College of Pharmacy/University of al-qadisyia Fourth Year. Clinical Pharmacy Skin Conditions Part I ) لطمت حمى ) 1-Cold Sore Background 1-A cold sore is a painful (not normally serious) recurrent virus infection of the area (1) around the lips . The virus responsible is the herpes simplex virus (HSV) of which there are two major types: HSV1 and HSV2. HSV1 typically causes infection around or in the mouth, whereas HSV2 is responsible for genital herpes infection (2).

2- Fluid from herpes vesicles contains live virus (4). Infection is spread by viral shedding into saliva and results from direct mucous membrane (e.g. kissing) contact (at sites of abraded skin) between an infected and an uninfected individual (3).

3-The infection is usually contracted in childhood; it may not manifest clinically for several years or at all, but the virus is never eliminated from the body (1)(Once the virus has infected a host, it can go through a period of dormancy and reactivation but that person is infected for life) (4).

Patient assessment with cold sore: A-location: Cold sore typically occurs around the mouth .They can also occur inside and around the nose, but this is less common (3). Lesions inside the mouth or affecting the eye ------referral (1).

B-Precipitating factors: Attacks are frequently triggered by the common cold, hence the common name of the condition (1) , fever (during infections such as colds and flu) (2). Outbreaks also often follow exposure to the sun. Other trigger factors include: fatigue; stress; exposure to cold weather and wind; trauma around the mouth; hormonal changes associated with the menstrual cycle (1).

C-Appearance and Symptoms: 1-Patients with cold sores typically experience prodromal symptoms (prodromal phase) of itching, burning, pain or tingling of up to 24 hours before any visible signs appear (1, 5).

2-Erythema then develops, followed by the formation of painful fluid-filled blisters, which break down into weeping ulcers. The ulcers then dry and form crusts, which are shed, and the area heals (5).

3-Cold sore resolved spontaneously within 7-14 days from the prodromal phase. Cold sore of more than 2 weeks duration ------referral (3).

1 4-Patient with painless sore -----referral (serious lesions ex. Cancer is painless and usually of long duration (2).

D-Previous history (help in the diagnosis): If a cold sore is returning in the same place in a similar way ------then it is likely to be cold sore (2) . Note: when cold sore occur for the first time it can be confused with impetigo (bacterial infection), however, impetigo usually more spread , has a honey– colored crust, does not necessarily start close to the lips, and more common in children------referral [oral antibiotics: (e.g.flucloxacillin) or topical (fusidic acid)] (2).

E-Severity Lesions that are severe and widespread (e.g. spread rapidly over the face)------referral (3) .

F-Medication: 1-Medication used in the previous episodes. 2-Immunocompromised patients (e.g. patients taking ctotoxic chemotherapy, corticosteroid,……) ------are at risk of serious and severe infection----referral (2).

Management: A-Practical point: preventing cross–infection: 1-Patient should be aware that HSV1 is contagious and transmitted by direct contact (2).

2-Lesion should be kept clean by gently washing with mild soap solution (5).

2 B-Aciclovir (5% cream)(zovirax®): 1-The cream is applied five times daily, at 4-hourly intervals, starting, if possible, as soon as prodromal symptoms occur (it may shorten attacks by a day or two if use is begun early enough (1)).

2- Treatment should be continued for 5 days (3). If healing is not complete, treatment can be continued for up to 5 more days, after which medical advice should be sought if the cold sore has not resolved (2).

3-Aciclovir cream is licensed for use in children and pregnant women (2).

C-Bland creams Keeping the cold sore moist will prevent drying and cracking, which might predispose to secondary bacterial infection. For the patient who suffers only an occasional cold sore, a simple cream, perhaps containing an antiseptic agent [e.g. cetrimide (Celavex®)], can help to reduce discomfort (2).

2-Hair Loss: Hair loss affects both men and women and is associated with strong emotional and psychological consequences (3). People link a full head of hair with youth and vitality, whereas baldness gives a feeling of unattractiveness and loss of youth (3).

The two major cause of hair loss are: A-Alopecia androgenetica (called male pattern baldness but sometimes called common baldness because it can affect women also)------treated by the OTC Minoxidil (2). B-Alopecia areata----sudden and patchy hair loss -----referral (2).

Patient assessment with alopecia androgenetica: 1-Age: Patient under 18 years with hair loss -----required referral (3).(safety and efficacy of minoxidil are not established under this age) (5).

2-History and duration of hair loss: Alopecia Androgenetica is characterized by gradual onset where: A-In men: the hair loss begin at the front of the head and recedes backward(3). Or it may begin on the top of the scalp (2).

