BNF - Chapter 11-15 - Low Weighted Chapters Flashcards
What eye preparations are available?
- Drops
- Gels
- Ointments
What counselling advice should you give if patient has to use two different eye drops?
Space out with a five minute interval and for longer if gel is being used.
If a combination of either eye drops, gels or ointment is being used, which one should you apply last?
Apply ointment last
What additional counselling advice can you give to patients for eye preparations?
- Wash hands before use
- Keep eyes closed as long as possible
- Patient may experience transient blurred vision, especially with eye ointments - apply at night.
DO not drive until vision is clear
What are the general expiry dates of eye preparations depending on the environment or setting it is being used in?
Home use = 28 days
Hospital use = 4 weeks (local practice may vary)
Outpatient/ surgery = single application
Which drugs given systemically may affect contact lens patients?
These include drugs which can cause corneal oedema (e.g. oral contraceptives–particularly those with a higher oestrogen content), drugs which reduce eye movement and blink reflex (e.g. anxiolytics, sedative hypnotics, antihistamines, and muscle relaxants), drugs which reduce lacrimation (e.g. older generation antihistamines, phenothiazines and related drugs, some beta-blockers, diuretics, and tricyclic antidepressants), and drugs which increase lacrimation (including ephedrine hydrochloride and hydralazine hydrochloride). Other drugs that may affect contact lens wear include isotretinoin (can decrease tolerance to contact lens), aspirin (can cause irritation), and rifampicin and sulfasalazine (can discolour lenses).
how many types of contact lenses are there?
2 types
Hard lenses
Soft lenses
With which type of lenses can you still use eye drops?
With hard lenses - can still use eye drops whilst wearing the lenses
What about if the patient has soft lenses (silicone hydrogel)?
- Remove lenses before using eye drops or use preservative-free eye drops; drugs and preservatives can accumulate in the lenses
Which eye preparations would you never wear lenses during use?
- Ointments never use when wearing lenses and also oily eye drops
Which two drugs can stain contact lenses orange?
Rifampicin and sulfasalazine
Which eye drops drugs are used for allergic conjunctivitis (eye allergies)?
- Sodium cromoglicate (mast cell stabiliser)
- Antazoline, azelastine (antihistamine)
- Xylometazoline, Naphazoline (vasoconstrictors reduce redness)
Which ingredients are used for dry eyes?
- Hypromellose = applied hourly
- Carmellose = applied QDS
Which ingredient is used for bacterial conjunctivitis?
Chloramphenicol eye drops/ointment
Which ingredient is used for viral conjunctivitis?
Aciclovir - 5 times a day until 3 days after healing
Which cream may be used for bacterial blepharitis?
Fusidic acid cream for staphylococcal infection
in which eye conditions may topical corticosteroid be used in?
Steroid glaucoma and cataracts
What does topical corticosteroid eye preparations increase the risk of?
Increased risk of infections and aggravates existing infections e.g. if used in ‘red eye’ caused by HSV can lead to corneal ulcers and blindness
What is used for corneal ulcers?
There is a possibility of blindness
Intensive antibiotic course with ciprofloxacin is needed
What is used to dilate pupils for eye examinations/ procedures?
Cycloplegics/ Mydriatics
Antimuscarinincs e.g. Atropine
Phenylepherine - MAOI interaction and risk of hypertensive crises
What does antimuscarinics do?
They paralyse ciliary muscle - DO not drive until vision is clear
Name two mast cell stabilisers used in eye preparations for treatment of allergic conjunctivitis?
- Sodium cromoglicate
- Lodoxamide
Name a NSAID used in eye prepartions for the prophylaxis and treatment of post-operative pain and inflammation associated with cataract surgery?
Nepanfenac
When is ciclosporin (immunosupressant - calcineurin inhibitor) eye preparations used?
In severe dry eyes disease that has not responded to treatment with tear substitutes (initiated by a specialist)
Name some ingredients used for dry eyes?
- Acetylcysteine
- Carbomers (e.g. viscotears, carbomer 980)
- Carmellose sodium (e.g. Celluvisc)
- Hydroxymethylcellulose
- Hypromellose
- Liquid paraffin with white soft paraffin and wool alcohols (Xailin night eye ointment)
- Paraffin yellow soft (Liquid paraffin)
- Polyvinyl alcohol (Liquifilm tears/ sno tears)
- sodium chloride
- Sodium hyaluronate (e.g. Hycosan, blink intensive)
- soybean oil
Which microorganism is blepharitis usually caused by?
- staphylococci
What is bacterial conjunctivitis usually caused by?
Bacterial conjunctivitis is commonly caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae.
What may keratitis be caused by?
Keratitis may be bacterial, viral, or fungal; it can also be caused by Acanthamoeba (parasite).
What is the treatment for anteroir bacterial blepharitis?
Anterior bacterial blepharitis is treated by application of an antibacterial eye ointment (such as chloramphenicol) to the conjunctival sac or rubbed into the lid margins, if blepharitis is not controlled by eyelid hygiene alone. Systemic treatment (e.g. tetracyclines in patients over 12 years of age) may be required in patients with posterior blepharitis. Treatments can be intermittently stopped and restarted, based on the severity of the blepharitis and drug tolerance.
Are most cases of bacterial conjunctivitis self-limiting?
Yes and resolve within 5-7 days without treatment
Is endophthalmitis a medical emergency?
YEs
Are antifungal preparations for the eye available?
Not generally available
For bacterial eye infections eye preparations containing which drugs may be used?
- Aminoglycosides (Gentamicin and tobramycin)
- Cephalosporin (second generation - Cefuroxime)
- Macrolides (Azithromycin)
- Quinolone - (Ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin)
- Chloramphenicol (a potent broad-spectrum antibiotic)
Is fusidic acid a broad or narrow spectrum antibiotic?
Narrow spectrum used for staphylococcal infections.
What is glaucoma?
Glaucoma is a group of eye disorders characterised by a loss of visual field associated with pathological cupping of the optic disc and optic nerve damage
What are the causes of glaucoma?
While glaucoma is generally linked to raised intra-ocular pressure, which is the main treatable risk factor, it can also occur when the intra-ocular pressure is within the normal range. Other risk factors include age, family history, ethnicity, corticosteroid use, myopia, type 2 diabetes mellitus, cardiovascular disease, and hypertension.
