Symptoms in the Pharmacy - Skin

Question 1

What Scheme do we use in Wales?

Answer 1

CAS - Community pharmacy Common Ailment Scheme
[public come into pharmacy and purchase medicines but pharmacy will be re imbursed for it]

Question 2

What conditions can be treated?
[26]

Answer 2

Ace
Chickenpox
Conjunctivitis
Diarrhoea
Hay-fever
Ingrowing toenail
Nappy rash
Sore throat/tonsilitis
Vaginal thrush
Athletes food
Cold sores
Constipation
Dry Eye
Head lice
Ringworm
Oral thrush
Teething
Verucca
Backache
Colic
dermatitis
Haemorrhoids
Indigestions/reflux
Mouth ulcers
Scabies
Threadworm

Question 3

Eczema & Dermatitis

Answer 3

Eczema often reserved for atopic eczema and dermatitis for contact dermatitis

Question 4

Atopic eczema

Answer 4

Chronic, itchy skin condition – common in children
Often accompanies other “atopic” conditions
Rash is dry, flaky and inflamed
Aetiology unclear – trigger factors

Question 5

Contact dermatitis

Answer 5

Commonly on the hands
Consider patient history and occupation
Nappy rash is a type of contact dermatitis

Question 6

Eczema & Dermatitis - Treatments

Answer 6

Emollients (1st) – they soothe the skin = form a waterproof barrier to prevent drying
Applied to soothe the skin/ used as soaps or bath additives

Topical corticosteroids, e.g. hydrocortisone 1% w/v, are available as P medicines. More potent corticosteroids avail.

Antipruritics to prevent itching are also available but generally not recommended

Question 7

When to refer for Eczema?

Answer 7

Infected rashes, e.g. weeping from the rash

Suspected ADR or unidentifiable cause

Failed medication, e.g. >1 week of topical corticosteroid use

Always consider meningitis / septicaemia

Question 8

Seborrhoeic dermatitis

Answer 8

Affects the sebaceous gland-rich regions ofthe skin, e.g. scalp

Can also occur at other hairy sites, e.g. under arms, chest

Dandruff is an (uninflamed) form of seborrhoeic dermatitis

Presents as scaly patches which typicallydo not itch
M
ay be referred to as “cradle cap” in babies

Question 9

What treatment can be used to treat Seborrhoeic dermatitis?

Answer 9

keratolytics such as salicylic acid
antifungals can be used
For infants mild shampoos +/- baby oil or olive oil

Question 10

Psoriasis (do nto confuse with eczema)

Answer 10

observe: inflamed skin toppedwith silver or white “plaques”

Cause unclear but Immune systembelieved to be involved

Question 11

Mild psoriasis typically treated with topical agents:

Answer 11

Emollients
Coal tar preparations
Dithranol and salicylic acid
Topical corticosteroids

Phototherapy an option for treatment
(bc eczema can get better in the sun normally when exposed to sunlight)

Question 12

Fungal - Skin infections

Answer 12

Ringworm is a fungal infection thatpresents as a circular rash

Spread by person-person / person-animal contact

Ringworm of the scalp is rare andshould be referred

Fungal nail infections should be referred as system antibiotics usuallyrequired

Athlete’s foot is a fungal foot infectionusually spread by person-person contact or from shared towels, changing rooms etc.

Question 13

Skin infections (Fungal) – Treatment

Answer 13

OTC with topical antifungals - ringworm and athlete’s foot

e.g. Itraconazole and terbinafine

powder and spray formulations are used

Question 14

What is the first lie treatment for athlete’s foot adn ringworm?

Answer 14

Imidazoles, e.g. miconazole cream (Daktarin®)

Question 15

When to refer - fungals

Answer 15

Treatment failure (>2 weeks)
Bacterial infection
Diabetic patients
Involvement of the nail

Question 16

Herpes - Skin infections

Answer 16

herpes/cold sores = managed OTC

usually around lips /nose caused by the herpes simplexvirus (HSV-1 in most cases)

OTC with aciclovir 5% cream (apply 5 × 5 + 5)

Question 17

causes cold sores/ herpes; factors =

Answer 17

Sunlight
Other infections (colds / flu)
Menstrual cycle

Question 18

When to refer - Herpes/ Cold sores?

