Dermatology - ClinicalKey

BOOKCHAPTER
Dermatology
PaulRutterBPharmMRPharmSPhD
CommunityPharmacy:Symptoms,DiagnosisandTreatment,Chapter7,195257
Inthischapter
Background195(sc0010)
Generaloverviewofskinanatomy195(s0010)
Historytaking196(s0040)
Physicalexamination196(s0045)
Hyperproliferativedisorders197(s0050)
Psoriasis197(s0060)
Dandruff(pityriasiscapitis)204(sc0015)
Seborrhoeicdermatitis207(sc0020)
Fungalskininfections210(sc0025)
Fungalnailinfection(onychomycosis)216(sc0030)
Hairloss(androgeneticalopecia)218(sc0035)
Wartsandverrucas222(sc0040)
Cornsandcalluses227(sc0045)
Scabies229(sc0050)
Acnevulgaris232(sc0055)
Coldsores236(sc0060)
Eczemaanddermatitis239(sc0065)
Sunexposureandmelanomarisk245(sc0070)
Selfassessmentquestions[CR]
Background
Theskinisthelargestorganofthebody.Ithasacomplexstructureandperformsmanyimportant
functions.Theseincludeprotectingunderlyingtissuesfromexternalinjury,overexposuretoultraviolet
light,barringentrytomicroorganismsandharmfulchemicals,actingasasensoryorganforpressure,
touch,temperature,painandvibrationandmaintainingthehomeostaticbalanceofbodytemperature.
Ithasbeenreportedthatdermatologicaldisordersaccountforupto15%oftheworkloadofUKGPs,with
similarfindingsreportedfromcommunitypharmacy.Itisthereforeimportantthatcommunitypharmacists
areabletodifferentiatebetweencommondermatologicalconditionsthatcanbemanagedappropriately
withoutreferraltotheGPandthosethatrequirefurtherinvestigationortreatmentwithaprescriptiononly
medicine.
Generaloverviewofskinanatomy
Principallytheskinconsistsoftwoparts,theouterandthinnerlayercalledtheepidermisandaninner,
thickerlayernamedthedermis.Beneaththedermisliesasubcutaneouslayer,knownasthehypodermis(
Fig.7.1(f0010)).
Fig.7.1
Theepidermis,dermisandassociatedstructures.
Theepidermis
Theepidermisisthemajorprotectivelayeroftheskinandhasfourdistinctlayerswhenviewedunderthe
microscope.Thebasallayeractivelyundergoescelldivision,forcingnewcellstomoveupthroughthe
epidermisandformtheouterkeratinisedhornylayer.Thisprocessiscontinualandtakesapproximately35
days.Pathologicalchangesintheepidermisproducearashoralesionwithabnormalscale,lossofsurface
integrityorchangestopigmentation.
Thedermis
Thedermisisthelayerbelowtheepidermis.Themajorityofthedermisismadeofconnectivetissue
collagenforstrength,andelasticfibrestoallowstretch.Itprovidessupporttotheepidermisaswellasits
bloodandnervesupply.Alsolocatedinthedermisarethehairfollicle,sebaceousandsweatglandsand
arrectorpilimuscle.Undercoldconditionsthearrectorpilimusclecontracts,pullingthehairintoavertical
positionandcausinggoosebumps.Conditionsofthedermisusuallyresultinchangesintheelevationof
theskin,e.g.papulesandnodules.
Thehair
Theprimaryfunctionofhairisoneofprotection.Eachhairconsistsofashaft,thevisiblepartofthehair,
andaroot.Surroundingtherootisthehairfollicle,thebaseofwhichisenlargedintoabulbstructure.
Sebaceousglands
Sebaceousglandsarefoundinlargenumbersontheface,chestandupperback.Theirprimaryroleisto
producesebumwhichkeepshairsuppleandtheskinsoft.Duringpubertytheseglandsbecomelargeand
activeduetohormonalchanges.Frequently,sebumwillaccumulateinthesebaceousgland,andisoneof
thefactorsthatleadtoacneformation.
Sweatglands
Thesearethemostnumerousoftheskinglandsandareclassedasapocrineoreccrine.Eccrineglandsare
locatedalloverthebodyandplayaroleineliminationofwasteproductsandmaintainingaconstantcore
temperature.Apocrinesweatglandsaremainlylocatedintheaxillaandbegintofunctionatpuberty.
Historytaking
Unlikeinternalmedicine,themajorityofdermatologicalcomplaintspresentingincommunitypharmacy
canbeseen.Thisaffordsthecommunitypharmacistanexcellentopportunitytobasehisorherdifferential
diagnosisnotonlyonquestioningbutalsoonphysicalexamination.Generalquestionsthatshouldbe
consideredwhendealingwithdermatologicalconditionsarelistedinTable7.1(t0010).Terminology
describingskinlesionscanbeconfusingandthemorecommontermsusedareshowninTable7.2(t0015).
Table7.1
Questionstoconsiderwhentakingadermatologicalhistory
Question Relevance
Wheredidthe Certainskinproblemsstartinoneparticularlocationbeforespreadingtoother
problemfirst partsofthebody,e.g.impetigousuallystartsonthefacebeforespreadingtothe
appear? limbs
Patientsmightneedpromptingtotellyouwheretheproblemstartedastheyare
likelytowanthelpforthemostobviousorlargeskinlesionbutneglecttotellyou
aboutsmallerlesionsthatappearedfirst
Arethereanyother Manyskinrashesareassociatedwithitchand/orpain
symptoms?
Milditchisassociatedwithmanyskinconditionsincluding,psoriasisandmedicine
eruptions.
Question Relevance
Severeitchisassociatedwithconditionssuchas,scabies,atopicandcontact
dermatitis.
Occupationalhistory Thisisparticularlypertinentforcontactdermatitis,e.g.dosymptomsimprovewhen
(relevanttoadults awayfromwork?
only)
Generalmedical Manyskinsignscanbethefirstmarkerofinternaldisease,e.g.diabetescan
history manifestwithpruritusfungalorbacterialinfectionandthyroiddiseasecanpresent
withhairlossandpruritus
Travel Morepeoplearetakinglonghaulholidaysandthereforeexposethemselvesto
tropicaldiseasesthatcanmanifestasskinlesions
Familyand Infectionssuchasscabiescaninfectrelativesandotherswithwhomthepatientis
householdcontact inclosecontact
history
Thepatient's Askforthepatient'sopinion.Thismighthelpwiththediagnosisoralternatively
thoughtsonthe shedlightonanxietiesandtheoriesastothecauseofthecondition
causeofthe
problem
Table7.2
Commontermsusedtodescribeskinlesions
Term Description
Macule Aflatlesionwhichislessthan1cmindiameter
Patch Aflatlesionwhichisgreaterthan1cmindiameter
Papule Araisedsolidlesionlessthan1cmindiameter
Nodule Araisedsolidlesiongreaterthan1cmindiameter
Vesicle Aclearfluidfilledlesionlastingafewdayswhichislessthan1cmindiameter
Bulla Aclearfluidfilledlesionlastingafewdayswhichisgreaterthan1cmindiameter
Pustule Apusfilledlesionlastingafewdayswhichislessthan1cmindiameter
Comedone Apapulewhichispluggedwithkeratinandsebum
Erythema Rednessduetodilatedbloodvesselsthatblanchwhenpressed
Excoriation Localiseddamagetotheskinduetoscratching
Lichenification Thickeningoftheepidermiswithincreasedskinmarkingsduetoscratching
Physicalexamination
Amoreaccuratedifferentialdiagnosiswillbemadeifthepharmacistactuallyseestheperson'sathlete'sfoot
orrashontheback.Providingadequateprivacycanbeobtainedthereisnoreasonwhythemajorityof
skincomplaintscannotbeseen.Ifexaminationsareperformed,clearlyexplaintheprocedureyouwantto
performandgaintheirconsent.Examinationsshouldbeconductedinconsultationrooms.Itisworth
rememberingthatmanypatientswillbeembarrassedbyskinconditionsandmightbeashamedoftheir
appearance.Whenperforminganexaminationoftheskin,anumberofthingsshouldbelookedfor(Table
7.3(t0020)).Thereisnosubstituteforexperiencewhenrecognisingskinproblems.Thisisnormallygained
throughseeingmultiplecaseshowever,afreeimagebank(http://www.dermnet.com/(http://www.dermnet.com/)
)isavailablewherefamiliaritycanbegainedofdifferentpresentationsofskinconditions.
Table7.3
Thingstoconsiderwhenperformingadermatologicalexamination
Lesions Relevance
Temperature Usethebacksofyourfingerstomaketheassessment.Thisshouldenableyoutoidentify
generalisedwarmthorcoolnessoftheskinandnotethetemperatureofanyredareas,e.g.
generalisedwarmthcanindicatefeverwhereaslocalwarmthmightindicateinflammationor
cellulitis
Lesions Distributionmanyskindiseaseshaveatypicalorclassicdistribution
Symmetricale.g.acneandpsoriasis
Asymmetricale.g.contactdermatitis
Unilaterale.g.shingles
Localisede.g.nappyrash

Arrangement
Discrete(withhealthyskininbetween)e.g.psoriasis
Coalescing(mergingtogether)e.g.eczema
Groupede.g.insectbites

