KPhA s 133 rd Annual Meeting and Trade Show

Transcription

1 1 KPhA s 133 rd Annual Meeting and Trade Show

2 KPhA s 133 rd Annual Meeting and Trade Show Be the Critical Link DoubleTree by Hilton Hotel Overland Park, Kansas Dermatology September 21, 2013 Emily Prohaska, Pharm.D.

3 3 Disclosures Dr. Prohaska has no disclosures to report.

4 4 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.

5 Getting Started

6 6 Skin Structure

7 7 Types of Skin Lesions

8 8 Estimating Body Surface Area

9 9 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 tradename and generic products Allergies: medication and other types of allergies Conditions: other medical conditions

10 Irritant and Allergic Contact Dermatitis

11 11 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 exerciseinduced 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 TID B. Refer to provider; methylprednisolone 4 mg dosepak, tud x 6 days C. Refer to provider; prednisone 10 mg, taper x 21 days D. Refer to provider; triamcinolone 0.1% cream, aaa BID

12 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 12

13 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 13

14 ICD vs. ACD Feature/ Characteristic Location Symptoms Borders Time to symptom development after exposure Mechanism of symptom development ACD Exposed areas, often the hands Primarily pruritus Distinct lines and borders Days Immune reaction ICD Usually the hands Burning, stinging, pruritis, pain Less distinct Minutes to hours Direct damage to exposed tissues 14

15 15 Images taken from: Clinical Presentation ICD

16 16 Images taken from:: Clinical Presentation ACD

17 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 17

18 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 18

19 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 minutes as needed Oral antihistamines Use at bedtime to relieve itching 19

20 20 Non-Prescription Pharmacologic Therapy Moderate-severe dermatitis Aluminum acetate solution Add 1 tablet or package to 1 pint cool water Soak minutes tid or apply compresses PRN Colloidal oatmeal baths One packet (30 grams) per tubful Soak minutes once or twice daily Severe dermatitis Requires referral to provider

21 21 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

22 22 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

23 23 Topical Corticosteroids: Very/Super High Potency Drug Name Betamethasone dipropionate, augmented Clobetasol Diflorasone diacetate Brand Name(s) Vehicle Strength Generic Diprolene G, L, O 0.05% Yes Clobex*, Cormax, Olux, Temovate Apexicon, Psorcon C, F, G, L, O, Sh, So, Sp 0.05% Yes* O 0.05% Yes Fluocinonide Vanos C 0.1% No Flurandrenolide Cordran T 4 mcg/cm 2 No Halobetasol Ultravate C, O 0.05% Yes 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

24 24 Topical Corticosteroids: High Potency 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^, O Diflorasone diacetate 0.25%, 0.05%^ Yes 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

25 25 Topical Corticosteroids: Medium Potency Drug Name Betamethasone valerate Clocortolone pivalate Brand Name(s) Vehicle Strength(s) Generic Luxiq C, F^, L, O 0.01%; 0.12%^ No 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^, L 0.005%^; 0.05% Yes C=Cream; F=Foam; G=Gel; L=Lotion; O=Ointment; So=Solution ^: Vehicle supplied as indicated strength

26 26 Topical Corticosteroids: Medium Potency (cont d) Drug Name Hydrocortisone butyrate Hydrocortisone valerate Brand Name(s) Vehicle Strength(s) Generic Locoid C, L, O, So 0.1% Yes 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

27 27 Topical Corticosteroids: Low Potency Drug Name Alcometasone dipropionate Desonide Fluocinolone acetonide Hydrocortisone Brand Name(s) Vehicle Strength(s) Generic Aclovate C, O 0.05% Yes Desonate, DesOwen, Verdeso* Capex, Derma- Smoothe/FS Cortaid, Cortizone, U- cort C, F, G, L, O 0.05% Yes* C, Oi, Sh, So 0.01% Yes C, O, L^ 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 0.5%, 1%, 2.5%^ Yes

28 28 Oral Corticosteroid Comparison Drug Equivalent Dose Duration of Action Cortisone 25 mg Short ++ Dexamethasone 0.75 mg Long No Hydrocortisone 20 mg Short ++ Methylprednisolone 4 mg Intermediate No Prednisolone Prednisone 5 mg 5 mg Intermediate (12 24 hours) Intermediate (12 24 hours) Mineralocorticoid Activity + +