Answer 18

Eyes / genital regions affected

Age of patient? (Zovirax® cream has no age restrictions)

Painless, in the mouth or lasting >2 weeks
Immunocompromised

Question 19

Warts & verrucae

Answer 19

Small growths on the skin caused by human papillomavirus (HPV)

verruca (plantar wart) is just a wart on the plantar region, i.e. sole of foot

Warts / verrucae contain a network ofcapillaries

Warts are limiting - but appearance can be distressing for patients

Question 20

Warts & verrucae – Treatments

Answer 20

Keratolytics =
Salicylic acid based products are commonly used. This active ingredient gradually destroys the affected area

Care to ensure that the formulation is only applied to the wart / verruca (protect surrounding skin with white soft paraffin)

Emphasise that successful treatment may take >3 months

Cryotherapy used to freeze off wart (10-14 days) – home kits available

liquid nitrogen can be used in secondary care by GPs

Question 21

When to refer - Warts & verrucae

Answer 21

Suspicious changes in shape or colour +/- bleeding and itching
(A) Asymmetrical – melanomas usually irregular shape
(B) Border – melanoma border often “ragged”
(C) Colours – at least 2 colours
(D) Diameter – most melanomas >6mm in diameter
(E) Evolving – moles that change in size may be a melanoma

Diabetic and immunocompromised patients
Anogenital warts in children
Failed treatment

Question 22

Acne

Answer 22

Acne vulgaris = common acne
Hair follicles and sebaceous glands

High incidence in teenagers and largely affects the face, but back and chest are other common sites

Classified as mild / moderate / severe

Question 23

Type of spots/ acne, when is it severe?

Answer 23

Closed comedones - white/black heads - MILD

Open comedones - MILD

Nodules - moderate to severe / Acne vulagris

Question 24

Acne – Treatments

Answer 24

Many OTC products are available
Benzoyl peroxide is usually the first line treatment
2.5%, 5% and 10% strengths available – start with lowest
Treatment required for at least 6-8 weeks
Antibiotics and retinoids are POMs and require referral
Sunlight may help, avoid greasy foundation

NOT to prevent acne but to put on before the nodules strart appearing

Question 25

When to refer - Acne?

Answer 25

Severe acne
Treatment failure
Suspected ADR
ABCDE concerns
Causing mental health issues

Question 26

Scabies

Answer 26

intensely itchy skin condition caused by a mite that burrows through the skin > rash

Burrows are often seen on the palmsof the hands but rash and itching canbe at other sites

Passed - close personal contact (schools, care homes)

Question 27

How much time des symptoms appear - scabies

Answer 27

may take up to 2 months

Question 28

Scabies - treatments:

Answer 28

Two applications of a topical acaricide required 7 days apart

Must be left on for 12-24 hours depending on the acaricide used

Other household members should be treated at the same time

Treatment can worsen the itch initially

Question 29

When to refer - scabies?

Answer 29

Age: young children and elderly

Outbreaks suspected, e.g. in a school

Crusted scabies (hyper-infection with mites)

Infected rash

Treatment failure

Acquired through sexual activity?

Question 30

Communicable diseases

Answer 30

Many (typically childhood) communicable diseases present with skin rashes

Shingles -elderly

If fever and/or malaise then unlikely to be asimple skin condition > consider communicablediseases

Question 31

Communicable disease - referral?

Answer 31

if suspected bacterial skin infection (paticurlarly diabetic patients, respiratory symptoms)

Measles, chickenpox, herpes Zoster (singles), rubella

Question 32

What are the red flags - skin

Answer 32

Skin cancer (ABCDE)
Meningitis – petechial rash
Erythroderma (>90% of skin affected)
Bullous disorders
Suspected ADR