What is the most common form of glaucoma?
An open-angle glaucoma (also known as primary open-angle
glaucoma)
where drainage of the aqueous humour through the trabecular meshwork is restricted, and the angle between the iris and the cornea is normal.
What is considered as having ocular hypertension?
AN intra-ocular pressure greater than 21mmHg
What are people with ocular hypertension at higher risk of developing?
- Chronic open-angle glaucoma
Is acute angle-closure glaucoma common?
They are less common and occur when the outflow of aqueous humour from the eye is totally obstructed by bowing of the iris against the trabecular meshwork.
What is closed angle glaucoma characterised by?
It is characterised by its abrupt onset of symptoms, and it is a sight-threatening medical emergency that requires urgent reduction of intra-ocular pressure to prevent loss of vision.
What is the aim of treatment of glaucoma?
The aim of treatment is to control intra-ocular pressure to prevent the development or progression of glaucoma and subsequent visual field damage, or sight loss.
What is the first-line treatment in patients with intra-ocular pressure of 24mmHg or greater and who are at risk of visual impairment within their lifetime?
- A topical prostaglandin analogue
Latanoprost
Tafluprost
Travoprost
Bimatoprost (a synthetic prostamide)
Do patients who are not at risk of visual impairment within their lifetime require treatment>
No - but should be monitored regularly.
What if the initial treatment with a topical prostaglandin analogue is not well tolerated?
- An alternative prostaglandin should be tried before switching to a topical beta-blocker such as:
- Betaxolol
- Levobunolol
- Timolol
What if treatment is still not well tolerated what is the next alternative option?
Carbonic anhydrase inhibitors -
- Brinzolamide
- Dorzolamide
Alternatives as either monotherapy or combination therapy with drugs from different therapeutic classes (topical beta-blockers, carbonic anhydrase inhibitors, or topical sympathomimetics), should also be offered to patients with an intra-ocular pressure of 24 mmHg or more whose current treatment is not reducing intra-ocular pressure sufficiently to prevent the risk of progression to sight loss.
What is the treatment steps for chronic open-angle glaucoma?
1) Topical prostaglandin analogues (Latanoprost, trafluprost or bimatoprost)
2) topical beta-blocker (betaxolol, levobunolol, timolol)
OR
Carbonic anahydrase inhibitor (brinzolamide or dorzalamide)
Or
a topical sympathiomimetic (apraclodinide or brimonidine)
or a combination of these should be offered
What are alternative non-pharmacological treatment options for chronic open angle glaucoma?
Alternative treatment options are laser trabeculoplasty or surgery with pharmacological augmentation (with mitomycin [unlicensed indication]).
What is a contraindication for beta blocker eye drops?
Asthma
What is a side effect of prostaglandin analogoue eye drops that patients should be counselled on?
Can cause long eye lashes and darker iris colour
Is carbonic anhydrase inhibitors also diuretics?
Yes
Which carbonic anhydrase inhibitor used for glaucoma is only available as tablet (taken orally)
Acetazolamide
List the topical beta-blockers available to be used in open angle glaucoma/ reduce intra-ocular pressure?
- Betaxolol
- Levobunolol
- Timolol
Name the carbonic anhydrase inhibitors used in closed angle galucoma/ reduce intra-occular pressure?
- Acetazolamide (Taken orally)
- Brinzolamide
- Dorzalamide
Name one parasympathomimetic used as a eye drop?
Pilocarpine
List the prostaglandin analogues used in open-angle glaucoma/ intra-occular pressure?
- Latanoprost
- Tafluprost
- Travoprost
- Bimatoprost
When are protaglandin analogues preferable to be administered?
In the evening
Name the sympathomimmetics (alpha 2 adrenoreceptor agonists) used in intra-ocular pressure/ open agnle galucoma?
- Apraclonidine
- Brimonidine
Can closed angle glaucoma be treated in primary care?
Closed-angle glaucoma is a medical emergency
What are the symptoms of closed angle glaucoma?
- Cloudy eye, nausea and vomiting, headache, intense eye pain, blurred hazy vision, sight loss, rainbow-coloured rings around lights
What age does age-related macular degenration occur?
In people aged 55 years and over
How many types of age-related macular degeneration are there?
Two types
dry and wet
What is dry age-related macular degenration?
Dry (non-neovascular) age-related macular degeneration progresses slowly as extensive wasting of macula cells occurs
What about with wet (neosvascular) age-related macular degeneration?
new blood vessels develop beneath and within the retina, and can lead to a rapid deterioration of vision.
What is wet age-related macular degeneration further classified as?
Wet age-related macular degeneration is further classified as wet-active (neovascular lesions that may benefit from treatment) and wet-inactive (neovascular disease with irreversible structural change).
Summarise the treatment for age-related macrovascular degeneration?
Counselling and support, advice on Smoking cessation, and use of visual aids is recommended in all patients with age related macular degeneration as appropriate.
An intravitreal anti-vascular endothelial growth factor (anti-VEGF), such as aflibercept, ranibizumab, or bevacizumab [unlicensed use], is first-line treatment for patients with wet-active age-related macular degeneration who have a visual acuity between 6/12 and 6/96. If visual acuity is less than 6/96, anti-VEGF treatment should only be given if the patient’s overall visual function is likely to improve (e.g. if the affected eye is the patient’s better-seeing eye). Anti-VEGF treatment should only be administered by healthcare professionals experienced in the use of intravitreal injections. See also National funding/access decisions for aflibercept and ranibizumab.
What does otitis externa refer to?
Inflammation of the external ear canal which in some cases may involve oedema
- Primarily caused by bacterial infection
It is important to consider underlying otitis media as otitis externa may be secondary to otorrhoea from otitis media.
What solution acts as a stringent in the external ear canal?
A solution of acetic acid 2% acts as an astringent in the external ear canal by reducing the pH and reducing bacterial and fungal cell growth
It may be used to treat mild otitis externa and is comparable to an anti-infective combined with a corticosteroid; efficacy is reduced if treatment extends beyond 1 week.
How long can a topical anti-infective with or without corticosteroid be used for in otitis externa?
These are used for a minimum of one week but if symptoms persist they can be used until they resolve, up to a maximum of 2 weeks
What can prolonged use of topical anti-infective affect?
