College of Pharmacy/University of Baghdad .Clinical Pharmacy Dept Fourth Year. Community Pharmacy workshop.

2009-2010

SKIN CONDITIONS part I

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COLD SORE (or fever blister-1(

Cold sore is an infection caused by Herpes simplex virus 1 (HSV1) (1). Infection usually results from direct mucus membrane (e.g. kissing) contact at sites of abraded skin between an infected and .uninfected individual The virus then infect skin cells causing skin vesicles--------at the same time , nerve endings infected also -------then the virus travels to the sensory nerve ganglia where it lies dormant until reactivation(1). Once the virus has infected a host, it can go through a period of dormancy and reactivation, but that person is infected for life (2).

Patient assessment with cold sore:

1-location:
Cold sore typically occur around the mouth (and for this reason it called herpes simplex labialis).they can also occur inside and around the nose, but this is less common (1). Lesions inside the mouth or affecting the eye ----------referral (3) .

2-precipitating factors (2) :

Triggers of virus reactivation include: UV radiation, stress, fatigue, cold, fever, injury, menstruation, dental work, use of immunosuppressant drugs,

3-Appearance and Symptoms:

Herpes simplex lesion is often preceded by prodromal symptoms in which patient notices: burning, itching, tingling, or numbness in the area of the lesion (2) --------these symptoms may be noticed from a few hours to 3 days (1) ----------------followed by the appearance of redness, blisters and vesicles(3) (tend to itch and be painful(1) ) ------they quickly break down with exudation and crusting(3) . Cold sore resolved spontaneously within 7-14 days from the prodromal phase (1) . Accordingly: A-patient with painless sore -----referral (serious lesions ex. Cancer is painless and usually of long duration (3) ) .B-cold sore of more than 2 weeks duration (1) ------referral

:(previous history(help in the diagnosis-4

. (If a cold sore is returning in the same place in a similar way -------then it is likely to be cold sore (3 Note: when cold sore occur for the first time it can be confused with impetigo, however, impetigo usually more spread , has a honey colored crust, dose not necessarily start close to the lips, and ( more common in children----referral(oral antibiotics:(e.g.flucloxacillin) or topical( fusidic acid)) (3

Severity-5
. (lesions that are severe and widespread(e.g. spread rapidly over the face)------referral (1

:Medication-6
.A-medication used in the previous episodes (,B-Immunocompromised patients(e.g. patients taking ctotoxic chemotherapy , corticosteroid .(are at risk of serious and severe infection----referral (3--------

:Management :Practical point: preventing crossinfection-1

:Patient should be aware that HSV1 is contagious and transmitted by direct contact. Therefore ( A-use a separate towel (1, 2, 3 1

(.(B-wash the hand after applying the treatment (3). (To prevent spread of infection to the eyes (6 .(C-lesion should be kept clean by gently washing with mild soap solution (2

:Aciclovir-2
It is an antiviral cream which is if applied in the prodromal stage ----reduce the total healing :time of subsequent lesion (by a day or so) (1).Accordingly .(A-if the lesion have already appeared-------aciclovir is not effective (1 B-it should only be recommended to patients who experienced prodromal symptoms(1),( i.e. know when the cold sore is going to appear)-----told them to put the cream as soon as they feel the ( tingling or itching which precedes the appearance of the lesion(3 .(Dose and duration: apply the cream 5 times daily (at about 4 hours intervals .(Treatment should be continued for 5 days (1 .(It can be used by pregnant women (1*****

:Antiseptic-3
They prevent a secondary bacterial infection only (but don not reduce healing time, pain, or :discomfort) (3). Examples are A-Cetrimide (Celavex) cream: in addition to its antiseptic property, the cream formulation will moist the lesion and prevent drying and cracking which might predispose to a secondary bacterial .(infection (3 :B-povidone iodine (10%) solution: can be used after the age of 2 years (1).but .( it can be used during pregnancy (1**** ****it should be avoided during pregnancy and breast feeding (3). ) ) Topical anesthetics (e.g. benzocaine, lidocaine):they are used to relief burning, itching , and -4 .(pain(2

Fungal skin infections-2

:Terminology
1-two main groups of fungi infect man: Candida yeast and the dermatophytes (1).the term tinea refers exclusively to dermatophyte infections(2). 2-funcgal skin infection are commonly called ringworm (however this is inaccurate because a worm does not cause the infection and most lesion are not observed as a ring (1)). 3-Most often, tinea infections are named based on the area affected (2):

Site
Scalp Feet Groin Body Nails

Name
Tinea capitis Tinea pedis Tinea cruris Tinea corporis Tinea unguium (onychomycosis)

note
Required referral Called athlete's foot See note below

: ) OTC ,amorolfine 5% 2006 Alan Nathan. Non-prescription medicines . 2006

:(A-Athlete's foot (Tinea pedis

Athlete's foot is the most prevalent cutaneous fungal infection in human and it is more common in .(adult (2 2

Patient assessment with Athlete's foot: 1-Location:

The usual site of infection is in the toe webs, especially the web space between the fourth and fifth toe(3). Severe infection may affect other part of the foot (sole of the foot, or even the upper surface) -------referral (3). Also if the toenails involved (Tinea unguium) -------referral (3).

