, which are determined by the amount of corticosteroid they contain. They are classified as below: Mild Corticosteroids Hydrocortisone, Fluocinolone etc. Moderate Corticosteroids Clobetasone, Mometasone, Fluticasone Potent Corticosteroids Betamethasone, Beclomethasone Very Potent / Super Potent Corticosteroids Clobetasol, Halobetasol, Ulobetasol etc. 34. How Clobetasol propionate is superior to other topical steroids? Clobetasol propionate is a very potent steroid which has a strong action to control the inflammation and redness, compared to other mild or mid potent steroids. Hence it offers quick control over inflammation and pruritic conditions, with limited applications only. However, other mild or mid-potent steroids require repeated applications to control the inflammation. Clobetasol propionate Super-high potency corticosteroid Offers quick control on inflammation Offers Rapid relief in pruritic conditions and steroid responsive dermatoses Drug of choice in treatment of Mixed Skin Infections Ensures better efficacy & patient compliance Beclomethasone dipropionate / Betamethasone Dipropionate / Mometasone /Other steroids Mild to mid potent corticosteroids Require long-term applications to control over inflammation Delayed effect in pruritic conditions and steroid responsive dermatoses Less preferred in treatment of Mixed Skin Infections due to its delayed effect Less efficacious hence poor patient compliance Note Clobetasol Propionate is a very potent steroid hence it should not be applied on face. 16

19 35. How Clobetasol propionate works in treatment of mixed skin infections? It is assumed that, Clobetasol acts by the induction of Phospholipase A2 inhibitory proteins (Lipocortins). It is assumed that these proteins control the biosynthesis of potent mediators of pain & inflammation which are Prostaglandins & Leukotrienes by inhibiting the release of their common precursor Arachidonic Acid. Arachidonic Acid is released from membrane phospholipids by phospholipase A2. Clobetasol binds to the steroid receptor, forms a complex, enters in to the cell nucleus and modifies their genetic structure that helps to prevent and control the inflammation. Diagrammatic representation of Mode of action of Corticosteroids CORTICOSTEROIDS (After application to the skin) Steroid receptor complex in the cell (Glucocorticoid Receptor) Binds to DNA Transcription /Copy (mrna protein synthesis) Synthesis of Lipocortins Inhibits the enzymes phospholipase A2 Inhibits the release of Prostaglandins & Leukotrienes Inhibits the formation of Arachidonic acid Inflammation 17

20 Clobetasol propionate is a high potency corticosteroid that offers quick relief in inflammatory & pruritic conditions of corticosteroid responsive dermatoses. Hence it is widely used in combinations with anti-fungal and anti-bacterial, for the treatment of mixed skin infections. 36. How Mexaderm+ is superior to other competitor brands available in the market? Mexaderm+ Cream Mexaderm+ has a unique microemulsion cream technology Cream particle size remains between 10 nm to 50 nm Has enhanced absorption & penetration across SC Offers reservoir effect in the skin that prevents recurrence Faster action with better efficacy Better patient compliance Safe and minimal side effects Other brands Ordinary creams prepared with conventional technology Particle size greater than 100 nm to 1000 nm Poor penetration & lesser absorption across SC No reservoir effect hence increased risk of recurrence Require long term application efficacious Poor patient compliance hence less Causes side effects like redness, burning sensation & skin sensitization on long term use 37. What are the benefits of Mexaderm+ microemulsion cream? Mexaderm+ offers, unique microemulsion cream technology for uniform drug delivery and better penetration of active drugs at the infected area of the skin. Mexaderm+ offers broad spectrum antifungal with fungicidal effect. It offers broad spectrum antibacterial coverage and rapid action over both aerobic and anaerobic bacteria. Mexaderm+ offers potent anti-inflammatory and anti-pruritic activity with quick and effective control over pruritus and scaling. Offers better results in infection treatment with lesser chances of recurrence. 38. What are the indications of Mexaderm+ microemulsion cream? Mexaderm+ Cream is indicated for the treatment of inflammatory conditions of corticosteroid responsive dermatoses when complicated by secondary infection caused by fungi or bacteria or by both causing mixed skin infections. 18