Feeloflesions
Rememberthatveryfewskinconditionsareinfectious,sodonotbeafraidtotouchthe
patient'sskin
Smoothe.g.urticaria
Roughe.g.solarkeratosis
Recent Isthereanysignthatindividuallesionshavedevelopedonasiteoftraumaorinjurysuch
trauma asascratch?Thisisseeninanumberofconditionssuchaspsoriasisandviralwarts
Hyperproliferativedisorders
Background
Hyperproliferativedisordersarecharacterisedbyacombinationofincreasedcellturnoverrateanda
shorteningofthetimeittakesforcellstomigratefromthebasallayertotheouterhornylayer.Typically,
cellturnoverrateistentimesfasterthannormalandcellmigrationtakes3or4daysratherthan35days.
Psoriasis
Background
Psoriasisisachronicrelapsinginflammatorydisordercharacterisedbyavarietyofmorphologicallesions
thatpresentinanumberofforms.Thecommonestformofpsoriasisisplaquepsoriasisandwillbetheform
mostfamiliartopharmacists.Dependingontheextentandseverityoflesions,psoriasiscanhavea
profoundaffectontheperson'sworkandsociallife.
Prevalenceandepidemiology
Psoriasisisacommonskindisorderwithanestimatedworldwideprevalencebetween1and3%.IntheUK
ithasbeenreportedtoaffect12%ofthepopulation.However,thisisprobablyanunderestimate,asmany
patientswithmildpsoriasisdonotpresenttotheirGP.
Psoriasiscanpresentatanytimeinlife,althoughitappearstobemoreprevalentinthesecondandfifth
decade.Itisrareininfantsanduncommoninchildren.Thesexesareequallyaffectedbutitismore
commoninCaucasians.
Aetiology
Theexactaetiologyofpsoriasisstillremainsunclearbutitisknownthatinheritedfactorsareimportant.
Forexample,ifthepatienthasoneparentwithpsoriasisthentheyhavea25to30%chanceofdeveloping
psoriasisandifbothparentssufferfrompsoriasisthenthefigurerisesto5060%.However,studiesin
twinsalsosuggestthatenvironmentalfactorsmightbeneededforclinicalexpressionofthediseasebecause
only70%ofgeneticallyidenticaltwinsbothdevelopthecondition.Studieshaveidentifiedaregionon
chromosome6asacontributortopsoriasissusceptibility(knownasPSORS1)andhasbeenassociatedwith
atleast50%ofpsoriasiscasesinseveralpopulations.
Psoriasislesionsalsodevelopatsitesofskintrauma,suchassunburnandcuts(knownastheKoebner
phenomenon),followingstreptococcalthroatinfectionandduringperiodsofstress.
Arrivingatadifferentialdiagnosis
Psoriasiscanbelocatedonvariouspartsofthebody(Fig.7.2(f0015))andpresentsinavarietyofdifferent
forms.Plaqueandscalppsoriasisaretheonlyformsoftheconditionthatcanbemanagedbythe
communitypharmacist.Itisthereforenecessarythatotherformsofpsoriasis,andconditionsthatlooklike
psoriasis,canberecognisedanddistinguished.Askingsymptomspecificquestionswillhelpthepharmacist
todetermineifreferralisneeded(Table7.4(t0025)).
Fig.7.2
Typicaldistributionofpsoriaticplaques.
Table7.4
Specificquestionstoaskthepatient:Psoriasis
Question Relevance
Onset Psoriasiscandevelopinpatientsofanyage,althoughitfirstoccursmostcommonlyinearly
adultlife.However,inyoungandelderlypatientsthelesionstendtobeatypical,whichcan
makethediagnosismoredifficult
Distribution Psoriasisoftenpresentsinasymmetricaldistributionandmostcommonlyinvolvesthescalp
ofrash andextensoraspectsoftheelbowsandknees.Theglutealcleftandumbilicuscanalsobe
affected(Fig.7.2(f0015))
Conditionsthatresemblepsoriasis,suchaslichenplanus(ofteninsideofthewrists)and
pityriasisrosea(thighsandtrunk)haveadifferentdistributiontopsoriasis
Other Itchisnotnormallythepredominantfeatureofpsoriasis,unlikeotherconditionssuchas
symptoms dermatitisandfungalinfections
Nailinvolvementintheformofpittingandonycholysis(separationofthenailplatefromthe
nailbed)isoftenseenandcaninvolveoneormoreofthenails.Thisisnormallyobservedin
patientswithlongstandingpsoriasisandisthereforeoflittlevalueinpatientspresentingwith
rashofrecentonset
Lookof Scalpandplaquepsoriasisusuallyshowscalingasanobviousfeature.Thisisnotseenwith
rash othercommonskinconditions(e.g.dermatitis)orotherformsofpsoriasis
Whenscalpinvolvementismild,psoriasiscanbeimpossibletodistinguishfromseborrhoeic
dermatitis
Previous Psoriasisisachronicrelapsingandremittingdiseaseanditislikelythatthepatientwillhave
historyof hadlesionsinthepast.Otherskindiseases,suchasfungalinfections,areacuteand
lesions patientsdonotnormallyhaveahistoryoftheproblem
Clinicalfeaturesofplaquepsoriasis
Plaquepsoriasisclassicallypresentswithcharacteristicsalmonpinklesionswithsliverywhitescalesand
welldefinedboundaries(Fig.7.3(f0020)).Lesionscanbesingleormultipleandvaryinsizefrompinpoint
tocoveringextensiveareas.Ifthescalesonthesurfaceoftheplaquearegentlyremovedandthelesionis
thenrubbed,itrevealspinpointbleedingfromthesuperficialdilatedcapillaries.Thisisknownasthe
Auspitz'signandisdiagnostic.
Fig.7.3
Typicalpsoriaticplaques.
ReproducedfromDJGawkrodger,2007,Dermatology:AnIllustratedColourText,4thedition,ChurchillLivingstone,with
permission.
Clinicalfeaturesofscalppsoriasis
Scalppsoriasiscanbemild,exhibitingslightrednessofthescalpthroughtoseverecaseswithmarked
inflammationandthickscaling(Fig.7.4(f0025)).Therednessoftenextendsbeyondthehairmarginandis
commonlyseenbehindtheears.
Fig.7.4
Scalyplaquesofpsoriasisinthescalp,withlocalisedhairloss.
permission.
Conditionstoeliminateforplaquepsoriasis
Pustularpsoriasis
Inthisrareformofpsoriasissterilepustulesareanobviousclinicalfeature.Thepustulestendtobelocated
ontheadvancingedgeofthelesionsandtypicallyoccuronthepalmsofthehandsandsolesofthefeet(Fig.
7.5(f0030)).
Fig.7.5
Pustularpsoriasis.
ReproducedfromJWilkinsonetal2004,DermatologyinFocus,ChurchillLivingstone,withpermission.
Seborrhoeicpsoriasis(alsoknownasflexuralpsoriasis)
Seborrhoeicpsoriasisreferstoclassiclesionsthataffectthescalpbutwithlesstypicallesions(lackscaling)
inthebodyfolds,especiallythegroinsandaxillae.Often,inmildcasesthescalpmightbetheonlypartof
thebodyinvolved.Itch,inthisform,canbeprominent.
Guttatepsoriasis(alsoknownasraindroppsoriasis)
Guttatepsoriasisischaracterisedbycropsofscatteredsmalllesions(lessthan1cm)coveredwithlightflaky
scalesthatoftenaffectsthetrunkandproximalpartofthelimbs(Fig.7.6(f0035)).Thisformofpsoriasis
usuallyoccursinadolescentsandoftenfollowsastreptococcalthroatinfectionandinpeoplegenetically
predisposedtopsoriasis.Theconditionisusuallyselflimiting.
Fig.7.6
Guttatepsoriasis.
Erythrodermicpsoriasis
Erythrodermicpsoriasispresentsasanextensiveerythemaandshowsveryfewclassicallesions.Itis
thereforedifficulttodiagnosis.Theconditionisseriousandcanevenbelifethreatening.Systemic
symptomscanbesevereandincludefever,jointpainanddiarrhoea.Patientsareextremelyunlikelyto
presentatacommunitypharmacy.
Tineacorporis
Tineacorporiscansuperficiallylooklikeplaquepsoriasis.Forfurtherinformationontineainfectionsee
page210.
Lichenplanus
Lichenplanusisanuncommonconditionandisreportedtoonlyaccountfor0.2to0.8%ofdermatological
outpatientconsultations.Thelesionsaresimilarinappearancetoplaquepsoriasisbutareitchyandare
normallylocatedontheinnersurfacesofthewristsandontheshins,anatypicaldistributionforpsoriasis.
Additionally,oralmucousmembranesarenormallyaffectedwithwhite,slightlyraisedlesionsthatlooka
littlelikeaspider'sweb.Thepersonwillnothaveafamilyhistoryofpsoriasis.
Pityriasisrosea
Theconditionischaracterisedbyerythematousscalingmainlyonthetrunk,butalsoonthethighsand
upperarms.Thecolouroftherashtendstobealighterpinkcolourthanpsoriasisandcanbemildlyitchy.A
targetdisclesion,oftenmisdiagnosedasringworm,isfollowed1weeklaterwithanextensiverash.Itmost
commonlyaffectsyoungadults.Theconditionusuallyremitsspontaneouslyafter4to8weeks.Anaccurate
historywillnormallyeliminatepityriasisroseafrompsoriasis,astheconditionisacuteinonsetandthe
patientcanoftenidentifytheinitialtargetlesion.
Medicationexacerbatedpsoriasis
Anumberofmedicinescanworsenoraggravateexistingpsoriasis.Medicationmostcommonlyassociated
arelithium,antimalarialsandbetablockers.Otherlesscommonlyimplicatedincludedigoxin,amiodarone,
clonidine,penicillin,tetracycline,terbinafine,bupropionandsulphonamides.Inadditionsystemic
corticosteroidshavebeenshowntoinduceflaresinpsoriasispatients.
Conditionstoeliminateforscalppsoriasis
Seborrhoeicdermatitis
Mildscalppsoriasiscanbeverydifficulttodistinguishfromseborrhoeicdermatitis.However,inpractice
thisisrarelyaproblemsincetreatmentforbothconditionsisoftenthesame.Forfurtherinformationon
seborrhoeicdermatitisseepage207(s0290).
Tineacapitis(fungalinfectionofthescalp)
Tineacapitisisanuncommoninfectionbutifthepatienthasscalingskin,brokenhairsandapatchof
alopeciathenatineainfectionshouldbeconsidered.
Figure7.7(f0040)willaidinthedifferentiationofplaquepsoriasis.
TRIGGERPOINTSINDICATIVEOFREFERRAL
Psoriasis
Lesionsthatareextensive,followrecentinfectionorcausemoderatetosevereitching
Patientswithpsoriatictypelesionsbutwhohavenofamilyhistoryorpastpersonalhistoryof
psoriasis
Pustularpsoriaticlesions
Fig.7.7
Primerfordifferentialdiagnosisofplaquepsoriasis.
Evidencebaseforoverthecountermedication
BeforeanytreatmentisofferedtothepatientitisfirstworthnotingthatsimpleOTCremediesshouldbe
limitedtomildtomoderateplaquepsoriasisandscalppsoriasis,asthesearemostlikelytorespondtosuch
measures.Apatientwhopresentswithsevereplaquepsoriasisoranotherformofpsoriasisshouldbe
referred.
Anytreatmentrecommendedshouldalsobeinconjunctionwithpatienteducation.Reassuranceshouldbe
givenaboutitsbenign,noncontagiousnaturebutitshouldbeemphasisedthattheconditionischronicand
longtermthathasperiodsofremissionandrelapse.
TreatmentOTCislimitedtotheuseofemollients,keratolytics,coaltar(ordithranol),althoughthereis
limitedpublishedliteraturesupportingefficacyofthesetreatments.Othertopicaltreatmentsandsystemic
agentsavailableonprescriptionhaveevidenceofefficacyifOTCoptionsareineffective.Afuturecandidate
forderegulationtoPharmacystatusiscalcipotriol(Dovonex)asithasprovenefficacyformildtomoderate
plaquepsoriasisandhasfewsideeffects.
Emollients
Nopublishedliteratureappearstohaveaddressedeitheremollientefficacyorwhetheroneemollientis
superiortoanotherintreatingpsoriasis.Subjectiveevidenceoveralongperiodoftimehasshownthat
emollientsareusefulandareanimportantaspectofpsoriasistreatment.Emollientsarefrequently
prescribedandusedtohelpsoftenscalingandsoothetheskinsoreducingirritation,crackinganddryness.
Oncurrentevidencethereisnowayofknowingifoneemollientissuperiortoanother.Patientsmighthave
totryseveralemollientsbeforefindingonethatismosteffectivefortheirskin.
Keratolytics
Keratolytics,suchassalicylicacidandlacticacidhavebeenincorporatedintoemollientstoaidclearing
scaleandareoftenusedforscalppsoriasiswhereverythickscalingcanoccur.Althoughthereappearstobe
nopublishedevidencefortheirefficacyinclearingscale,clinicalpracticesuggeststhattheyshouldbeused
firstwhensignificantscalingispresentbeforeusingothertreatments.
Coaltar
Goeckermandemonstratedtheeffectivenessofcoaltarasearlyas1925.Thisremainedthemainstayof
treatmentuntiltheintroductionofdithranol,corticosteroids,andmorerecently,vitaminDandA
analogues.Anumberofclinicalstudieshaveconfirmedthebeneficialeffectcoaltarhasonpsoriasis,
althoughamajordrawbackinassessingtheeffectivenessofcoaltarpreparationsisthevariabilityintheir
compositionmakingmeaningfulcomparisonsbetweenstudiesdifficult.Comparisonsbetweencoaltarand
othertreatmentregimenshavebeenconducted.Thametal(1994)comparedtheeffectivenessofcalcipotriol
50gtwicedailyversus15%coaltarsolutioneachday.Bothtreatmentswereshowntobeeffective,
althoughcalcipotriolwassignificantlybetterthanthecoaltarsolution. Harrington(1989)comparedtwo
pharmacyonlyproducts,PsorinandAlphosyl.Findingsshowedthatbothhelpedinthetreatmentof
psoriasisbutPsorin(whichincludes0.11%dithranol)wassignificantlymoreeffective.
Dithranol
Dithranolwasfirstusedinthe1950sandhasbecomeanestablishedtreatmentoptionasclinicaltrialshave
establisheditsefficacy.Asystematicreviewin2009identifiedthreeplacebocontrolledtrialswith
dithranol,alldemonstratingastatisticallysignificantimprovementoverplacebo(Masonetal2009).There
appearstobenodefinitiveanswerastowhichstrengthismostappropriate,however,currentpractice
dictatesstartingonthelowestpossibleconcentrationandgraduallyincreasingtheconcentrationuntil
improvementisnoticed.Inaddition,shortcontactregimensareadvocated.However,onereviewof
publishedstudiesinvolvingshortcontactdithranoltherapyconcludedthatduetomethodologicalflawsin
manyofthetrialsitisimpossibletoobjectivelydeterminetheefficacyofthisregimen( Naldietal1992).
Practicalprescribingandproductselection
PrescribinginformationrelatingtothemedicinesusedtotreatpsoriasisdiscussedinthesectionEvidence
baseforoverthecountermedicationissummarisedinTable7.5(t0030)usefultipsrelatingtopatients
presentingwithpsoriasisaregiveninHintsandTipsBox7.1(b0015).
Table7.5
Practicalprescribing:Summaryoftarbasedproducts
Scalp,Skinor Salicylic Sulphur Other Children Application

both acid ingredients
Alphosyl2in1 Scalp No No No Allages Every2to3days

Shampoo
Capasal Scalp Yes No Coconutoil Allages Daily

1%
CarboDome Cream No No No Allages Twoorthreetimesa

day
Cocois Scalp Yes Yes No >6 Weekly

years
Exorex Scalp No No No >12 2to3timesaday

years
Pentraxshampoo Scalp No No No Allages Twiceweekly
Pinetarsol Skin No No No Allages Canbeusedasasoap

substitute
Polytar&Polytar Scalp No No No Allages Onceortwiceweekly

Plus
Psoriderm Both No No No Allages Onceortwiceaday
SebCo Scalp Yes Yes No >6 Dailywhenneeded

