a common, chronic, inflammatory skin disorder of the pilosebaceous unit (hair follicle and surrounding sebaceous glands).
substance that constricts skin tissue to decrease inflammation, relieve itching, and dry up secretions.
a common bacterial infection of the skin that occurs after skin trauma or abrasion and is characterized by a nonelevated, red, hot, and painful area of the skin with possible swelling.
Comedo or comedones (plural)
primary acne lesion, thought to be formed by the plugging of the pilosebaceous unit.
an acute or chronic inflammatory, erythematous (red in color) rash, which may be caused by skin contact with an allergen or irritant.
substance that softens or soothes the skin by slowing the evaporation of water.
inflammation of hair follicles.
a contagious bacterial infection that occurs most commonly on the face of children and is characterized by pus-filled blisters that burst to form a thick yellow crust.
chronic inflammatory skin disorder most commonly characterized by red lesions, or plaques, with silvery-white scales.
common fungal infections of the skin that occur mostly on areas of the skin that are moist and poorly ventilated, such as the feet or groin.
After completing this chapter, you should be able to
Define the most common dermatologic disorders.
Explain the disease process (pathophysiology) of each dermatologic disorder.
Describe nonpharmacologic treatment options for dermatologic disorders.
State the brand and generic names of the most widely used medications indicated for dermatologic disorders, along with their routes of administration, dosage forms, and available doses.
Explain the mechanism of action and common adverse effects of prescription and nonprescription agents for the treatment of dermatologic disorders.
Recognize commonly used treatment regimens for each dermatologic disorder.
The skin, as the largest organ, is subject to many of the same types of disorders as other parts of the body. These include infection, inflammation, and autoimmune disease, although these often cause different symptoms when they affect the dermatologic system. Some diseases that are distinctively considered skin conditions are actually caused by a combination of factors. Patients are usually able to see and localize dermatologic problems more easily and specifically than issues involving internal organs, and they frequently seek advice from pharmacists about self-treatment.
Acne is characterized by the formation of comedones, or lesions, in the pilosebaceous units of the skin. The pilosebaceous units include the hair follicle and surrounding sebaceous glands. Acne lesions are most commonly found on the face, chest, and back. While these lesions are self-limiting, they may lead to scarring and psychological distress.
Mr. Josh Jones is an 18-year-old Caucasian male with mild to moderate acne lesions on his face, back, and chest, which have been present for 6 months. Mr. Jones has tried frequent face and body washings with no improvement. He has both open and closed comedones and is known to pick at them, leading to increased redness and irritation. His freshman year of college is quickly approaching and Mr. Jones is anxious to improve his complexion and avoid the embarrassment of his breakouts.
Four factors contribute to the formation of comedones: increased sebum production, sloughing of keratinocytes, bacterial growth, and inflammation. An increase in androgen, as seen during puberty, or an increased response to androgen leads to increased sebum production from the sebaceous glands. Increased sebum may result in plugged sebaceous glands and the formation of a comedo. The sloughing or turnover of keratinocytes in the hair follicle is a normal process; however, in acne there is excessive sloughing of the skin cells, which may adhere together and cause blockage of the hair follicle and sebaceous glands, leading to an open comedo or blackhead. Blackheads appear dark due to the accumulation of the pigment melanin. Propionibacterium acnes (P. acnes), a bacterium that is normally found in the hair follicle, grows rapidly in the mixture of sebum and keratinocytes. The increased sebum, keratinocyte sloughing, and bacterial proliferation leads to inflammation and the appearance of a closed comedo or whitehead. Whiteheads may appear as small, 1–2 mm, white, elevated lesions.
Mild acne can be managed with the use of a variety of medications and treatment regimens. Antimicrobials and retinoids are among the most commonly used medication classes for the treatment of acne. The range of treatment regimens include the use of just one medication, a combination of medications, or a combination of medication and nonpharmacologic therapy.
Acne management usually begins with nonpharmacologic treatments. Patients should use a mild, nondrying facial soap or nonsoap cleanser twice daily. Excessive washing or scrubbing does not typically reach deep enough into the follicles to remove plugging and should be avoided. Harsh, abrasive products may worsen acne and patients should avoid oil-based cosmetics or shampoos. Clothing, headbands, and helmets may induce irritation, resulting in acne lesions. Avoiding pinching, squeezing, and other manipulation of the lesions is important to reduce the chances of further inflammation or scarring. Changes in diet, through restriction of specific foods, have not been demonstrated to be of benefit in the treatment of acne.
What nonpharmacologic treatment options might be appropriate for Mr. Jones?
Pharmacologic treatment of acne is available in a wide variety of preparations and dosage forms. Some are sold over the counter (OTC) and others are available only by prescription. Medication Table 33-1 summarizes representative products. (Medication Tables are found at the end of the chapter.) One of the most common agents used in the management of mild acne is topical benzoyl peroxide. Although the precise mechanism is unknown, benzoyl peroxide has been shown to have antibacterial activity against P. acnes. It also increases keratinocyte turnover and the loosening of follicular plugs, which helps to unclog pores. Benzoyl peroxide is applied topically and is available in a variety of both nonprescription and prescription preparations in concentrations ranging from 1% to 10%. These preparations may cause dryness and irritation, which can sometimes be limited by using products of lower concentration and decreasing the frequency of use. The effectiveness of benzoyl peroxide may be enhanced when used in combination with topical retinoids or topical antibiotics.
Topical retinoids (tretinoin, adapalene, tazarotene, and trifarotene) are used as first-line agents for the treatment of mild acne and are often combined with benzoyl peroxide or topical antimicrobials in moderate acne. Most are prescription products, although adapalene is available OTC in some formulations and strengths. They work by increasing cell turnover in the follicle, thereby promoting unclogging. Adverse effects that may be experienced with topical retinoid use include redness, irritation, dryness, peeling, and photosensitivity (sensitivity to ultraviolet light or sunlight). Patients may experience an initial worsening of their acne with topical retinoid use and may not see significant lesion improvement for several months. Adverse effects may be minimized by initiating treatment with a low potency formulation and titrating to higher potency formulations as needed.
Products containing benzoyl peroxide may stain clothing, bed linens, and hair.
For inhibition of P. acnes, topical antimicrobials (clindamycin, erythromycin, and dapsone) may be prescribed in combination with topical retinoids and benzoyl peroxide for the treatment of mild to moderate acne. Each of these antibiotics is formulated in a variety of dosage forms. Adverse effects include dryness, redness, and itching. Although rare and most often associated with oral clindamycin use, diarrhea and pseudomembranous colitis (discussed in Chapter 27) may also occur with topical use.
Dapsone may cause temporary yellow or orange skin discoloration when used with benzoyl peroxide.
Azelaic acid is another (prescription only) topical agent useful in the treatment of mild to moderate acne. It is reserved for patients who are unable to tolerate benzoyl peroxide or topical retinoids. Its mechanism of action includes anti-inflammatory and antibacterial properties, as well as skin-lightening properties that may be useful in treating hyperpigmentation (skin darkening) due to acne. Overall azelaic acid is well tolerated; however, patients may experience burning, itching, stinging, or peeling.