29 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 29

30 Atopic Dermatitis

31 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 31

32 32 Symptoms Papules and vesicles Intense itching Redness and chapping of the skin Crusting and scaling may also occur

33 33 Images taken from: Clinical Presentation

34 34 Self-Treatment Exclusions Involvement of large body surface areas < 2 years of age Secondary skin infection Severe condition with intense itching

35 35 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

36 36 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

37 Non-Prescription Therapies Astringents Aluminum acetate Dilute before use Soak 2-4 times daily for minutes Apply wet compresses as needed Witch hazel Topical corticosteroid Hydrocortisone Apply 3-4 times daily for up to 7 days 37

38 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 38

39 39 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 % 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

40 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 calcineurin inhibitors in these cases Consider chronic topical corticosteroids for those with frequent exacerbations 40

41 Urticaria

42 42 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 qday B. Self treat; loratadine 40 mg qday C. Self treat; loratadine 10 mg qday + famotidine 10 mg BID D. Refer to provider; prednisone 50 mg qday x 3 days

43 43 Overview Also known as hives Many causes, including allergy, cold, heat, or medication Can be acute or chronic

44 44 Symptoms Well defined wheals or plaques May be paler in center Can be swollen/raised or flat Highly pruritic Worsening at night

45 45 Images taken from:: Clinical Presentation

46 46 Self-treatment Exclusions Signs of angioedema Swelling of lips, throat, tongue Non-Pharmacologic Therapy Identification and removal of trigger exposure

47 47 Pharmacologic Therapy: Non-Sedating Antihistamines Drug Name Certirazine Brand Name Vehicle Strength Generic Typical Dose OTC Zyrtec Ch, Li^, T Fexofenadine Allegra Li*^, T Loratadine Claritin Ch, Li^, T 5mg 10mg 1mg/mL^ 5mg/mL^ 60mg 180mg 30mg/mL^ 5mg 10mg 5mg/mL^ Yes Yes* Yes Up to 40mg qday Up to 720mg qday Up to 40 mg qday Yes Yes Yes Ch=Chewable; Li=Liquid; T=Tablet ^: Vehicle supplied as indicated strength *: Preparation not available as a generic product

48 48 Pharmacologic Therapy: Sedating Antihistamines Drug Name Chlorpeniramine Brand Name Vehicle Strength Generic Chlor- Trimeton Li^, T, X^ Clemastine Tavist Li^, T Diphenhydramine Benadryl Ch*, Li, T Hydroxyzine Atarax Li^, T 4mg, 12mg^ 2mg/5mL^ 1.34mg, 2.68mg 0.67mg/5mL^ 12.5mg, 25mg 12.5mg/5mL 10mg, 25mg, 50mg, 100mg, 10mg/5mL^ Yes Yes Yes Yes Typical Dose 4mg QID 1.34mg QID 25mg QID 25mg QID OTC Yes Yes Yes* No Ch=Chewable; Li=Liquid; T=Tablet ; X=Extended release ^: Vehicle supplied as indicated strength *: Preparation not available as a generic product

49 49 Pharmacologic Therapy: H 2 Antagonists Drug Name Famotidine Brand Name Vehicle Strength Generic Pepcid T, Ch*, Li^ Nizatadine Axid Li, Cp, T Ranitidine Zantac T 10mg, 20mg, 10mg/mL^ 150 mg, 300 mg 15 mg/ml~ 75mg, 150mg, 300mg ~ Yes Yes Yes Typical Dose 10mg BID 150 mg BID 150mg BID OTC Yes* Yes~ 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

50 50 Pharmacologic Therapy - Refractory Add-on therapy options chronic urticaria or failed initial therapy H 2 antagonists Add-on to H 1 antagonists therapy Corticosteroid burst Prednisone 50mg x 3d Follow burst therapy with H 1 antagonists

51 51 Counseling Points Most cases will resolve spontaneously Initial selection of product should depend on patient schedule and ability to dose medication