Prolonged and extensive use of topical anti-infective or corticosteroid treatment may affect the flora in the ear canal, increasing the risk of fungal infections
In view of reports of ototoxicity, treatment with topical aminoglycosides is contraindicated in patients with what?
With a perforated tympanic membrane (eardrum)
Baseline assessment of what should be performed before commencing treatment?
Baseline audiometry should be performed, if possible before treatment is commenced
What is used for severe pain in otitis externa?
For severe pain associated with otitis externa, a simple analgesic, such as paracetamol or ibuprofen, is usually sufficient; codeine phosphate may be used for severe pain.
Are oral antibacterial indicated for otitis externa?
Rarely indicated
Is acute otitis media self-limiting?
Yes and mainly affects children
What is acute otitis media characterised by?
t is characterised by inflammation in the middle ear associated with effusion and accompanied by the rapid onset of signs and symptoms of an ear infection. The infection can be caused by viruses or bacteria; often both are present simultaneously.
What doe children with acute otitis media usually prhildren and their carers should be reassured that antibacterial drugs are usually not required.esent with?
usually present with symptoms such as ear pain, rubbing of the ear, fever, irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoea. Symptoms usually resolve within 3 to 7 days without antibacterial drugs and they make little difference to the development of complications such as short-term hearing loss, perforated eardrum or recurrent infection.
Children and their carers should be reassured that antibacterial drugs are usually not required.
When should an immediate antibacterial drug be given to a child for otitis media?
An immediate antibacterial drug should be given if the child is systemically very unwell, has signs or symptoms of a more serious illness, or is at high risk of complications such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, or young children who were born prematurely.
An immediate antibacterial drug can also be considered if otorrhoea (discharge following perforation of the eardrum) is present, or in children under 2 years of age with bilateral otitis media.
What is otitis media with effusion (glue ear)?
is characterised by the collection of fluid within the middle ear without any signs of inflammation. It occurs most frequently in children, often in those aged 2 to 5 years; it is the most common cause of hearing impairment in children
Which children is glue ear more common in?
It is more common in children with cleft palate, Down’s syndrome, primary ciliary dyskinesia, and allergic rhinitis.
Whats the treatment for glue ear in children?
Children with otitis media with effusion should be observed (for 6–12 weeks) as it commonly resolves spontaneously. Systemic antibacterials, antihistamines, mucolytics, decongestants, and corticosteroids are not recommended due to lack of evidence supporting their use.
Referral to a specialist in certain circumstances (including in children with Down’s syndrome and cleft palate) are warranted to avoid complications such as severe hearing impairment, and communication and developmental difficulties.
What is another name for earwax?
Cerumen
What can ear wax be softened using?
Ear wax can be softened using simple remedies such as olive oil ear drops or almond oil ear drops; sodium bicarbonate ear drops are also effective, but may cause dryness of the ear canal
The drops can be used three to four times daily for several days. Lying down with the affected ear uppermost, ear drops are instilled before waiting for 5 minutes.
Ear irrigation to remove wax should be avoided in what age?
In children under the age of 12
Cana person who has hearing in one ear only have ear irrigated?
No - because even a slight risk of damage may lead to permanent deafness
Which aminoglycosides can be used for otitis externa?
- Framycetin
- Gentamicin
- Neomycin
Which quinolone can be used for otitis externa?
- Ciprofloxacin
Can chloramphenicol be used for otitis externa?
YEs
What do many nasal preparations contain that may irritate the nasal mucosa?
- Sympathomimetic drugs
What may be used as nasal irrigation in allergic rhinitis for modest symptom reduction, and to reduce the need for other drug treatment.?
Sodium chloride 0.9% solution
What is mild allergic rhinitis controlled by?
Antihistamines or topical nasal corticosteroids
Which are faster acting, topical antihistamines or oral antihistamines?
Topical antihistamines (e.g. azelastine hydrochloride) are faster acting than oral antihistamines and therefore useful for controlling breakthrough symptoms in allergic rhinitis; they are less effective than topical nasal corticosteroids.
What can topical nasal decongestant be used to allow?
Topical nasal decongestants can be used for a short period to provide quick relief from congestion and allow penetration of a topical nasal corticosteroid.
Are systemic nasal decongestants good at reducing nasal obstruction?
Systemic nasal decongestants are weakly effective in reducing nasal obstruction but have considerable potential for side-effects, and therefore are not recommended.
What can be added to allergic rhinitis treatment when watery rhinorrhoea persists despite treatment with topical nasal corticosteroids and antihistamines
Nasal Ipratropium (SAMA) - has antimuscarinic effects
Can topical nasal corticosteroids be used when there is a nasal?
No
Which nasal corticosteroids have higher absorption?
The extent of absorption varies between steroids; mometasone furoate and fluticasone have negligible systemic absorption, others have modest absorption, whilst betamethasone has high systemic absorption and should only be used short-term.
What should be monitored in children getting corticosteroids?
The growth of children receiving treatment with corticosteroids should be monitored; especially in those receiving corticosteroids via multiple routes.
Can nasal corticosteroids be used in pregnancy?
Yes - safety hasn’t been established through clinical trials - only minimal amounts of nasal corticosteroids are systemically absorbed
. Beclometasone dipropionate, budesonide, and fluticasone are widely used in asthmatic pregnant women; fluticasone has the lowest systemic absorption when used intra-nasally
Are decongestants recommended in pregnancy?
No, however, some antihistamine and sodium cromoglicate may be used
What can elimination of organisms such as staphylococci from the nasal vestibule can be achieved by the use of?
Antimicrobial preparations such as chlorhexidine with neomycin (Naseptin)
Or a nasal ointment Mupirocin (bactroban) if naseptin is unsuitable or ineffective
In hospitals or in care establishements what can be used for the eradication of nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA)?
Mupirocin (Bactroban)
What is sinusitis?
Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses
Is acute sinusitis (Rhinosinusitis) self-limiting?
Yes - usually triggered by a viral upper-respiratory tract infection such as the ‘common cold’.
What do patients with acute sinusitis usually present with?
Patients with acute sinusitis usually present with symptoms of nasal blockage or congestion, nasal discharge, dental or facial pain or pressure, and reduction or loss of the sense of smell.
