Taking Action Against Skin Reactions by Ann Mcmahon Wicker, Pharmd, BCPS; and Jessica Helmer Brady, Pharmd, BCPS

continuing education

Taking Action Against Skin Reactions By Ann McMahon Wicker, PharmD, BCPS; and Jessica Helmer Brady, PharmD, BCPS

Useful Web Sites pon successful completion of this skin. The epidermis regu- article, the pharmacist should be lates the water content of ■ www.emedicinehealth.com able to: the skin and controls drug eMedicineHealth, owned and operated 1. Describe the anatomy and physi- absorption into the dermis, by WebMD and part of the WebMD Net- ology of the skin. hypodermis, and systemic work, is a health information site written 2. State criteria for self-care treatment of com- circulation. It consists of by physicians for patients and consum- U ers. The content is evidence based and mon dermatological conditions. five layers: the stratum updated regularly. 3. Determine criteria for referral and further corneum, stratum lucidum, ■ www.mayoclinic.com evaluation of a patient’s skin condition. stratum granulosum, The Mayo Clinic’s Web site gives access 4. Recommend nonprescription treatment of stratum spinosum, and to the experience and knowledge of common dermatological conditions. stratum germinativum. The more than 3,300 physicians, scientists, 5. Provide counseling tips to the public con- stratum corneum serves as and researchers. This site is owned by cerning over the counter dermatological the principle barrier against Mayo Foundation for Medical Education products. the environment. It is at this and Research. outermost layer of the skin ■ www.intelihealth.com Community pharmacists are consulted by that keratinocytes, the cells Aetna InteliHealth’s Web site provides the public for a variety of self-care treatments containing the structural information with solutions for healthier due to their accessibility. With an estimated protein keratin, flatten and lives. It provides information from various 5 percent of the population suffering from form their protective bar- sources, including Harvard Medical School and the Columbia University Col- chronic skin, hair, or nail conditions, and many rier. Many skin conditions lege of Dental Medicine. Aetna Inteli- others from acute or seasonal skin disorders, are related to the abnormal Health is a subsidiary of Aetna Corp. it is important that the pharmacist know which accumulation of these ke- self-care treatment is appropriate and most im- ratinocytes at the stratum cor- portantly, when the patient should be referred neum. The second layer, the dermis, consists of collagen to a primary health care provider. This article and elastin, providing the skin its elasticity and resistance reviews skin conditions that may be self treat- to injury. It is 40 times thicker than the epidermis and is able, focusing on dermatitis, fungal infections, where immune cells, nerve endings, hair follicles, blood and acne. vessels, sebaceous (oil), and sweat glands are located. The innermost layer, the hypodermis, provides nourish- Anatomy of the Skin ment, and cushioning for the epidermis and dermis. It is The skin, the body’s largest organ, functions as composed of fat, collagen, and larger blood vessels. a two-way barrier. It acts to preserve body fluid, Protecting the body from external damaging agents prevent dehydration, and to protect against is skin’s most important function. Dermatological condi- harmful substances and infectious agents. The tions often present when the barrier function of the skin is epidermis, the dermis, and the hypodermis disrupted or an overproduction and accumulation of ke- are the three main layers that compose the ratinocytes occurs. Inflammatory lesions may occur due

www.americaspharmacist.net May 2009 | america’s Pharmacist 39 Table 1: Basic Skin Care for Patients with Atopic Dermatitis

• Use mild, non soap cleansers due to the drying effect associated with most soaps • Avoid skin care products that contain alcohol and astringents • Try not to scratch or rub the itchy area of the skin • Wear cotton clothing as other materials are more irritating to the skin • Launder all clothing with liquid detergent, which is easier to rinse out than the powder form • Add a second rinse cycle to increase removal of irritating substances • Reduce exposure to or contact with trigger factors • Avoid extremes of temperature and use nonirritating sunscreens • Shower with a cleanser to remove chlorine after swimming • Daily skin moisturizing after a tepid bath helps prevent further drying of the skin