years
T/Gel Scalp No No No Allages 2to3timesaweek
HINTSANDTIPSBOX7.1:
Psoriasis

Problemswithtar Coaltaranddithranolsharecommonproblemsofpatientcompliance.Both
anddithranol aremessytouse,haveanunpleasantodourandcanstainskinandclothing
products
UVLight 90%ofpatientswithpsoriasisimprovewhenexposedtosunlightandmost
patientsnoticeanimprovementwhentheygoonholiday
Emollientuse Remindpatientsthattheseshouldbeusedregularlyandliberally
Emollientbath Somebathadditives,forexampleoilatum,willmakethebathslipperyand
additives patientsshouldbewarnedtoexercisecarewhengettingoutofthebath
Emollients
Allemollientsshouldberegularlyandliberallyappliedwithnoupperlimitonhowoftentheycanbeused.
Allarechemicallyinertandcanthereforebesafelyusedfrombirthonwardsbyallpatients.Theydonot
haveanyinteractionswithothermedicines.Formoreinformationonemollientsseepage242(s1160).
Tarbasedproducts
Allpatientgroups,includingpregnantandbreastfeedingwomen,canusethemajorityofproductsoneither
theskinorscalp.Theyhavenodruginteractionsbutcancauselocalskinorscalpirritationandstainskin
andclothes.Therehasbeenrecentconcernovertopicaltarproductsassociationwithanincreasedriskof
skincancer,althoughthereisatpresentnofirmepidemiologicalevidence(
http://www.bad.org.uk/site/1114/default.aspx(http://www.bad.org.uk/site/1114/default.aspx)accessed13November
2012).
Dithranol(e.g.Dithrocream)
Dithranolpreparationsarepharmacyonlymedicinessolongasthestrengthdoesnotexceedamaximumof
1.0%.Althoughdithranolhasevidenceofefficacy,recommendationisnotadvocatedinapharmacycontext
duetoitsadverseeffects,evenatlowconcentrations.Whenused,shortcontacttherapyisoftenadvocated
becauseprolongedexposurecanleadtoirritationandburningskin.Thisinvolvesusingtheloweststrength
fortheshortestperiod,whichcontrolssymptoms.
Furtherreading
ClarkC:Psoriasis:firstlinetreatments.PharmJ2004274:pp.623626.
DoddWA:Tars.Theirroleinthetreatmentofpsoriasis.DermatolClin199311:pp.131135.
FreemanK:Psoriasis:notjustaskindisease.ThePrescriber20075thJune:pp.4245.49
GelfandJM,WeinsteinR,PorterSB,et.al.:PrevalenceandtreatmentofpsoriasisintheUnitedKingdom:a
populationbasedstudy.ArchDermatol2005141:pp.15371541.
LearyMR,RappSR,HerbstKC,et.al.:Interpersonalconcernsandpsychologicaldifficultiesofpsoriasis
patients:effectsofdiseaseseverityandfearofnegativeevaluation.HealthPsychol199817:pp.530536.
MacKieRM:ClinicalDermatology.1999.OxfordUniversityPressHongKong
NevittGJ,HutchinsonPE:Psoriasisinthecommunity:prevalence,severityandpatients'beliefsand
attitudestowardsthedisease.BrJDermatol1996135:pp.533537.
SconP,HenningBoehnckeW,Psoriasis:NEnglJMed2005352:pp.18991912.
TristaniFirouziP,KrueggerCG:Efficacyandsafetyoftreatmentmodalitiesforpsoriasis.Cutis199861:
pp.1121.
Websites
ThePsoriasisAssociation:http://www.psoriasisassociation.org.uk/(http://www.psoriasisassociation.org.uk/)
PsoriaticArthropathyAlliance:http://www.paalliance.org/(http://www.paalliance.org/)
Dandruff(pityriasiscapitis)
Background
Dandruffisachronicrelapsingnoninflammatoryhyperproliferativeskinconditionthatisoftenseenas
sociallyunsightlyandasourceofembarrassment.Consequently,therearemanyproductsmarketedtohelp
withtheproblem.
Dandruffisverycommonandaffectsbothsexesandallagegroups,althoughitisunusualinprepubescent
children.Ithasbeenestimatedtoaffect13%ofthepopulation(Guptaetal,2004).
Aetiology
Increasedcellturnoverrateisresponsiblefordandruffbutthereasonwhycellturnoverincreasesis
unknown.Increasingly,researchhasfocusedontherolethatmicroorganismshaveonthepathogenesisof
dandruff,andinparticulartheyeastMalassezia(previouslyknownasPityrosporum)ovale,althoughthe
evidenceisinconclusiveastowhetherM.ovaleistheprimarycauseofdandrufforisacontributoryfactor.
IthasbeenshownthatM.ovalemakesupmoreofthescalpfloraofdandruffsufferersandmightexplain
whydandruffimprovesinthesummermonths(fungalorganismsthriveinwarmandmoistenvironments
thatexistonthescalpduetowearingofhatsandcaps).FurtherevidencetosupportaroleofM.ovalein
theaetiologyofdandruffisthepositiveeffectthatantifungaltherapyhasontheresolutionofdandruff.
Mostpatientswilldiagnoseandtreatdandruffwithoutseekingmedicalhelp.However,forthosepatients
thatdoaskforhelpandadviceitisimportanttodifferentiatedandrufffromotherscalpconditions.Asking
symptomspecificquestionswillhelpthepharmacisttodetermineifreferralisneeded(Table7.6(t0040)).
Table7.6
Specificquestionstoaskthepatient:Dandruff
Question Relevance
Presenceof Dandruffisnotassociatedwithscalprednessunlessthepersonhasbeenscratching.
erythema Rednessischaracteristicofpsoriasisandiscommoninadultseborrhoeicdermatitis
Itch Dandrufftendstocauseitchingofthescalpunlikepsoriasisandseborrhoeicdermatitis
Presenceof Anadultwithscalpinvolvementonlyislikelytohavedandruff,especiallyintheabsence
otherskin oferythema
lesions
Question Relevance
Manypatientswhohavescalppsoriasisalsohaveplaquepsoriasisaffectingarms,legs
andtheback
Clinicalfeaturesofdandruff
Thescalpwillbedry,itchyandflaky.Flakesofdeadskinareusuallyvisibleinthehairclosetothescalpand
arevisibleontheshouldersandcollarsofclothing.
Conditionstoeliminate
Typically,seborrhoeicdermatitiswillaffectareasotherthanthescalp.Inadults,thetrunkiscommonly
involved,asaretheeyebrows,eyelashesandexternalear.Ifonlyscalpinvolvementispresentthenthe
patientmightcomplainofsevereandpersistentdandruffandtheskinofthescalpwillbered.Forfurther
informationonseborrhoeicdermatitisseepage207(s0290).
Contactdermatitis
Enquiryshouldbemadetotheuseofnewhairproductssuchasdyesandperms.Thesecancauseirritation
andscaling.Avoidanceoftheirritantshouldseeanimprovementinthecondition.Ifimprovementisnot
observedafteravoidanceof1to2weeksthenareassessmentoftheconditionisneeded.
Tineacapitis
Iftheproblemispersistentandassociatedwithhairlossthenfungalinfectionofthescalpshouldbe
considered.
Figure7.8(f0045)willaidthedifferentiationofdandrufffromotherscalpdisorders.
Dandruff
OTCtreatmentfailurewithamedicatedshampoo
Suspectedfungalinfection
Fig.7.8
Primerfordifferentialdiagnosisofdandruff.
Theuseofahypoallergenicshampooonadailybasiswillusuallycontrolmildsymptoms.Inmore
persistentandseverecasesamedicatedshampoocanbeusedtocontrolthesymptoms.Treatmentoptions
includecoaltar,seleniumsulphide,zincpyrithioneandketoconazole.
Coaltar
Themechanismofactionforcrudecoaltarinthemanagementofdandruffisunclear,althoughitappears
thattarsaffectDNAsynthesisandhaveanantimitoticeffect.Therearevirtuallynopublishedstudiesinthe
literaturetoassesstheefficacyofcoaltarsinthetreatmentofdandruff.AreviewinClinicalEvidence
identifiedonestudycomparingcoaltartoplacebo( Manrquez&Uribe2007).Thestudyinvolving111people
withseborrhoeicdermatitisordandrufffoundcoaltarreduceddandruffscoresandrednesscomparedto
placeboat29days.Despitethelackofevidence,tarderivativesarefoundinaplethoraofOTCmedicated
shampoosandhavebeengrantedFDAapprovalinAmericaasanantidandruffagent.
Seleniumsulphide
Seleniumisthoughttoworkbyitsantifungalaction.Itisacceptedthatseleniumiseffectiveasan
antidandruffagentandstudieshaveshownittobesignificantlybetterthanplaceboandnonmedicated
shampoos.
Zincpyrithione
Zincpyrithione,likeselenium,exhibitsantifungalpropertiesbutalsoreducescellturnoverrates.Itis
believedthatoneorbothofthesepropertiesconfersitseffectivenessintreatingdandruff.Fewtrialshave
beenconductedwithzincpyrithionealthoughtrialshaveshownsignificantimprovementindandruff
severityscores.
Ketoconazole
Ketoconazole,anazoleantifungal,inhibitsM.ovalereplicationbyinterferingwithcellmembrane
formation.Ithelpsincontrollingtheitchingandflakingassociatedwithdandruff.Studieshaveshownitto
beaneffectivetreatment.Ithasbeendemonstratedthatketoconazoleissignificantlybetterthanzinc
pyrithioneandhassimilarefficacytoselenium,althoughitisbettertoleratedthanselenium.Ketoconazole
hasalsobeenshowntoactasaprophylacticagentinpreventingrelapse.
Inadditiontotheingredientslisted,salicylicacidisaningredientinsomecombinedproducts(e.g.Capasal
andMeted)andincludedforitskeratolyticproperties,althoughtrialsarelackingtosubstantiateitseffect.
Prescribinginformationrelatingtothespecificproductsusedtotreatdandruffanddiscussedinthesection
EvidencebaseforoverthecountermedicationisdiscussedandsummarisedinTable7.7(t0045)useful
tipsrelatingtodandruffshampooaregiveninHintsandTipsBox7.2(b0025).
Table7.7
Practicalprescribing:Summaryofmedicinesfordandruff
Nameof Usein Likelyside Drug Patients Pregnancy&Breastfeeding

medicine children effects Interactions inwhich
ofnote care
exercised
Coaltar Allages Localirritation None None OK

products anddermatitis
reportedbut
Selenium >5 Manufacturersstatetoavoidinfirst
rare
years trimesterbutsafetydatashowsittobe
OKwhenusedonsmallareasovera
limitedtime
Noevidencetosayitwouldbe
absorbedintobreastmilk
Zinc Allages OK
pyrithione
Ketoconazole Allages
HINTSANDTIPSBOX7.2:
Dandruff

Selsun Gold,silverandothermetallicjewelleryshouldberemovedpriortouse,becauseitcan
Shampoo bediscoloured.Italsohasanunpleasantodour
Allantidandruffshampooscancauselocalscalpirritation.Ifthisisseveretheproductshouldbe
discontinued.Anypatientgroupcanusethem,althoughsomemanufacturersstateproductsshouldbe
avoidedduringthefirst3monthsofpregnancy.However,thereappearstobenodatatosubstantiatethis
precautionduringpregnancy.
Coaltarproducts
Productscontainingcoaltararediscussedunderpracticalprescribingforpsoriasis.Forfurtherinformation
oncoaltarproductsseepage203(s0180).
Seleniumsulphide(e.g.Selsun)
Adultsandchildrenovertheageof5shouldusetheproducttwiceaweekforthefirst2weeksandthen
onceaweekforthenext2weeks.Thehairshouldbethoroughlywetbeforeapplyingtheshampooandleft
incontactwiththescalpfor2to3minutesbeforerinsingout.Seleniumshouldbeavoidedifthepatienthas
inflamedorbrokenskinbecauseirritationcanoccur.Seleniumcanalsocausediscolourationofthehairand
alterthecolourofhairdyes.
Zincpyrithione(e.g.HeadandShoulders)
Zincbasedproductscanbeusedbyallpatientsandatanyage.Itshouldbeusedonadailybasisuntil
dandruffclears.Dermatitishasbeenreportedwithzincpyrithioneandshouldbeborneinmindwhen
treatingpatientswithpreexistingdermatitis.
Ketoconazole(NizoralDandruffandNizoralAntiDandruffShampoo)
Nizoralcaneitherbeusedtotreatacuteflareupsofdandrufforasprophylaxis.Totreatacutecasesadults
andchildrenshouldwashthehairthoroughly,leavingtheshampooonfor3to5minutesbeforerinsingit
off.Thisshouldberepeatedevery3or4days(twiceaweek)forbetween2and4weeks.Ifusedfor
prophylaxis,theshampooshouldbeusedonceevery1to2weeks.Itcancauselocalitchingoraburning
sensationonapplicationandmayrarelydiscolourhair.
Furtherreading
ArreseJE,PierardFranchimontC,DeDonckerP,et.al.:Effectofketoconazolemedicatedshampooson
squamometryandMalasseziaovalisloadinpityriasiscapitis.Cutis199658:pp.235237.
DanbyFW,MaddinWS,MargessonLJ,et.al.:Arandomizeddoubleblindcontrolledtrialofketoconazole
2%shampooversusseleniumsulfide2.5%shampoointhetreatmentofmoderatetoseveredandruff.JAm
AcadDermatol199329:pp.10081012.
NigamPK,TyagiS,SaxenaAK,et.al.:Dermatitisfromzincpyrithione.ContactDermatitis198819:pp.
219.
OrentreichN:Comparativestudyoftwoantidandruffpreparations.JPharmSci196958:pp.12791284.
PereiraF,FernandesC,DiasM,et.al.:Allergiccontactdermatitisfromzincpyrithione.ContactDermatitis
199533:pp.131.
PeterRU,RicharzBarthauerU:Successfultreatmentandprophylaxisofscalpseborrheicdermatitisand
dandruffwith2%ketoconazoleshampoo:Resultsofamulticentre,doubleblind,placebocontrolledtrial.Br
JDermatol1995132:pp.441445.
PierardFranchimontC,GoffinV,DecroixJ,et.al.:Amulticenterrandomizedtrialofketoconazole2%and
zincpyrithione1%shampoosinseveredandruffandseborrhoeicdermatitis.SkinPharmacolApplSkin
Physiol200215:pp.434441.
RigoniC,ToffoloP,CantuA,et.al.:1%econazolehairshampoointhetreatmentofpityriasiscapitisa
comparativestudyversuszincpyrithioneshampoo.GItalDermatolVenereol1989124:pp.6770.
VanCustemJ,VanGervenF,FransenJ,et.al.:.JAmAcadDermatol199022:pp.993998.
Background
Therearetwodistincttypesofseborrhoeicdermatitis:aninfantileform,oftenreferredtoascradlecap,and
anadultform.Seborrhoeicdermatitiscanpresentwithvaryingdegreesofseverity,rangingfrommild
dandrufftoasevereandexplosiveforminacquiredimmunedeficiencysyndrome(AIDS)patients.
Estimatesoftheprevalenceofclinicallysignificantseborrhoeicdermatitisrangefrom1to5%ofthe
population,althoughcradlecapisreportedtobemoreprevalentthantheadultform(Naldi&Rebora2009).
Cradlecapusuallystartsininfancy,beforetheageof6monthsandisusuallyselflimitingtheadultform
tendstobechronicandpersistent.Seborrhoeicdermatitisismorecommoninadultmenthanwomen,and
alsomorecommoninpeoplewithunderlyingneurologicalillness,forexample,Parkinson'sdisease(
Johnson&Nunley2000).
Aetiology
Despiteitsname,thereappearstobenochangesinsebumsecretion.Likepsoriasisanddandruff,
seborrhoeicdermatitisischaracterisedbyanincreasedcellturnoverrate.Theprecisecauseofseborrhoeic
dermatitisremainsunknownandseveraltheorieshavebeenputforward,rangingfromimmunological,
hormonalandnutritionalmechanisms.Likedandruff,Malasseziaovaleplaysanimportantroleinthe
developmentofseborrhoeicdermatitishowever,ithasnotyetbeenestablishedwhetherithasaprimaryor
secondaryroleintheclinicalpresentationofseborrhoeicdermatitis.
Infantileseborrhoeicdermatitisisrelativelyeasytorecognisebutcansometimesbeconfusedwithatopic
dermatitis.Arrivingatadifferentialdiagnosisoftheadultformismoreproblematicastheconditioncan
affectdifferentareasandpresentwithdifferentdegreesofseverity.Inmildcasesitneedstobe
differentiatedfromdandruffandinmoresevereformsfromallergiccontactdermatitis,psoriasisand
pityriasisversicolor.Askingsymptomspecificquestionswillhelpthepharmacisttodetermineifreferralis
needed(Table7.8(t0055)).
Table7.8
Specificquestionstoaskthepatient:Seborrhoeicdermatitis
Question Relevance
Itching Incradlecaptherashdoesnotitch.Thisisusefulindifferentiatingcradlecapfromatopic
dermatitisasthereisoftenoverlapintheageatwhichtheypresent.
Location Infantileandadultformsofseborrhoeicdermatitisdopresentindifferentlocations(Fig.7.9
(f0050)).Additionally,thedistributionintheadultformvariesfromothersimilarskinconditions
(e.g.psoriasistypicallyinvolvesknees,elbowsandsacralarea).
Positive Patientstendnottohaveafamilyhistoryinseborrhoeicdermatitis.Thisisincontrastto
family patientswithpsoriasisandthosepatientssufferingfromatopicdermatitis.
history
Question Relevance
Other Earandeyelidproblemsareassociatedwithseborrhoeicdermatitis.
symptoms
Thegeneralhealthofachildwithseborrhoeicdermatitiswillbeunaffected.Incontrastachild
whoisfractiousandmiserableismorelikelytohaveatopicdermatitis.
Seborrhoeicdermatitisusuallyhasyellowgreasyscale,unlikepsoriasis,whichhasasilvery
scale.
Physical Ifyourunyourfingersthroughthehairofsomeonewithseborrhoeicdermatitislittleisfelt.In
signs psoriasis,accumulationofscalesgivethescalpanuneven,lumpyfeel.
Fig.7.9
Typicaldistributionofseborrhoeicdermatitis.
Clinicalfeaturesofseborrhoeicdermatitis
Cradlecapappearsaslargeyellow,greasyscalesandcrustsonthescalp.Thiscanbecomethickandcover
thewholescalp(Fig.7.10(f0055)).Otherareascanbeinvolvedsuchasthefaceandnapkinarea.
Fig.7.10
Infantileseborrhoeicdermatitis.
ReproducedfromRKliegman,REBehrman,WEmersonNelsonandHBJenson,2007,NelsonTextbookofPediatrics,
SaundersElsevierwithpermission.
Theadultformofseborrhoeicdermatitisischaracterisedbyahistoryofintermittentskinproblems.The
distributionofrashissynonymouswithskinareaswithhighnumbersofsebaceousglands,typicallythe
centralpartoftheface,scalp,eyebrows,eyelids,ears,nasolabialfoldsandmidchest(Fig.7.11(f0060)).The
rashisredwithgreasylookingscalesandismildlyitchy.Blepharitisandotitisexternaarealsocommon
secondarycomplications.
Fig.7.11
Seborrhoeicdermatitisaffectingtheface.
permission.
Atopicdermatitis
Ininfants,atopicdermatitisusuallypresentsasitchylesionsonthefaceandtrunk.Scalpinvolvementis
lesscommonandthenappyareaisusuallyspared.Apositivefamilyhistoryoftheatopictriadofdermatitis,
asthmaorhayfeveriscommon.Forfurtherinformationondifferentiatingatopicdermatitisseepage291.
Psoriasis
Adultswithscalppsoriasiscanbeconfusedwiththosepatientswhopresentwithsevereandpersistent
dandruffcausedbyseborrhoeicdermatitis.However,inscalppsoriasistheplaquestendtobecrustyand
extendawayfromthehairlinewhereasseborrhoeicdermatitiscausesscalingwithunderlyingredness.It
alsoaffectstheeyebrowsandeyelids,unlikepsoriasis.
Pityriasisversicolor(meaningbranlikescalyrashofvariouscolour)
Pityriasisversicolor,ayeastinfection,canbemistakenforadultseborrhoeicdermatitisbecausethelesions
exhibitfinesuperficialscaleandarelocatedontheuppertrunk.Thelesionsareusuallysmall(lessthan
1cm)butcanjointogethertoformlargerplaques.Theconditionisassociatedwithwarmclimatesandmost
peoplewillhavepickedtheinfectionupwhenonholiday.Therashdoesnotitchsignificantlyandthefaceis
usuallyspared.Itcanbetreatedwithantifungallotionsandshampoos(seeDandruffpage206(s0260)),orif
asmallnumberoflesionswithimidazolecreams(seeFungalinfectionspage213(s0450)).Antifungal
shampoossuchasketoconazole,andseleniumsulphide(2.5%)areappliedfor10minutesandthenwashed
off,andthisisrepeateddailyfor10days.Imidazolecreamsareapplieddailyfor10days.
Rosacea
Rosaceapredominatelyaffectsthefaceanareausuallyinvolvedinadultseborrhoeicdermatitis.Formore
informationonrosaceaseepage233(s0970)undertheacnesection.
Medicationthatcantriggeroraggravateseborrhoeicdermatitis
Anumberofmedicinesareassociatedwithtriggeringoraggravatingexistingseborrhoeicdermatitis.These
include:buspirone,cimetidine,gold,griseofulvin,haloperidol,interferonalfa,lithium,methyldopaand
phenothiazines.
TreatmentfailurewithOTCmedicines
Lesionsthatappearafterholidaytowarmclimates
Treatmentoptionsforseborrhoeicdermatitisarethesameasdandruff.Unfortunately,seborrhoeic
dermatitistendstobemoreresistanttotherapyandoftenrecurswhatevertreatmentischosen.
Forinfantswithcradlecapsimplemeasuresareusuallyonlyrequiredinmostcases.Dailyuseofababy
shampoofollowedbygentlebrushingwillimprovethecondition.Ifthisfails,thescalescanberemovedby
applyingoliveoiltothescalpovernightfollowedbyusingababyshampoothenextmorning.Ifsymptoms
persistamedicatedshampoocontainingakeratolytic(e.g.Meted)orkeratolytictarcombination(e.g.
Capasal)couldbetried.IfthisfailsthechildshouldbereferredtotheGP.
Inadults,OTCpreparationsshouldonlybeusedonmildtomoderateseborrhoeicdermatitisinvolvingthe
scalp.Inmildcasesofscalpinvolvementzincpyrithionecanbetried,reservingseleniumandketoconazole
forresistantormoremoderatedisease.Forinvolvementonthefaceandtorsoantifungalsand
corticosteroidsareeffectivebutOTCproductlicencesprecludetheiruse.
Prescribinginformationrelatingtospecificproductsusedtotreatseborrhoeicdermatitisisdiscussedunder
Dandruffonpage206(s0260).Inaddition,atleastoneproductismarketedspecificallyforcradlecapand
isdiscussedandsummarisedinTable7.9(t0060).
Table7.9
Practicalprescribing:Summaryofmedicinesforcradlecap
Nameofmedicine Usein Likelyside Drug Patientsinwhich Pregnancy&