21 The major indications of Mexaderm+ Cream are as below; Mixed skin infections Secondary bacterial skin infections Secondary fungal skin infections Superinfected eczematous conditions 39. Which are the key discussion points of Mexaderm+ microemulsion cream? Mexaderm+ Microemulsion Cream offers, Unique microemulsion cream technology for uniform drug delivery at the affected site Broad spectrum antifungal with two antibacterials to cover aerobic and anaerobic bacteria Strong fungicidal action with reservoir effect in skin up to 12 weeks Potent anti-inflammatory & anti-pruritic action for quick control of pruritus and scaling Faster penetration at the site of infection Rapid onset of action Quicker clearance of infections Improved efficacy Better patients compliance Offers better results in infection treatment with lesser chances of recurrence. 40. What is the pack size and MRP of Mexaderm + microemulsion cream? Mexaderm+ Microemulsion Cream is available in 15 gm Lami tube packed in an attractive carton with the M.R.P. of Rs.55.00/- Incl. of All Taxes. 41. How long the patients can use Mexaderm + Cream? Mexaderm+ Cream should be applied twice daily on the affected area till complete cure of the infection, but not for more than two weeks. We suggest it to be used as directed by the physician. 42. In which age group of children Mexaderm + can be used? Safety and effectiveness of the ingredients in Mexaderm + in children have not been established; therefore, Mexaderm+ should not be used in children below 12 years of age. It is suggested to use this preparation as per the doctors / physicians advice. 43. Is there any side effect of Mexaderm + Cream? Burning, itching, irritation and dry skin eczema are some of the rarely occurring side effects of this combination. 19

22 44. Can Mexaderm + cream be used in pregnant woman? There are no adequate and well-controlled studies available regarding the use of this combination in pregnant women. Hence, Mexaderm+ should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. 45. Do patients need to take any precaution while using Mexaderm+ Cream? This preparation should not be used if the patients who have any known sensitivity or allergy with any of the ingredients of this preparation. The drug applied area should not be dressed unless suggested by the doctor. Clobetasol Propionate is a very potent steroid hence it should not be applied on face. 46. Which are the major competitors of Mexaderm+ Microemulsion cream? There are more than 25 brands available containing the similar combination of Ofloxacin, Ornidazole, Terbinafine and Clobetasol propionate. As per IMS MAT Dec 2014 data, following are the major competitors of Mexaderm+ Microemulsion Cream. Brands Marketed By Packing MRP PANDERM+ Macleods 15 gm TERBINAFORCE PLUS Mankind 15 gm CANDID TOTAL Glenmark 20 gm FUNZI MX Corona 15 gm TOTALDERM PLUS Alkem 15 gm AFDERM-MX AFD 15 gm ORNODERM Aristo 15 gm OF DERM JB Chemicals 15 gm O2DERM Medley 15 gm ORKID Indchemie 15 gm

23 47. What is the size of derma market as a whole in IPM? Overall derma market is valued around Rs Cr which is growing by 19.37% as per IMS MAT Dec '2014. The top fast growing categories in Dermatology segment are as below: TOP DERMA GROUPS TOP 5 CATEGORIES IN DERMA MAT VALUE in Rs. Cr. MAT UNITS in 000 % Growth Dec 2014 Dec 2013 Dec 2014 Dec 2013 Value Units Cort + Antifung. + Anti-inf Emollients Protectives Demelanizing Agents Antiacne Preparations Topical Antibiotics Plain Antifung. Syst. Ex. Gris Antiseptic Disinfectant Antifungal Dermat Cortico + Antifungals The corticosteroid + antifungal + antibacterial, is the biggest category in derma market in terms of volume and value both. We are currently present in one of the biggest sub-segment with our brand Tezcort-GM. Now we are entering in the fastest growing sub-segment of the combination market i.e. Ofloxacin + Ornidazole+ Terbinafine + Clobetasol with Mexaderm+ Microemulsion Cream. 48. What is the market size of the preparations available in treatment of Mixed Skin Infection? The available market size of the preparations for Mixed Skin infection is Rs.584Cr. Top 5 Sub Categories of the Preparations for Mixed Skin Infections SUBGROUP MAT Value in Rs. Cr. MAT Units in 000 % Growth Dec 2014 Dec 2013 Dec 2014 Dec 2013 Value Units Clobet.+ Oflo.+ Orni.+ Terbi Beclo.+ Neo.+ Clotri. Comb Oth. Clobetasol + A.fun + A.in Beta + Genta + Mico. Comb Clobetasol.+ Gen.+ Mico Other Cort + Antifung + Antiinf Beclo.+ Genta.+ Clotri. Com Others TOTAL