52 Sunburn

53 53 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

54 54 Common Photosensitizing Medications Diuretics (especially thiazide-type) Chlorthalidone, furosemide, HCTZ Sulfonamides Sulfadiazine, sulfamethoxazole, sulfasalazine Sulfonylureas Glimepiride, glipizide Tetracyclines Doxycycline, minocycline, tetracycline

55 55 Symptoms Erythema of exposed skin Occurs 3-5 hours after exposure Begins healing after hours Blistering of exposed skin Increased sensitivity of skin to mechanical pressure Severe sunburn can lead to fever, chills, nausea/ vomiting, and shock

56 56 Images taken from: RM%2F88081&topicKey=DERM%2F6624&rank=1~68&source=see_link&search=sunburn&utdPopup=true Clinical Presentation

57 57 Self-treatment Exclusions < 6 months of age Severe systemic symptoms Nausea Fever Headache Extreme pain

58 58 Non-Pharmacologic Therapy 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

59 59 Non-Pharmacologic Therapy No therapies shown to decrease healing time Cold compresses Aloe-vera based gels Emollients Cover ruptured blisters with bandages

60 60 Pharmacologic Therapy Ibuprofen mg q4-6h Topical antimicrobials Mupirocin 2% Silver sulfadiazine

61 61 Counseling Points Photosensitizing medications New sunscreen labeling

62 Acne

63 63 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 BID B. Refer to provider; tretinoin 0.025% aaa qhs C. Refer to provider; spironolactone 50 mg qday + tretinoin 0.025% aaa qhs D. Refer to provider; doxycycline 100 mg BID + tretinoin 0.025% aaa qhs + benzoyl peroxide 5% aaa BID

64 64 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

65 65 Medication-Related Causes P.I.M.P.L.E.S. Phenytoin Isoniazid Moisturizers Phenobarbital Lithium Ethionamide Steroids Also azathioprine, cyclophosphamide, rifampin

66 66 Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16 th ed. Washington, DC: the American Pharmacists Association; Precursor Acne Lesions

67 67 Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16 th ed. Washington, DC: the American Pharmacists Association; Noninflammatory Acne Lesions

68 68 Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16 th ed. Washington, DC: the American Pharmacists Association; Inflammatory Acne Lesions

69 69 Symptoms and Classification Mild < 20 comedones; < 15 inflammatory lesions; < 30 total lesions Moderate comedones; inflammatory lesions; total lesions Severe > 5 cysts; > 100 comedones; > 50 inflammatory lesions; > 125 total lesions

70 70 Images taken from: Clinical Presentation

71 71 Self-Treatment Exclusions Moderate-severe acne Possible rosacea

72 72 Non-Pharmacologic Therapy Identify and avoid exacerbating factors Avoid touching face Washing face with mild soaps or cleansers BID UV exposure Hydration

73 73 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 AA=azelaic acid; BPO=benzoyl peroxide; OA=oral antibiotic; OAAn=oral antiandrogenic; OI=oral isotretinoin; SA=salicylic acid; TA=topical antimicrobial; TR=topical retinoid

74 74 Pharmacologic Therapy: Retinoids Drug Name Brand Name(s) Vehicle Strength(s) Generic Typical Dose Adapelene Differin C, G^, L 0.1%, 0.3%^* Yes* qhs Isotretinoin Absorica, Amnesteem, Claravis, Myorisan, Zenatane Cap 10, 20, 30, 40 mg Tazarotene Tazorac C, G 0.05%, 1% No qhs Tretinoin Atralin, Renova, Retin-A, Tretin-X C, G C=Cream; Cp=Capsule; G=Gel; L=Lotion ^: Vehicle supplied as indicated strength *: Preparation not available as a generic product 0.01%, 0.025%, %, 0.04%, 0.05%, 0.1% No Yes mg/kg/day in 1 to 2 divided doses qhs

75 75 Pharmacologic Therapy: Topical Antimicrobials Drug Name Benzoyl Peroxide Clindamycin Brand Name(s) Vehicle Strength(s) Generic Typical Dose Oscion, PanOxyl Cleocin, ClindaGel C, G, L, Pl F, G, L, Pl, So 2.5%, 5%, 10% Yes BID 1% Yes qday BID Dapsone Aczone G 5% No BID Erythromycin Sulfacetamide Akne-Mycin, Ery Klaron, Ovace G, Pl, So 2% Yes BID L, Su, W 10% Yes BID C=Cream; G=Gel; L=Lotion; Pl=Pledget; So=Solution; Su=Suspension; W=Wash