children effects interactionsof careexercised breastfeeding
note
DentinoxCradle Birth None None None Notapplicable

CapShampoo onwards reported
DentinoxCradleCapShampoo
Thiscontainssodiumlaurylethersulphosuccinate6%andsodiumlaurylethersulphate2.7%.Theshampoo
shouldbeappliedtwiceduringeachbathtimeuntilthescalpclears,afterwhichitcanbeusedwhen
needed.
Furtherreading
BergbrantIM,FaergemannJ:.SeminDermatol19909:pp.262268.
DanbyFW,MaddinWS,MargessonLJ,et.al.:Arandomizeddoubleblindcontrolledtrialofketoconazole
2%shampooversusseleniumsulfide2.5%shampoointhetreatmentofmoderatetoseveredandruff.JAm
GoIH,WientjensDP,KosterM:Adoubleblindtrialof1%ketoconazoleshampooversusplacebointhe
treatmentofdandruff.Mycoses199235:pp.103105.
GuptaAK,BluhmR:Seborrhoeicdermatitis.JEurAcadDermatolVenereol200418:pp.1326.
McGrathJ,MurphyGM:Thecontrolofseborrhoeicdermatitisanddandruffbyantipityrosporaldrugs.
Drugs199141:pp.178184.
Fungalskininfections
Background
Twomaingroupsoffungiinfectman:Candidayeastsandthedermatophytes.However,inthissectiononly
dermatophyteinfectionsareconsidered.Fungalinfectionsarecommonlyandinaccuratelyreferredtoas
ringworm.Dermatophyteskininfectionsareclassedbyanatomicallocation,forexample:Athlete'sfoot
(tineapedis)groininfection(tineacrurisorjockitch)ringwormoftheskin(tineacorporis)andscalp
ringworm(tineacapitis).
Globally,dermatophyticfungiaremoreprevalentintropicalandsubtropicalareasbecausefungal
organismspreferhightemperaturesandhighhumidity.Havingsaidthis,dermatophyteinfectionsare
commonlymetinmoretemperateWesterncountries.Tineapedis(athlete'sfoot)isthemostcommon
fungalinfection,althoughprevalenceratesvarydependingonthepopulationstudiedandwhether
diagnosisismadebyclinicalsymptomsorcultureconfirmation.Athlete'sfootissaidtoaffectabout15%of
theUKpopulationandiscommoninpeopleofallages.
Othertineainfectionssuchastineacorporisandtineacrurismightpresentinthecommunitypharmacybut
areuncommonTineaunguium(nailinfection)iscoveredseparatelyonpage216(sc0030).Tineacapitisis
thecommonestinfectioninchildrenWorldwidebutinWesternnationsisrare(forfurtherinformationon
fungalscalpinfectionseepage203(s0180)).
Aetiology
Dermatophyteinfectionsarecontagiousandtransmitteddirectlyfromonehosttoanother.Theyinvadethe
stratumcorneumoftheskin,hairandnailsbutdonotgenerallyinfiltratelivingtissues.Thefungusthen
beginstogrowandproliferateinthenonlivingcornifiedlayerofkeratinisedtissueoftheepidermis.
Transmissionofathlete'sfootisthoughttobecommonlyacquiredfromcommunalrooms(e.g.changing
rooms)whereasinfectionofthegroincanbeacquiredfromcontaminatedtowelsandbedsheets,orby
autoinoculationfromanexistingfootinfection.
Dependentontheareaaffectedtheinfectionwillmanifestitselfinavarietyofclinicalpresentations(Fig.
7.12(f0065)).Recognitionofsymptomsforeachsiteaffectedwillfacilitaterecognitionandaccurate
diagnosis.Allformsoftineainfectionshouldberelativelyeasytorecognise,perhapswiththeexceptionof
isolatedlesionsonthebody.
Fig.7.12
Distributionoffungalinfections.
Patientswithathlete'sfootwilloftenaccuratelyselfdiagnosethecondition.However,thepharmacist
shouldstillconfirmthisselfdiagnosisthroughacombinationofquestions(Table7.10(t0065))and
inspectionofthefeet.Thisisimportantasitalsoprovidesanopportunitytocheckforfungalnail
involvement.
Table7.10
Specificquestionstoaskthepatient:Fungalinfections
Question Relevance
Ageandsexof Athlete'sfootismostprevalentinadolescentsandyoungadults,especiallymen
patient
Nailinvolvementusuallyoccursinolderadults
Infectioninthegroinismuchmorecommoninmenthanwomen
Presenceof Fungalinfectionsusuallycauseitch,irritationorburningsensations.Thisusually
itch eliminatesconditionssuchaspsoriasisbutnotdermatitis/eczema
Associated Fungallesionstendtobedryandscaly(exceptathlete'sfoot)andhaveasharpmargin
symptoms betweeninfectedandnoninfectedskin
Previousand Fungalinfectionsareusuallyacuteinonsetwithnopreviousepisodes,although
familyhistory athlete'sfootmaybecomerecurrent
Forlesionsthatdonotshowaclassictextbookdescription,apositivefamilyhistoryof
dermatitisorpsoriasismightinfluenceyourdifferentialdiagnosis
Clinicalfeaturesoftineainfections
Athlete'sfoot
Athlete'sfootischaracterisedbyitching,flakingandfissuringoftheskinandwillappearwhiteandsoggy
duetomacerationoftheskin(Fig.7.13(f0070)).Thefeetoftensmell.Theusualsiteofinfectionisinthetoe
webs,especiallythefourthwebspace(webspacenexttothelittletoe).
Fig.7.13
Athlete'sfoot.
ReproducedfromABFleischeretal2000,20CommonProblems,withpermissionoftheMcGrawHillCompanies.
Onceacquiredtheinfectioncanspreadtoothersitesincludingthesoleandinstepofthefoot.Overtime
thiscaninfectthenails(seepage216(sc0030)forfungalnailinfection(sc0030)).Casesoftineainfectionwhere
theplantarsurfacehasbecomeinvolvedmaybepersistentanddifficulttotreat.
Tineacorporis
Tineacorporisisdefinedasaninfectionofthemajorskinsurfacesthatdonotinvolvetheface,hands,feet,
groinorscalp.Theusualclinicalpresentationisofitchypinkorredscalyslightlyraisedpatcheswithawell
definedinflamedborder(Fig.7.14(f0075)).Overtimethelesionsoftenshowcentralclearingasthecentral
areaisrelativelyresistanttocolonisation.Thisappearanceledtothetermringworm.Lesionscanoccur
singly,benumerousoroverlaptoproduceasinglelargelesionandappearpolycyclic(severaloverlapping
circularlesions).
Fig.7.14
Tineacorporis.
permission.
Tineacruris
Therashisusuallyisolatedtothegroinandinnerthighs,butcanspreadtothebuttocks.Itisoftenbilateral
andisnormallyintenselyitchy,reddishbrownandhasawelldefinededge.
Tineafaciei
Fungalinfectionsonthefacearerareandareconsequentlyoftenmistakenforotherfacialskinconditions.
Thelesionsaresimilarinappearancetotineacorporisinthattheywillnormallyhaveasharpwelldefined
border,showscalingandbeitchy.Conditionssuchasacne,rosaceaandlupusneedtobeconsideredinits
differentialdiagnosis.
Tineamanuum
Tineamanuumisoftenmisdiagnosedaseczemaorpsoriasisduetoitsatypicaltineaappearance.The
patientusuallysuffersfromchronicdiffusescalingofonepalm.Oftenathlete'sfootwillbepresent,asthe
infectionhasspreadtothehandsfromthefeetduetothepatientscratchingtheirfeet.Theconditionisnot
commonandifnofootinvolvementisimplicatedthenthediagnosisstronglypointstodermatitis.
Psoriasis
Isolatedfungalbodylesionscanbedifficulttodistinguishfromplaquepsoriasis.However,ifthepatienthas
psoriasistherewillnormallybeafamilyhistoryofpsoriasisandthelesionstendnottoitch,exhibitmore
scalinganddonotshowcentralclearing.
Dermatitisallergicandcontactforms
Dermatitisallergicandcontactforms
Bothfungalinfectionsanddermatitisexhibitreditchylesionsandthereforecanbedifficulttodistinguish
fromoneanother.Patientswithdermatitiswilloftenhaveafamilyandpersonalhistoryofdermatitisorbe
abletodescribeaneventthattriggeredtheonsetoftherash.Misdiagnosisofafungalinfectionfor
dermatitisandsubsequenttreatmentwithasteroidbasedcreamwilldiminishtheitch,rednessandscaling
buttheinfectingorganismwillproliferate.Onwithdrawalofthesteroidcreamthevisiblesignsofthe
infectionwillreturnandbeworsethanbefore,ofteninapapularform(tineaincognito).
Discoideczema
Thispresentsasround,raised,coinshapedlesionsthatparticularlyaffectsthearmsandlegs.Itcanitch
andshowsuperficialscale.Itoccursmainlyinmiddleagedpeople.
Tineainfections
Involvementoflargeareasofthetrunk(possibleoraltreatmentneeded)
OTCtreatmentfailure
Suspectedfacialorscalpinvolvement
SuperficialdermatophyteinfectionscanbetreatedeffectivelywithtopicalOTCpreparations.Sixclassesof
medicineshaveprovenefficacyintheirtreatment.
Allylamines
TerbinafinehasbeenexemptfromPOMcontrolintheUKsince2000.Itinhibitsthebiosynthesisof
ergosterolanessentialcomponentoffungalcellmembranes.Reviewshaveshownterbinafinetohave
highcurerates,slightlybetterthantheimidazoles(Crawford&Hollis2007).
Benzoicacid
BenzoicacidactsbyloweringintracellularpHofdermatophytesandiscombinedwithsalicylicacid
(Whitfield'sointment).AlthoughWhitfield'sointmenthasbeenonthemarketfornearlyacenturyitstill
hasaroletoplayasaneffectiveantifungal,butnewerproducts,withhighercurerates,quickerresolution
andmorecosmeticallyacceptableformulationshavereplaceditswidespreaduseinWesternsociety.
Imidazoles
Imidazoles,likeallylamines,actbyinhibitingergosterolproductionbutatalaterstageintheergosterol
biosynthesispathway.Theyhavelargelyreplacedbenzoicacid,undecenoatesandtolnaftate,becausethey
havegreaterefficacyandanexcellentsafetyrecord(Crawford&Hollis2007).Thereappearstobeno
clinicallysignificantdifferencesincureratesbetweenthedifferentimidazolesandtreatmentchoicewill
probablybedrivenbypatientacceptabilityandcost.
Griseofulvin
Griseofulvin(asa1%spray)worksbyinhibitingcellularmitosis.Ithasproveneffectivenesswhentaken
orallybuthasonlylimitedtrialdataasatopicalformulation.Onetrialreportedan80%mycologicalcure
rateafter4weekswithoncedailyapplication(Alyetal1994).
Tolnaftate
Tolnaftateisthoughttoworkbydistortingfungalhyphae.Itappearstohavetheleastamountoftrialdata
supportingitsefficacy.Lowpatientnumbersinvolvedinthestudiesfurthercompoundsthedifficultyin
assessingitsefficacy.
Undecenoates
Theexactmechanismofactionforundecenoatesisnotunderstood.Theyhavebeenusedtotreatathlete's
footforover30yearsandfeaturesinthemostrecentUnitedStatesPharmacopoeia.InarecentCochrane
review,undecenoicacidwassaidtobeefficaciousintreatingfungalinfectionsforskinandnailinfectionsof
thefoot(Crawford&Hollis2007).
Summary
Oncurrentevidence,animidazoleorterbinafinewouldbefirstlinetreatmentforsuperficialfungal
infection.Bothhavesimilarmycologicalandsymptomcurerates,althoughterbinafinemightbepreferred
becauseitclearssymptomsinashorterspaceoftime,althoughitismoreexpensive.
Prescribinginformationrelatingtospecificproductsusedtotreatfungalinfectionsanddiscussedinthe
sectionEvidencebaseforoverthecountermedicationissummarisedinTable7.11(t0070)andproducts
availablesummarisedinTable7.12(t0075)usefultipsrelatingtopatientspresentingwithfungalinfections
aregiveninHintsandTipsBox7.3(b0040).
Table7.11
Practicalprescribing:Summaryofmedicinesfortineainfections
Nameofmedicine Useinchildren Likelyside Drug Patientsin Pregnancy&