24 The fastest growing and now the biggest market in the above sub categories is of Clobetasol + Ofloxacin + Ornidazole + Terbinafine combinations, which is valued around Rs Cr. and 75%. We are launching Mexaderm+ Cream containing the same combination, which is the top growing combination in mixed skin infection market, with intention to exploit the excellent opportunity for Glowderma. 49. Which are the top 10 brands in overall Mixed skin infections (Corticosteroid + Antifungal + Anti-infective) market? Out of the total Brands of the above combination, the top 10 brands are as below: TOP 10 BRANDS - CATEGORY - CORT.+ANTIFUNG+ANTIINF.CO BRANDS MAT Value in Rs. Cr. MAT Units in 000 % Growth Dec 2014 Dec 2013 Dec 2014 Dec 2013 Value Units Panderm Quadriderm RF Lobate GM-NEO Surfaz SN Betnovae GM Cloben G Candiderma Plus Terbinaforce Plus Clop GM Neo Betamil GM The above 10 Brands Captures 73% Share of the overall Mixed skin infection market. Panderm + has now become the biggest brand in the entire derma market. The growth is 65% this proves that there is tremendous opportunity in this category. 50. What is the market size & market growth of the preparations containing combinations like, Ornidazole, Ofloxacin, Terbinafine & Clobetasol propionate? According to IMS MAT Dec 2014 data, the total size of the market containing Ofloxacin, Ornidazole, Terbinafine & Clobetasol brands is around Rs Cr. and the market is growing by 75%. TOTAL MARKET CLOBETASOL + OFLOXACIN + ORNIDAZOLE + TERBINAFINE SUBGROUP MAT Value in Rs. Cr. MAT Units in 000 % Growth CLOBET.+ OFLO.+ ORNI.+TERBI Dec 2014 Dec 2013 Dec 2014 Dec 2013 Value Units

25 TOP BRANDS - CLOBETASOL + OFLOXACIN + ORNIDAZOLE + TERBINAFINE TOP 10 BRANDS MAT Value in Rs. Cr. MAT Units in 000 % Growth Dec 2014 Dec 2013 Dec 2014 Dec 2013 Value Units PANDERM TERBINAFORCE PLUS CANDID TOTAL FUNZI MX TOTALDERM PLUS AFDERM-MX ORNODERM OF DERM O2DERM ORKID TRIBEN-XT What is our objective at Glowderma for Mexaderm+ Cream? Overall market for the treatment of Mixed Skin Infection preparations is valued around Rs.584Cr as per IMS MAT Dec 2014 data and is growing by 27% with a positive growth trend. Based on the present positive growth trend in both value & volume, the expected market value in the yr would be approx. Rs.741Cr. with total volume of 21 Crore units. The value & volume growth of CLOBET.+OFLO.+ORNI.+TERBI market in would be approx. Rs.367Cr. with the volume of nearly 8 crores units. Thus just 0.5% of the entire Mixed skin infection market comes around Rs.4Cr. in Value and 12 Lacs in Units. In other words If we can grab the share of just 1% from CLOBET.+ OFLO.+ORNI.+TERBI market, it would come around Rs.4Cr. in Value and 12 Lacs in Units. If we think of just 0.5% share from the total segment, it will be approximately 12, 00, 000 (12 Lacs) Units in the year Further, if we just target only Panderm+ (Valued Rs.166Cr. with 57 Lac Units) and stay behind it to grab just 2% of its available market, we can make Mexaderm+ a brand of Rs.4Cr with 12 Lac Units. This is possible with the PCPM of just 500 Units of Mexaderm+. Hence monthly expected volume would be around 1, 00, 000 (1 Lacs) Units. The minimum PCPM of Mexaderm+ would be of just 500 Units, which is quite achievable. Thus we can make Mexaderm + a brand of Rs.4Cr in the launch year itself. 23