Some cases of moderate or severe acne cannot be treated effectively with topical agents. Physicians sometimes prescribe oral antimicrobials (erythromycin, tetracycline, doxycycline, minocycline, and sarecycline) for these patients. Because they can limit the colonization and anti-inflammatory properties of P. acnes, the oral antimicrobial agents treat and prevent the formation of new acne lesions. Tetracycline, doxycycline, minocycline, and sarecycline can cause gastrointestinal upset and phototoxicity, and all antibiotics mentioned here have drug interactions with antacids and iron. Erythromycin may also cause gastrointestinal disturbances and has many drug interactions. Despite its effectiveness against P. acnes, oral clindamycin is rarely used due to the risk of pseudomembranous colitis. Long-term use of oral antibiotics may lead to the development of antibiotic resistance and treatment failure. For this reason, oral antibiotic use is seldom prescribed as monotherapy and is usually limited to short treatment courses.
Bacterial resistance is reduced by combining topical erythromycin or clindamycin with benzoyl peroxide, so patients must be reminded that it is important to use both products as directed by their physicians, even if they are using an OTC preparation of benzoyl peroxide.
Prescribers, pharmacies, drug wholesalers, manufacturers, and all patients, male or female, taking isotretinoin must be enrolled in and comply with the iPLEDGE program, a pregnancy prevention and management program. Certain procedures must be followed, including the use of multiple forms of birth control and monthly pregnancy tests. (Prescriptions must be picked up by the patient within 7 days of the test.) For more information, visit the iPLEDGE website (https://www.ipledgeprogram.com).
Isotretinoin is an oral retinoid and is typically reserved for the treatment of acne not responsive to topical and systemic agents. By causing atrophy of the sebaceous gland, decreasing sebum production, inhibiting P. acnes, and decreasing inflammation, isotretinoin is considered the most effective agent for the treatment of acne. Furthermore, a 15- to 20-week treatment course may lead to the complete remission of acne lesions. Side effects that are frequently reported with isotretinoin include dryness of the skin, nose, mouth, and eyes (in approximately 90% of patients), peeling skin, itching, photosensitivity, increased triglycerides, increased blood glucose, muscle pain, and depression. The initial cost of treatment with isotretinoin in severe acne may be more expensive than other agents; however, in the long term it may be more cost effective. Isotretinoin is a known teratogen, and its use by pregnant women carries a high risk of severe birth defects such as craniofacial, cardiovascular, thymus, parathyroid gland, and CNS (central nervous system) structure malformations. Spontaneous abortion and premature birth may also occur with fetal exposure.
For female patients with moderate to severe acne, estrogen-containing oral contraceptives are sometimes considered as second-line agents because they decrease sebum production by decreasing androgen levels. The US Food and Drug Administration (FDA) has approved products containing ethinyl estradiol and norgestimate or ethinyl estradiol and norethindrone for the treatment of acne; however, other estrogen-containing contraceptives are considered to be equally effective. Spironolactone, along with its derivative, drospirenone, may also be used for the treatment of acne. Spironolactone and drospirenone are considered to have antiandrogen effects due their ability to block androgen receptors. Drospirenone is found in combination with ethinyl estradiol in the oral contraceptive, Yaz®. Spironolactone, when prescribed for the treatment of acne, is used at high doses (50–200 mg) and may cause hyperkalemia (high potassium in the blood), menstrual irregularities, or breast tenderness.
Mr. Jones has not tried any nonprescription or prescription pharmacologic agents for the treatment of his acne. Which pharmacologic agent(s) might be appropriate for his use?
Psoriasis is a chronic skin disease characterized by lesions, also called plaques, which are generally well defined, raised, and red to violet in color, and with silvery-white scales (Figure 33-1). Lesions are found most commonly on the scalp, elbows, knees, hands, feet, trunk, and nails and can vary in size from pinpoint to covering large areas of the body. Removal of the scales or trauma to the lesion can lead to bleeding. Patients often complain of intense itching at the site of the plaques.
Mrs. Roberts, a 52-year-old woman, presents to the pharmacy complaining of intense itching on her elbows, knees, and hands. She has very defined dark red lesions in these areas covered with white, loose scales. Areas where she has scratched the lesion and removed some of the scales have small scabs where bleeding occurred.
Approximately 2% of the US population is affected with psoriasis, which is known to have a strong genetic component. Ethnicity may also play a role, with lower prevalence rates among African Americans compared to the general population. Environmental factors such as trauma to the skin, infection, seasonal changes, and medications may trigger the eruption (formation) of new plaques or the worsening of existing plaques. Patients may experience periods of remission, where no lesions are present, lasting from weeks to years. Despite remission, however, psoriasis remains a chronic condition for which there is no cure.
Psoriasis is an autoimmune disorder involving the T cells. Patients with psoriasis have an abnormal number of certain T cells present in the skin. Activation of the T cells by an environmental factor leads to the release of cytokines such as interleukin-2 (IL-2), interferon-γ (IFN-γ), tumor necrosis factor (TNF-α), and others. These cytokines promote inflammation and rapid cell growth, particularly keratinocytes, leading to the development of skin lesions.
What information in the case suggests Mrs. Roberts may be suffering from psoriasis?
The management of psoriasis centers on modification of the immune response that leads to plaque development. Both nonpharmacologic and pharmacologic therapies may be used and therapies are often combined or alternated. Treatment choice usually depends on the severity of the disease. Mild to moderate psoriasis is typically managed with topical agents, phototherapy, or oral agents, while more severe disease is managed with combination therapy or injectable biologic agents. Disease severity is determined by the percentage of body surface area affected and the effect of psoriasis on the patient’s quality of life. The use of biologic agents earlier in disease progression is becoming more common, as these therapies may result in remission (complete clearing of the lesions) and improved quality of life. Combinations of topical agents or topical and oral agents are often used in moderate to severe cases.
Nonpharmacologic therapies may provide additional relief for patients with psoriasis, especially when combined with pharmacologic therapies. Emollients are often added to other pharmacologic therapies or used alone during drug-free periods. Their usefulness comes from their ability to hydrate (moisturize) the stratum corneum, minimize water loss, increase skin pliability, and decrease itching. They are most effective when used multiple times per day. Some emollients may cause folliculitis or contact dermatitis.
Emollients should be applied after showering or bathing. When used with other topical therapies, they should always be applied after (rather than before) the pharmacologic agent.
What nonpharmacologic treatment(s) might the pharmacist recommend for Mrs. Roberts?
Phototherapy involves skin exposure to either ultraviolet A (UVA) or ultraviolet B (UVB) rays to help clear skin lesions. A topical pharmacologic agent, usually methoxsalen, may be applied prior to exposure to make the skin more sensitive to UVA rays. Phototherapy is usually prescribed two to three times per week. Adverse effects include nausea, dizziness, headache, increased risk of melanoma, and possibly nonmelanoma cancers. Other topical agents are not typically used with PUVA (psoralen and ultraviolet A phototherapy) unless they are applied after treatment. UVB therapies are often used alone, but they may also be used with the topical pharmacologic therapies described later.