Symptoms of sinusitis usually improve within how many days without requiring treatment?
2-3 weeks
Whats the recommendation for patients with sinusitis for 10 days or less?
Patients presenting with symptoms for around 10 days or less, should be given advice about the usual duration of acute sinusitis, self-care of pain or fever with paracetamol or ibuprofen, and when to seek medical help. Patients should be reassured that antibiotics are usually not required. Some patients may try nasal saline or nasal decongestants, however there is limited evidence to show they help to relieve nasal congestion.
What is the other name for dry mouth?
Xerostomia
What is dry mouth a result of?
Resulting from reduced saliva secretion
Which drugs may dry mouth be casued by?
- antimuscarinics, antihistamines, tricyclic antidepressants, and some diuretics.
What else can dry mouth be caused by?
It can also be caused by irradiation of the head and neck region, dehydration, anxiety, or Sjögren’s syndrome.
Patients with dry mouth may be at greater risk for developing what?
Patients with dry mouth may be at greater risk of developing dental caries, periodontal disease, and oral infections (particularly candidiasis).
What simple measures may stimulate salivation?
such as frequent sips of cold unsweetened drinks, or sucking pieces of ice or sugar-free fruit pastilles, or chewing sugar-free gum.
What can be considered if simple stimulatory measures are inadequate?
An artificial saliva substitute can be considered if simple stimulatory measures are inadequate. The acidic pH of some artificial saliva products may be inappropriate for some patients as it may damage the enamel of natural teeth. Artificial saliva products are available in oral lozenges, oral gel, oral spray, and pastille forms.
When are pilocarpine tablets are licensed for the treatment of xerostomia?
Pilocarpine tablets are licensed for the treatment of xerostomia following irradiation for head and neck cancer, and dry mouth and dry eyes (xerophthalmia) in Sjögren’s syndrome.
How long do pilocarpine tabs take to work?
They may take up to 3 months to be effective; treatment should be withdrawn if there is no response within this time.
What are aphthous ulcers?
Aphthous ulcers are often recurrent and are not associated with an underlying systemic disease; they are small, round or ovoid mouth ulcers with defined margins.
What may aphthous ulcer be triggered by?
Aphthous ulcers may be precipitated by triggers such as certain food and drinks, allergies, anxiety, or hormonal changes.
Patients with an unexplained mouth ulcer of more than how many weeks should be referred to a specialist?
Of more than 3 weeks’ duration should be referred urgently
What is the non-drug treatment of aphthous ulcers?
Advise patients to avoid known triggers for ulceration, such as oral trauma (e.g. biting during chewing, ill-fitting dentures) or certain food and drinks (e.g. coffee, gluten-containing products). If the ulcers are mild, infrequent, and do not interfere with daily activities (such as eating), treatment may not be required.
What is used first line for aphthous ulcers?
Topical corticosteroids
A short course of systemic corticosteroids may be prescribed for patients with severe recurrent aphthous ulcers.
What is pericoronitis?
Pericoronitis is swelling and infection of the gum tissue around the wisdom teeth, the third and final set of molars that usually appear in your late teens or early 20s. It is most common around the lower wisdom teeth.
What is the treatment for pericoronitis?
Public Health England advises antibacterial use only in the presence of systemic features of infection, or persistent swelling.
Metronidazole, or alternatively, amoxicillin
Suggested duration of treatment 3 days or until pain reduction allows for oral hygiene
What is Gingivitis (acute necrotising ulcerative)?
Acute necrotizing ulcerative gingivitis (ANUG) is a rapidly destructive, non-communicable microbial disease of the gingiva (gums) min the context of an impaired host immune response.
What is the treatment for Gingivitis?
Metronidazole
Suggested duration of treatment 3 days.
If metronidazole is contra-indicated, use alternative, amoxicillin.
What is the treatment for abscess (periapical or periodontal)?
Public Health England advises antibacterial use only if there are signs of severe infection, systemic symptoms, or a high risk of complications.
Phenoxymethylpenicillin, or alternatively, amoxicillin
Alternative in penicillin allergy: clarithromycin
If signs of spreading infection (e.g. lymph node involvement, systemic signs), add metronidazole
Suggested duration of treatment up to 5 days; review at 3 days.
What is the antibiotic choice for sore throat infections?
Phenoxymethylpenicillin
Suggested duration of treatment 5 to 10 days.
If penicillin-allergic, clarithromycin (or erythromycin)
Suggested duration of treatment 5 days.
Fungal infections of the mouth are usually caused by which organisms?
caused by Candida spp. (candidiasis or candidosis).
When thrush is associated with corticosteroid inhalers, what advice can you give?
rinsing the mouth with water (or cleaning a child’s teeth) immediately after using the inhaler may avoid the problem.
In immunocompromised patients is topical or oral preferred?
Topical therapy may not be adequate in immunocompromised patients and an oral triazole antifungal is preferred.
What is angular Cheilitis?
Angular cheilitis (angular stomatitis) is characterised by soreness, erythema and fissuring at the angles of the mouth
may represent a nutritional deficiency or it may be related to orofacial granulomatosis or HIV infection
What is used for angular cheilitis?
While the underlying cause is being identified and treated, it is often helpful to apply miconazole cream or fusidic acid ointment; if the angular cheilitis is unresponsive to treatment, hydrocortisone with miconazole cream or ointment can be used.
Is Nystatin absorbed from the GI tract?
Nystatin is not absorbed from the gastro-intestinal tract and is applied locally (as a suspension) to the mouth for treating local fungal infections.
What about miconazole is that absorbed from the GI tract?
Miconazole is applied locally (as an oral gel) in the mouth but it is absorbed to the extent that potential interactions need to be considered.
Miconazole also has some activity against Gram-positive bacteria including streptococci and staphylococci.
Which out of the three, bacterial, viral or fungal is the most common cause of a sore throat?
Viral infections
What is the management of primary herpetic gingivostomatitis?
a soft diet, adequate fluid intake, and analgesics as required, including local use of benzydamine hydrochloride. The use of chlorhexidine mouthwash will control plaque accumulation if toothbrushing is painful and will also help to control secondary infection in general.
In the case of severe herpetic stomatitis which drugs may be required?
a systemic antiviral such as aciclovir is required. Valaciclovir and famciclovir are suitable alternatives for oral lesions associated with herpes zoster.