effects interactions whichcare breastfeeding
ofnote exercised
Imidazoles
Bifonazole Allages Mild None None OK

burningor
Clotrimazole
itching
Miconazole
Ketoconazole
Imidazole/steroid >10years
combination
Tolnaftate
Mycil Nolowerage None None None OK

Nameofmedicine stated
Useinchildren reported
Likelyside Drug Patientsin Pregnancy&
effects interactions whichcare breastfeeding
ofnote exercised
Tinaderm
Undecenoates
Mycota Nolowerage None None None OK

stated reported
Benzoicacid
Whitfield'sOintment Nolowerage None None None OK

stated reported
Terbinafine
Lamisilrange&Scholl >16years(>18 Redness, None None OK

AdvanceAthlete'sFoot yrsforLamisil itching
Cream Once)
Griseofulvin(GrisolAF) Nolowerage Stinging None None OK

stated
Table7.12
Summaryofantifungalproductsandformulations
Activeingredient Brand Formulations
Bifonazole CanestenBifonazoleOnceDaily Cream
Clotrimazole1% CanestenAF Cream,spray
Canesten Cream,spray,solution
Clotrimazole1%&Hydrocortisone1% CanestenHydrocortisone Cream
Miconazole2% DaktarinActiv Cream,spray,powder
Daktarin Creamandpowder
Miconazole2%&hydrocortisone1% DaktacortHydrocortisone Cream
Ketoconazole DaktarinGold Cream
Terbinafine LamisilAT Spray,cream,gel
LamisilOnce Solution
SchollAdvanceAthlete'sFootCream Cream
Tolnaftate Mycil Ointment,spray,powder
SchollAthlete'sfoot Cream,spray,powder
Activeingredient Brand Formulations
Tinaderm Cream
Undecenoicacid Mycota Cream,spray,powder
HINTSANDTIPSBOX7.3:
Fungalinfection
Reinfection Itisnotknownifimprovingfoothygieneorchangingfootwearcanhelptocure
and athlete'sfootbutmeasurestoreducetransmissioninclude:
transmission 1.Drytheskinthoroughlyaftershoweringorhavingabath.Keepapersonaltowel
anddonotshareittopreventtheinfectionspreadingfrompersontoperson
2.Wearcottonsocksandchangeatleastonceaday
3.Avoidtheuseofocclusivenonbreathableshoes
4.Dustshoesandsockswithantifungalpowder
5.Avoidscratchinginfectedskin
6.Useflipflops(orequivalent)whenusingcommunalchangingrooms
Steroid Thelicensestatesthatthemaximumperiodoftreatmentis7days.Thislimitstheir
containing usefulness,asmanyfungalinfectionswilltakelongertoclearthan7days,especially
products asproductsneedtobeusedafterthelesionshaveclearedtopreventreinfection.
Thereforetheyareprobablybestusedtocontrolinitialsymptomsofrednessanditch
beforeswitchingtoanimidazoleonlyproductaftertheinitial7daysoftreatment
Imidazoles
Alltopicalimidazoleshaveexcellentsafetyrecordsandcanbeusedbyallpatientgroups,including
pregnantandbreastfeedingwomen.Theydonothaveanydruginteractionsandthemajorsideeffect
associatedwiththeiruseisirritationonapplication.Topreventreinfection,imidazolesshouldbeusedafter
thelesionshavecleared,although,thelengthoftimevariesfromproducttoproduct.
Clotrimazole(e.g.Canestenrange)
Clotrimazolecontainingproductscanbeusedforalldermatophyteandcandidainfections.Canestenand
CanestenAFcreamshouldbeappliedtwoorthreetimesaday,whereasCanestenHydrocortisonecanonly
beusedtwiceaday.
Bifonazole(CanestenBifonazoleOnceDaily1%w/wCream)
Bifonazoleislicensedforathlete'sfoot.Forallpatientsthecreamshouldbeappliedoncedaily.
Ketoconazole(DaktarinGold)
Ketoconazole(DaktarinGold)
Ketoconazolehasalicenseforathlete'sfoot,groininfectionandcandidalintertrigo.Forathlete'sfootthe
creamshouldbeappliedtwiceadayfor1week.Forgroininfectionsandcandidalintertrigo,thecream
shouldbeappliedonceortwicedaily.Ifnoimprovementinsymptomsisexperiencedafter4weeks
treatmentthenthepatientshouldbereferredtotheGP.Forallconditionstreatmentshouldbecontinued
for2to3daysafterallsignsofinfectionhavedisappearedtopreventrelapse.
Miconazole(e.g.Daktarinrange,DaktacortHydrocortisone)
Productscontainingmiconazoleonlyaresuitableforpatientsofallagesandshouldbeusedtwiceaday.
Treatmentshouldcontinuefor10daysafteralllesionshavedisappearedtopreventrelapse.Daktacort
hydrocortisoneissuitableforchildrenagedover10andislicensedforsweatrashandathlete'sfoot.
Tolnaftate(e.g.Mycil,Tinaderm,SchollAthlete'sFootPowder,liquid&cream)
Productscontainingtolnaftatehavenointeractionsorsideeffectsandcanbeusedbyallpatients.Theycan
beusedforathlete'sfootandinfectionsofthegroinandshouldbeusedtwiceadaywithtreatment
continuingforatleast1weekaftertheinfectionhasclearedup.
Undecenoates(e.g.Mycota)
Productscontainingundecenoateshavenointeractionsandcanbeusedbyallpatients.Theyarelicensed
forathlete'sfootandshouldbeusedtwiceadayandtreatmentcontinuedforatleast1weekafterthe
infectionhasclearedup.Localirritationhasbeenreported.
Benzoicacid(e.g.Whitfield'sointment)
Benzoicacid(incombinationwithsalicylicacid)isnowrarelyused.However,itisasafemedicineandcan
beusedbyallpatients.
Terbinafine(Lamisilrange&SchollAdvanceAthlete'sFootCream)
Terbinafinecanbeusedtotreatathlete'sfoot,groininfectionandtineacorporis.Thecreamshouldbe
appliedonceortwiceadaywhereasthesprayandgelshouldbeusedonlyoncedaily.Ithasnointeractions,
hasfewreportedsideeffectsandcanbeusedbyallpatients.Allproductsarelicensedforpeopleagedover
16,exceptLamisilOnce,whichisforuseinpeopleagedover18yearsofage.
Griseofulvin(GrisolAFspray)
Licensedforathlete'sfoot,Grisolshouldbeappliedtotheareaoncedaily.Eachspraydelivers400gof
griseofulvinwithamaximumofthreespraysin24hoursformoreextensiveorsevereinfection.Thespray
shouldbeusedfor10daysafterthelesionscleartopreventreinfection.Ithasnointeractions,hasfew
reportedsideeffectsandcanbeusedbyallpatients.
Furtherreading
DrakeLA,DinehartSM,FarmerER,et.al.:Guidelinesofcareforsuperficialmycoticinfectionsoftheskin:
tineacorporis,tineacruris,tineafaciei,tineamanuum,andtineapedis.Guidelines/OutcomesCommittee.
AmericanAcademyofDermatology.JAmAcadDermatol199634:pp.282286.
ElewskiB:Tineacapitis.DermatolClin199614:pp.2331.
MoriartyB,HayR,MorrisJonesR:Thediagnosisandmanagementoftinea.BMJ2012345:pp.e4380.
Fungalnailinfection(onychomycosis)
Background
ThederegulationofamorolfineintheUKandotherWesterncountries(e.g.Australia)nowmakesit
possibleforcommunitypharmaciststotreatinfectionaffectingthetoenails.Onychomycosisisdefinedasa
chronicfungalinfectionofthefingernailsortoenails,althoughonlyinfectionofthetoenailiscoveredinthe
text.Theinfectioniscommonbutisprobablyunderreportedbecauseofpatientembarrassmentor
ignorancethattheyhaveaninfection.Ifleftuntreateditcanleadtopainanddiscomfort,whichcanmake
wearingshoesdifficult.Nails,overtime,willdisfigureandcrumbleaway.
Itisestimatedthatover10%ofthegeneralpopulationsufferfromonychomycosis(Thomasetal2010).The
incidenceofinfectionincreaseswithincreasingageandisparticularlycommoninpeopleagedover70
yearsofage(e.g.estimatedatupto50%).
Aetiology
Over90%ofcasesarecausedbydermatophytes(TrichophytonrubrumandT.interdigitale),withthe
remaindercausedbyyeastsandmoulds.Inmostcasespredisposingfactorscanbedeterminedinthe
developmentofnailinfection:forexample,aninitialskininfection(tineapedis),inimmunocompromised
patients,orpoorperipheralcirculationandneuropathies(e.g.diabetes).
Thereareanumberofdifferenttypesofonychomycosisanditisimportanttobeabletodifferentiate
betweenthembecauseamorolfineisonlylicensedforthetreatmentofdistallateralsubungual
onychomycosis.Takingahistoryofthepresentingsymptomwillbehelpfulbutavisualinspectionofthe
toenailsisstronglyadvocated.
Clinicalfeaturesofdistallateralsubungualonychomycosis(DLSO)
DLSOisusuallyasymptomaticandpeopleoftenseekmedicalhelpbecauseofconcernsaboutthe
appearanceofthenail.Thenailtakesonadullopaqueandyellowappearance.Overtimethenailthickens
anddistortsandasinfectionspreadsandworsensthenailbecomesbrittleandcrumblesawayorfallsoff(
Fig.7.15(f0080)).ThekeyclinicalsymptomsthatdifferentiateDLSOfromothertypesofonychomycosisare
summarisedinTable7.13(t0085).(Formoreimagesoffungalnailinfectionvisit
http://www.dermnetnz.org/fungal/onychomycosis.html(http://www.dermnetnz.org/fungal/onychomycosis.html)
accessed13November2012.)
Fig.7.15
Tineaunguium.
permission.
Table7.13
Maintypesofonychomycosis
Type Keycharacteristics Spreadofinfection
DLSO Mainlybigtoe Noteyellowingstartsatdistalpartoftoeor

sideofnail
Proximalsubungual Immunocompromisedpatients Yellowspotsappearatthebaseofthenail

onychomycosis(PCO) (i.e.inthehalfmoonareaofthenail)
Superficialwhite Oftenoccursinpreviouslydamaged Locatedonthesurfaceofthenail

onychomycosis nails
Chalkywhiteinappearanceand
canbescrapedoffthenailsurface
Otherconditionstoeliminate
Psoriasis,eczemaandtraumacanaffectthenailandneedtobeconsideredinpsoriasis,nailpittingis
visiblefortraumathereshouldbeanidentifiableeventwhichaffectedthenailandineczemaandpsoriasis
theskinshouldbeaffected,eithernearandaroundthefeet(eczema)orremotely(psoriasisplaqueson
areassuchaskneesandelbows).
DLSO
FungalinfectionotherthanDLSO
OTCtreatmentfailure
Suspectedpoorcompliance
Amorolfineisabroadspectrumantifungalagentthatworksbyinhibitingergosterolsynthesis.Anopen
labelled,nonrandomisedtrialhasshownittobeeffective,producingclinicalcurein37%oftoenail
infections(Zaug1992).However,thestudysufferedfromlargedropoutrates(nearly30%),andtherewas
nocomparisonswithotheravailabletopicalantifungaltreatments.Afurthertrial,comparingonceversus
twiceweeklyapplicationofamorolfinereportedsimilarcurerates(46%)withweeklyapplication(
Reinel1992).ACochranereviewfoundlimitedevidencefortheefficacyofanytopicaltreatmentsfornail
infections,butsuggestedthatcureratesmaybebetterwithamorolfine,althoughbasedonsmalltrials(
Crawford&Hollis2007).Prodigyguidance(July2012)advocatetheuseofamorolfinewhentheinfectionis
mildandsuperficial.
PrescribinginformationrelatingtoamorolfineissummarisedinTable7.14(t0090)usefultipsrelatingto
patientspresentingwithfungalnailinfectionaregiveninHintsandTipsBox7.4(b0050).
Table7.14
Practicalprescribing:Summaryofmedicinesforfungalnailinfections
Nameof Usein Likely Drug Patientsinwhich Pregnancy&breastfeeding

medicine children side interactions careexercised
effects ofnote
Amorolfine >18 Skin None None Manufacturersstateavoid,although

years irritation evidencesuggestsitissafetouse
(rare)
HINTSANDTIPSBOX7.4:
Curanail