to disturbed epidermal turnover and water loss through AD, along with three or more of the following the stratum corneum. Barrier permeability may also lead criteria: onset of the skin condition before age to invasion by infectious agents. The skin’s ability to pro- 2; visible rashes involving the elbows, back of tect the body from foreign bodies depends on maintain- knees, front of neck, or eyelids; or dermatitis on ing an intact stratum corneum in addition to a person’s the cheeks or extensor areas of the knees or age, immunologic status, and underlying disease states. elbows in infants; history of dry skin in the past year; history of asthma or allergic rhinitis, or Dermatitis family history of atopic disease in a first-degree Dermatitis is a nonspecific term used to describe various relative in children younger than 4; or history inflamed skin conditions that are generally characterized of dermatitis on the flexural areas. Referral to a by redness. Atopic dermatitis, contact dermatitis, and physician should be considered if a large area seborrheic dermatitis are the most common forms of ec- of the body is affected, the condition is consid- zema. The treatments of choice for all types of dermatitis ered severe with intense pruritis, the patient is a are topical corticosteroids and oral antihistamines. child less under 2, or the skin appears infected. Atopic dermatitis (AD) is a recurring inflammatory When assisting a patient with an appropriate skin disease that typically begins early in life, but can self-care treatment regimen for AD, several non- occur at any age. This condition often occurs in people pharmacologic measures should be discussed. with a personal or family history of asthma and aller- (See Table 1 above). If there is an oozing or weep- gies. Allergens, irritants (fragrances, soaps, paints), ing lesion, counseling on the use of wet tap water extremes of temperature, dry skin, and emotional stress compresses for 20 minutes four to six times daily may exacerbate atopic dermatitis. It is considered the should be provided in addition to basic skin care most common dermatologic condition of children, with techniques. Also, colloidal oatmeal baths may be more than 60 percent of cases occurring within the first soothing. Recommendation of adjunctive mea- year of life. Any area of the skin can be affected by AD, sures to minimize scratching is advised, as inform- and lesions are normally symmetric. In infants, it initially ing a patient not to scratch is generally ineffective. presents on the cheeks as red, raised vesicles that can These measures include keeping fingernails cut be dry or oozing, but may also appear on other areas of short, smooth, and clean and placing socks or the face, neck, and trunk. Dry, thickened plaques and hy- cotton gloves on the hands to lessen scratching. perpigmentation of the neck, wrist, elbow, and knees are the first-line treatment for AD is topical seen in children between the ages of 2 and 4. Remission corticosteroids. These agents possess anti- can occur, and recurrences often diminish in intensity or inflammatory, antipruritic, and vasoconstrictive even disappear as the child approaches adulthood. In an properties. The only topical steroid available adult, dry, thickened plaques and hyperpigmentation of without a prescription is hydrocortisone. Twice the hands and flexor surfaces is seen. daily application of hydrocortisone 0.5–1 per- Diagnosing AD is based on clinical signs and cent is recommended as initial treatment for five symptoms. Pruritis must be present for the diagnosis of to seven days. These preparations are available

40 america’s Pharmacist | May 2009 www.americaspharmacist.net Table 2: Irritant Versus Allergic Contact Dermatitis

Criteria Irritant Allergic Risk Increases with repeated contact or exposure Must be previously sensitized Mechanism Direct tissue damage Delayed-type hypersensitivity Symptoms Burning, stinging, soreness Itching, redness Appearance Erythema, fissures, edema, desquamation Erythema, severe edema, vesicles, crusting and scaling, distribution consistent with exposure Typical onset Minutes to hours Hours to days Common agents Water, soaps, detergents, acids, bases, solvents, Poison ivy, poison oak, poison sumac, saliva, urine, stool, physical conditions, oils, metals, cosmetics, medicines, foods, coolants, powders, dusts rubbers, resins, adhesives as ointments or creams. Ointment-based prep- recommend the use of topical antihistamines for more arations increase the hydration of the stratum than seven consecutive days unless the patient is under corneum, provide better delivery of the medica- the watch of a primary health care provider. tion, and have fewer numbers of additives. They contact dermatitis, from both allergic and irritant are preferred for infiltrated, thickened, leathery etiologies, is the most common occupational disease lesions. Cream preparations may be better in the United States and accounts for 90 percent of skin tolerated during hot or humid conditions, and disorders acquired in the workplace. Characterized by are the preferred topical formulation to be used redness, itching, burning, and vesicle and pustule forma- on moist skin or areas where opposing skin tion, contact dermatitis is an inflammatory skin condition surfaces touch and rub, such as skin folds. occurring on dermal areas exposed to irritant or allergenic Patients should be counseled on appropri- agents. Irritant contact dermatitis (ICD) has been reported ate steps for optimal application of topical corti- to be the most common form, identified when the contact- costeroids which include: washing the affected induced inflammatory change is not mediated by the im- area before applying the medication; proper mune system. Cellular damage is caused by the irritating hand washing before and after application agent. Common irritants linked to ICD include cleaning of the medication; and gently rubbing a thin agents, solvents, metals, or oils. When a predictable im- layer of the medication on to the affected skin munological response to an allergen occurs, the contact surface. Unless instructed by a primary health dermatitis is labeled allergic contact dermatitis (ACD). care provider, they should also be advised not the hands, having much interaction with the environ- to cover or wrap the area, as this leads to an ment and irritants, are most frequently affected by ICD. increase in the percutaneous absorption of the Patients with ICD should avoid exposure to known skin medication. Topical hydrocortisone should not irritants and use personal protective equipment such as be recommended by a pharmacist for children gloves to prevent relapses of dermatitis when avoidance under the age of 2, or for patients presenting is not possible. Other measures to protect the skin, such with yellow, crusting, eczematous lesions. as the use of moisturizers, may also be beneficial. oral antihistamines have been used to An intact skin surface is necessary to deter antigen treat the itching of dermatologic disorders, with penetration in ACD. Any disruption of the skin barrier can variable results. They are useful as short-term lead to increased accessibility of antigens and irritants. adjuvant agents to topical treatment for their Examples of failed barrier function of the skin include sedative properties. Topical antihistamines can maceration by sweating, occlusion, or water immersion, be used to alleviate itching, but topical cortico- or dryness or scaling. steroids remain the preferred treatment option. in ACD, an individual must have been exposed to The Food and Drug Administration does not an antigen and upon subsequent exposure, develops