Which two anti viral is used for the prevention of frequently recurring herpes simplex lesions of the mouth?
Aciclovir and valaciclovir are also used for the prevention of frequently recurring herpes simplex lesions of the mouth, particularly when implicated in the initiation of erythema multiforme.
Which is better for chronic dry skin areas - creams or ointments?
Ointments are greasy preparations which form a more occlusive barrier over skin; most hydrating for chronic dry skin areas
Which dries out more quicker, cream or ointment?
Cream dries out quicker than ointments and applied more frequently
What do gels contain a high content of?
A high water content suitable for scalp and face application
What effect do lotions have?
They have a cooling effect, preferred for applying over large or hairy areas.
What base do lotions have?
Lotions have an alcoholic base which can sting broken skin
Can salicylate be used in neonates (babies aged 1-28 days old)?
No toxic in neonates
What other ingredient should you not use in neonates?
Avoid benzyl alcohol in neonates = fatal toxicity syndrome
In what direction should you apply emollients?
Apply emollient in direction of hair growth; reduce risk of folliculitis
What is there an hazard with bath emollients?
A slipping hazard
With bath additives how long should you soak for?
For at least 10-20 minutes to improve hydration
How should you use administer the bath emollients?
Remove from tubs using clean spoon to avoid contamination
What is there a risk of with paraffin-based skin emollients?
Paraffin-based skin emollients.
Clothes/ dressings easily ignited by a naked flame. Do not smoke.
What do topical corticosteroids do for skin?
Reduces inflammation in inflammatory skin conditions e.g. eczema, dermatitis.
Topical corticosteroids are contraindicated on which skin conditions?
- Acne
- Rosacea
- Skin infections (exacerbates)
Which topical corticosteroid is a mild strength?
Hydrocortisone <2.5%
Which topical corticosteroids are moderate strength?
- Clobetasone (Eumovate)
- Betamethasone 0.025% (Betnovate-RD)
Which topical corticosteroids are potent strength?
- Betamethasone 0.1% (Betnovate)
- Hydrocortisone Butyrate
- Mometasone
Which topical corticosteroids are very potent strength?
Clobetasol (Dermovate)
How should you apply topical steroid?
Apply thinly to affected areas no more than twice daily
Why should you avoid prolonged use with topical corticosteroids?
- avoid especially on the face because steroids cause skin thinning and hypo or hyper-pigmentation
Which should you apply first, emollient or steroid?
Apply emollient first and wait half hour before steroid for maximum absorption.
What is a fingertip unit (FTU)?
A FTU (about 500mg) is the amount of medication needed to squeeze a line from the tip of an adult finger to the first crease of the finger.
How much fingertip units is recommended for different parts of the body?
Genitals - 0.5 FTU
Hands, elbow and knees - 1 FTU
Feet including soles - 1.5 FTU
Face and neck - 2.5 FTU
Scalp - 3 FTU
A hand and arm, or buttocks - 4 FTU
Legs and chest, or legs, and back - 8 FTU
Which skin infections require systemic antibacterial treatment?
Cellulitis
Erysipelas
Leg ulcer
What is mupirocin useful to treat - which organisms?
Mupirocin is not related to any other antibacterial in use; it is effective for skin infections, particularly those due to Gram-positive organisms but it is not indicated for pseudomonal infection.
To avoid mupirocin resistance development, what should you not do?
mupirocin or fusidic acid should not be used for longer than 10 days and local microbiology advice should be sought before using it in hospital.
Which drug is used in the treatment of infected burns?
- Silver sulfadiazine
Is fusidic acid broad or narrow spectrum?
Fusidic acid is a narrow-spectrum antibacterial used for staphylococcal infections.
What is metronidazole used topically for?
topically for rosacea and to reduce the odour associated with anaerobic infections
Which bacteria is oral metronidazole used to treat?
Wounds infected with anaerobic bacteria
To prevent relapse of antifungal skin infections, how long should antifungal treatment be continued?
local antifungal treatment should be continued for 1–2 weeks after the disappearance of all signs of infection.
What are the names for ringworm infections in diff parts of the body?
Ringworm infection can affect the scalp (tinea capitis), body (tinea corporis), groin (tinea cruris), hand (tinea manuum), foot (tinea pedis, athlete’s foot), or nail (tinea unguium).
What does scalp fungal infection require?
Systemic treatment;
What is used for angular cheilitis?
- Miconazole cream is used in the fissures of angular cheilitis when associated with Candida
What about viral infections of the skin?
Aciclovir cream is licensed for the treatment of initial and recurrent labial and genital herpes simplex infections; treatment should begin as early as possible. Systemic treatment is necessary for buccal or vaginal infections and for herpes zoster (shingles).
What about penciclovir?
Penciclovir cream is also licensed for the treatment of herpes labialis; it needs to be applied more frequently than aciclovir cream
What is used for Scabies?
Permethrin is used for the treatment of scabies (Sarcoptes scabiei)
What can be used for scabies if permethrin is inappropriate?
Melathion
Can benzyl benzoate be used in children for treatment of scabies?
No it is an irritant and should be avoided in children; it is less effective than malathion and permethrin
What counselling is needed for scabies treatment?
- All members of the affected household should be treated simultaneously.
- Treatment should be applied to the whole body including the scalp, neck, face and ears.
- Particular attention should be paid to the webs of the fingers and toes and lotion brushed under the ends of nails
How often is permethrin or malathion applied for treatment of scabies?
It is now recommended that malathion and permethrin should be applied twice, one week apart.
It is important to warn users to reapply treatment to the hands if they are washed.
What about benzyl benzoate in adults for treatment of scabies?
up to 3 applications on consecutive days may be needed
What should patients be counselled on regarding itching of scabies?
The itch and eczema of scabies persists for some weeks after the infestation has been eliminated and treatment for pruritus and eczema may be required.
Application of crotamiton can be used to control itching after treatment with more effective acaricides.
A topical corticosteroid may help to reduce itch and inflammation after scabies has been treated successfully; however, persistent symptoms suggest that scabies eradication was not successful
Oral administration of a sedating antihistamine at night may also be useful.
What is effective against head lice?