76 76 Phamacologic Therapy: Oral Antibiotics Drug Name Doxycycline Brand Typical Name(s) Vehicle Strength(s) Generic Dose Doryx, Monodox*, Vibramycin Cp, T; TX 50, 75, 100, 150, 200 mg Yes* Erythromycin Ery-tabs T 500 mg Yes BID Minocycline Minocin, Solodyn Cp, T, TX^ Cp: 50, 75, 100 mg T: 45^, 50, 55*^, 65*^, 80*^, 90^, 100, 105*^, 115*^, 135 mg^ Yes qday BID 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

77 77 Phamacologic Therapy: Misc. Drug Name Azelaic acid Combination oral contraceptives Salicylic Acid OTC Brand Name(s) Vehicle Strength(s) Generic Azelex, Finacea C, G 15%, 20% No BID Typical Dose Various T Various Yes qday Neutrogena, Stridex, others Spironolactone Aldactone T C, F, G, Pl C=Cream; F=Foam; G=Gel; Pl=Pledget; T=Tablet 2% Yes qday BID 25, 50, 100 mg Yes 25 to 200 mg in 1 to 2 divided doses

78 78 Pharmacologic Therapy: Combination Products Drug Name BPO Adapalene BPO Clindamycin BPO Clindamycin BPO Erythromycin Clindamycin- Tretinoin Brand Name(s) Vehicle Strength Generic Typical Dose Epiduo G 2.5% - 1% No qhs Benzaclin G 5% - 1% Yes BID Acanya *, Duac G 2.5% - 1.2% Yes * qday Benzamycin G 5% - 3% Yes BID Veltin; Ziana G 1.2% % No qhs BPO=Benzoyl Peroxide; G=Gel *: Preparation not available as a generic product

79 79 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

80 Insect Bites

81 81 Overview Reactions caused by bites from many species of insects Rarely dangerous, but highly irritating to the patient

82 82 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

83 83 Images taken from:: Clinical Presentation Chigger bites Brown recluse spider bite Mosquito bites Scabies

84 84 Self-Treatment Exclusions <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

85 85 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

86 86 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

87 87 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

88 88 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

89 Pediculosis

90 90 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 treatment B. Self treat; repeat permethrin 1% and comb for nits C. Refer to provider; spinosad 0.9% x 1 application D. Refer to provider; SMZ-TMP mg BID x 10 days

91 91 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

92 92 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

93 93 Images taken from:: Clinical Presentation

94 94 Self-treatment Exclusions <2 years of age Infestations involving the eyelids or eyebrows Pregnancy or breast-feeding Allergy to chrysanthemums

95 95 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

96 96 Pharmacologic Therapy: Pediculicides Drug Name Citric acid, cytanyl 5, isopropanol Brand Name Vehicle Strength Generic Typical Dose Lycelle G -- No 1x No Ivermectin Sklice L 0.5% No 1x No Permethrin Nix L 1% Yes 1x Yes Pyrethrins/ piperonyl butoxide RID, Tisit, Pronto Sh, L, G, M^ 0.3%/3%, 0.3%/4%^ OTC No 1x Yes Spinosad Natroba Li 0.9% Yes 1x No G=Gel; Li=Liquid; L=Lotion; M=Mousse; Sh=Shampoo; ^: Vehicle supplied as indicated strength

97 97 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

98 98 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

99 Fungal Skin Infections

100 100 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 welldefined, 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 weeks B. Self treat; miconazole powder, aaa BID x 4 weeks C. Self treat; tolnaftate spray, aaa BID x 4 weeks D. Refer to provider; terbinafine 250 mg qday x 12 weeks

101 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

102 102 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

103 103 Images taken from: Clinical Presentation

104 104 Self-Treatment Exclusions 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

105 105 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

106 106 Pharmacologic Therapy: Azole Antifungals Drug Name Brand Name Vehicle Strength Generic Typical Dose 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% No qday or BID OTC No C=Cream; L=Lotion; O=Ointment