www.americaspharmacist.net May 2009 | america’s Pharmacist 41 specific sensitivity to the allergen. A patient’s history cracked, scaly, or thickened skin characterizes and clinical findings form the basis for a tentative ACD the chronic phase. The mainstay of treatment diagnosis. A classic example is an individual who never involves avoidance of the offending agent, with has been sensitized to poison ivy developing only a mild identification of the agent necessary for avoid- dermatitis in the weeks following the initial exposure, but ance. After exposure, washing the exposed typically develops severe dermatitis within one to two area and removing soiled items of clothing may days on the second and subsequent exposures. prevent further spread and irritation. in the United States, Rhus or Toxicodendron genus When exposures are unavoidable or the of- (poison ivy/oak/sumac) dermatitis is the principal cause of fending agent has not been identified for avoid- ACD and exceeds the incidence of all other causes of ACD ance, treatment may be recommended, with combined. It is estimated to occur in up to 80 percent of symptom relief as the main therapeutic goal. Alu- the population, due to sensitivity to urushiol released from minum acetate astringent or water-wet dressings the plant upon damage to the plant itself. Urushiol can be may aid in soothing and debriding acute cases found in the plants leaves, stems and roots. of contact dermatitis. Sodium bicarbonate pastes Rhus or Toxicodendron dermatitis may be suspected or baths may also provide relief and comfort. in a patient who presents with vesicles or bullae ar- Mild forms of dermatitis may be treated with an ranged in a linear fashion on an exposed area several antipruritic lotion or the application of a hydro- days after performing outdoor tasks in an area known to cortisone cream or ointment. These agents are have these plants. Having sensitivity to any species of useful as long as the rash remains dry. Products Toxicodendron is likely to cause allergy to all members containing calamine, menthol, phenol, or cam- of the genus. Remember, “Leaves of three, let it be.” phor may be used to treat itching associated with These species are often identified as having three leaves ICD and ACD. Systemic antihistamines such as originating from a central stem, with the middle leaflet diphenhydramine are another antipruritic choice. situated at the terminal end of the stem. Initially, intense Because of the sedating effects of this medica- itchy patches develop and vesicles form 24–48 hours tion, patients should be advised against operat- after exposure in a previously sensitized person. A com- ing machinery or vehicles. Knowing a patient’s mon misconception is that fluid from vesicles contains medical and medication history is warranted to antigenic material that may further spread the dermatitis. prevent drug-drug or drug-disease interactions. Patients should be assured that this is not the case. If itching is not relieved, topical anesthetic agents unwashed, contaminated hands and fingernails are containing benzocaine or pramoxine may be the principal sources of rash on protected areas of the recommended, but only after other forms of anti- body. Therefore, patients should be counseled on sev- pruritic therapy have failed. Severe cases may be eral nonpharmacologic measures. These include wash- best referred to a physician for further treatment. ing the affected area with soap and water as soon as in chronic cases of contact dermatitis, skin contact is made; meticulously cleaning under the finger- protectants or emollients are often recom- nails to remove trapped urushiol to avoid infecting clean mended. Topical agents such as petrolatum skin surfaces; washing all clothes exposed to urushiol in provide an occlusive film, protecting the skin a washing machine separate from nonexposed items; from fissuring and moisture evaporation. If and thoroughly washing any other protective garments applied while the affected area is moist, these (including shoes, gloves, jackets), sports equipment, products are more effective. garden and work tools as soon after use as possible. Barrier creams may be beneficial in prevent- Patients should also be advised that recognition and ing ACD associated with the Toxicodendron ge- avoidance of these plants are the best defenses. nus. Bentoquatam, an organoclay, is available contact dermatitis can be classified as acute or in a 5 percent lotion containing alcohol and is chronic. In the acute phase, the affected area may be de- believed to physically block urushiol from being scribed as weepy, edematous, vesicular, or blistered. Dry, absorbed into the skin. Applied at least 15 min-