26 52. What is the punch line (promotional line) of Mexaderm+ Cream? Maximum eradication with xtraordinary technology 53. What is the minimum expected PCPM for Mexaderm+ Cream? The minimum expected PCPM of Mexaderm+ Cream is Units per BE per month 54. Which are the target doctors for Mexaderm+ Microemulsion Cream? Only General Practitioners (GPs) Major prescribers of Panderm+, Terbinaforce Plus & Candid Total etc. Potential prescribers of similar preparations Prescribers of Triple Combinations (other than Tezcort-GM) Mexaderm+ Microemulsion Cream should be promoted to GPs only; it should not be promoted to dermatologists. 55. What would be the promotional strategy for Mexaderm+ Microemulsion Cream? To select top potential prescribers for exclusive & wide spread promotion of Mexaderm+. To generate maximum prescriptions from each selected doctor (GPs) and from the prescribers of other similar preparations. To create fast, concrete and wide prescriber base i.e. of minimum 50 prescribers per H.Q. To generate minimum 10 prescriptions from each GP selected for Mexaderm+ Cream. Ensuring the maximum availability at retail chemist outlets / chemists. Build the strong brand identity in the minds of a customer (doctors and chemists). Innovative launch inputs, regular brand reminder activities, innovative promotional inputs to create TOM (Top of the mind) awareness. Create a different value perception of the brand by highlighting the benefits of Microemulsion cream technology. 24

27 56. What would be our communication theme and communication strategy for the promotion of Mexaderm+ Microemulsion Cream? Our promotional theme would be The Mextraordinary Solution for Mixed Skin Infections. Mexaderm + offers maximum eradication of bacteria (aerobic and anaerobic) involved in the mixed skin infection with its extra ordinary technology of Microemulsion Cream. To highlight the benefits of the potent antifungal with a potent steroid to avoid recurrence. Our punch line (promotional line) for Mexaderm+ Microemulsion Cream would be The Mextraordinary edge over Ordinary Our communication strategy would be to highlight the maximum benefits of this extraordinary Microemulsion Cream technology and its advantages over ordinary cream preparations available in this category. To highlight the benefits of micro particle size of Mexaderm+ Microemulsion cream and its faster penetration in to the skin pores compared to ordinary creams available in the market. Highlight on the benefit of faster results with minimal side effects and maximum patient compliance. 57. Which are our key promotional points for Mexaderm+ Cream? Mexaderm+ Microemulsion Cream offers an innovative microemulsion cream technology that has unique benefits over the other similar combinations available in the market. o Enhanced absorption & penetration in the Stratum Corneum. o Lesser accumulation of drug at the affected site. o Improves the efficacy of the drug. o Minimizes the side effects. Mexaderm+ Microemulsion Cream offers the combination of a steroid with an anti-fungal and the synergistic action of antibacterial to kill the both, aerobic & anaerobic bacteria. Mexaderm+ Microemulsion Cream offers two broad spectrum antibacterial to cover both aerobic and anaerobic bacteria. Mexaderm+ Microemulsion Cream contains very potent steroid Clobetasol to ensure faster results. Mexaderm+ Microemulsion Cream offers quick control over infection & itching with uniform drug delivery. Mexaderm+ Microemulsion Cream does not cause burning sensation and skin sensitization after application. 58. Brand Positioning of Mexaderm+ Microemulsion Cream? In mixed skin infections The Mextraordinary Solution that offers Maximum eradication with xtraordinary Technology. 25