Topical corticosteroids are the most commonly used agents for the management of psoriasis. Corticosteroids are classified by their potency from low to very high (Medication Table 33-2), based on their ability to cause blood vessel constriction. The agents that are the most potent constrictors provide the most anti-inflammatory relief; however, they also have the highest risk for adverse effects and cannot be used for long periods of time. Very-high- and high-potency corticosteroids should be used for the shortest time possible, on the smallest body surface area needed, and may be effective when used as infrequently as 1 or 2 days per week, especially when combined with vitamin D analogues. Lower-potency steroids are safer for use on the face, groin, armpits, and skinfolds and should be used for children or patients who must cover large areas of the body. These products may be applied 2 to 4 times daily. All topical steroids can cause streaks or lines in the skin, known as striae, skin atrophy or thinning, acne, skin infections, and a flushed swelling of the face called rosacea. Long-term use may lead to systemic corticosteroid adverse effects or adrenal suppression. Patients may experience a worsening of psoriasis when discontinuing corticosteroids, an effect known as tachyphylaxis.
In addition to corticosteroids, other treatments for psoriasis include vitamin D analogues, keratolytic agents, oral agents, and biologic agents. Some are for topical use and others are administered for their systemic effects. Medication Table 33-3 details the drugs in each class.
Vitamin D analogues (calcipotriol, calcipotriene) and the topical retinoid tazarotene (discussed with the acne treatments), affect keratinocyte function and alter the immune response. Vitamin D analogues may cause burning and stinging in approximately 10% of patients, which may be lessened by combination therapy with topical corticosteroids. The combination of vitamin D analogues and topical corticosteroids improves psoriasis more than either agent alone. Tazarotene may also cause skin irritation and can be combined with topical corticosteroids. Women using tazarotene should be advised that it is teratogenic.
Acitretin is teratogenic and contraindicated in pregnant women and women who intend to become pregnant within 3 years following discontinuation of treatment.
Acitretin is an oral retinoid that is considered to be a first-line oral agent for the treatment of severe psoriasis. The combination of acitretin with other therapies such as UV light therapy and topical calcipotriol is very effective and may limit adverse effects from either agent. Acitretin is teratogenic and should not be used in anyone who is pregnant or intending to become pregnant at any time during therapy or for up to 3 years after therapy. Concurrent use of alcohol increases the elimination half-life of acitretin; therefore, alcohol should be avoided during therapy and for up to 2 months after treatment. Other adverse effects of acitretin include lipid abnormalities, dry mucous membranes (lips, mouth, eyes, nose, skin), and hepatotoxicity.
Long-term use (>2 years) of cyclosporine may increase the risk of cancer.
Other options for oral treatment of psoriasis include cyclosporine, methotrexate, and other immunosuppressive agents. Methotrexate and cyclosporine therapy are often alternated or rotated to minimize the systemic toxicities of each agent. Cyclosporine is an immunosuppressive agent that inhibits T cell activation and may be used alone or in combination with calcipotriol or methotrexate for the treatment of psoriasis. To limit the risk of toxicity, the dose of cyclosporine should not exceed 5 mg/kg/day and the dose should be decreased if the patient’s kidney function is impaired.
Methotrexate is teratogenic and contraindicated in pregnant women.
Methotrexate inhibits T and B cell function and is associated with gastrointestinal side effects such as nausea and vomiting, which can be minimized by dividing the daily dose. Patients taking methotrexate are at risk for bone marrow toxicity, which may present as leukopenia (low white blood cells), anemia (low red blood cells), or thrombocytopenia (low platelets); patients should be monitored through monthly complete blood counts.
Biologic psoriasis therapy is typically used only for severe disease. All of the five FDA-approved agents—adalimumab, alefacept, etanercept, infliximab, ustekinumab, and secukinumab—are very costly. Though each agent differs in mechanism of action, all modify the T cell activation or response. Biologic agents impair the immune system and place the patient at a higher risk for infection and possibly cancer. For this reason, patients should be evaluated for latent tuberculosis through a tuberculin skin test (PPD) prior to therapy. The adverse effect profiles of the biologic agents vary, as well as their effectiveness in plaque improvement and length or duration of plaque remission.
Oral psoriasis therapies are generally reserved for patients who have failed topical therapy or who have moderate to severe disease.
Because their immune systems may be impaired, patients being treated with biological therapy should not receive live or live attenuated vaccines.
Dermatitis is a general term that refers to an inflammatory condition of the skin. There are many different types of dermatitis; however, this chapter describes the two types of contact dermatitis: irritant and allergic. The difference between these subgroups depends on whether the cause is an antigen (allergic) or irritant. Presentation of an allergen in allergic contact dermatitis triggers an allergic response; however, irritant contact dermatitis is not an allergic response but rather an inflammatory reaction as a result of direct irritation, most commonly due to chemical exposure.
If Mrs. Roberts gets a prescription for etanercept to treat her psoriasis, what types of vaccines might not be appropriate for her?
Irritant Contact Dermatitis
Jennifer Johnson, a 12-week-old infant, is brought into the pharmacy by her mother. Ms. Johnson is extremely upset because the rash on her daughter’s upper thighs and buttocks, which began light pink, has become darker red and appears to be very irritating to the child. The rash appeared 2 days ago and she suspects that her daughter’s diaper is not being changed frequently at daycare.
Exposure to chemicals, such as strong acids or bases, detergents, solvents, and oxidizers, may cause irritant dermatitis, which occurs most commonly due to the exposure of unprotected skin in the workplace. Irritant dermatitis may also occur as a result of prolonged skin exposure to urine or feces, which is the cause of diaper dermatitis, a subtype of irritant dermatitis. Exposure to these substances is thought to cause direct damage to the dermal layer of the skin, destroying the skin structure and impairing its function. Damage to the dermal layer increases the risk for further irritation and infection, so prompt, effective treatment is important.
Irritant contact dermatitis most commonly presents as a red, raised, or swollen rash. Papules or blisters are not typically seen in diaper dermatitis or mild cases of irritant dermatitis but may be seen in moderate to severe cases. Patients may complain of irritation, itching, stinging, or burning. The rash may range from light pink with poorly defined edges to dark red with a clear edge.
After exposure and throughout treatment, the area should be cleaned with copious amounts of lukewarm water and a mild soap. For cases of diaper dermatitis, the area should be allowed to air dry fully before another diaper is applied and diaper changes should be done as frequently as possible to avoid urine and fecal contact with the skin. Occlusive diapers and clothing over areas of exposure should be avoided, if possible. Patients can be reminded of methods to avoid repeat exposure, such as wearing gloves or other protective clothing.
Skin barriers or protectants, such as zinc oxide, petrolatum, lanolin, and vitamin A and D, form an occlusive barrier between the skin and offending agent to avoid skin irritation. These agents can be applied after every diaper change and discontinued when the rash resolves. Skin protectants are available in a variety of formulations, including creams, ointments, and pastes, and are often combined with moisturizers.
Astringents, such as aluminum acetate and calamine lotion, and topical steroids, such as hydrocortisone cream, may be used to relieve itching in adults. The use of topical steroids should be limited to the lowest potency and to a maximum of a 2-week treatment duration in infants. Antibacterials and antifungals should only be used in cases of infection and only when prescribed by a physician. Adults may experience relief from itching with an oral antihistamine. The FDA has determined that OTC oral antihistamines are neither safe nor effective in children younger than 2 years of age and product labels now recommend against their use in children under the age of 4. Diphenhydramine, hydroxyzine, or doxylamine have sedative effects, which may be useful for intense itching at night, although some patients may experience excitability or restlessness upon administration. The use of topical antihistamines should be avoided due to the risk of an allergic reaction. Medication Table 33-4 lists some representative agents useful in the treatment of dermatitis.