42 america’s Pharmacist | May 2009 www.americaspharmacist.net utes before exposure, it is effective in protecting patients from the urushiol common to all Toxi- Patient counseling tips for codendron plants. It should be reapplied once dermatologic treatment • Atopic dermatitis is not curable, but most patients’ every four hours to maintain effectiveness. symptoms can be managed satisfactorily. Basic skin care With any agent recommended for contact techniques are important to follow. dermatitis, if no improvement is seen in seven • For suspected contact dermatitis, wash the affected area as to 14 days, further evaluation may be required. soon as contact is made. Recognition and avoidance are the Always prompt patients to contact their health best defenses. care provider if their condition worsens or does • Seborrheic dermatitis is manageable, but not curable. Treatment is aimed at symptom relief. not improve. • Clean, dry skin is the best defense to ward off fungal infec- Seborrheic dermatitis is an inflammatory skin tions. Tight fitting clothes or occlusive footwear should be disorder occurring predominantly on the scalp, avoided. face, and trunk, as well as other areas with a • In cases of acne, gently cleanse the skin with a non medi- prominence of sebaceous glands. Prevalence of cated soap twice daily. Do not scrub or over cleanse. seborrheic dermatitis ranges from 1–5 percent, • Topical medication should be applied to the affected area after the skin has been properly cleaned and dried. It is for with no known etiology. While data is conflicting, dermatological use only. it is suggested that Malassezia, also known as Pityrosporum ovale or P. orbiculare, a lipophilic yeast, plays an important role in this condition. Skin lesions in patients with seborrheic der- Self-care treatment may be used to reach those goals, matitis are visible on the scalp, eyebrows, eye- and includes shampoos and topical preparations contain- lids, nasolabial folds, cheeks, ears, axillae, and ing selenium sulfide, pyrithione zinc, keratolytics (salicylic the groin region, along with others and are clas- acid and coal tar), antifungal agents, and corticosteroids. sically symmetric. Erythematous plaques are Commonly used antifungal agents include ketoconazole, often covered in dull, yellowish, and oily scales. miconazole, clotrimazole, and terbinafine. Hydrocortisone Scalp lesions are seen in 90–95 percent of all is the only nonprescription topical corticosteroid approved patients. Comorbid diseases may also affect for OTC use. Keratolytic agents, selenium sulfide, and the incidence of seborrheic dermatitis. Patients pyrithione zinc aid in the removal of scales and are often infected with the Human Immunodeficiency used before treatment with topical corticosteroids. The Virus and those with Parkinsonism, among other benefit gained from the use of antifungal therapy supports conditions, have greater rates of occurrence. the possible role of Malassezia in seborrheic dermatitis. in infants, seborrheic dermatitis, referred to in infants, massaging the scalp with a mild shampoo or as “cradle cap,” often clears without treatment baby oil is often sufficient for removal of the scales associ- by their first birthday. Treatment focuses mainly ated with seborrheic dermatitis. In older patients, topical on hygienic measures, as absorption through shampoo therapy should be worked into the scalp and the skin is much greater in infants than older allowed to remain in contact with the affected area for up children and adults. After infancy, the condition to five minutes. Medicated shampoos containing pyrithione does not tend to reappear until puberty and be- zinc, selenium sulfide, sulfur, ketoconazole, salicylic acid, comes most apparent near the fourth decade. or coal tar may be recommended. Initially, these products The disease course waxes and wanes over time may be used up to once daily depending on the severity of and is affected by environmental conditions. the condition. Once the condition is under control, patients Flares seem to occur in colder months, with may decrease the use of these medicated shampoos, us- improvement seen during warmer seasons. ing only as needed. Also, use of a nonmedicated shampoo treatment goals for seborrheic dermatitis prior to treatment may assist in the loosening of scales. include reduction of inflammation and minimi- topical hydrocortisone may be applied up to two to zation, or elimination of erythema and scaling. three times a day until symptoms subside and then used as

www.americaspharmacist.net May 2009 | america’s Pharmacist 43 Table 3: Tinea Infections

Type Location Common causative species Tinea capitis Head, scalp, eyebrows, eyelashes T. tonsurans M. andouinii M. canis Tinea corporis Anywhere on the body except the scalp, beard, T. rubrum feet, or hands M. Canis T. tonsurans T. verrucosum Tinea cruris Groin T. rubrum E. floccosum Tinea pedis Feet T. rubrum T. mentagrophytes var interdigitale E. floccosum Tinea unguium Nails T. rubrum T. mentagrophytes var mentagrophytes