28 Mexaderm+ Cream is better solution for maximum eradication of the bacteria (Gram +Ve & Gram Ve) and anaerobes involved in Mixed Skin Infections, with the benefit of extraordinary Microemulsion cream technology. However the other brands are available with ordinary creams base that require long term application and has the chances of recurrence. Glowderma offers additional benefit of Microemulsion for maximum eradication with faster results, better efficacy with maximum patient compliance. 59. Summary of the key benefits (promotional points) of Mexaderm+ Microemulsion Cream. Faster penetration at the site of infection Rapid onset of action Quicker clearance of infections Improved efficacy Better patient compliance 60. What are the launch inputs of Mexaderm+ Cream? 1. Mexaderm+ Product Manual 2. Mexaderm+ Launch Shirt (Formal) 3. Mexaderm+ Clearance Chips 4. Mexaderm+ Visual aid Detailing 5. Mexaderm+ Staircase Dispenser 6. Mexaderm+ Launch Stickers 7. Mexaderm+ Punch Reminder Card 8. Mexaderm+ Availability Card 9. Mexaderm+ Rose Thank You Card 10. Mexaderm Magic Pan For Second Visit 26

29 61. What are the 2 nd, 3 rd & further visit inputs plan of Mexaderm+ Cream? Inputogram Qty/ BE Mexaderm Launch Formal Shirt 2 Visit Plan Mexaderm Visual aid 1 Mexaderm Clearance Chips 2 Mexaderm Launch Stickers 50 Mexaderm Availability card 100 Mexaderm Samples -- Mexaderm Rose Thank You Cards 50 Mexaderm Staircase Dispenser 50 Mexaderm Paper Weight 50 Mexaderm Podium Box 1 Mexaderm Punch Reminder Cards 100 Mexaderm Launch Pan 1 Mexaderm Launch LBL Mexaderm Box Dispenser 50 Mexaderm cube dispenser 50 Mexaderm 4 Pack Dispenser 50 Mexaderm Plus signed detailer 1 Mexaderm Plus signed LBL 100 Mexaderm Multifold Detailer 1 Mexaderm Multifold LBL 100 Mexaderm Rx pad 50 Mexaderm tent card 100 Mexaderm chit cube 50 27

30 62. Give the details of Mexaderm+ Indications. Mexaderm + Cream - Indication Glossary: Mixed Skin Infections - These are generally the secondary skin infections with itching & irritation, redness & swelling that are either caused by bacteria and fungi and, or mixed with both causing restlessness to the concern. Tinea Infections (Ringworm): The organisms that cause dermatophytoses or tinea infections are called dermatophytes. The resulting diseases are also often called ringworm (even though there is no worm involved). The name arose because of the ring-shaped skin patches created by the infection. These dermatophytoses are caused by Microsporum, Trichophyton, and Epidermophyton genera of fungi. o Athlete's foot (Tinea pedis): It is a common fungal infection of toes that usually appears during warm weather. Either Trichophyton or Epidermophyton usually cause it. These fungi most commonly grow in the warm, moist areas between the toes. The fungus can produce mild scaling with or without redness and itching. Sometimes scaling is severe, with breakdown and painful cracking (fissuring) of the skin. Fluid-filled blisters can also form. Because the fungus may cause the skin to crack, athlete's foot can lead to bacterial infection especially in older people and in people with inadequate blood flow to the feet. o Nail ringworm (Tinea unguium / onychomycosis): It is an infection of the nail most often caused by Trichophyton. The fungus may get into the nail, producing a thickened, lusterless, and deformed nail. Infection is more common on the toenails than on the fingernails. An infected toenail may separate from the toenail bed, crumble, or flake off. 28