Allergic Contact Dermatitis
Aaron Murphy, a 25-year-old male, presents to your pharmacy with complaints of itching and shows you a red, raised rash on his arms. He tells you that he had spent the weekend clearing brush with his father on his family’s property while wearing gloves and work boots. He admits his other clothing was just a T-shirt and shorts. He says his rash looks similar to the one he had before when he came into contact with poison ivy while camping.
What might the pharmacist recommend for the treatment of baby Johnson’s diaper dermatitis?
Allergic contact dermatitis is caused by direct contact with an object, such as a plant, or a fomite (an object that contacted the plant) or by inhalation. Metals, medications, and chemicals can all cause an allergic reaction; however, allergic contact dermatitis is most commonly caused by exposure to urushiol oil, which is found in poison ivy, poison oak, or poison sumac plants. Skin contact and presentation of the antigen leads to an allergic reaction and an inflammatory response in the dermal layers of the skin.
Patients typically present with red, elevated lesions or blisters and intense itching. After the first few days, the lesions may break open and begin to weep and crust. Contact dermatitis is not spread by touching the weeping pustules of an individual with an eruption of contact dermatitis and the disease state is self-limiting, meaning that if untreated, the lesions will clear in approximately 1 to 3 weeks with or without treatment.
What information in Mr. Murphy’s case supports a diagnosis of allergic contact dermatitis rather than something else?
After initial exposure to an antigen, patients should wash skin and clothing immediately using regular soap and laundry detergent. Any objects or tools that may be contaminated should also be cleaned, as urushiol oil, for example, may remain and cause dermatitis on subsequent exposures. Once any remaining antigens have been washed away, cool, soapless showers or the application of a cool, moist compress may relieve the itching associated with allergic dermatitis. The application of harsh or abrasive cleansers is not recommended; only gentle soaps, if needed, should be used. Emollients should be liberally applied after bathing.
Astringents, such as aluminum acetate, witch hazel, calamine, zinc oxide, and sodium bicarbonate, cause a drying effect that helps to soothe weeping or oozing lesions, relieve itching, and decrease inflammation. Patients may apply these agents as soaks, compresses, or other topical products. Examples of these are listed in Medication Table 33-4.
Topical corticosteroids (Medication Table 33-2) decrease inflammation and redness and relieve itching. Hydrocortisone cream or ointment may be applied up to four times daily. To minimize the risk of infection, do not place hydrocortisone ointment over weeping lesions, as it can be occlusive and encourage bacterial growth. Soaking the affected area in a colloidal oatmeal bath (Aveeno®) for 15 to 20 minutes may relieve itching. Keep the bath water running or stirred to avoid clumping and use caution when exiting the bathtub as the bath may be slippery. Following the bath, pat the skin dry, leaving the colloid film on the skin. Oral antihistamines (diphenhydramine, hydroxyzine, doxylamine) may relieve itching, either through the blockade of the histamine (H1) receptor or by sedation. Oral antihistamines may cause dizziness, blurred vision, confusion, and low blood pressure.
What treatments, nonpharmacologic and pharmacologic, might the pharmacist recommend for Mr. Murphy?
For patients with moderate to severe allergic contact dermatitis or those who fail to respond to nonprescription therapies, a course of systemic, prescription corticosteroids (prednisone or methylprednisolone, discussed in Chapter 9) may be needed. In severe cases where the rash is widespread or present on the face or genitals, intravenous (IV) or intramuscular (IM) administration of a corticosteroid may provide symptomatic relief.
Topical antihistamines should be avoided in contact dermatitis due to possible worsening of the condition.
Mr. Sanchez, a 38-year-old man, went to the doctor because he thought he had an infected spider bite. His leg is red, swollen, and painful to the touch. Upon further examination, however, his doctor diagnosed him with a skin infection.
If the pharmacist’s recommendations do not relieve Mr. Murphy’s problem, what remedies might his physician prescribe?
As described in Chapter 32, one of the main functions of the skin is to act as a barrier. Because the lipid layer of the skin helps to prevent water loss from the epidermis, as well as the slightly acidic and constantly shedding properties exhibited, the skin is typically very resistant to infection. However, in the event that one or more of these protective functions of the skin are disrupted, a skin infection is likely to occur. Most skin infections are a result of a skin puncture or abrasion. However, some people have conditions that predispose them to skin infections. Examples of patients with additional risk factors are persons with very moist skin or an inadequate blood supply to the surface of the skin, or those with diabetes or human-immunodeficiency virus.
Skin infections can be classified as either primary or secondary infections. Primary infections are those that involve previously healthy skin and are usually caused by a single microorganism. If the infection is in an area of previously damaged skin, it is classified as a secondary infection. An example of a secondary infection is an infection developing on a skinned knee or accidental abrasion. Some secondary skin infections may be prevented or treated using OTC preparations such as bacitracin or double- or triple-antibiotic ointments (see Medication Table 33-5).
Patients purchasing OTC anti-infective agents for the skin should be made aware of the labeling, which advises them to stop use and contact a healthcare provider if the condition persists longer than 7 days or worsens, or if a rash or other allergic reaction develops.
Skin infections are also classified as complicated or uncomplicated. Complicated skin infections may require surgery to remove part of the damaged skin or may involve patients with a compromised immune system. A variety of microorganisms may cause skin infections, including bacteria, viruses, and fungi. Certain conditions place a person at risk for different microorganisms. For example, someone who plays a contact sport or who frequently uses a locker room may be at a higher risk for both bacterial and fungal infections. Additionally, poor hygiene and improper wound care may also increase the likelihood of developing a bacterial skin infection. Treatment of serious skin infections is typically done on an outpatient basis with topical and oral antimicrobials. Patients who have a fever, appear to be ill, or have a complicated skin infection may be hospitalized and placed on IV antimicrobial therapy.
Bacterial Skin Infections
Cellulitis is a common bacterial skin infection that occurs after a wound from a minor trauma, abrasion, ulcer, or surgery. Insect bites can also cause skin barrier disruption and may lead to subsequent skin infections. Cellulitis is characterized by a nonelevated, erythematous (redness of the skin), hot, and painful area of the skin surface. If left undetected and untreated for an extended period of time, cellulitis is potentially a life-threatening infection requiring hospitalization and IV antibiotics.
Impetigo is another common community-acquired superficial bacterial skin infection. Unlike cellulitis, which is more common in the adult population, impetigo occurs mostly in children 2 to 5 years of age. Other distinguishing factors are that it is highly contagious and is diagnosed by the presence of fluid-filled vesicles (small pouches) that develop rapidly into pus-filled blisters. Once these blisters rupture, a golden-yellow crust forms on the skin, which is characteristic of impetigo. Favorable conditions for developing impetigo are hot, humid weather, areas with poor hygiene or crowded living conditions, daycare centers, and schools. Impetigo occurs most commonly on the face and is easily transmitted to other children who are in close contact with one another. Impetigo may resolve spontaneously; however, if left untreated, a secondary cellulitis infection may develop.