Dimeticone;
It coats head lice and interferes with water balance in lice by preventing the excretion of water; it is less active against eggs and treatment should be repeated after 7 days
If head lice infestation is present what formulation should be used?
Head lice infestation (pediculosis) should be treated using lotion or liquid formulations only if live lice are present. Shampoos are diluted too much in use to be effective.
How long contact time is recommended for lotions and liquids?
A contact time of 8–12 hours or overnight treatment is recommended for lotions and liquids; a 2-hour treatment is not sufficient to kill eggs.
In general, a course of treatment for headlice should be how long and how many applications?
2 applications of product 7 days apart to kill lice emerging from any eggs that survive the first application.
All affected household members should be treated simultaneously.
What is the wet combing method?
Head lice can be mechanically removed by combing wet hair meticulously with a plastic detection comb (probably for at least 30 minutes each time) over the whole scalp at 4-day intervals for a minimum of 2 weeks, and continued until no lice are found on 3 consecutive sessions; hair conditioner or vegetable oil can be used to facilitate the process.
What may be used to eliminate crab lice (Pthirus pubis)?
- Permethrin
- Malathion
How is crab lice treated?
An aqueous preparation should be applied, allowed to dry naturally and washed off after 12 hours; a second treatment is needed after 7 days to kill lice emerging from surviving eggs. All surfaces of the body should be treated, including the scalp, neck, and face (paying particular attention to the eyebrows and other facial hair). A different insecticide should be used if a course of treatment fails.
What are the main types of eczema?
irritant, allergic contact, atopic, venous and discoid.
Is aqueous cream recommended for eczema?
Not generally recommended due to the high risk of developing skin reactions
Which tretinoin is licensed for use in severe chronic hand eczema?
Alitretinoin is licensed for the treatment of severe chronic hand eczema refractory to potent topical corticosteroids; patients with hyperkeratotic features are more likely to respond to alitretinoin than those with pompholyx
What is the treatment for seborrhoeic dermatitis?
Seborrhoeic dermatitis (seborrhoeic eczema) is associated with species of the yeast Malassezia and affects the scalp, paranasal areas, and eyebrows. Shampoos active against the yeast (including those containing ketoconazole or coal tar) and combinations of mild topical corticosteroids with suitable antimicrobials are used.
Can psoriasis involve nail or joint?
Yes
What is the most common type of psoriasis?
Chronic plaque psoriasis
What is chronic plaque psoriasis characterised by?
- Epidermal thickening and scaling, usually affecting extensor surfaces and the scalp
Which drugs may provoke or exacerbate psoriasis?
drugs such as lithium, chloroquine and hydroxychloroquine, beta-blockers, non-steroidal anti-inflammatory drugs, and ACE inhibitors. Psoriasis may not be seen until the drug has been taken for weeks or months.
What is first-line to all patients with psoriasis?
Topical treatment
What are the topical treatment options for psoriasis?
- Emollients, topical corticosteroids, coal tar preparations, and topical vitamin D or Vitmamin D analgoues
What can continuous long-term use of potent or very potent topical corticosteroids cause?
may cause psoriasis to become unstable, and lead to irreversible skin atrophy and striae
In psorasis, consecutive use of potent topical corticosteroids should not be used for more than how many weeks?
for More than 8 weeks at any one site
In psorasis, consecutive use of very potent topical corticosteroids should not be used for more than how many weeks?
4 weeks for very potent topical corticosteroids
Application may be restarted after how many weeks break?
After a 4 weeks break
What properties does coal tar have?
anti-inflammatory, antipruritic, and anti-scaling properties and is often combined with other topical treatments for psoriasis.
Name a few topical vitamin D and vitamin D analogue preparations?
Tacalcitol and calcitriol may be less irritating than calcipotriol
Is the use of coal tar based shampoos alone for the treatment of severe scalp psoriasis recommended?
No
Which type of phototherapy can be used in Psoriasis?
Narrowband ultraviolet B (UVB) phototherapy can be offered to patients with plaque or guttate psoriasis in whom topical treatment has failed to achieve control.
Which other phototherapy is available?
Photochemotherapy combining psoralen with ultraviolet A (PUVA) is available in specialist centres, given under the supervision of an appropriately trained healthcare professional. Psoralen enhances the effects of UVA and is administered either by mouth or topically.
Which non-biological systemic treatment options are there for psoriasis?
systemic non-biological treatment with methotrexate or ciclosporin may be offered to some patients with psoriasis that cannot be controlled with topical treatment and if the psoriasis has a significant impact on physical, psychological or social well-being.
For which patients is ciclosporin considered first line in for psoriasis?
Ciclosporin can be considered first-line in patients who need rapid or short-term disease control, have palmoplantar pustulosis, or who are considering conception (both men and women).
When can acitretinin be considered?
Only consider acitretin in patients where methotrexate and ciclosporin are not appropriate or have failed, or in patients with pustular forms of psoriasis.
Are topical corticosteroids recommended in the routine treatment of urticaria?
No
Are topical corticosteroids recommended for acne vulgaris?
No
How long can hydrocortisone 1% be used for uninfected inflammatory leisons on the lips?
7 days
Which organisms are susceptible to miconazole?
Candida spp. and many Gram-positive bacteria including streptococci and staphylococci.
Is creams or ointments preferred for moist or weeping lesions?
Water-miscible corticosteroid creams are suitable for moist or weeping lesions whereas ointments are generally chosen for dry, lichenified or scaly lesions or where a more occlusive effect is required.
What are the contra-indications of topical corticosteroids?
Acne; perioral dermatitis; potent corticosteroids in widespread plaque psoriasis; rosacea; untreated bacterial, fungal or viral skin lesions
What are the side effects of topical corticosteroids?
Skin reactions, Telangiectasia, Adrenal suppression, Hypertrichosis (hair growth), Skin depigmentation (May be reversible),
One fingertip unit (approximately 500mg from a tube with a standard 5mm diameter nozzle) is enough to cover how much?
is sufficient to cover an area that is twice that of the flat adult handprint (palm and fingers).
With acitretin use what should be noted about pregnancy checks?
Exclude pregnancy up to 3 days before treatment, every month during treatment, and every 1-3 months for 3 years after stopping treatment
Effective contraception needed for females at least one month before the treatment, during and 3 years after stopping treatment
Are oral-progestogen only contraceptives suitable for contraception for acitretin?