B- In women: hair loss tends to be diffuse and generalized (2).

3-Size of the affected area:

3 If the diameter of the area is less than 10 cm ------then treatment is worth trying (2). .

4-Other symptoms: A-Coarsening of the hair and hair loss associated with recent weight gain, deepening of the voice, feeling of tiredness------may indicate hypothyroidism------referral (2).

B-Hair loss associated with itching and redness of the scalp------may indicate inflammatory scalp condition (e.g. Tinea capitis, psoriasis, …..)------referral (2).

5-Specific events: During pregnancy(or after childbirth)-----hormonal changes ------hair loss-----the patient should be reassured that this is completely normal and that the hair will grow back------treatment is not appropriate (2). (Pregnancy----increased estrogen levels-----hair thickening-----after delivery the hair loss occur to the normal prepregnancy state) (3).

6-Deficiency state: Iron deficiency is associated with female hair loss. (A 2-months course of iron supplementation should result in thickening of the hair) (3).

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

Treatment timescale: 4 months (2).

Management: A-Minoxidil : it available as 2% and 5% lotion: however Women should not use the 5% product, since it can cause hirsutism at other sites, such as the face, chest, ear rim, and back (6).

Practical points: 1-The earlier the use -----the more the successful (2). 2-Response to minoxidil(2): a- In about 1/3 of patients------regrowth of normal hair. b- In about 1/3 of patients------regrowth of fine (vellus) hair. 4 c- In about 1/3 of patients------no any improvement.

3-Hair may continue to fall out for the first two weeks of minoxidil use (6).

4-After 4-6 weeks------the patient can expect to see a reduction in hair loss (2).

5-Application: In men Topical minoxidil is proven effective for hair growth only on the crown of the head. It has not been proven to grow hair on the front of the scalp and should not be applied there (6). A-Apply it to dry scalp and hair. B-Rub about 1 ml of the lotion to the area of the scalp twice daily. C-The hair should not be washed for at least 1 hour after using the lotion (2). But the hands should be washed after the application (4).

6-Long-term effect: A-after 30 months the effect is still greater than baseline but, not achieve cosmetically acceptable hair growth-----therefore minoxidil may be useful for patient who want to buy himself time from the inevitable balding process (2).

B-New hair growth will fall 2-3 months after treatment is stopped (2).

7-Manufacturer advice avoid in hypertension, angina, heart disease, pregnancy, and lactation (2).

مالحظت: ٌوجذ أٌضا مٍنوكسذٌل سبراي ...وٌستعمل مرتان فً الٍوم أٌضا ....و تتبع تعلٍماث النشرة المرفقت بخصوص عذد البخاث المستعملت فً كل مرة .

B- The POM drug finasteride (Propecia® 1 mg tab.)(Dose 1mg/day)------Inhibits the enzyme responsible for androgenetic alopecia------is used to treat Alopecia Androgenetica in men (3).

Note: Other than minoxidil and Propecia, no remedies have been proven to regrow hair (6).

2-Fungal skin infections Terminology: Most often, tinea infections are named based on the area affected (4):

5 Site Name Note Scalp Tinea capitis Required referral Feet Tinea pedis Called athlete's foot Groin Tinea cruris Body Tinea corporis Nails Tinea unguium See note below (onychomycosis)

مالحظت: كاند كرة الصيدلح ذضع فطزياخ األظافز من الحاالخ آلري ذسروجة إحالح إلى الطثية ولكن ذم في عام 2006 ذحويل دواء ,amorolfine 5% إلى OTC لعالج هذه الحالح وفق شزوط وضواتظ خاصح )مذكورج في كراب Non-prescription medicines. 2010 لمؤلفه Alan Nathan.

A-Athlete's foot (Tinea pedis): Athlete's foot is the most prevalent cutaneous fungal infection in human and it is more (4) common in adult . The infection is easily transmitted in moist or humid locations, e.g. sports clubs, hence the common name of the condition (1).

Patient assessment with Athlete's foot: 1-Location: The usual site of infection is in the toe webs, especially the web space between the fourth and fifth toe (2). Severe infection may affect other part of the foot (sole of the foot, or even the upper surface) ------referral (2). Also if the toenails involved (Tinea unguium) ------referral (2).

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

3-Severity (2): Severe athlete's foot (broken and macerated skin with signs of bacterial involvement (weeping, pus or yellow crusts)-----referral.

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

5-Medication (2): To identify the identity and method (especially the duration) of use of any treatment. 6 Athlete's foot unresponsive to appropriate medication------referral.

Treatment timescale: 2 weeks.