What type of skin infection does Mr. Sanchez most likely have?
Most community-acquired bacterial skin infections, such as cellulitis and impetigo, are caused by Staphylococcus aureus (S. aureus) or Streptococcus pyogenes. Although both these Gram-positive bacteria are part of the normal skin flora, they may become pathogenic (infectious) if they are present on the skin in high concentrations and given the opportunity to penetrate the skin barrier. Other types of bacteria, such as other Gram-positive bacteria, Gram-negative bacteria, or anaerobic bacteria, may also cause skin infections but are less common.
Over the past few decades, there has been increasing concern for resistant S. aureus infections. Methicillin-resistant S. aureus (MRSA) is a particular strain of bacteria that is resistant to the antibiotic class that is used as first-line treatment for bacterial skin infections (antistaphylococcal penicillins). Once found only in hospitals, these resistant infections are now being detected in the community setting.
The treatment of bacterial skin infections involves both pharmacological and nonpharmacological strategies. The goal of antibiotic therapy is to achieve rapid eradication of the bacteria to prevent any additional complications that may arise from a prolonged infection.
Community-acquired MRSA outbreaks are common in correctional facilities, school systems, and among military personnel. Close contact during contact sports and in locker room areas place athletes at the highest risk.
There are a few different nondrug therapies that can be used to decrease symptoms associated with cellulitis and impetigo. Cool sterile dressings for cellulitis may decrease pain associated with cellulitis. Also, crust removal by soaking the affected skin in soap and water will often help to relieve itching associated with impetigo. Additionally, keeping the wound clean and reinforcing good skin hygiene is essential to prevent the infection from spreading to other areas.
Pharmacological treatment includes the use of topical or oral antibiotic medications (listed in Medication Table 33-5). The choice of antibiotic therapy is determined by the severity, location, and causative bacteria, as well as effectiveness and potential side effects of the medications. The most effective antibiotic regimen is one that targets only the most likely microorganisms. This strategy is essential to prevent the development of antibiotic resistance. Additionally, the use of topical antibiotics may be preferred in some cases to avoid potential side effects from systemic antibiotic therapy. All of the agents used must be effective against S. aureus and S. pyogenes, the two most common bacterial causes of cellulitis and impetigo.
Systemic Antibiotic Therapy
Oral antibiotics are used most often to treat cellulitis, except for severe cases, which may require IV antibiotic therapy. The most effective systemic (oral or IV) antibiotic classes for cellulitis and impetigo are antistaphylococcal penicillins and first-generation cephalosporins. Both of these antibiotic classes are bacteriocidal (kill the bacteria). The antistaphylococcal penicillins used for cellulitis are nafcillin, oxacillin, and dicloxacillin. The first-generation cephalosporins used for cellulitis are cefazolin and cephalexin. The duration of antibiotic therapy for cellulitis is usually 5 to 10 days. Penicillins and cephalosporins are very well tolerated, with the most common side effects being rash, diarrhea, and stomach upset. A rare but serious adverse effect is diarrhea that can lead to pseudomembranous colitis. Patients should not take penicillins or cephalosporins if they have had a severe allergic reaction to any of the medications contained in these antibiotic classes.
Nafcillin and cefazolin are IV antibiotics given to patients who are admitted to the hospital with a severe cellulitis infection.
Patients taking oral antibiotics should receive reminders and alerts about the importance of taking their antibiotics as directed and until finished to ensure complete eradication of the infection.
Patients may have an allergy to penicillins and/or cephalosporins. First-generation cephalosporins may be used in patients who have a mild penicillin allergy (rash). If a patient has a severe penicillin allergy (anaphylaxis—a life-threatening condition that involves swelling of the throat and a severe drop in blood pressure) or a cephalosporin allergy, the infection should be treated with vancomycin, linezolid, or clindamycin. Like the penicillins and cephalosporins, vancomycin is bactericidal. Clindamycin, however, is bacteriostatic (inhibits cell growth but does not kill the bacteria).
Because clindamycin is given orally, it may cause stomach upset. It is important to remind the patient to take clindamycin with food to decrease the occurrence or severity of stomach upset.
In the event a patient fails to respond to one of the above treatment regimens or if a resistant infection (MRSA) is suspected, alternative antibiotics such as vancomycin, linezolid, ceftaroline, sulfamethoxazole/trimethoprim, or clindamycin may be used. Vancomycin, ceftaroline, and linezolid are most effective for MRSA infections. Vancomycin and ceftaroline must be administered intravenously, while linezolid can be given either orally or intravenously. Sulfamethoxazole/trimethoprim and clindamycin may be used to treat susceptible community acquired CA-MRSA isolates. Side effects of sulfamethoxazole/trimethoprim are stomach upset and rash. Patients with a sulfa-allergy should not take sulfamethoxazole/trimethoprim. These antibiotics are discussed more extensively in Chapter 27.
While many topical antibiotic preparations have the same active ingredients as similar preparations for the eye, agents labeled for use on the skin should never be used to treat conditions of the eye.
Topical Antibiotic Therapy
Topical antibiotic therapy may be used to treat impetigo. Although bacitracin, neomycin, and polymyxin administered alone or in combination have been used to treat impetigo, these agents may not be as effective as mupirocin or retapamulin. Mupirocin and retapamulin are as effective as and have fewer side effects than oral therapy for impetigo. In cases when impetigo covers a large area, oral therapy may be preferred due to ease of use. Topical antibiotics are very well tolerated; however, skin irritation may occur.
Topical antibiotic therapy is not used to treat cellulitis.
Mr. Sanchez comes to the pharmacy with a prescription for cephalexin 500 mg twice a day for 7 days. He says he has finished the six-pill sample pack his doctor gave him and his infection is much better. He wonders whether it is worth it to get the prescription filled. What should the technician do or say?
Fungal Skin Infections
A mother brings her 16-year-old son, Derek, to the pharmacy and tells the pharmacist he has been complaining of a burning, itching sensation, and redness between his toes on both feet. His symptoms have become progressively worse each day since starting football practice about 2 weeks ago. When asked, he says his toenails appear to be normal with no apparent discoloration.
Athlete’s foot, ringworm, jock itch, and onychomycosis are all types of fungal infections. Named for the area of the body affected, these fungal infections are referred to as dermatophytosis or tinea infections. Most commonly, fungal skin infections are caused by the Trichophyton, Microsporum, or Epidermophyton genii of the fungi family. These fungi are known as dermatophytes and are able to penetrate the keratinous areas of the skin, causing various symptoms related to the location of penetration (Table 33-1).
Fungal Skin Infections
Occurs between the toes and on the bottom surface of the foot; usually affects one foot but may affect both feet; characterized as an itching or stinging sensation of the feet with possible fissuring, scaling, and redness
Ringworm of the skin
Ring-shaped rash; may be red, crusty, and/or scaly; occurs on any part of the body
Ringworm of the scalp
Ring-shaped, red, crusty, and/or scaly rash located on the scalp; most commonly found in children
Occurs on the inner part of the thigh and pubic area, often on both sides of the body; characterized as a red, elevated area with possible small, red vesicles, itching, and/or pain; more common in men than women
Onychomycoses (fungal infection of toenails or fingernails)
Affects toenails more than fingernails; nails gradually become opaque, thick, rough, yellow, and brittle; the nail may separate from the nail bed and eventually fall off completely
What do you think Derek’s problem is? Why?