31 o Jock itch (Tinea cruris): It is the common infection develops in the skin folds near the genital area particularly during warm weather. The infection can spread to the upper inner thighs. Jock itch can be quite itchy and may be painful. A susceptible person may have repeated infections. o Scalp ringworm (Tinea capitis): It is the ringworm (fungal) infection at the scalp caused by Trichophyton. It may produce a pink scaly rash that may be somewhat itchy, or it may produce a patch of hair loss without a rash. Less commonly it can cause a painful, inflamed, swollen patch on the scalp that sometimes oozes pus (a kerion). A kerion is caused by an allergic reaction to the fungus. o Body ringworm (Tinea corporis): It is the fungal infection of the body, caused by Trichophyton, Microsporum, or Epidermophyton. The infection generally produces round patches with pink scaly borders, clear areas in the center with or without itching. Body ringworm can develop anywhere on the skin and can spread rapidly to other parts. 29

32 o Beard ringworm (Tinea barbae): It is the infection at beard area of face. Bacteria, not fungi, cause most skin infections in the beard area. Tinea barbae is also called as Ringworm of beard. o Tinea manuum - A fungal infection of the hands especially on palms. Atopic Dermatitis - Red, itchy, dry skin which easily rashes; most common in infants; a result of an exposure to an allergen or an irritant. Balanitis - inflammation of the head / tip of the penis i.e. at the glans penis. Contact dermatitis - Contact dermatitis or Irritant dermatitis is a term for a skin reaction resulting from exposure to allergens (allergic contact dermatitis) or irritants (irritant contact dermatitis). Cutaneous candidiasis It is an infection of the skin caused by Candida fungus. Dermatophytosis - Infection of the skin caused by fungi called as dermatophytes which grow on the dead layers of the skin i.e. stratum corneum / Keratinophilic. (Especially at the moist parts that are covered by clothing). Eczema in children - A patterned form of inflammation of the skin resulting from endogenous (within body) or exogenous (outside body) causes. Ichthyosis - any of several acquired or congenital diseases where the skin is dry & scaly (like scales of a fish). Inflammatory skin conditions - any skin diseases showing redness, swelling, and pain or itching and often scaling. Intertrigo - An intertrigo is an inflammation (rash) of the body folds (adjacent areas of skin). 30

33 Onycomycosis - A fungal infection that affects the fingernails or toenails. It can be caused by Dermatophytes or moulds or yeasts. Otomycosis - (also known as Singapore Ear) is a fungal infection of the external ear. Post herpetic neuralgia - a severe, sometimes relentless pain that follows an attack of shingles/herpes zoster. It occurs primarily in the older population groups. Seborrhoeic dermatitis - A common, inflammatory skin condition that causes flaky, white to yellowish scales to form on oily areas such as the scalp or inside the ear or eyelids. It can occur with or without reddened skin" OR Seborrhoeic dermatitis has been called a more extensive and severe form of dandruff. Skin & Soft tissue infections It is the infection of skin or subcutaneous tissue. Super infected eczemas A condition of Eczemas which can get secondarily infected with bacteria or fungi. Vulvo Vaginitis -Inflammation of the vagina and vulva most often caused by the bacterial, fungal, or parasitic infection. Vulvar itching Irritation & itching of vulva caused by bacterial, fungal, or parasitic infection. Vaginal candidiasis: It is infection of the vagina and /or vulva with a yeast-like fungus, typically Candida albicans. Symptoms may include pain, itching, redness and a white discharge. Vaginal candidiasis is more common and more difficult to treat in HIV positive women; recurrent episodes may be an early sign of HIV infection. Candidal Balanitis: It is an inflammation of the end of the penis (the glans). Often the foreskin is also inflamed at the same time as the glans. (The foreskin is the loose skin that covers the glans if not circumcised.) Balanitis is common, and it can occur at any age. Symptoms include redness, irritation, and soreness of the end of the penis. Dermatomycosis: It is one of the most frequent dermal lesions in which, except the skin, dermal appendages viz. hair and nails also get affected. Such as, Tinea pedis, Tinea corporis, Tinea unguium (onychomycosis), and dermal candida infections. Bacterial Infections of Skin: Staph Infection: Staph is short name for Staphylococcus bacteria which can live harmlessly on many skin surfaces, especially around the nose, mouth, genitals, and anus. But when the skin is punctured or broken for any reason, staph bacteria can enter the wound and cause an infection. The staph family of bacteria has more than 30 species, but most staph infections are caused by the species Staphylococcus aureus. S. aureus most commonly causes skin infections like folliculitis, boils, impetigo, and cellulitis that are limited to a small area of a person's skin. People with skin problems like burns or eczema may be more likely to get staph skin infections. It is contagious and can spread to other body parts and in other people coming in contact with infected person. 31