Whyonlytwo ThisisinlinewithUKguidanceasmoresevereinfectionsrequiresystemic
nails? treatment(e.g.terbinafine)
Hygiene Keeptheareaclean
measures
Changesocksregularly
Avoidtraumatothenails
Avoidsharingtowels
Amorolfine(Curanail)
Amorolfineisavailableasa5%naillacquer.Itisusedweeklyandtreatmentlastsuntiltheaffectednail(s)
haveregrownandareclearofinfection.Thistakesapproximately6monthsforfingernailsand9to12
monthsfortoenails.EachpackofCuranailgives3monthstreatmentwhichaffordsthepharmacistan
opportunitytoreviewtreatmentbeforefurthermedicationisgiven.Theproductlicencerestrictsusetono
morethantwonailsinpeopleaged18oroverandhavenounderlyingmedicalconditionsthatpredispose
themtofungalinfection(e.g.immunocompromisedanddiabetics).Themanufacturerstatesitshouldnot
beusedinpregnantorbreastfeedingwomen.Toapplyamorolfinethenailmustbefirstfiledandcleaned.
Filesandcleaningpadsareprovidedinthetreatmentpackandarenotreusable.Thelacquershouldthenbe
evenlyappliedandlefttodry.Amorolfineisunlikelytocausesideeffects,butskinirritationhasbeen
reported.
Furtherreading
SeebacherC,BraschJ,AbeckD,et.al.:Onychomycosis.JDDG20071:pp.6166.
FinchJJ,WarshawEM:Toenailonychomycosis:currentandfuturetreatmentoptions.DermatolTherapy
200720:pp.3146.
Websites
http://www.dermnetnz.org/fungal/onychomycosis.html(http://www.dermnetnz.org/fungal/onychomycosis.html)
Hairloss(androgeneticalopecia)
Background
Eachhairconsistsofashaft,madeupofdeadkeratinisedcells,andaroot(Fig.7.1(f0010))andisfoundon
mostskinsurfaces(hands,feetandlipsbeingnotableexceptions).Eachhairfolliclegoesthroughagrowth
cycle,whichconsistsofalonggrowingphase(anagen)followedbyashortrestingphase(telogen).Atthe
endofrestingphase,thehairfallsout(catagen)andanewhairstartsgrowinginthefollicle,beginningthe
cycleagain.Thehaircycleoccursrandomlyforeachfolliclesothatnormalhairlossfromtheadultscalpis
approximately100hairsperdaywheretherateisgreaterthanthisthentheclinicalsignsofhairlosscan
beobserved.Hairlossaffectsbothmenandwomenandisassociatedwithstrongemotionaland
psychologicalconsequences.Peoplehavebeensocialisedtolinkafullheadofhairwithyouthandvitality,
whereasbaldnessportraysafeelingofunattractivenessandlossofyouth.Hairlosscanbeduetoanumber
ofaetiologieshowever,thissectionconcentratesonandrogeneticalopecia(malepatternbaldness)because
itisthemostcommoncauseofhairloss.
Menaremoresusceptiblethanwomentoandrogeneticalopeciaandusuallyexperiencemoreseverehair
loss.Mentendtobeaffectedfromtheseconddecadeonwards(30%ofmenby30yearsoldwillbeaffected
tosomedegree)andtheprevalenceofmalepatternbaldnessinCaucasianswhoreacholdageapproaches
100%.Inwomentheconditionbecomesmorepronouncedaftermenopause.
Patientsusuallyhaveapositivefamilyhistory.Thenatureandextentofhairlosswillfollowidentical
patternstothoseseeninthepatient'simmediateparentsandgrandparents,whichcanbeusedasa
predictortothepatient'spotentialhairlosspattern.
Aetiology
Hairisclassedaseitherterminalorvellushair.Terminalhairislongerandthickerandfoundonthescalp
andeyebrows.Vellushaircoverstheremainderofthebodyandisshorteranddowny.Inandrogenetic
alopeciaterminalhairfolliclestransformintomorevelluslikehairfolliclesasaresultofpreferential
bindingbydihydrotestosterone(producedfromtheconversionofandrogenby5alphareductase)tohair
folliclereceptors.Eventuallythefollicleceasesactivitycompletelywithresultinghairloss.
Hairlossisobviouslyeasytodetect.Empathyandunderstandingtowardthepatientneedstobeexercised.
Althoughandrogeneticalopeciaisthemostcommonformofhairloss,othercausesneedtobeeliminated(
Fig.7.16(f0085)).Askingsymptomspecificquestionswillhelpthepharmacisttodetermineifreferralis
needed(Table7.15(t0100)).
Fig.7.16
Primerfordifferentialdiagnosisofhairloss.
Table7.15
Specificquestionstoaskthepatient:Hairloss
Question Relevance
Hairloss Androgenicalopeciaisnotassociatedwithothersymptoms.Itchand/orerythemaare
accompanied indicatorsthatanothercause,e.g.fungalscalpinfection,psoriasisorseborrhoeic
withother dermatitis,mightberesponsibleforthehairloss
symptoms
Patternofhair Inmen,hairlossbeginsatthefrontoftheheadandrecedesbackwardsoratthecrown.
loss Inwomen,hairlosstendstobegeneralisedanddiffuse.Presentationsthatdiffertothis
oraresuddeninonsetsuggestanothercauseofhairloss
Deficiency Thereisnowstrongevidencethatirondeficiencyinwomencancausehairloss
states
Question Relevance
Underlying Anumberofendocrineconditionscancausehairloss,mostnotablythyroiddisorders
pathology
Medicine Anumberofmedicinescancausehairloss(Table7.16(t0105))
inducedhair
loss
Hairloss Hairlosscanbecausedbyastressfuleventorfollowingsurgeryorafterchildbirth
triggeredbya
specificevent
Clinicalfeaturesofandrogeneticalopecia
Meninitiallynoticeathinningofthehairandafrontalrecedinghairlinethatmightormightnotbe
accompaniedwithhairlossatthecrown.Inwomenthefrontalhairlineismaintainedwithdiffusehairloss
thatissomewhataccentuatedatthecrown.
Telogeneffluvium
Telogeneffluviumrepresentsashiftofmorehairsintotherestingphase(telogen)ofthehaircycle,which
resultsinsheddingofhair.Thiscanbecausedbyanumberoffactors:
Postpartum
Duringpregnancy,circulatinglevelsofoestrogenincrease,witharesultingriseinthenumberoffolliclesin
anagen(growthphase)thehairthereforethickens.However,afterdeliverythehairfolliclesreturntothe
restingphaseandthehairisshed.Womenmightbelievethattheyareexperiencinghairlosswheninreality
thehairisreturningtothenormalprepregnancystate.Reassuranceshouldbegiventhatthisisa
temporaryandselflimitingproblem.
Stress
Stressisknowntoinducehairloss.Thereasonbehindthisispoorlyunderstood.Enquirytoascertain
lifestylefactorsthatmighthavecausedrecentstressandanxietytothepatientshouldbeexplored.
Nutritionalfactors
Irondeficiencyisassociatedwithfemalehairloss.Ifirondeficiencyisthecause,a2monthcourseofiron
supplementationshouldresultinthickeningofthehair.Ifthepatientfailstorespondtotreatmentthenthe
patientshouldbereassessed.
Underlyingendocrinedisorder
Diabetesmellitusandhypothyroidismcanresultinpoorhairgrowth.Inhypothyroidismthehairisthin
andbrittleandthepatientmightbelethargicandhaveahistoryofrecentweightgain.ReferraltotheGPfor
bloodtestsshouldbeconsidered.
Fungalscalpinfection(tineacapitis)
Thefirstsignsofinfectionaretheappearanceofawellcircumscribedroundpatchofalopeciathatis
associatedwithitchandscaling.Commonareasofinvolvementincludetheoccipital,parietalandcrown
region.Inspectionoftheareamightrevealerythemaandblackdotsonthescalpasaresultofinfected
hairs.
Alopeciaareata
Referstohairlossofunknownorigin,althoughthereisoftenanassociationwithatopyandautoimmune
diseaseandapositivefamilyhistoryisfoundinupto25%ofpatients.Itisrelativelyuncommonaffecting
0.1to0.2%oftheUKpopulation.Unlikeandrogeneticalopeciathehairlossissuddenandmainlyaffects
childrenandadolescents(60%willhavehadtheirfirstepisodebeforetheageof20).Itmostcommonly
involvesonlysmallpatchesofhairlossalthoughthewholescalpcanbeaffected.Theconditionisusually
selflimitingandregrowthofhairisoftenobservedbutrepeatedepisodesarenotunusual.
Tractionalopecia
Mostcommonlyseeninwomen,tractionalopeciareferstohairlossduetoexcessandsustainedtensionon
thehair,usuallyasaresultofstylinghairwithrollersoraparticulartypeofhairstyle.Itisreversibleifthe
tensiononthehairisremoved.
Medicineinducedcauses
Manymedicinescaninterferewiththehaircycleandcausetransienthairloss,cytotoxicmedicinesbeing
oneofthemostobviousexamples.However,manymedicineshavebeenassociatedwithhairloss.Table7.16
(t0105)listssomeofthemorecommonlyimplicatedmedicines.Ifmedicinesotherthancytotoxicsare
suspectedofcausinghairloss,theprescribershouldbecontactedtodiscussotherpossibletreatment
options.
Table7.16
Medicinesknowntocausehairloss
Medicineormedicineclass Incidenceofhairloss
Antineoplastics Almost100%(tovaryingdegrees)
Anticoagulants Telogeneffluviuminapproximately50%
Lithiumcarbonate Telogeneffluviuminapproximately10%
Interferons Telogeneffluviumin20to30%
Oralcontraceptives Seen2to3monthsafterstopping
Retinoids Approximately20%ofpatients
Colchicine,carbimazole Rare
Trichotillomania
Trichotillomaniaisapsychiatricdisorder,whichreferstopatientswhohaveanimpulsivedesiretotwist
andpullscalphair,butoftendenyit.Hairlossisasymmetricalandanunusualshape.Itwouldbevery
unusualforsuchpatientstopresenttoacommunitypharmacy.
Hairloss
Fungalinfectionofthescalp
Patientsunder18yearsold
Possibleendocrinecause
Suddenonset
Suspectedirondeficiencyforbloodtest
Trichotillomania
Currently,minoxidilistheonlyproductmarketedforandrogeneticalopecia.Itisavailableaseithera2or
5%solution.
Anumberofclinicaltrialshaveinvestigatedtheefficacyandsafetyofminoxidilat2and5%concentrations.
Themajorityofthesehavebeenconductedonpreciselythepopulationthatwouldrespondthebestto
treatmentmenagedbetween18to50,withmildtomoderatethinningofthehairatthevertex.Despite
this,trialresultsarenottotallyconvincing.Minoxidilissuperiortoplacebo(althoughplacebodoesinvokea
largeinitialresponse)andpromotesasmallincreaseinregrowthofvellushairandincreasesthediameter
ofthehairshaft.However,longitudinalstudiesshowthatlessthanhalfofpatientstreatedexperience
moderatetomarkedhairgrowth.Haircountsappeartobegreatestafter12monthsoftreatmentbut,by30
months,haircountshavedecreased(albeitstillabovebaseline)andthebaldareaincreasesbackinsizeto
itsinitialdiameter.
Minoxidilthereforeappearstodelayandslowdownhairlossinlessthanhalfofitstargetpatient
population.Furthermore,iftreatmentisstoppedanyhairgrowthachievedislostwithin6to8weekson
discontinuationoftherapyandbaldnessreturnstopretreatmentlevels.
Thesituationinwomenisnottoodissimilar,althoughthe5%solutionoffersnoadvantageoverthe2%
solutionandhasthereforenotbeengrantedaproductlicenceatthatstrength.
Summary
Minoxidilwillnotsignificantlyhelpthemajorityofbaldingindividuals.Itwillpromotehairgrowthin
approximately50%ofminimallybaldingyoungmenbut,overtime,theeffecttailsoff.After30monthsthe
effectisstillgreaterthanbaselinebut,onthewhole,willnotachievecosmeticallyacceptablehairgrowth.In
otherwordstheuseofminoxidilisusefulforspecificpatientswhowanttobuythemselvestimefromthe
inevitablebaldingprocess.
Oralfinasteride(1mgperday)canbeusedtotreatandrogenicalopeciainmenbutcurrentlythereisno
goodqualityevidencethatitissuperiortominoxidil.
PrescribinginformationrelatingtominoxidilisdiscussedandsummarisedinTable7.17(t0110)usefultips
relatingtothetreatmentofpatientswithminoxidilaregiveninHintsandTipsBox7.5(b0060).
Table7.17
Practicalprescribing:Summaryofmedicinesforhairloss
Nameof Usein Likelyside Drug Patientsinwhichcare Pregnancy&

medicine children effects interactionsof exercised breastfeeding
note
Minoxidil Not Skinirritation, None Avoidinhypertensive Avoid