Tinea infections can be spread from person to person, animal to person, or soil to person. Tinea generally presents on areas of the skin that are moist and poorly ventilated, such as the feet and groin area. Prolonged exposure to sweaty clothes, failure to bathe regularly, presence of skin folds, sedentary lifestyle, and bed confinement are all risk factors for the development of fungal infections. Furthermore, certain risk factors, such as older age, family history, immunodeficiency, diabetes, psoriasis, peripheral vascular disease, smoking, nail trauma, and tinea pedis place patients at an increased risk for fungal infections of the nail.
Treatment of fungal skin infections involves both nonpharmacological and pharmacological strategies. The goals of treating fungal skin infections are to provide symptomatic relief, clear the existing infection, and prevent future fungal infections.
The goal of nondrug therapy is mostly to prevent the spread of the fungal infection to other areas of the body. One important counseling point for patients is to launder contaminated towels and clothing in hot water to disinfect them. When using a towel, it is important to dry the affected area last or to use a separate towel to dry the infected area. Proper hygiene and daily showers are essential. Other ways to avoid contracting a fungal infection are to wear cotton socks and properly fitting shoes because wool or synthetic fibers trap air and prevent the skin from breathing. Finally, it is important to avoid exposure to infected areas and surfaces. One way to do this is to wear sandals, slippers, or other types of footwear in shower areas of locker rooms and public restrooms.
Tinea pedis, tinea corporis, and tinea cruris infections can often be treated with nonprescription topical antifungal agents. Numerous topical antifungal agents are available OTC (listed in Medication Table 33-6). The choice of topical antifungal agent should be patient specific and based on failure of previous topical antifungal therapy, cost, and compliance. Topical antifungals with the fewest daily applications and with the shortest treatment length are recommended for those who may have difficulty complying with other regimens. Directions and duration of use for most topical antifungal agents are to apply sparingly to the affected area twice daily for 2 to 4 weeks. Patients who present with tinea capitis (also known as ringworm of the scalp) or tinea unguium should receive both topical and oral antifungals.
Clotrimazole, miconazole, ketoconazole, econazole, oxiconazole, sertaconazole, and sulconazole are topical imidazole derivatives that act by inhibiting the synthesis of various components involved in the production of the fungal cell wall, thereby making the cell more permeable. (Refer to Chapter 29 for additional details.) All topical azole antifungals are indicated for tinea pedis, tinea cruris, and tinea corporis. Clotrimazole and miconazole are the most commonly used agents in this class because they are available OTC and in low-cost generic formulations. Ketoconazole, itraconazole, and fluconazole can be used as oral agents for the treatment of tinea capitis.
LOOK-ALIKE/SOUND-ALIKE—Diflucan should not be confused with Diprivan (propofol).
Butenafine, terbinafine, and naftifine are topical allylamines that act by inhibiting squalene epoxidase, an enzyme used for production of sterol components of the fungal cell wall, leading to cell death. All topical allylamine derivatives are indicated for tinea pedis, tinea cruris, and tinea corporis. Butenafine and terbinafine are used more often than naftifine because they are available OTC and have low-cost generic formulations. Terbinafine, the only allylamine derivative available in an oral formulation, is the most commonly prescribed medication for onychomycoses.
Butenafine is the only topical antifungal that has once daily application for tinea infections and may be the best treatment option if compliance with twice daily application is of concern.
Tolnaftate, a nonazole derivative, has a mechanism of action different from the allylamines. Although its mechanism of action is unknown, it is believed to stunt the growth of the fungal cell. Tolnaftate is indicated for the treatment of tinea pedis, tinea cruris, and tinea corporis and is available as an OTC antifungal with a low-cost generic formulation. Ciclopirox, a nonazole derivative, inhibits the transport of essential elements in the fungal cell, disrupting the synthesis of DNA, RNA, and proteins inside the cell. Ciclopirox is indicated for the topical treatment of tinea pedis, tinea cruris, and tinea corporis. Also, ciclopirox is available in a lacquer solution that can be used for mild onychomycoses infections. Both topical formulations of ciclopirox are by prescription only. Griseofulvin, a nonazole derivative, has a unique mechanism of action different from any other antifungal agent. It is a derivative of penicillin that deposits itself in the keratin of human skin cells to prevent fungal invasion. Although it is an option for oral treatment of tinea infections, its use has fallen out of favor; the newer agents are preferred because of their higher cure rates and lower rates of relapse. As with the other oral antifungal agents, griseofulvin is available only as a prescription.
Overall, topical antifungals are well tolerated. Side effects are rare and may include mild cases of skin irritation, burning, or stinging. There are no known drug-drug interactions with these topical agents because only minimal amounts are absorbed systemically. As mentioned above, the topical antifungal of choice will vary based on each patient’s needs. Typically, creams and solutions are the most effective and easiest to use formulations to treat tinea infections. Sprays and powders are often less effective. This may be due to the fact that sprays and powders are not rubbed into the skin adequately after administration. Powders and sprays are most effective for prevention of superficial fungal infections.
Adverse effects with oral antifungals are more common. Nausea, vomiting, and headache are the most common side effects associated with oral antifungal agents. Because they are metabolized in the liver, these agents also have the potential for many drug-drug interactions with other agents metabolized by the liver. Although many drug interactions exist, two of the most significant drug-drug interactions include administration of macrolide antibiotics (erythromycin and clarithromycin) or warfarin with azole antifungals. Patients should be counseled to inform both their pharmacist and their physician of all medications they are taking so they can check for potential serious drug interactions. If antifungals must be administered with a drug known to be metabolized by the liver, the patient should be counseled to watch for side effects of both medications and to inform their physician or pharmacist if these occur. Also, patients should be counseled not to take antacids within 2 hours of taking azole antifungal agents as this may decrease their absorption. Terbinafine may be taken without regard to meals and griseofulvin should be taken with food.
Derek’s mother has brought a tube of Lotrimin to the counter and asks if this product will work for him. Is this the most appropriate choice to treat Derek’s athlete’s foot? Why or why not? What might the pharmacist tell her?
Rae is a 13-year-old female who comes into the pharmacy with her father. She is complaining of what she thinks are two warts on her left index finger and one on the bottom of her right foot. She first noticed these about a month ago. The lesions on her index finger are rough, cauliflower-like lumps just a few millimeters apart. The lesion on the bottom of her foot is a hard, keratinized, grayish circular area. Her father asks if the lesions on her hand and foot could be warts and if there is anything he can buy to put on them to make them go away as she is embarrassed by the way they look.
Pathophysiology and Presentation
Warts are caused by a virus called human papillomavirus (also known as HPV). They may occur on any skin surface and are common in children. The common wart is also known as verruca vulgaris and is seen most often on the hands. Plantar warts, verruca plantaris, occur on the soles of the feet. Warts can spread from person to person or by indirect exposure to the virus in public showers or swimming pools. The warm water of swimming pools and showers softens the skin layer of the soles of the feet, allowing entry of the virus into the skin. It may take up to 3–4 months for a wart to appear after exposure to the virus.