34 Carbuncle: A carbuncle is a bacterial infection of skin mainly caused by Staphylococcus aureus. The infected material forms a lump, which occurs deep in to the skin. A carbuncle is made up of several skin boils (furuncles) involving group of hair follicles. The infected mass is filled with fluid, pus and dead tissue. Fluid may drain out of the carbuncle, but sometimes the mass is so deep that it cannot drain on its own. When there is more than one carbuncle, the condition is called carbunculosis (secondary bacterial infection). It is contagious and can spread to other areas of the body or other people. Carbuncles can develop anywhere on skin. But they are most common on the back and the nape of the neck. Men get carbuncles more often than women. The causes may be the friction from clothing or shaving, poor hygiene, poor overall health and in the person with diabetes, dermatitis, and weakened immune systems are more likely to develop staph infections that can cause carbuncles. Boils: A boil is common a bacterial skin infection caused by Staphylococcus aureus that affects group of hair follicles and nearby skin tissues. A boil may begin as a tender, pinkish-red, swollen, firm area in the skin. It is painful and feels like a water-filled balloon or cyst. 32

35 When the condition worsens (secondary bacterial infection) it is known as carbunculosis & folliculitis. They can also be caused by other type bacteria or fungi found on the skin's surface causing mixed skin infection. Damage to the hair follicle allows the infection to grow deeper into the follicle and the tissues under it. Boils are most common on the face, neck, armpit, buttocks, and thighs. There can be one or many boils. Pain gets worse as it fills with pus and dead tissue. Impetigo: Impetigo is a skin infection caused by bacteria. It is usually caused by staphylococcal bacteria, but it can also be caused by streptococcal bacteria. It is most common in children between the ages of two and six. It usually starts when bacteria get into a break in the skin, such as a cut, scratch, or insect bite. Symptoms of impetigo start with red or pimple-like sores surrounded by red skin. These sores can be anywhere, but usually they occur on face, arms and legs. The sores fill with pus, then break open after a few days and form a thick crust. They are often itchy, but scratching them can spread the sores. Impetigo can spread by contact with sores or nasal discharge from an infected person. Pilonidal Cyst: It is an abnormal pocket in the skin that usually contains hair and skin debris. A pilonidal cyst found always located near the tailbone at the top of the cleft of the buttocks. 33

36 These cysts occur when hair punctures the skin and then becomes embedded. If a pilonidal cyst becomes infected, the resulting abscess is often extremely painful. Pilonidal cysts most commonly occur in young men and the problem has a tendency to recur. People who sit for prolonged periods of time, such as truck drivers, are at higher risk of developing a pilonidal cyst. When it is infected it becomes a swollen mass (abscess) with pain, redness, drainage of pus or blood from an opening in the skin and foul smell from draining pus. Cellulitis: It is an infection of the skin and its deep underlying tissues and is commonly caused by group A Streptococcal bacteria. The bacteria enter in the body when there is an injury, such as a bruise, burn, surgical cut, or wound. It starts with fever and chills, swollen glands or lymph nodes, a rash with painful, red, tender skin. The skin may blister and scab over. ALL THE BEST!!! 34