107 107 Pharmacologic Therapy: Amines & Miscellaneous Drug Name Butenafine Ciclopirox Brand Name(s) Vehicle Strength(s) Generic Typical Dose Mentax, C 1% No Loprox, Penlac C, G, La %, Su^ 0.77%^, 1% Yes Naftifine Naftin C^, G % 1%, 2%^ No Terbinafine Tolnaftate Lamisil Tinactin T^ C, G, P, So, Sp C=Cream; G=Gel; La=Laquer; So=Solution; Sp=Spray; Specified product available OTC %: Dosing for specified vehicle ^: Vehicle supplied as indicated strength 1%, 250 mg^ Yes qday or BID qday % BID or qday % or BID qday or BID OTC No Yes 1% Yes BID Yes

108 108 Product Selection Creams, solutions Most efficient and effective Sprays, powders Adjunct therapy Prophylaxis Active ingredient(s) Check product labeling

109 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

110 110 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

111 111 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 exerciseinduced 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 TID B. Refer to provider; methylprednisolone 4 mg dosepak, tud x 6 days C. Refer to provider; prednisone 10 mg, taper x 21 days D. Refer to provider; triamcinolone 0.1% cream, aaa BID

112 112 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 qday B. Self treat; loratadine 40 mg qday C. Self treat; loratadine 10 mg qday + famotidine 10 mg BID D. Refer to provider; prednisone 50 mg qday x 3 days

113 113 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 BID B. Refer to provider; tretinoin 0.025% aaa qhs C. Refer to provider; spironolactone 50 mg qday + tretinoin 0.025% aaa qhs D. Refer to provider; doxycycline 100 mg BID + tretinoin 0.025% aaa qhs + benzoyl peroxide 5% aaa BID

114 114 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 treatment B. Self treat; repeat permethrin 1% and comb for nits C. Refer to provider; spinosad 0.9% x 1 application D. Refer to provider; SMZ-TMP mg BID x 10 days

115 115 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 welldefined, 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 weeks B. Self treat; miconazole powder, aaa BID x 4 weeks C. Self treat; tolnaftate spray, aaa BID x 4 weeks D. Refer to provider; terbinafine 250 mg qday x 12 weeks

116 116 Acknowledgements Amanda Applegate, Pharm.D.

117 References 1. Berardi R, Ferreri S, Hume A, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16 th ed. Washington, DC: the American Pharmacists Association; Lexi-Comp Online TM, Lexi-Drugs Online TM, Hudson, Ohio: Lexi-Comp, Inc.; Longyhore DS. Dermatology and HEENT. ACCP Updates in Therapeutics 2013: The Ambulatory Care pharmacy Preparatory Review and Recertification Course. ACCP: Mayoclinic.com. Dermatitis. Updated 24 April Hogan D. Contact dermatitis, irritant. Updated 16 October Hogan D. Contact dermatitis, allergic. Updated 3 June Usatine R & Riojas M. Diagnosis and management of contact dermatitis. American family Physician. 2010; 82(3): Mayoclinic.com. Atopic dermatitis (eczema). Updated 22 August NIAMS. Atopic dermatitis. Updated May Weston WL & Howe W. Treatment of atopic dermatitis (eczema). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, PL Detail-Document, Comparison of Topical Corticosteroids. Pharmacist s Letter/Prescriber s Letter. September Using oral corticosteroids: a toolbox. Pharmacist's Letter/Prescriber's Letter 2010;26(5): Bingham CO. New onset urticaria. In UpToDate, Sani S; Callen J (ed), UpToDate, Waltham, MA FDA.gov. FDA sheds light on sunscreens. Updated 20 August Young AR; Tewari A. Sunburn. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA Graber E. Treatment of acne vulgaris. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, PL Detail-Document, Pharmacotherapy of Acne. Pharmacist s Letter/Prescriber s Letter. August Goldstein AO & Goldstein BG. Pediculosis capitis. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA Goldstein AO & Goldstein BG. Pediculosis corporis. In UpToDate, Basow, DS (ed), UpToDate, Waltham, MA Goldstein AO & Goldstein BG. Dermatophyte (tinea) infections. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, Topical treatment of superficial fungal infections. Pharmacist's Letter/Prescriber's Letter 2009;(8):

118 Questions? Emily Prohaska, Pharm.D.