2-Appearance:
The skin in the web spaces appears white and (soggy). The area is normally itchy And the feet tend to smell (1).the skin become macerated and begin to peel off and the underneath skin usually reddened and may be sore (3).

3-severity (3):
Severe athlete's foot (broken and macerated skin with signs of bacterial involvement(weeping, pus or yellow crusts)-----referral.

4-previous history:
A- Athlete's foot may be recurrent ------so we ask about the previous bouts and action taken about there (3). B-Any diabetic patient (3) (or any other immunocompromised patients (2)) who present with athlete's foot-----best referred(diabetics may have impaired circulation or innervations of the feet, and low
immunity----more prone to secondary bacterial infection).

5-Medication(3):
To identify the identity and method (especially the duration) of use of any treatment. *athlete's foot unresponsive to appropriate medication------referral. Treatment timescale: 2 weeks.

Management: A-practical advice to prevent reinfection:

1-clean the skin daily with soap and water (2).Dry the skin thoroughly after bath. Keep a personal towel and dont share it to prevent the infection spreading from person to person (1). 2-Socks should frequently change (1) and washed regularly. Cotton sock can facilitate the evaporation of moisture, where as nylon socks will prevent this (3). 3-Avoid wearing occlusive, non-breathable shoes (1) (in summer, open toe sandals can be helpful (3)) and shoes should be left off where possible (3). 4-Dust shoes and socks with antifungal powder (1). (e.g. miconazole powder : a once daily prophylactic us of powder in shoes and socks is sufficient )

B-Antifungal: Antifungal
1-ketocdonazole 2-Terbinafine 3-miconazole 4-clotrimazole(fugidin) 5-tolnaftate(tinaderm)

Dose(daily applications)
Twice daily(3) Twice daily(3) Twice daily(3) Twice daily(3) Twice daily(3)

z
1 week(advantage) (3)(2-3 days after the disappearance of symptoms(1)) 1 week(advantage) (3) 2 weeks after the disappearance of symptoms to prevent relapse(3) 2 weeks after the disappearance of lesion to prevent relapse(3) Up to 6 weeks(3) (1 week after the disappearance of symptoms (1) )

Note: 1-Benzoic acid ( usually present in combination with salicylic acid(Whitfield's ointment))---is a traditional treatment for athlete's foot but its effectiveness is questionable(3) , and have been replaced by the above new agents(1). 2-Other OTC antifungal for athletes foot are : Econazole cream (pevaryl), Sulconazole cream , Griseofulvin spray, and undecenoates cream, powder and spray(5).

Practical point:
3

1-product should be applied after careful cleaning and drying of the foot especially between the toes (3). 2-they can be used during pregnancy (1) . 3-Agents used for cutaneous fungal infections are formulated as: creams, ointments, solutions, sprays, and powders. Creams or solutions are the most effective dosage form for the delivery of active ingredient to the epidermis. sprays and powders are less effective because they are often not rubbed into the skin.---------they are probably more useful as adjunct to creams and solutions or as a prophylactic agents in preventing new recurrent infections(2) . B-Tinea cruris (you will see the pictures in the lab). It is the fungal infection of the groin , inner thigh and may be spread to the buttocks(1) .the lesion is normally intensely itchy, reddish brown, and has a well defined edge(1).the problem is more common in men than in women(3). Treatment: by the same above antifungals.

C-Tinea corporis: (you will see the pictures in the lab).

Is a fungal infection of the major skin surface that do not involves hands, face, feet, groin or scalp . It occurs as an itchy circular lesion (ringworm: central clear area with a red advancing edge.) (3) Lesion can occur singly, be numerous, or overlap to produce a large lesion that appear polycyclic (several overlapping circular lesion) (1). Treatment: by the same above antifungals.
(1)

D-Pityriasis(tinea) versicolor (6,7)

Pityriasis versicolor, a superficial skin infection caused by a yeast, Malassezia furfur (previously known as Pityrosporum ovale, or Pityrosporum orbiculare) . The organism is more common in hot, sunny areas.

Signs and symptoms

1-Macular (flat) patches of altered pigmentation occurring mainly on the trunk and upper legs and arms. In white-skinned people patches are brownish and look as if suntanned, whereas on darkerskinned or heavily tanned people patches are pale or white. 2-The affected area has an overall dappled appearance. 3-There is a superficial scale that can be removed by scraping with a fingernail. 4-Pruritus, if any, is mild.

Differential diagnosis and circumstances for referral

The condition is most likely to be confused with vitiligo, but vitiligo is much more widespread over the body and usually includes the face.