Warts can appear on any skin surface. Typically, warts are rough and cauliflower like in appearance. They can occur alone or in groups. Over time, warts tend to increase in size. They begin as a lesion with a smooth, skin colored surface. Common warts are usually asymptomatic. Plantar warts may become painful if they cover a large area of the heel or ball of the foot. While standing, walking, or running, pressure is applied to the plantar wart. If it is a raised lesion, the lesion is forced inward where it can stimulate local nerve endings causing pain and discomfort. Plantar warts are more common in adolescents and adults.
Unfortunately, no single therapy has been proven to be effective at clearing warts in every patient. Topical agents and procedures to remove warts can decrease pain and possibly remove warts. It is important to note that warts usually clear spontaneously in 2 to 3 years without treatment. Due to the lack of highly effective treatment options, doing nothing is often the treatment of choice. A painful, disfiguring, or disabling lesion often leads to the decision to treat. The goals of wart treatment are to remove the wart, to avoid scarring, and to prevent the spread of the virus to other areas of the body or to other individuals. Most topical treatments for wart removal are available as nonprescription products, with patient self-treatment being a common approach.
Topical salicylic acid, a keratolytic agent that breaks down the wart lesion, has been proven as a safe and effective agent for wart removal. Salicylic acid is available in liquids, gels, disks, and patches. Product choice should be individualized based on the size and location of the wart as there is no clear advantage to any product formulation. Plantar warts require a higher concentration of salicylic acid than warts on the hands. Once the salicylic acid is applied, it is important to counsel the patient to practice good hygiene to prevent the spread of the virus. If the wart does not clear in 12 weeks, consultation with a physician is recommended. Additionally, it is recommended that painful plantar warts be treated by a physician.
In the physician’s office cryotherapy with liquid nitrogen has been a standard treatment for wart removal. Dimethyl ether and propane (also known as DEMP) is an OTC agent that has also been used to effectively remove warts. The proposed mechanism behind cryotherapy is to irritate the infected tissue to provoke a host immune reaction against the virus. It is recommended to apply the DMEP solution for 20 seconds to freeze the wart, repeating the process in 10 days if the wart does not fall off. Patients should use caution to only apply the cryotherapy solution to the wart and to avoid affecting healthy tissue surrounding the wart. Imiquimod is a prescription-only topical immune response modifier used for genital warts. Topical imiquimod has demonstrated potential efficacy for nongenital warts; however, high cost limits its use. Systemic and topical retinoids, discussed in the section on acne, are also used for wart removal. Due to the risk of birth defects, retinoid therapy is used as a second-line treatment option. Laser treatments and immunotherapy are options for wart removal that are performed at the physician’s office. Laser therapy is as effective as other treatments. Immunotherapy is recommended as a second- or third-line option for treatment-resistant warts. Therapy for warts is summarized in Medication Table 33-7.
To avoid the spread of warts, patients should wash hands before and after touching the wart surface, avoid contaminating clothing and towels, and avoid walking in bare feet unless the wart is covered. Also, patients should be counseled not to pick at or disrupt the wart surface. This may increase the risk of spreading the virus to other areas.
Cold sores, like warts, are caused by a virus. Herpes simplex 1 (also known as HSV-1) is the virus known to cause cold sores. Exposure to HSV-1 is usually by direct contact. Once a person is infected, the virus goes through periods of dormancy and reactivation, leaving the individual infected for life. Cold sores commonly occur on the lip but may also occur inside the mouth. Lesions are usually preceded by burning, itching, tingling, and numbness of the area. Next, a papule will form that will evolve into a fluid-filled vesicle that may burst to form crusts. Typically, cold sores last for 10 to 14 days. If the cold sore is not properly cared for, a bacterial infection may occur. Possible triggers for reactivation of HSV-1 are exposure to the sun, stress, fatigue, and menstruation.
Rae’s dad has chosen to buy Compound W Freeze Off® and Dr. Scholl’s® Clear Away® Ultra Thin Discs to treat her warts. How should the pharmacist counsel Rae and her dad about use of these products? Will they likely be effective?
Goals for cold sore treatment include relief of discomfort, prevention of secondary bacterial infection, and prevention of viral spread. The mainstay of cold sore treatment is topical skin protectants. Any type of lip balm may be used to keep the cold sore moist to prevent cracking. The only topical medication approved to treat cold sores is docosanol. Topical docosanol inhibits the HSV-1 virus from infecting human cells to prevent viral replication. Docosanol should be applied at the first sign of a cold sore to decrease the size of outbreak. Once the cold sore has erupted, docosanol is of little benefit. Oral antiviral agents, such as acyclovir and valacyclovir, may be used for recurrent cold sores. Other treatment measures are to avoid triggers for activation of the virus and exercise proper hygiene to prevent viral spread. Therapy for cold sores is summarized in Medication Table 33-7.
Head lice and scabies are forms of ectoparasites. Ectoparasites are organisms that live on the outside of the human body, using the human body as a means to survive. The most common symptoms of lice and scabies are itching and skin irritation. Female lice deposit eggs called nits on the hair. After 10 days, the nits hatch and mature to lice in approximately 2 weeks. Lice feed on human blood by piercing the skin with their mouths. Lice can live on clothes and other items. Scabies is caused by an itch mite. Unlike lice, the scabies mite infects areas in between the fingers, back of the knee, armpit, umbilicus, and scrotal areas. Risk factors for lice and scabies are poor personal hygiene and social contact with other persons infected by the parasite.
Clothing and bedding infected with lice or scabies should be washed in hot water and dried in a dryer to kill remaining lice, nits, or mites. An alternative to washing and drying items is to place them in a sealed plastic bag for at least 2 weeks. It is also recommended to vacuum rugs and furniture. Because lice generally survive for less than 2 days away from the human host, the use of permethrin spray is discouraged. It is highly suggested to avoid the use of permethrin spray to prevent resistant infections. See Medication Table 33-8.
Permethrin (Nix) is the treatment of choice for lice. Available as a nonprescription lotion, permethrin is a readily available option that effectively kills both lice and eggs. Permethrin acts on the nerve cells of the louse to cause paralysis and death. Once applied as directed, permethrin has residual effects for up to 10 days so retreatment is not necessary unless lice reappear. Side effects of permethrin are itching, burning, stinging, and tingling of the skin. Persons who are allergic to chrysanthemums should not use permethrin.
Pyrethrins (Rid) are another nonprescription product to treat lice. Like permethrin, pyrethrins block the nerve impulse of the louse, causing paralysis and death. Unlike permethrin, pyrethrins require a second application 7 to 10 days after the first application to kill any remaining nits that have hatched. When applied in two applications, pyrethrins are as effective as permethrin. Persons who are allergic to chrysanthemums should not use pyrethrins.
Four prescription-only products are available for lice treatment, malathion (Ovide), benzyl alcohol 5% (Ulesfia), spinosad (Natruba), and lindane (Kwell). These agents are reserved for resistant lice infestations. Due to a recent FDA black box warning issued concerning neurotoxicity with lindane (can cause seizures), it is now recommended only as a second-line treatment option. Lindane should not be used in infants or children. Therapy for lice is summarized in Medication Table 33-8.