No
Can patients take alcohol while on acitretin?
No - patients should be advised to avoid alcohol while on treatment and for 2 months after stopping treatment
What is hyperhidrosis?
Hyperhidrosis is defined as sweating in excess of normal body temperature regulation. It can be localised (focal) or affect the entire skin area, and can be classified by the absence (primary) or presence (secondary) of an underlying cause.
What should Patients with primary focal hyperhidrosis affecting axillae, palmar, or plantar areas, should be offered?
A topical preparation containing 20% aluminium chloride hexahydrate
What may specialist give for more severe cases of hyperhidrosis?
- Glycopyrronium bromide as a 0.05% solutions
- Botox® contains botulinum toxin type A complex and is licensed for intradermal use for severe hyperhidrosis of the axillae unresponsive to topical antiperspirant or other antihidrotic treatment.
Give brand names of topical aluminium chloride hexahydrate 20%?
Anhydrol
Driclor
Can pruritus occur in biliary obstruction?
Pruritus is common in biliary obstruction, especially in primary biliary cirrhosis and drug-induced cholestasis. Oral administration of colestyramine is the treatment of choice.
Which hormonal contraceptive pill type may improve acne?
Oral combined hormonal contraceptive
What is the first-line treatment options for mild to moderate acne?
Fixed combination topical benzoyl peroxide with clindamycin.
What is the first line treatment for moderate to severe acne?
Fixed combination topical adapalene with benzoyl peroxide with oral lymecycline or doxycycline, or
Topical azelaic acid with oral lymecycline or doxycycline.
Alternative antibacterial options if lymecycline or doxycycline unsuitable: trimethoprim [unlicensed] or a macrolide (such as erythromycin).
Review first-line treatment of acne after how many weeks?
After 12 weeks
For patients whose treatment included an oral antibacterial and their acne has completely cleared, what should you consider?
Consider continuing their topical treatment and stopping the oral antibacterial
Treatment courses that include an antibacterial should only be continued for more how many months?
Treatment courses that include an antibacterial should only be continued for more than 6 months in exceptional circumstances, and should be reviewed every 3 months.
For patients with severe acne (such as acne conglobata or fulminans, nodulo-cystic acne, or acne at risk of permanent scarring) that is resistant to adequate courses of oral antibiotic-containing first line treatments, which drug can be considered?
Isotretinoin
Which drugs can be used for rosacea?
Brimonidine tartrate is licensed for the treatment of facial erythema in rosacea. The pustules and papules of rosacea respond to topical azelaic acid, topical ivermectin or to topical metronidazole.
What oral treatment is an alternative to rosacea?
Alternatively oral administration of oxytetracycline or tetracycline, or erythromycin, can be used; courses usually last 6–12 weeks and are repeated intermittently.
What is brimonidine used for?
Facial eruthema (Face redness)
What MHRA warning is there for brimonidine?
Risk of systemic cardiovascular effects - bradycardia, hypotension and dizziness.
To minimise systemic absorption with brimonidine what can you do?
Avoid application to irritated or damaged skin, including after laser therapy
What should be noted about initiating brimonidine gel?
Risk of exacerbation of rosacea - initiate treatment with small amount of gel for one week, then increase gradually, based on tolerability and response.
Counsel patients to not exceed the maximum daily dose, and to stop an report if symptoms worsen
What are used for Rosacea - Pustules and papules?
Topical - metronidazle, azeliac acid, Ivermectin OR
Oral - Oxytetracycline, tetracycline, erythromycin
Does topical isotretinoin require contraception?
YEs
How long is Rx valid for for isotretinoin?
For 7 days
Maximum 30 days supply for women
Are repeats or Fax Rx accepted for isotretinoin?
No
What are some side effects of isotretinoin?
Hyperglycaemia, hypertriglyceridaemia high cholesterol Pancreatitis Heptatoxicity Visual disturbances Skin peeling Redness Severe dryness of skin and mucous membranes
Rare reports of erectile dysfunction and decreased libido with oral use
Is isotretinoin linked to suicide?
YEs - STOP if psychiatric reactions: depression, anxiety, suicidal ideation
Which oral contraceptive is an ‘anti-androgen’ licensed for use in hormonal acne?
Co-cyprindol
Risk of venous thromboembolism
What may cradle cap in infants be treated with?
Coconut oil or olive oil applications followed by shampooing
Can weight loss affect hirsutism?
YEs weight loss can reduce hirsutism in obese women
Which drugs may be used for Hirsutism?
Co-cyprindiol (cyproterone acetate with ethinylestradiol) may be effective for moderately severe hirsutism. Metformin hydrochloride is an alternative in women with polycystic ovary syndrome [unlicensed indication]. Systemic treatment is required for 6–12 months before benefit is seen
Which drug is licensed for the treatment of androgenetic alopecia in men?
Finasteride
Continuous use for 3–6 months is required before benefit is seen, and effects are reversed 6–12 months after treatment is discontinued.
How are chilblains best managed?
By avoidance of exposure to cold
What is used for superficial thrombophlebitis/ bruising/ haematoma?
Heparinoid
What is cutaneous warts caused by?
By infection of keratinocytes with human papillomavirus (HPV)
What are the treatment options for non-facial warts?
Topical keratolytic salysilic acid (or salicyclic acid with lactic acid)
or cryotherapy using liquid nitrogen, or a combination of both
What is licensed for removal of corns and calluses?
Salicylic acid with lactic acid
What about anogenital warts?
Patients with anogenital warts should be referred to a sexual health specialist where possible, and treatment should be accompanied by screening for other sexually transmitted infections. Treatment is not always required, as warts may resolve spontaneously, usually within 6 months.
What does Hib, menigitis C vaccine protect against and when is it given?
Protects against haemophilus influenzae type b (Hib) and menigitis C
Given at 12-13 months
When are the MMR vaccines two doses given?
1st dose - 12-13 months
2nd dose - 3 years and 4 months
When is the booster: pneumonoccocal infection (PCV) vaccine given?
at 12-13 months and protects against pneumococcal infection, which can cause pneumonia, septicaemia and meningitis
What does Men B protect against?