Treatment
1-An imidazole cream applied daily for 3 weeks. 2-Or ketoconazole 2% shampoo. Apply undiluted and wash off after 5 minutes. Repeat daily for 1 week, then weekly for several weeks to prevent reinfection.

Additional advice
To prevent reinfection, ketoconazole shampoo should be used as above once a fortnight

3-Hair Loss
Hair loss affects both men and women and is associated with strong emotional and psychological consequences (1). The two major cause of hair loss are: 4

A-alopecia androgenetica(called male pattern baldness but sometimes called common baldness because it can affect women also)-----treated by the OTC minoxidil(3). B-Alopecia areata----sudden and patchy hair loss -----referral (3).

Patient assessment with alopecia androgenetica: 1-Age:

Patient under 18 years with hair loss -----required referral(1).(safety and efficacy of minoxidil are not established under this age) (2).

2-history and duration of hair loss:

Alopecia Androgenetica is characterized by gradual onset where : A-in men: the hair loss begin at the front of the head and recedes backward(1). Or it may begin on the top of the scalp (3).

b- In women: hair loss tend to be diffuse and generalized (3).

3-Size of the affected area (3):

If the diameter of the area is less than 10 cm -------then treatment is worth trying.

4-other symptoms:
A-coarsening of the hair and hair loss associated with recent weight gain, deepening of the voice , feeling of tiredness-------may indicate hypothyroidism------referral (3). B-hair loss associated with itching and redness of the scalp------may indicate inflammatory scalp condition( e.g. Tinea capitis, psoriasis, ..)--------referral(3).

5-specific events:
During pregnancy(or after childbirth)-----hormonal changes ------hair loss-----the patient should be reassured that this is completely normal and that the hair will grow back-------treatment is not appropriate(3).
(Pregnancy----increased estrogen levels-----hair thickening-----after delivery the hair loss occur to the normal prepregnancy state) (1).

6-Deficiency state:
Iron deficiency is associated with female hair loss. ( a 2-months course of iron supplementation should result in thickening of the hair ).

6-Medication:
A number of drugs can cause hair loss e.g.: cytotoxic (almost 100% of them to varying degrees), Anticoagulant, retinoid, oral contraceptive (seen 2 -3 months after stopping) (1), lipid lowering agents(3). If medicines other than cytotoxic are suspected of causing hair loss-----discuss possible alternative with the prescriber (3). 5

Treatment timescale: 4 months. Management: A-Minoxidil it available as 2% and 5% lotion: however Women should not use the 5% product, since it can cause hirsutism at other sites, such as the face, chest, ear rim, and back (4).

Practical points:
1-the earlier the use -----the more the successful (3). 2-response to minoxidil(3): a- In about 1/3 of patients------regrowth of normal hair. b- In about 1/3 of patients------ regrowth of fine(vellus) hair. c- In about 1/3 of patients------no any improvement. 3-Hair may continue to fall out for the first two weeks of minoxidil use (4). 4-after 4-6 weeks------the patient can expect to see a reduction in hair loss. 5--Application: In men Topical minoxidil is proven effective for hair growth only on the crown of the head. It has not been proven to grow hair on the front of the scalp and should not be applied there (4). a-apply it to dry scalp and hair. B-rub about 1 ml of the lotion to the area of the scalp twice daily. c-the hair should not be washed for at least 1 hour (3) (4 hours (2)) after using the lotion. But the hands should be washed after the application (2). 5-Long-term effect: A-after 30 months the effect is still greater than baseline but, not achieve cosmetically acceptable hair growth-----therefore minoxidil may be useful for patient who want to buy himself time from the inevitable balding process (1). B-new hair growth will fall 2-3 months after treatment is stopped (3). 6-manufacturer advice avoid in hypertension, angina, heart disease, pregnancy, and lactation(3). B- The POM drug finasteride (Propecia 1 mg tab.)(Dose 1mg/day)--------------- Inhibits the enzyme responsible for androgenetic alopecia------------is used to treat Alopecia Androgenetica in men (1).

Note: Other than minoxidil and Propecia, no remedies have been proven to regrow hair (4).

References: 1-Community Pharmacy. Symptoms, Diagnosis and Treatment. By Paul Rutter.2004. 2-Handbook of Non-prescription drugs.2002 3-Symptoms in the pharmacy . A guide to the managements of common illness. 4th edition By Alison Blenkinsopp and Paul Paxton .2002. 4-Joshua J. Pray, Steven Pray, Is Hair Loss Self-Treatable. Vol. No: 28:08 Posted: 8/15/03 5--Nathan A. Non-prescription medicines. 3rd edition. London: Pharmaceutical Press; 2006. 6- Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press; 2008. 7- Klaus Wolff. Fitzpatricks Color Atlas and Synopsis of Clinical Dermatology. Copyright 2007 The McGraw-Hill Companies.