Permethrin 5% cream (Elimite) is the treatment of choice for scabies. Lindane may be used as a second-line agent; however, the FDA warning for neurotoxicity limits its use. It is recommended to limit the amount of lindane used to 1 or 2 ounces and to avoid use in infants and children. Therapy for scabies is summarized in Medication Table 33-8.
The skin is subject to a variety of conditions, both chronic and acute. Many require treatment by physicians and prescription therapies, while others can be effectively managed with over-the-counter (OTC) preparations. The pharmacist can assist patients in deciding whether to seek medical attention or try self-treatment with an OTC product. Technicians should be aware of the importance of pharmacist counseling and recommendations for skin conditions because so many patients assume they can manage without help and it is so easy to make poor choices.
National Library of Medicine, DailyMed. Bethesda, MD: U.S. National Library of Medicine, National Institutes of Health, Health & Human Services; 2021. https://dailymed.nlm.nih.gov/dailymed/. Accessed July 12, 2021.
KrinskyDL, FerreriSP, HemstreetB, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care.19th ed. Washington DC: American Pharmacists Association; 2019. https://doi-org.ezproxy.findlay.edu/10.21019/9781582122656. Accessed January 11, 2020.
KrinskyDL, FerreriSP, HemstreetB, et al., eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 19th ed. Washington DC: American Pharmacists Association; 2019. https://doi-org.ezproxy.findlay.edu/10.21019/9781582122656. Accessed January 11, 2020.)| false
DiPiroJT, YeeGC, PoseyL, et al., eds. Pharmacotherapy: A Pathophysiologic Approach.11th ed. New York, NY: McGraw-Hill Medical; 2019. http://accesspharmacy.mhmedical.com.ezproxy.findlay.edu:2048/content.aspx?bookid=2577§ionid=219306022. Accessed January 11, 2020.
DiPiroJT, YeeGC, PoseyL, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 11th ed. New York, NY: McGraw-Hill Medical; 2019. http://accesspharmacy.mhmedical.com.ezproxy.findlay.edu:2048/content.aspx?bookid=2577§ionid=219306022. Accessed January 11, 2020.)| false
Chisholm-BurnsMA, SchwinghammerTL, MalonePM, et al., eds. Pharmacotherapy: Principles & Practice. New York, NY: McGraw-Hill; 2019. http://ppp.mhmedical.com.ezproxy.findlay.edu:2048/content.aspx?bookid=2440§ionid=189491584. Accessed January 11, 2020.
Chisholm-BurnsMA, SchwinghammerTL, MalonePM, et al., eds. Pharmacotherapy: Principles & Practice. New York, NY: McGraw-Hill; 2019. http://ppp.mhmedical.com.ezproxy.findlay.edu:2048/content.aspx?bookid=2440§ionid=189491584. Accessed January 11, 2020.)| false
iPLEDGE Program. Available at https://www.ipledgeprogram.com/AboutiPLEDGE.aspx. Accessed January 11, 2020.
StevensDL, BisnoAL, ChambersHF, et al.Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America.CID2014;59(2):e10–52.
StevensDL, BisnoAL, ChambersHF, et al.Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. CID 2014;59(2):e10–52.)| false
Apply sparingly once daily; dose may be increased gradually to 2–3 times/day until desired effect; if excessive dryness or peeling occurs, reduce dose, frequency, or concentration; if excessive stinging or burning occurs, wash area with mild soap and water
May discolor hair and clothing; may increase sensitivity to sunlight
Azelaic acid (ay ze LAY ik) (AS id)
Azelex, Finacea, Finacea Plus
Wash and dry skin thoroughly before application; gently massage a thin film into the affected area twice daily (morning and evening); wash hands immediately following application
Treatment usually begins with a low concentration and is increased as tolerated; wash area and let dry completely before application; apply once daily in evening to acne lesions; decrease frequency of application if stinging or irritation develops
May increase sensitivity to sunlight
Adapalene (a DAP a leen)
Differin, Differin XP
Cleanse the face gently and dry face completely; apply once daily before bedtime
May increase sensitivity to sunlight
Tazarotene (taz AR oh teen)
Arazlo, Fabior, Tazorac
Cleanse the face gently and dry face completely; apply a thin film once daily (evening)
May increase sensitivity to sunlight
Trifarotene (trye FAR oh teen)
Cleanse the face gently and dry completely; apply a thin film once daily (evening)
May increase sensitivity to sunlight
Isotretinoin (eye soe TRET i noyn)
Amnesteen, Claravis, Zenatane
0.5–1 mg/kg/day in 2 divided doses
Used for severe acne; iPLEDGE registration required to decrease risk of birth defects
Augmented betamethasone dipropionate (bay ta METH a sone) (dye PROE pee oh nate)
0.05% ointment, gel, lotion
Do not discontinue high-potency agents abruptly; treatment duration for high-potency agents should not exceed 2 weeks; avoid use on face, groin, armpits, or skinfolds; do not use occlusive dressings with these agents
Clobetasol proprionate (kloe BAY ta sol) (PROE pee oh nate)
Cormax, Embeline, Embeline E, Temovate, Temovate E, Olux, Olux-E, Clobex, Clobevate
Shampoo and lotion: apply shampoo to dry hair and leave in for 10 min; wash and rinse with water; use a fine-tooth comb to remove nits; repeat treatment in 7–10 days
Spray: use to remove nits from bedding, not for human use
Lindane (LIN dane)
Lice: apply shampoo to dry hair and massage into hair for 4 minutes, adding small quantities of water to hair until lather forms; rinse hair thoroughly and comb with a fine-tooth comb to remove nits
Scabies: apply a thin layer of lotion and massage it on skin; after 8–12 hours, shampoo/bathe to remove the drug
Lice and scabies
Permethrin (per METH rin)
Nix (OTC), Elimite (Rx)
Lotion, cream, spray
Lice: wash hair with shampoo, rinse, and towel dry; apply a sufficient volume of creme rinse to saturate the hair and scalp; leave on hair for 10 minutes before rinsing off with water; remove remaining nits with a fine-tooth comb; may repeat in 1 week if lice or nits still present
Scabies: apply cream from head to toe; leave on for 8–14 hours before washing off with water; may reapply in 1 week if live mites appear
Spray: use to remove nits from bedding, not for human use
Lice (lotion) and scabies (cream)
Malathion (mal a THYE on)
Sprinkle lotion on dry hair and rub gently until the scalp is thoroughly moistened; allow to dry naturally, leaving it uncovered; after 8–12 hours, wash hair with a nonmedicated shampoo; rinse and use a fine-tooth comb to remove dead lice and eggs; if required, repeat with second application in 7–9 days
Spinosad (SPIN oh sad)
Shake bottle well; apply to dry scalp and rub gently until the scalp is thoroughly moistened, then apply to dry hair, completely covering scalp and hair; leave on for 10 minutes (start timing treatment after the scalp and hair have been completely covered); the hair should then be rinsed thoroughly with warm water; shampoo may be used immediately after the product is completely rinsed off; if live lice are seen 7 days after the first treatment, repeat with second application; avoid contact with the eyes; nit combing is not required, although a fine-tooth comb may be used to remove treated lice and nits
Benzyl alcohol (BEN zil AL ka hol)
Apply appropriate volume for hair length to dry hair and completely saturate the scalp; leave on for 10 minutes; rinse thoroughly with water; repeat in 7 days