needed to control acute exacerbations. Topical antifungal antifungal therapy. Therefore patients should agents may be applied once or twice daily. If the patient’s be referred to a primary health care provider condition does not improve after seven to 14 days of treat- for treatment. Patients should also be referred ment, they should be referred to their primary health care to a primary health care provider if the fungal provider for further options. Also, it is important to remind infection covers an extensive area, worsens, is patients that these recommended therapies are used to oozing purulent material or is resistant to initial help control their condition, as there is no cure. therapy. Additionally, patients with diabetes, have circulatory problems or are immunocom- Fungal Infections promised should be referred for evaluation and Tinea infections are superficial fungal infections clas- treatment by a primary health care provider. sified according to their anatomic location. (See Table Tinea corporis can occur at any age and is 3, above.) The three genera of pathogenic fungi, also more common in those who live in hot, humid known as dermatophytes that cause tinea infections are climates. Lesions present in a characteristic Trichophyton, Microsporum and Epidermophyton. These ringworm pattern on the face, trunk and limbs infections, which occur in both healthy and immunocom- and can vary in size, involvement and inflam- promised individuals, are acquired through direct contact mation. Self care of ringworm with topical with infected persons or animals, and indirect contact agents includes the use of clotrimazole, mi- from exposure to contaminated soil or fomites. The in- conazole, terbinafine, and tolnaftate. Treatment fected skin is limited to the stratum corneum. Tinea—also should be continued for at least one week after termed ringworm—has characteristic lesions that are resolution of symptoms. Oral therapy is war- ring-shaped with clear centers and red, scaly, elevated ranted if there are extensive superficial lesions. borders which may appear as single or multiple lesions. “Jock itch” or tinea cruris occurs most However, some lesions may differ from their ring form and commonly in adolescent and young adult present as mild scaling to deep inflamed, nodular-size men. It involves the medial thighs and inguinal lesions. Since presentation of these lesions vary and can folds also known as the groin area. The infec- closely resemble other diseases, if self treatment is not tion usually presents as a bilateral red scaling effective, laboratory confirmation is often required. plaque accompanied by pruritis. Unlike can- in many instances, tinea corporis, tinea cruris, and dida infections, involvement of the penis and tinea pedis can be treated with nonpharmacologic scrotum is unusual. Topical treatment options measures and topical nonprescription antifungal agents. for self care of tinea cruris include miconazole, Tinea capitis and tinea unguium require prescription oral terbinafine, tolnaftate, and undecylenic acid.

44 america’s Pharmacist | May 2009 www.americaspharmacist.net Table 4: Nonprescription Medications for Treatment of Fungal Infections

Drug Indication Administration Guideline Patient Counseling Tips Butenafine Tinea corporis Apply to affected area once • Low incidence of side effects Hydrochloride Tinea cruris daily for 2 weeks • Avoid contact with eyes, mouth, nose, (1% cream) and other mucous membranes Tinea pedis-interdigital Apply to affected area twice daily for 1 week, or once daily for 4 weeks Clotrimazole Tinea corporis Apply to affected area twice • Mild skin irritation, stinging and burning (1% cream, lotion, Tinea pedis daily for up to 4 weeks infrequently occurs with use solution) & • “Do not use in children under 2 years of Miconazole Nitrate age unless directed by a doctor (2% ointment, cream, Tinea cruris Apply to affected area once to • If using spray application, shake can powder, spray powder, twice daily for up to 2 weeks. well and hold 4 to 6 inches from skin spray liquid, solution, • Do not puncture spray cans, the gel) contents are under pressure Terbinafine Tinea corporis Apply to affected area once • May cause irritation, burning, itching/ Hydrochloride Tinea cruris daily for 7 days dryness at application site (1% cream, gel, spray) • Do not use the spray form on the face Tinea pedis-interdigital Apply to affected area twice daily for 7 days*

Tolnaftate† Tinea pedis-plantar Apply to affected area twice • If using spray application, shake can (1% cream, solution, daily for 2 weeks well and hold 6 to 10 inches from skin liquid, gel, powder, • If using liquid, powder, or powder spray spray powder, spray Tinea corporis Apply to affected area once to forms, apply to feet, between toes and liquid) Tinea pedis-interdigital twice daily for 4 weeks in socks and shoes Tinea cruris Apply to affected area daily for • A mild temporary stinging may be 2 weeks experienced when using the aerosol dosage form Undecylenic Acid Tinea corporis Apply to affected area once • Burning can occur due to high alcohol (10%, 12%, 19% Tinea pedis daily for 4 weeks concentration in solutions powder; 8%, 20% • Strong odor can contribute to cream; 25% solution; noncompliance soap) • Avoid contact with eyes • Do not inhale the powder formulation • Choice of product is important: Use ointments, creams, and liquids as primary therapy; powders are generally used as adjunctive therapy

* Terbinafine treatment for one week has been shown in clinical trials to cure athlete’s foot. † Tolnaftate is the only nonprescription drug approved for both prevention and treatment of athlete’s foot.