Given at 12-13 months
This protects against infection from meningicoccal (Men( group B bacteria
When is the the annual children’s flu vaccine given?
This is an annual nasal spray vaccine
Given at age 2, 3, 4, 5 and 6
Second dose MMR vaccine is given at 3 years and 4 months, which other vaccine is also given at this age?
The 4 in 1 booster vaccine:
- Protects against diphtheria, tetanus, pertussis (whooping cough) and polio
Which vaccine is given at 12-13 years to girls?
The human papillomavirus (HPV) - two doses of the HPV vaccine are given to girls 6-12 months apart to protect against cervical cancer and genital warts
Which vaccine is given at 13-18 years?
Booster - Diphtheria, tetanus, polio
The 3-in-1 vaccine tops up protection against tetanus, diphtheria and polio
What is the Men ACWY vaccine?
“Fresher” students going to university for the first time should make sure they’ve had the MenACWY vaccine to prevent meningitis and septicaemia, which can be deadly.
The MenACWY vaccine is also routinely offered to teenagers in school Years 9 and 10.
The MenACWY vaccine is given by a single injection into the upper arm and protects against 4 strains of the meningococcal bacteria – A, C, W and Y – which cause meningitis and blood poisoning (septicaemia).
The MenACWY vaccine is called Nimenrix.
Children aged 13 to 15 (school Years 9 or 10) are routinely offered the MenACWY vaccine in school alongside the 3-in-1 teenage booster.
Summarise the England Childhood vaccine schedule?
2 Months: First 5 in 1, Rotavirus, Pneumococcal and MenB
3 Months: Second 5 in 1 and Rotavirus
4 Months: Third 5 in 1; Pneumococcal and MenB
12-13 months: First MMR, boosters MenB, Pneumococcal, Hib/MenC
Primary School:
3 Years 4 Months: Second MMR, 4 in 1 (minus Hib)
2-11 Years: Annual Flu Vaccine
Secondary School:
12-13 Years: HPV School girls only
13-18 years: 3 in 1 (minus Hib and pertussis) MEN ACWY
What should be noted about vaccines?
Do not give live vaccines in immuocompromised patients
Do not give flu jab in egg allergy
IS MMR vaccine linked with autism or bowel disease?
No link
Is the MMR vaccine safe to use in egg allergy?
Yes
What may the MMR vaccine cause?
May cause aseptic meningitis and idiopathic thormbocytopenic purpura
Routine pneumococcal vaccine is offered to patients aged what and over?
65 years and over
Routine annual flu vaccination is offered to which patients from september?
- Aged 50 years and over
- and anyone with a medical condition which is elgile for free annual vaccination e.g. asthma
Which patients is shingles vaccine routinely offered to?
Patients aged 70 years and over
Who is chickenpox vaccine (live vaccine) offered to?
- Non-immune healthcare workers
- Close relatives and carer (not had chickenpox before) of people who are unwell e.g. immunocompromised
What about tuberculosis vaccine (BCG)?
BCG only if high risk of coming into contact with tuberculosis
What is the eligibility criteria for free Flu vaccination?
Age 50 and over
Pregnant women
Household contacts of immunocompromised adults
Carers
Living in long-stay residential care homes or other care facilities
Underlying long-term health conditions:
- Diabetes
- Chronic respiratory disease e.g. severe asthma i.e. on steroids, COPD
- Chronic heart disease e.g. Heart Failure
- Chronic kidney disease - stage 3 onwards
- Chronic liver disease
- Chronic CND disease: Parkinson’s MS, learning disability
- Weakened immune system: HIV/AIDS/chemo/splenic dusfunction
Anaesthetists must know what about a patient?
They must know about all drugs a patient takes
What is there a risk of combing corticosteroids with anaesthetics?
Adrenal suppression:
The combination can cause a dangerous fall in blood pressure
Which drugs should be stopped before surgery?
- Combined oral contraceptives (stop 4 weeks before major surgery and all surgery to legs or surgery that involves prolonged immobilisation due to risk of venous thromoboembolism)
- Hormone replacement therapy (Stop 4-6 weeks before surgery and restart on full mobilisation)
- Antidepressants: MAOI -(Gradually withdraw 2 weeks before surgery)
- TCA: (inform anaesthetist if continued; risk of arryhthmias and hypotension)
- Lithium (Stop 24 hours before major surgery - constant fluid and electrolyte balance to avoid toxicity)
- Potassium-sparing drugs (ACE inhibitors/ ARBs - also cause severe hypotension), potassium-sparing diuretics as risk of hyperkalaemia if renal perfusion is impaired or if there is tissue damage
- Antiplatelet/ oral anticoagulants (consider stopping if increased risk of bleeding and convert to Heparin for during surgery.
- Diabetes (Switch patient to insulin during surgery. Give infusion of glucose with potassium and insulin on a sliding scale. Once patient begins to eat, start SC insulin before breakfast and stop IV insulin 30 minutes after).
Which drugs may you continue during surgery?
- Anti epileptics
- Antiparkinson
- Antipsychotics
- Anxiolytics
- Bronchodilators
- Cardiovascular drugs (except potassium sparing ones)
- Glaucoma drugs
- Immunosuppresants
- Progestogen only contraceptive
- Thyroid and antithyroid drugs
Which type of surgery should ibuprofen be avoided for post-op pain?
Surgery for hip fracture
Which IV NSAID is preferred for post-op pain?
Reserve for those unable to take by mouth
Use a traditional NSAID rather than a COX-2 inhibitor
How do local anaesthetic drugs act?
act by causing a reversible block to conduction along nerve fibres. They vary widely in their potency, toxicity, duration of action, stability, solubility in water, and ability to penetrate mucous membranes.
Which has local anaesthetic has long duration of action?
Bupivacaine hydrochloride has a longer duration of action than other local anaesthetics. It has a slow onset of action, taking up to 30 minutes for full effect.
Why may addition of a vasoconstrictor be of benefit with local anaesthetics?
Local anaesthetics cause dilatation of blood vessels. The addition of a vasoconstrictor such as adrenaline/epinephrine to the local anaesthetic preparation diminishes local blood flow, slowing the rate of absorption and thereby prolonging the anaesthetic effect.
What is used for dental anaesthesia?
- Lidocaine hydrochloride can be sued in combination with adrenaline/epinephrine