(Regaine) applicable headache patients
HINTSANDTIPSBOX7.5:
Hairloss

Changestohair Somepatientshaveexperiencedchangesinhaircolourand/ortexturewith
colourandtexture Regaineuse.Thepatientshouldbewarnedofthispossibleproblembefore
usingtheproduct
Howlongshould Itcantake4monthsormorebeforeevidenceofhairgrowthcanbeexpected.
thepatientuse Usersshoulddiscontinuetreatmentifthereisnoimprovementafter1year
Regaine?
Minoxidil(e.g.Regainerangeaseithersolutionorfoam)
Thedoseforminoxidilis1mLofsolution(or1goffoamequivalenttohalfacapful)appliedtodryhairto
thetotalaffectedareasofthescalptwicedaily.Iffingertipsareusedtofacilitatedrugapplication,hands
shouldbewashedafterwards.Althoughminoxidilisappliedtopically,absorptionintothesystemic
circulationcanoccurandresultinchestpain,rapidheartbeat,faintnessordizziness,althoughtheseare
rare.Iftheseoccurthepatientshouldstopusingtheproductimmediately.Otherlessimportantadverse
effectsassociatedwithtopicalminoxidilarelocalirritation,rednessanditchingbuttheseappeartobe
relatedtothevehiclepropyleneglycolratherthanminoxidil.Changesinbloodpressureshouldnot
occurbecausetheserumlevelofminoxidilaftertopicalapplicationisbelowthatneededtocausechangesto
bloodpressure,howeverasaprecautionminoxidilshouldbeavoidedinhypertensivepatientsifpossible.
Somepatientsalsoreportatemporaryincreaseinhairshedding2to6weeksafterbeginningtreatment.
Thissubsidesandismostlikelyduetotheactionofminoxidil,shiftinghairsfromtherestingtelogenphase
tothegrowinganagenphase.
Furtherreading
BurkeKE:Hairloss.Whatcausesitandwhatcanbedoneaboutit.PostgradMed198985:pp.5258.67
73,77
GilharA,EtzioniA,PausR:Alopeciaareata.NEnglJMed2012366:pp.15151525.
KatzHI,HienNT,PrawerSE,et.al.:Longtermefficacyoftopicalminoxidilinmalepatternbaldness.JAm
KoperakiJA,OrenbergEK,WilkinsonDL:Topicalminoxidiltherapyforandrogeneticalopecia:a30month
study.ArchDermatol1987123:pp.14831487.
PriceVH,MenefeeE,StraussPC:Changesinhairweightandhaircountinmenwithandrogeneticalopecia,
afterapplicationof5%and2%topicalminoxidil,placebo,ornotreatment.JAmAcadDermatol199941:
pp.717721.
RietschelRL,DuncanSH:Safetyandefficacyoftopicalminoxidilinthemanagementofandrogenetic
alopecia.JAmAcadDermatol198716:pp.677685.
RobertsJL:Androgeneticalopeciainmenandwomen:anoverviewofcauseandtreatment.DermatolNurs
19979:pp.379388.
TostiA,MiscialiC,PiracciniBM,et.al.:Druginducedhairlossandhairgrowth:incidence,management
andavoidance.DrugSaf199410:pp.310317.
Websites
2012.BritishAssociationofDermatologists'guidelinesforthemanagementofalopeciaareata.
http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Alopecia%20areata%20guidelines%202012.pdf
(http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Alopecia%20areata%20guidelines%202012.pdf)
Wartsandverrucas
Background
Wartsandverrucasarebenigngrowthsoftheskincausedbythehumanpapillomavirus(HPV).Certain
typesofHPVhaveanaffinityforcertainbodylocations,forexamplehands,face,anogenitalregionandfeet.
Spontaneousresolutionisseenin30%ofpeoplewithin6monthsandtwothirdsofcaseswithin2years.
Despitetheirselflimitingnaturetheyarecosmeticallyunacceptabletomanypatientsandwithnearly60%
ofpeopletryinganOTCtreatmentbeforevisitingaGPthepharmacisthasamajorroletoplayintheir
management.
Theprevalenceofwartshasnotbeenaccuratelydocumentedandpublishedprevalencedatavarieswidely.
However,itisclearchildrenaremostaffected,havingbeenreportedtoaffectbetween2and20%of
schoolchildren,withapeakincidencebetween12and16yearsold.Wartsareuncommonininfantsandthe
elderlyandcautionshouldbeexercisedifanelderlypatientpresentstothepharmacywithaselfdiagnosed
wart.
Aetiology
HPVgainentrytothehostbyepithelialdefectsintheepidermis.Itistransmittedbydirectskintoskin
contact,althoughcontactwithaninfectedperson'sshedskincanalsotransmitthevirus.Infectionviathe
environmentismorelikelytooccuriftheskinismaceratedandincontactwithroughenedsurfaces,for
exampleinswimmingpoolsandcommunalwashingareas.Onceestablishedintheepithelialcells,thevirus
stimulatesbasalcelldivisiontoproducethecharacteristiclesion.
Patients,especiallychildren,shouldbewarnednottopick,biteorscratchwartsasthiscanallowviral
particlesheddingtopenetrateskinbreaks.Thisprocessisknownasautoinoculationandisresponsiblefor
multiplelesionsbecomingestablishedandtransferredtootherpartsofthebody.
Wartsandverrucasarenotdifficulttodiagnose.However,pharmacistsmustbeabletorecogniseother
similarconditionsthatsuperficiallylooklikewartsandverrucas.Askingsymptomspecificquestionswill
helpthepharmacisttodetermineifreferralisneeded(Table7.18(t0120)).HPVinfectionsinvolvingthe
anogenitalareaareoutsidetheremitofcommunitypharmacistsandmustbereferred.
Table7.18
Specificquestionstoaskthepatient:Humanpapillomavirus
Question Relevance
Ageofpatient Wartsareunusualinveryyoungchildren,e.g.infants.Youngchildrenand
adolescentsaremostlikelytogetwartsbutthisisalsotheagegroupinwhich
molluscumcontagiosumismostprevalent
Thelikelihoodthatnodularlesionsarecausedbyseborrhoeicwartsorcarcinoma
increaseswithincreasingage
Location Wartsarecommononthehandsandkneesverrucasareusuallyontheweight
bearingpartsofthesole
Wartscanoccuronthefacebutsotoocanplanewartsandcarcinoma.Referralis
alwaysneededasallOTCtreatmentcancausescarring
Associated Itchingandbleedingisnotassociatedwithwartsandverrucasandmustbeviewed
symptoms withsuspicion,especiallyinolderpatients
Painonwalkingisoftenassociatedwithverrucas
Colour/appearance Typicallywartshaveacauliflowerappearanceandareraisedandpale
Wartswithareddishhueorchangecolourshouldbereferred
Lesionsthatareraised,smoothandhaveacentraldimplesuggestsmolluscum
contagiosum
Clinicalfeaturesofwartsandverrucas
Warts
Wartsmostoftenoccuronthebacksofthehands,fingersandknees,eithersinglyorincrops.When
examinedthewartappearsasaraised,hyperkeratoticpapulewiththrombosed,blackvesselsoftenvisible
asblackdotswithinthewart.Theytendtoberoughtextured,skincolouredandareusuallylessthan1cm
indiameter(Fig.7.17(f0090)).
Fig.7.17
Commonwart.
Verrucas
Verrucasarefoundonthesoleofthefoot,usuallyinweightbearingareas,forexampleonthemetatarsal
headsorheel.Owingtoconstantpressureimpartedonthesoleofthefootthenormaloutwardexpansionof
thewartisthwartedandinsteadgrowsinward.Pressureonnervescanthencauseconsiderablepainand
patientsoftencomplainofpainwhenwalking.Inspectionofthelesionwillnormallyrevealtinyblackdots
(thrombosedcapillaries)onthesurface(Fig.7.18(f0095)).Owingtokeratinbuildupthischaracteristicsign
mightnotbevisibleunlessthehardenedskinisfirstshavedaway.Verrucas,likewarts,arerarelylarger
than1cmindiameterandcanoccursinglyorincrops.Anumberofcloselylocatedplantarwartscan
coalescetoformalargesingleplaqueandistermedamosaicwart.
Fig.7.18
Verruca.
permission.
Planewarts(flatwartsorverrucaplana)
Thesemostfrequentlyoccuringroupsonthefaceandthebackofthehands.Theyaresmallinsize(1to
5mmindiameter),slightlyraisedandcantakeontheskincolourofthepatient(Fig.7.19(f0100)).Asdrug
treatmentisdestructiveinnature,planewartslocatedonthefaceshouldbereferredtoavoidtheriskof
scarring.
Fig.7.19
Planewarts.
permission.
Molluscumcontagiosum
Molluscumcontagiosumprimarilyaffectschildrenunder5yearsold.Itisnotparticularlycommonanda
GPwithalistsizeof2000willprobablysee5newcasesperyear.Itiscausedbyapoxvirusandpatients
presentwithmultiplelesionsusuallyonthefaceandneck,althoughthetrunkcanbeinvolved.Thelesions
resemblecommonwartsbuteachraisedpapuletendstobesmoothandhaveacentraldimple,thelatterisa
usefuldiagnosticpoint(seeFig.9.6,page301).Lesionstendtobebetween1to5mmindiameter.The
conditionisselflimitingandwillresolvewithoutmedicalintervention.Patientsshouldbetoldthis,butif
theybelievetreatmentisnecessary,referraltotheGPisadvisable.
Corns
Cornsandplantarwartscanbeconfused.Thereaderisreferredtopage228(s0825)oncornsandcalluses
forinformationondifferentiatingcornsfromverrucas.
Basalcellpapilloma(seborrhoeicwart)
Basalcellpapilloma(seborrhoeicwart)
Basalcellpapillomasarebenigngrowthsthatareincreasinglycommonwithincreasingage.Theyusually
occuronthetrunkandpresentasraisedoftenmultiplelesionsthathaveasuperficialstuckonorwaxy
appearance(Fig.7.20(f0105)).Lesionsareusuallybrownbutcanrangeincolourfrompinktoblack.
Fig.7.20
Seborrhoeicwart.
permission.
Basalcellcarcinoma
Basalcellcarcinomaisthecommonestformofskincanceranditsincidenceisrelatedtosunlightexposure.
Ittypicallyoccursinolderpeopleespeciallywherethereisahistoryofprolongedskinexposure.Menare
twiceaslikelytobeaffected.Theusualsitewherelesionsdevelopistheface.Anywartlikelesionthatis
itchy,hasanirregularoutline,pronetobleedingandexhibitscolourchangeshouldbereferredtoeliminate
seriouspathology.Formoreinformationonskincancersseepage245(s1185).
Wartsandverrucae
Anogenitalwarts OutsidescopeofOTCtreatment
Multipleandwidespreadwarts
Diabeticpatients Treatmentoptionscancauseskindamage
Lesionsontheface
Patientsagedover50presentingwithafirsttimewart Potentialsinisterpathology,e.g.BCC
Wartsthatitchorbleedwithoutprovocation
Wartsthathavegrownandchangedcolour
Anumberofingredientsareusedtotreatwartsandverrucas,althoughsalicylicacidisthemostcommonly
usedagentandcanbefoundinmanyOTCtreatments,bothaloneandcombinedwithlacticacid.
ArecentCochranereview(Gibbs&Harvey2006)investigatedtopicaltreatmentsforthecureofwarts.This
reviewidentified60trialsthatmettheirinclusioncriteria.Overall,thequalityofthetrialswaslowdueto
poormethodologyandreporting.However,placebowasfoundtohaveasubstantialeffectalthoughsalicylic
acidincomparisonwassignificantlymoreeffective.Cureratesforsalicylicacid(frompooleddata)showed
73%cureratescomparedtocontrolcureratesof48%overa6to12weekperiod.However,thereappearsto
benoevidencetosuggestwhichconcentrationofsalicylicacidismosteffective.
Inaddition,thereissomeevidencetoshowthatcommonwartsaremoreresponsivetokeratolytictherapy
thanplantarwartsandresolutionmightbeenhancedbysoakingthewartorverrucapriortoapplication
and/orocclusionofthesite(byuseofplastersorcollodionlikevehicle)toaidpenetration.
Compliancewithtreatmenthasbeenidentifiedasalimitingfactorinthecurerateforwartsandverrucas.
OnestudythatinvestigatedOcclusalreportedan80%curerateafteronly2weeksoftherapy.Thismightbe
analternativeoptionforpatientswhosecompliancecouldbequestioned.However,thestudysufferedfrom
poordesignandhadonlyasmallnumberofpatientsandtheresultsmustbeviewedwithcaution.
Salicylicacidisoftencombinedwithotheringredients,inparticularlacticacid.However,thereisno
evidencetosupportadditionallyefficacywhenlacticacidisadded.Monochloroaceticacidhasalsobeen
combinedwithsalicylicacid.Cureratesforthiscombinationarecomparabletocureratesofsalicylicacid
aloneorwhenmonochloroaceticacidisusedsingly.Itthereforeappearsthatthecombinationhasno
additionalbenefitthanwhenactiveingredientsareusedasmonotherapy.Asfarastheauthorisaware,no
commerciallyavailablepreparationcontainsmonochloroaceticacid.
Otheragentscommerciallyavailableinclude,formaldehyde,glutaraldehydeandsilvernitratepencils.
Informationregardingtheireffectivenessstemsfromsmallscaleorpoorlydesignedstudies,andthey
shouldnotberoutinelyrecommended.
Cryotherapyusingliquidnitrogenhasbeenusedformanyyearsasatreatmentofrecalcitrantor
widespreadwarts.However,thelimitedcomparisonsbetweentopicalsalicylicacidandcryotherapyhave
failedtoshowanydifferenceinresponserates(Gibbsetal2002).OTCproductscontainingvolatile
hydrocarbonsaremarketedashomecryotherapysolutionsforthetreatmentofwarts(e.g.Wartner).There
isalackofdatacomparingsalicylicacidpreparationswithhomecryotherapy.However,comparisons
betweenhomecryotherapysolutionsandcryotherapywithliquidnitrogenhavesuggestedliquidnitrogenis
superior( Gibbsetal2002).
Summary
Anysalicylicacidbasedproductshouldhavemodestsuccessratesinclearingwartsandverrucasaftera12
weektreatmentperiod,providingpatientcomplianceisgood.Iftreatmenthasbeenunsuccessfulwith
salicylicacidthenasecondlinemedicinesuchasglutaraldehydeorformaldehydecouldbetried.
CryotherapyisprobablybestlefttotheGPtoperformratherthanthepatientduetoitsdestructiveaction
onskin.
Prescribinginformationrelatingtospecificproductsusedtotreatwartsandverrucasinthesection
EvidencebaseforoverthecountermedicationissummarisedinTable7.19(t0130)usefultipsrelatingto
patientspresentingwithwartsandverrucasaregiveninHintsandTipsBox7.6(b0070).
Table7.19
Practicalprescribing:Summaryofmedicinesforwartsandverrucas
Nameof Usein Likelysideeffects Drug Patientsin Pregnancy&breastfeeding

medicine children interactions whichcare
ofnote exercised
Salicylicacid
Compound >6 Localskinirritation None Avoidin OK

