W20 Symptoms in the pharmacy: Skin

Question 1

What are the skin conditions treated under the Community Pharmacy Common Ailments Scheme? (8)

Answer 1

Acne
Nappy rash
Athletes Foot
Cold sores
Intertrigo/ringworm
Verruca
Dermatitis (acute)
Scabies

Question 2

Eczema & Dermatitis:
When are these terms used?

Answer 2

• These two terms are often used interchangeably
• Eczema often reserved for atopic eczema and dermatitis for contact dermatitis

Question 3

What is Atopic eczema?

Answer 3

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

Question 4

What is Contact dermatitis?

Answer 4

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

Question 5

What are the treatments for Eczema & Dermatitis? (3)

Answer 5

1. Emollients are the mainstay of treatment –they soothe the skin and can form a waterproof barrier to prevent drying
   − May be applied to soothe the skin or used as soaps or bath additives
2. Topical corticosteroids, e.g. hydrocortisone 1%
   w/v, are available as P medicines.
   More potent corticosteroids are also available
3. Antipruritics to prevent itching are also available but generally not recommended

Question 6

When to refer Eczema and Dermatitis:

Answer 6

− 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 7

What is Seborrhoeic dermatitis?
How can it be treated?

Answer 7

− Affects the sebaceous gland-rich regions of the 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 typically do not itch
− May be referred to as “cradle cap” in babies

• Treatment may involve the use of keratolytics such as salicylic acid
• Antifungals may also be required
• For infants mild shampoos +/- baby oil or olive oil

Question 8

What is psoriasis?
What causes it?

Answer 8

• A skin condition sometimes confused with eczema
• Characterised by inflamed skin topped with silver or white “plaques”
• Cause unclear but Immune system believed to be involved
• Non-Caucasians tend to have greater areas of skin affected

Question 9

How can psoriasis be treated?

Answer 9

• Mild psoriasis typically treated with
  topical agents:
  − Emollients
  − Coal tar preparations
  − Dithranol and salicylic acid
  − Topical corticosteroids
• Phototherapy an option for treatment

Question 10

What are some fungal skin infections?

Answer 10

Ringworm, Fungal nail infections, Athlete’s foot

Question 11

What is ringworm and ringworm of the scalp?
How is it spread?

Answer 11

Ringworm
-A fungal infection that presents as a circular rash
- Spread by person-person/ person-animal contact
- Ringworm of the scalp is rare and should be referred

Question 12

Should Fungal nail infections be referred?

Answer 12

Should be referred as system antibiotics usually required

Question 13

What is Athlete’s foot?
How is it spread?

Answer 13

A fungal foot infection
Usually spread by person-person contact or from shared towels, changing rooms etc.

Question 14

How is ringworm and athlete’s foot treated?

Answer 14

• Ringworm and athlete’s foot can be treated OTC with
  topical antifungals
• Imidazoles, e.g. miconazole cream (Daktarin®), are the usual first line treatment for ringworm and are also used for athlete’s foot
• Itraconazole and terbinafine (an allylamine) are also used OTC in athlete’s foot treatment
• Powder and spray formulations are commonly used for athlete’s foot

Question 15

When to refer Ringworm and Athlete’s foot:

Answer 15

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

Question 16

What is Herpes?
What is it triggered by? (3)

Answer 16

• Skin infection –usually around lips/nose caused by the herpes simplex virus (HSV-1 in most cases)
  − Sunlight
  − Other infections (colds / flu)
  − Menstrual cycle

Question 17

How can Cold sores ( aka Herpes simplex labials) be treated?
When to refer to GP? (4)

Answer 17

Treatment OTC with aciclovir 5% cream (apply 5 × 5 +5)
When to refer:
− Eyes / genital regions affected
− Age of patient? (Zovirax® cream has no age restrictions)
− Painless, in the mouth or lasting >2 weeks
− Immunocompromised

Question 18

What are warts & verrucae?

Answer 18

• Small growths on the skin caused by human papillomavirus (HPV)
• Peak incidence in secondary school children
• A verruca (plantar wart) is just a wart on the plantar region, i.e. sole of foot
• Warts / verrucae contain a network of capillaries
• Warts and verruca will eventually resolve without treatment, but the appearance can be distressing for patients

Question 19

How can warts and verrucae be treated?
How to counsel the patient on applying the treatment:
How to protect the surrounding skin”

Answer 19

• Treatment options typically use 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

Question 20

When to refer warts and verrucae:

Answer 20

− 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 21

What is Acne?

Answer 21

• Acne vulgaris = common acne
• Hair follicles and sebaceous glands become blocked
• High incidence in teenagers and largely affects the face, but back and chest are other common sites
• Classified as mild / moderate / severe

Question 22

How is acne treated?

Answer 22

• Mild to moderate acne can be managed without referral
  − 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

Question 23

When to refer acne?

Answer 23

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

Question 24

What is scabies?

Answer 24

• Scabies is an intensely itchy skin condition caused by a mite that burrows through the skin →rash
• Burrows are often seen on the palms of the hands but rash and itching can be at other sites
• Passed on through close personal contact –common in schools, universities, care homes
• Can be up to 2 months before symptoms start to appear

Question 25

How to treat scabies:

Answer 25

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 26

When to refer scabies:

Answer 26

− 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 27

What are Communicable diseases?
Examples?

Answer 27

• Many (typically childhood) communicable
  diseases present with skin rashes
• Details will not be covered in this lecture
• Shingles more likely in elderly individuals
• If fever and/or malaise then unlikely to be a
  simple skin condition →consider communicable
  diseases
• Referral required if suspected bacterial skin
  infection (particularly in diabetic patients, respiratory symptoms

Measles, Chickenpox, Shingles (Herpes Zoster)

Question 28

What are the Red flags of Communicable diseases?

Answer 28

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

Question 29

Treatment of chicken pox

Answer 29

Antihistamine- Chlorphenamine 2mg/5ml
Possibly Calamine lotion