Management: A-practical advice to prevent reinfection: 1-Clean the skin daily with soap and water (4). Dry the skin thoroughly after bath. Keep a personal towel and don’t share it to prevent the infection spreading from person to person (3).

2-Socks should frequently change (3) and washed regularly. Cotton sock can facilitate the evaporation of moisture, where as nylon socks will prevent this (2).

3-Avoid wearing occlusive, non-breathable shoes (3) (in summer, open toe sandals can be helpful (2)) and shoes should be left off where possible (2).

4-Dust shoes and socks with antifungal powder (3). (e.g. miconazole powder: a once daily prophylactic us of powder in shoes and socks is sufficient )

B-Antifungal:

Antifungal Dose (daily Duration applications) 1-Ketocdonazole Twice daily(2) 1 week(advantage) (2)(2-3 days after the disappearance of symptoms(3)) 2-Terbinafine Twice daily(2) 1 week(advantage) (2) 3-Miconazole Twice daily(2) 2 weeks after the disappearance of symptoms to prevent relapse(2) 4-Clotrimazole(fugidin®) Twice daily(2) 2 weeks after the disappearance of lesion to prevent relapse(2) 5-Tolnaftate(tinaderm®) Twice daily(2) Up to 6 weeks(2) (1 week after the disappearance of symptoms (3) )

Note: 1-Benzoic acid ( usually present in combination with salicylic acid(Whitfield's ointment®))--- is a traditional treatment for athlete's foot but its effectiveness is questionable(3) , and have been replaced by the above new agents (3).

2-Other OTC antifungal for athlete’s foot are : Econazole cream (pevaryl®), Sulconazole cream , Griseofulvin spray, and undecenoates cream, powder and spray (5).

3-Antifungal/steroid combination: (Miconazole 2% Et hydrocortisone 1%: Daktacort Hydrocortisone®) (Clotrimazole 1% Hydrocortisone 1%: Canesten Hydrocortisone ®): They are used to control initial symptoms of redness and itch in patients aged over 10 (3). 7

Practical point: 1-Product should be applied after careful cleaning and drying of the foot especially between the toes (2).

2-They can be used during pregnancy (3) .

3-Agents used for cutaneous fungal infections are formulated as: creams, ointments, solutions, sprays, and powders.

Creams or solutions are the most effective dosage form for the delivery of active ingredient to the epidermis. sprays and powders are less effective because they are often not rubbed into the skin. ------they are probably more useful as adjunct to creams and solutions or as a prophylactic agents in preventing new recurrent infections (4) .

B-Tinea cruris: It is the fungal infection of the groin , inner thigh and may be spread to the buttocks (1) .the lesion is normally intensely itchy, reddish brown, and has a well defined edge(1).the problem is more common in men than in women (2).

Treatment: by the same above antifungals.

C-Tinea corporis: Is a fungal infection of the major skin surface that do not involves hands, face, feet, groin or scalp (3). It occurs as an itchy circular lesion (ringworm: central clear area with a red advancing edge.) (2) Lesion can occur singly, be numerous, or overlap to produce a large lesion that appear polycyclic (several overlapping circular lesion) (3).

Treatment: by the same above antifungals.

D-Pityriasis (tinea) versicolor (1,7) Pityriasis versicolor, a superficial skin infection caused by a yeast, Malassezia furfur . The organism is more common in hot, sunny areas.

8 Signs and symptoms 1-Macular (flat) patches of altered pigmentation occurring mainly on the trunk and upper legs and arms. In white-skinned people patches are brownish and look as if suntanned, whereas on darker-skinned or heavily tanned people patches are pale or white.

.appearance ُم َزقَّظ 2-The affected area has an overall dappled

3-There is a superficial scale that can be removed by scraping with a fingernail.

4-Pruritus, if any, is mild.

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

Treatment 1-An imidazole (clotrimazole, miconazole, ketoconazole) cream applied daily for 3 weeks.

2-Or ketoconazole 2% shampoo. Apply undiluted and wash off after 5 minutes. Repeat daily for 1 week.

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

References 1- Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press; 2008 2-Symptoms in the pharmacy . A guide to the managements of common illness. 6th edition By Alison Blenkinsopp and Paul Paxton .2009. 3-Community Pharmacy. Symptoms, Diagnosis and Treatment. By Paul Rutter.2013. 4-Handbook of Non-prescription drugs.2010. 5- Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press; 2010. 6-Joshua J. Pray, Steven Pray, Is Hair Loss Self-Treatable. Vol. No: 28:08 Posted: 8/15/03 7- Klaus Wolff. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. Copyright ©2007 The McGraw-Hill Companies

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