Lesions may appear to respond quickly, but for fungal growth. Additionally, communal baths and locker treatment should continue for at least 10 days. room floors create an environment for exposure to fungal Topical therapy is sufficient, but oral therapy elements. The infection often occurs on the feet in the third is needed if the infection spreads to the lower or fourth toe web and the skin appears wet, soggy and thighs or buttocks. white. It may also present with the classic ringworm pattern tinea pedis also known as “athlete’s foot” on the top of the foot, or as a chronic dry, thickened skin of is the most common superficial fungal infection, the soles and sides of the foot known as “moccasin type” occurring in up to 70 percent of adults during tinea pedis. Self care treatment options for interdigital tinea their lifetime. Males between 20 and 40 are the pedis include topical application of miconazole, terbin- most frequently affected. A moist environment, afine, tolnaftate, and undecylenic acid. Tolnaftate is also along with macerated skin, are predisposing the recommended treatment for plantar tinea pedis. Treat- factors to acquiring tinea pedis. A warm, moist ment may be required for four weeks, and should continue environment is promoted by shoes and suitable one week after symptoms have resolved.

www.americaspharmacist.net May 2009 | america’s Pharmacist 45 When using all of these medications, it is advised to present with a mixture of comedos, pustules, clean and dry the affected area before application. In- papules, nodules, and cysts. An open com- struct the patients to apply a thin film of the product over edo (blackhead) is formed when sebum mixes the affected area and approximately 2 cm of the imme- with excess loose cells in the follicular canal, diately surrounding skin, massaging the medication into forming a keratinous plug. Melanin pigment is the area. Thorough hand washing with soap and water responsible for this discoloration. (A common should be performed after applying the medication. It is misconception is that the black or brown color best not to apply an occlusive dressing. comes from embedded dirt.) A closed comedo A patient’s ability to comply with the recommended (whitehead), results from inflammation or trauma therapy is an essential factor in the outcome of therapy. to the follicle. Closed comedos may develop Compliance with the treatment course may be chal- into larger, inflammatory lesions secondary to lenging due to the length of time required to resolve the P. acnes activity. Pustules form from follicular infections. Patients may be tempted not to complete wall damage or rupture. Papules are similar to the course of therapy, especially when symptoms sub- pustules, except that they lack purulent fluid. side but prior to complete eradication of the infection. Nodules are similar lesions, but larger in size Another determining factor for treatment of fungal infec- when compared to papules. tions is a patient’s compliance with nonpharmacologic Self-care treatment is targeted at reduction measures. These measures are intended to compliment or prevention of new eruptions, most often for nonprescription topical therapy and help prevent future mild to moderate cases of acne. Initial treat- infections. Nonpharmacologic measures patients should ment is aimed at reducing lesion count and will be counseled on include keeping the skin clean and dry, vary in duration, depending on the severity of laundering contaminated items in hot water to prevent the acne and treatment response. These treat- spread of infection, not sharing personal items, avoiding ments may take up to eight weeks to produce contact with people who have fungal infections and when results. After two months of treatment and possible wear loose fitting clothing. Patient with tinea no improvement in acne, patients should be pedis should also be advised regarding keeping the feet referred to a primary health care provider for a dry, wearing cotton socks, changing socks frequently, prescription acne medication. avoiding occlusive footwear and applying an antiperspi- When assisting a patient with an appropri- rant to the soles of the feet to prevent reinfection. ate over the counter treatment regimen for acne, several nonpharmacologic measures Acne should be discussed. Excessive scrubbing or Acne, a chronic inflammatory disorder of the pilosebaceous cleansing of the skin may lead to irritation and unit, is the most common skin disorder in the United States, also may not positively affect acne. Surface affecting approximately 85 percent of all people between the cleaning has minimal impact on the follicles, ages of 15 and 24. The pilosebaceous unit, located in the and thus a relatively small impact on acne dermis layer of the skin, is made up of the sebaceous gland treatment. Gentle, nondrying cleansing agents and adjacent hair follicle. Sebaceous glands, predominantly should be recommended. located on the face, chest, and upper back, provide sebum Product selection for the treatment of to the follicular canal and eventually to the skin surface acne should be based on the patient’s skin through the follicular opening, or pore. Sebum is an oily type and sensitivity. Gel formulations are often substance that provides a thin coating of fat over the skin, most potent, containing alcohol, propylene slowing the evaporation of water. It also has antibacterial glycol, or water. Alcohol-based products gen- properties. Contents of the follicular canal include keratino- erally cause more dryness and irritation. Pa- cytes, Propionibacterium acnes, and free fatty acids. tients with oily skin may prefer these products Acne’s severity is based on the number and type of le- for their drying properties. Patients should be sions present, ranging from mild to severe. Patients often advised to apply products to dry skin only,

46 america’s Pharmacist | May 2009 www.americaspharmacist.net waiting approximately 30 minutes after wash- Salicylic acid slows shedding of cells inside the fol- ing because moist skin may be more sensi- licles, which prevents the pores from clogging. It may tive. Also, to limit irritation and improve patient also break down blackheads and whiteheads. Patients tolerance, patients should initiate therapy with may experience mild stinging and skin irritation. Nonpre- a low-potency formulation and increase either scription salicylic acid acne products are available with strength or application frequency as directed. 0.5 to 2 percent salicylic acid. Use should be discontinued if excessive irrita- Sulfur is included in acne products for its keratolytic tion or allergy occurs. and antibacterial properties, available in concentrations Many topical product formulations, including of between 3–10 percent. Sulfur may also be combined lotions, creams, gels, solutions, and disposable with resorcinol in acne products. In a concentration of wipes are available for self care treatment of 2 percent, resorcinol enhances the keratolytic effects acne. Benzoyl peroxide, salicylic acid, sulfur, and of sulfur. The combination of sulfur and resorcinol may resorcinol are the most common active ingre- cause redness and peeling, often occurring several days dients found in nonprescription acne prepara- after using the product. tions. First-line topical therapy includes products Patients with severe acne or cystic lesions, and those containing benzoyl peroxide. This antimicrobial with worsening of acne or no improvement after six to is lipophilic and suppresses the growth of P. eight weeks of self-care therapy should be referred for acnes effectively. Sloughing of epithelial cells medical evaluation. occurs, loosening the follicular plug and thus acts somewhat comedolytic. Benzoyl peroxide has no Conclusion anti-inflammatory properties and can cause local As an accessible member of the health care community, irritation and allergic contact dermatitis. Contin- pharmacists are often consulted by the public regarding ued use of benzoyl peroxide is not known to be treatment for dermatological disorders. Assessment of associated with P. acnes resistance. the condition and product recommendation should take Benzoyl peroxide is available in numerous into account the individual’s age, chief complaint and his- formulations and concentrations, ranging from tory, and skin lesion type. An in-depth interview is impor- 2.5 to 20 percent. This product may cause tant in determining the appropriate course of action. Sup- excessive dryness, scaling, redness, and minor portive care is often the treatment course recommended, swelling, and may also make the skin more utilizing over the counter products. It is essential for sensitive to ultraviolet exposure. Another disad- pharmacists to be able to recognize and suggest appro- vantage is that benzoyl peroxide can bleach or priate nonprescription treatment for skin disorders and, discolor some fabrics, including clothing, bed most importantly to recognize and recommend referral to linens, or towels. a primary health care provider when warranted. Keratolytic therapy should be recommended secondary to benzoyl peroxide. Salicylic acid, sulfur, and resorcinol are classified as Ann McMahon Wicker, PharmD, BCPS, is assistant professor of clini- keratolytic agents. In acne, follicular keratiniza- cal pharmacy practice at the University of Louisiana at Monroe (Baton tion often involves keratinocyte clumping and Rouge campus) College of Pharmacy. subsequent plugging of the pore. In the concentrations allowed, keratolytic agents may be Jessica Helmer Brady, PharmD, BCPS, is assistant professor of clini- less irritating than benzoyl peroxide, but they cal pharmacy practice at the University of Louisiana at Monroe Col- are not considered as effective comedolytic lege of Pharmacy. agents. Other disadvantages of keratolytics for acne treatment are the odor produced from the Editor’s Note: To obtain the complete list of references used reaction of sulfur with the skin and the brown in the article, contact Chris Linville at NCPA (703-838-2680) scale from use of resorcinol. or at [email protected].

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CONTINUING EDUCATION QUIZ 6. John presents to your pharmacy and asks Select the correct answer. for assistance in preventing and treating his condition. What nonpharmacologic measures 1. Which of the following layers of the epidermis is where could you recommend? many skin conditions occur? a. Continue wearing personal protective a. Stratum corneum equipment b. Stratum lucidum b. Wash with a nondrying agent after c .Stratum granulosum exposure d. Stratum spinosum c. Use emollients such as petroleum jelly to provide moisture 2. For a diagnosis of atopic dermatitis, which of the following d. All of the above signs and symptoms would be needed? a. History of atopic dermatitis, allergic rhinitis, bronchitis, and 7. John also informs you that he has also pruritis been working in his yard lately and proceeds b. Onset of atopic dermatitis under 2 years of age, history of to show you a linear rash with fluid-filled dermatitis on the flexural areas, asthma, and dry skin vesicles on his right forearm. He believes he c. Pruritis, dry skin, history of atopic dermatitis, history of has poison ivy. What type of skin condition is allergic rhinitis poison ivy considered? d. Skin pruritus, onset under 2 years of age, history of dry a. Atopic dermatitis skin, and skin crease involvement b. Allergic contact dermatitis c. Irritant contact dermatitis 3. Basic skin care counseling for patients with atopic d. Seborrheic dermatitis dermatitis should include: a. Bathing in hot water 8. John believes that if the vesicles burst, b. Daily skin moisturizing his rash will spread. Is this statement true or c. Wearing nylon clothing false? d. Scratching the affected area to relieve itching a. True b. False 4. Antihistamines are the preferred treatment option for patients with atopic dermatitis. 9. Topical anesthetic agents such as a. True benzocaine and pramoxine are used as first b. False line therapy for pruritus. a. True 5. John is a 46-year-old man. He works at an automobile b. False manufacturing facility in the paint room. His position requires the use of personal protective equipment consisting of a 10. Mrs. Patterson presents to your pharmacy mask, body suit, and gloves. Despite this use of protective with oily, yellow scales near her eyebrows equipment, John often has to use cleansing agents to and on her scalp. She complains of severe remove residual paint from his skin. At the end of his shift itching associated with her condition. She each day, his hands are red, swollen, and burning. John is has had this condition for several years. Mrs. most likely experiencing what type of skin disorder? Patterson is most likely experiencing which a. Atopic dermatitis skin condition? b. Allergic contact dermatitis a. Atopic dermatitis c. Irritant contact dermatitis b. Allergic contact dermatitis d. Seborrheic dermatitis c. Irritant contact dermatitis d. Seborrheic dermatitis

48 america’s Pharmacist | May 2009 www.americaspharmacist.net

11. Mrs. Patterson, with the assistance of 17. The nonprescription drug approved for both prevention the pharmacist, chooses a topical shampoo and treatment of athlete’s foot is containing selenium sulfide. How should Mrs. a. Undecylenic Acid Patterson be counseled on the use of this b. Tolnaftate product? c. Terbinafine a. Use three times daily, even after resolution of d. Miconazole symptoms b. Allow lather to remain in contact with the 18. Clinical trials showed cure of tinea pedis with one week affected area up to five minutes use of which nonprescription medication? c. The product will not aid in the removal of scales a. Butenafine or crusts. b. Miconazole d. All of the above c. Terbinafine d. Tolnftate 12. All of the following conditions are associated with a greater incidence or occurrence of 19. Which of the following patients presenting with fungal seborrheic dermatitis EXCEPT infections should be referred to a primary care provider? a. HIV a. A patient with one to two ringworm lesions on the trunk b. Parkinson’s b. “moccasin type” tinea pedis c. Warm weather c. Diabetes patients d. Cold weather d. All of the above

13. Antifungal therapy is effective in seborrheic 20. Patients currently being treated for athlete’s foot should dermatitis. be counseled to: a. True a. Keep the infected skin clean and dry b. False b. Change socks frequently c. Choose cotton socks to help 14. In the United States, what is the most keep feet dry common skin condition? d. All of the above a. Acne b. Contact dermatitis c czema d. Seborrheic dermatitis

15. Acne affects what percentage of persons between the ages of 15 to 24? a. 15 percent b. 35 percent c. 60 percent d. 85 percent

16. A ringworm infection of the nails is called: a. Tinea capitis b. Tinea corporis c. Tinea cruris d. Tinea unguium

www.americaspharmacist.net May 2009 | america’s Pharmacist 49

Taking Action Against Skin Reactions May 1, 2009 (expires May 1, 2012)

FREE ONLINE C.E. Pharmacists now have online access to NCPA’s C.E. programs through Powered by CECity. By taking this test online—go to the Continuing Education section of the NCPA Web site (www.ncpanet.org) by clicking on “Professional Development” under the Education heading you will receive immediate online test results and certificates of completion at no charge.

To earn continuing education credit: ACPE Program 207-000-09-005-H01-P A score of 70 percent is required to successfully complete the C.E. quiz. If a passing score is not achieved, one free reexamination is permitted. Statements of credit for mail-in exams will be available online for you to print out approximately three weeks after the date of the program (transcript Web site: www.cecerts.ORG). If you do not have access to a computer, check this box and we will make other arrangements to send you a statement of credit: q

Record your quiz answers and the following information on this form. q NCPA Member License NCPA Member No. ______State ______no. ______q Nonmember State ______no. ______

All fields below are required. Mail this form and $7 for manual processing to: NCPA C.E. Processing Ctr.; 405 Glenn Drive, Suite 4; Sterling, VA. 20164 ______Last 4 digits of SSN MM-DD of birth ______Name ______Pharmacy name ______Address ______City State ZIP ______Phone number (store or home) ______Store e-mail (if avail.) Date quiz taken

Quiz: Shade in your choice a b c d e a b c d e 1. q q q q q 11. q q q q q 2. q q q q q 12. q q q q q 3. q q q q q 13. q q q q q 4. q q q q q 14. q q q q q 5. q q q q q 15. q q q q q

6. q q q q q 16. q q q q q 7. q q q q q 17. q q q q q 8. q q q q q 18. q q q q q 9. q q q q q 19. q q q q q 10. q q q q q 20. q q q q q

Quiz: Circle your choice 21. Is this program used to meet your mandatory C.E. requirements? a. yes b. no 22. Type of pharmacist: a. owner b. manager c. employee 23. Age group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. Over 60 24. Did this article achieve its stated objectives? a. yes b. no 25. How much of this program can you apply in practice? a. all b. some c. very little d. none

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NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. NCPA has assigned two contact hours (0.2 CEU) of continuing education credit to this article. Eligibility to receive continuing education 50 america’s Pharmacist | May 2009 credit for this article expires three years from the month published.