W years diabetic
patients
Bazuka >2
Extra years
Strength
Occlusal No
lower
Verrugon
age
Wartex stated
Salicylicacidandlacticacid
Bazuka No Localskinirritation None Avoidin OK

lower diabetic
Cuplex age patients
stated
Duofilm >2
years
Salactol No
lower
Salatac age
stated
Glutaraldehyde
Nameof Usein Likelysideeffects Drug Patientsin Pregnancy&breastfeeding
medicine children interactions whichcare
ofnote exercised
Glutarol No Localskinirritation. None Avoidin OK

lower Skinwillbestained diabetic
age brown patients
stated
Formaldehyde
Veracur No Nolocalaffects None Avoidin Pregnancy

lower reported diabetic Manufactureradvisesavoidance,
age patients althoughtherearenoreportsof
stated teratogenicity
Breastfeeding
OK
Silver No Localskinirritation None Avoidin OK

nitrate lower diabetic
(Avoca) age patients
stated
HINTSANDTIPSBOX7.6:
Verrucasandwarts
Isitaverruca Ifdiagnosisisuncertainthenremovalofthetoplayerofskinfromthelesioncanbe
oracorn? performed.Ifblackspotsarenotvisiblethisimpliesthelesionisacornandnota
verruca
Lengthof Patientsshouldbetoldthatitisaslowprocess.Treatmentcommonlylasts3
treatment months.IfOTCmedicationhasbeenunsuccessfulafterthistimethenthepatient
couldbereferredtotheGP
Salatacgel Thegelformsanelasticfilmafterapplication.Thishastoberemovedeachtime
beforethegelcanbereapplied
Bazukaand Don'tbefooledintothinkingtheextrastrengthhasbettercurerates.Ithasahigher
BazukaExtra concentrationofsalicylicacid(26%asopposedto12%)butthisdoesnot
Strength necessarilyequatetoamoreefficaciousproduct
Asthemajorityofwartsandverrucaswillspontaneouslyresolvetreatmentisnotnecessarilyneeded.
Pharmacistsshoulddeterminefromthepatienthowmuchthewartorverrucaaffectsdaytodaylifeand
alsowhatsocialimpactthelesionshaveonthepatient.Itisalsoworthassessingpatientmotivationto
complywithmedicationregimensbecausetreatmentisoveraperiodofmonthsnotdaysorweeks.
Salicylicacidproducts(e.g.CompoundW(17%),BazukaExtraStrength(26%),Occlusal
(50%),Verrugon(50%),Wartex(50%))&Salicylicacid/lacticacidcombinations(Bazuka,
Cuplex,Duofilm,Salactol,Salactac).
Thereisawidechoiceofsalicylicacidbasedproductsfortheremovalofwarts,verrucas(andcorns).Prior
tousingasalicylicacidbasedproducttheaffectedareashouldbesoakedinwarmwaterandtowelleddry.
Thesurfaceofthewartorverrucashouldberubbedwithapumicestoneoremeryboardtoremoveany
hardskin.Thisshouldbedoneatleastonceperweek.Afewdropsoftheproductshouldbeappliedtothe
lesion,takingcaretolocalisetheapplicationtotheaffectedarea.Theprocedureshouldberepeateddaily.
Salicylicacidcanberecommendedtomostpatients,althoughdiabeticsareanotableexception.Salicylic
aciddoesnotinteractwithanymedicines.Itcancauselocalskinirritationandbecauseofitsdestructive
actionshouldbekeptawayfromunaffectedskin.
Glutaraldehyde(Glutarol)
Applicationofglutaraldehydeisthesameassalicylicacidbutitshouldbeusedtwiceaday.Itcancause
skinirritationandstainstheouterlayeroftheskinbrown.
Formaldehyde(Veracur)
Veracurismarketedparticularlyforverrucasand,likeglutaraldehyde,isappliedtwiceaday.Inallother
respectsithassamesideeffectsandprecautionsforuseassalicylicacid.
Silvernitrate(e.g.Avoca)
Tousesilvernitratepencilsthetipmustbefirstmoistenedandthenappliedtothewartorverrucafor1to2
minutes.Thisshouldberepeatedafter24hours.Itisrecommendedthat3applicationsareusedforwarts
andsixapplicationsforverrucas.Likeothertreatmentstheprocessisdestructiveandthesurroundingskin
shouldbeprotected.
Furtherreading
Dall'oglioF,D'AmicoV,NascaMR,et.al.:Treatmentofcutaneouswarts:anevidencebasedreview.AmJ
ClinDermatol201213:pp.7396.
JohnsonLW:Communalshowersandtheriskofplantarwarts.JFamPract199540:pp.136138.
HiroseR,HoriM,ShukuwaT,et.al.:Topicaltreatmentofresistantwartswithglutaraldehyde.JDermatol
199421:pp.248253.
SteeleK,IrwinWG:Liquidnitrogenandsalicylic/lacticacidpaintinthetreatmentofcutaneouswartsin
generalpractice.JRCollGenPract198838:pp.256258.
SteeleK,ShirodariaP,O'HareM,et.al.:Monochloroaceticacidand60%salicylicacidasatreatmentfor
simpleplantarwarts:effectivenessandmodeofaction.BrJDermatol1988118:pp.537543.
YazarS,BasaranE:Efficacyofsilvernitratepencilsinthetreatmentofcommonwarts.JDermatol1994
21:pp.329333.
Websites
BritishAssociationofDermatologistsinformationoncutaneouswarts.
http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Cutaneous%20Warts.pdf
(http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Cutaneous%20Warts.pdf)
Effectivenessandcosteffectivenessofsalicylicacidandcryotherapyforcutaneouswarts.Aneconomic
decisionmodelAHealthTechnologyAssessmentMonograph.http://www.hta.ac.uk/fullmono/mon1025.pdf
(http://www.hta.ac.uk/fullmono/mon1025.pdf)
Cornsandcalluses
Background
Itisestimatedthatonaverageapersonwalkstheequivalentof1000milesayear.Itisthereforehardly
surprisingthatpeopleexperiencefootproblems.Footdisorderscanbebroadlysubdividedintoeitherthose
thatresultfromopportunisticinfectionorthoseresultingfromincorrectdistributionofpressure.This
sectiondiscussesthelatter.
Theexactprevalenceofcornsandcallusesisnotknown.Surveyshaveindicatedthatupto18%ofworking
peoplecomplainofcornsandcalluses(Springettetal2003).Cornsandcallusestendtomoreoftenbeseen
inolderpatients,(usefultipsrelatingtopatientspresentingwithcornsisgiveninHintsandTipsBox7.7
(b0075)).
HINTSANDTIPSBOX7.7:
Corns
Shoestorelieve Patientsshouldbeencouragedtowearopenshoessuchassandalsor
pressure thongs
Aetiology
Cornsformduetoacombinationoffrictionandintermittentpressureagainstoneofthebonyprominences
ofthefeet(e.g.heelandmetatarsalheads).Inappropriatefootwearisfrequentlythecause.Continued
pressureandfrictionresultsinhyperkeratoses(excessiveskingrowthofthekeratinisedlayer)leavingeven
lessspacebetweentheshoeandthefootandthereforethecornispressedevenmorefirmlyagainstthe
underlyingsofttissuesandbone.
Callusformationisalsocausedbyconstantfrictionandpressure.Callusescanbebeneficial,providinga
naturalbarriertoobjectsandprotectingunderlyingtissueshowever,whensuchathickenedmassofskin
occursinabnormalplaces(e.g.borderofthebigtoe)painisexperienced.
Diagnosisofcornsandcallusesisbestdonebyappearance.Pharmacistsshouldthereforeasktoinspectthe
person'sfeetbecausetryingtotakeadescriptionofwhattheproblemlookslikecanbedifficult.
Differentialdiagnosisshouldbestraightforwardandisusuallybetweencorns,callusesandverruca.Most
patientswillaccuratelyselfdiagnoseandseekadviceandhelptoremedythesituation.Thepharmacist's
rolewillbetoconfirmtheselfdiagnosisandgiveadviceand/ortreatmentwhereappropriate.Asking
symptomspecificquestionswillhelpthepharmacisttodeterminethebestcourseofaction(Table7.20
(t0145)).
Table7.20
Specificquestionstoaskthepatient:Corn/callus
Question Relevance
Location Lesionsonthetopsorbetweenthetoessuggestacorncomparedwithverrucas,whichare
ontheplantarsurfaceofthefoot
Aggravating Painexperiencedwithcornsisaresultofpressurebetweenfootwearandthetoes.If
orrelieving footwearistakenoffthenthepainisrelieved
factors
Painassociatedwithverrucaswillbefeltirrespectiveiffootwearisworn
Appearance Cornsandcallusesappearaswhiteoryellowhyperkeratinisedareasofskinunlike
verrucasthatshowblackthrombosedcapillariesseenasblackdotsonthesurfaceofthe
verruca
Previous Patientswithcornswilloftenhaveaprevioushistoryoffootproblems.Thecauseisusually
history duetopoorlyfittingshoes,suchashighheels.Prolongedwearofsuchfootwearcanlead
tocallusesandpermanentdeformityofbunions
Clinicalfeaturesofcorns
Corns(helomas)havebeenclassifiedintoanumberoftypes,althoughonlysoftandhardcornsare
commonlymetinpractice.Hardcorns(helomadurum)aregenerallylocatedonthetopofthetoes.Corns
exhibitacentralcoreofhardgreyskinsurroundedbyapainful,raised,yellowringofinflammatoryskin.
Anyofthetoescanbeaffectedbutiscommonestonthesecondtoe.Softcorns(helomamolle)form
betweenthetoesratherthanonthetopsoftoesandareduetopressureexertedbyonetoeagainstanother.
Theyhaveawhitenedappearanceandremainsoftduetomoisturebeingpresentbetweenthetoescausing
macerationofthecorn.Softcornsaremostcommoninthefourthwebspace.
Clinicalfeaturesofcalluses
Calluses,dependingonthecauseandsiteinvolved,canrangeinsizefromafewmillimetrestocentimetres.
Theyappearasflattened,yellowwhiteandthickenedskin.Inwomen,theballsofthefeetareacommon
site.Othersitesthatcanbeaffectedaretheheelandlowerborderofthebigtoe.Patientsfrequently
complainofaburningsensationresultingfromfissuringofthecallus.
Verrucas
Verrucascanbemistakenforacornorcallus,althoughverrucastendtohaveaspongytexturewiththe
centralareashowingtinyblackspots.Theyarealsorarelylocatedonorbetweenthetoesandcommonly
occurinyoungerpatientsthancornsandcalluses.Forfurtherinformationseepage222(sc0040).
Bunions
Bunionsare10timesmorecommoninwomenthanmenandaredirectlyrelatedtowearingtightshoes.
Initially,irritationofskinbyillfittingshoescausesbursitisofthebigtoe.Overtimetheinflamedarea
beginstohardenandsubsequentlybursalfluidsolidifiesintoagelatinousmass.Theresultwillbeabunion
joint(thefirstmetatarsalphalangealjoint).Patientsoftencomplainofpain,havedifficultyinwalkingand
wearingnormalshoes.Referraltoapodiatristisrecommended.
Cornsandcalluses
Initiallyapatientshouldbereferredtoapodiatristif:
Discomfort/painiscausingdifficultyinwalking
Thereisimpairedperipheralcirculation,e.g.diabetes
Softcornsarepresent
Thereistreatmentfailure
Cornsandcallusesareduetofrictionandpressure.Removaloftheprecipitatingfactorswillresultin
resolutionoftheproblem.Thereforepreventativemeasuresshouldformthemainstayoftreatment.
Correctlyfittingshoesareessentialtohelppreventcornandcallusformation.Ifpressureandfrictionstill
persistwhencorrectlyfittedshoesarewornthenpatientscanobtainreliefbyshieldingorpadding.
Moleskinorthinpodiatryfeltplacedaroundthecornallowspressuretobetransferredfromthecorntothe
padding.Specificproprietaryproductsareavailableforsuchpurposes.Incallusformationashock
absorbinginsertsuchasametatarsalpadisusefultorelieveweightoffthecallusandsoreducestresson
theplantarskin.
Treatmentshouldbeavoidedifpossible,butifdeemedappropriatekeratolyticscanbeusedalthoughthere
isnoevidencetosuggestthattheyareeffective.
Productsusedtotreatcornsandcallusesareexactlythesameasthoseusedforwartsandverrucas.
Prescribinginformationrelatingtospecificproductsusedtotreatcornsandcallusesisthereforediscussed
inthesectionEvidencebaseforoverthecountermedicationforwartsandverrucasonpage224225
(s0750).However,anumberofproprietaryproductsaremarketedforsuffererswithcornsandcalluses,for
exampleproductsintheCarnationandSchollrange.Theseproductscontainhighconcentrationsof
salicylicacid(usually50%)thataresurroundedbyanonmedicatedselfadhesivering.
Furtherreading
RobbinsJM:Recognizing,treatingandpreventingcommonfootproblems.CleveClinJnlMed200067:
pp.4556.
SilfverskioldJP:Commonfootproblems.Relievingthepainofbunions,keratoses,cornsandcalluses.
PostgradMed199189:pp.183188.
Scabies
Background
ScabiescanbedefinedasapruriticskinconditioncausedbythemiteSarcoptesscabiei.Itiseasilymissed
ormisdiagnosedasdermatitis.Thediagnosticburrowsaresmallanddifficulttolocatebecausetheyare
oftenobscuredbytheeffectsofscratching.
Scabiesisnotgenderoragespecific.Infantstotheelderlycanacquiretheinfestation,althoughitismore
commonintheelderly.Outbreaksinschoolsandcarehomesarenotuncommon.Theincidenceofscabies
intheUKislowbutepidemicscanoccuronacyclicalbasisapproximatelyevery15years.Intemperate
climates(e.g.theUK),itappearstobemoreprevalentinurbanareasandinthewintermonths.
Aetiology
Themiteisusuallytransmittedbydirectphysicalcontact(e.g.holdinghands,huggingorsexualcontact).
Rarely,itcanbecaughtfrombedlinenbecausethemitecansurviveawayfromhumanskinfor24to36
hoursatroomtemperature.Thefemalemiteburrowsintothestratumcorneumtolayeggs.Thefaecal
pelletssheleavesintheburrowcausealocalhypersensitivityreactionandisassumedtocausetherelease
ofinflammatorymediatorsthattriggersanallergicreactioninvokingintenseitching.Thisnormallytakes15
to20daysinaprimaryinfestationbutcantakeupto6weekstodevelop.Insubsequentinfestationsthis
hypersensitivityreactiondevelopsmuchmorequickly.Duringtheasymptomaticperiodthemitecanbe
passedontoothersunknowingly.Theeggshatchandmaturein14daysafterwhichthecyclecanbegin
again.
Thediagnosisofscabiesisconfirmedbyextractionofthemitefromitsburrow,althoughinprimarycare
thisisrarelyperformedandadifferentialdiagnosisismadeonclinicalappearance,patienthistoryand
symptomsreportedbyclosefamily.Confusioncanarisefrommistakingscabiesforotherpruriticskin
disorderssuchasallergiccontactdermatitisordermatitisherpetiformis,especiallywhentheconditionis
extensive.Askingsymptomspecificquestionswillhelpthepharmacisttodeterminethebestcourseof
action(Table7.21(t0150)).
Table7.21
Specificquestionstoaskthepatient:Scabies
Question Relevance
Visible Burrows,whichareupto1cmlongandbluegreyincolour,mightbevisiblealthoughin
signsof practicethischaracteristicisoftennotpresent.Forthepharmacist,whowillonlyseealimited
themite numberofcases,itisbesttoconcentrateonotherclinicalsignsratherthanattempttolook
forsignsofburrows
Question Relevance
Location Scabiesclassicallyaffectsthefingerwebs,thesidesofthefingersandwrists.
ofrash
Historyof Ifcontactdermatitisissuspectedthenquestioningshouldrevealapasthistoryofsimilarskin
presenting lesions
complaint
Oftenpeoplewithscabieswillbecareworkerslookingafterinstitutionalisedpeople
Apositivehistoryinotherfamilymembersincreasesthelikelihoodthatthepatienthas
scabies
Clinicalfeaturesofscabies
Severepruritus,especiallyatnightisthehallmarksymptomofscabies.Besidesclassiclocationoflesions,in
menthepenileandscrotalskinandinwomenbeneaththebreastsandnipplescanbeaffected.Infantswho
arenotyetwalkingmayhavemarkedsoleinvolvement.Therashisusuallymadeupofsmallredpapules
thatovertimecanchangeintovesicles.
Insectbites
Ahostofinsects,fleasandmitescaninflictabiteorsting.Thisusuallyresultsinanitchypapulethatcan
becomefirmandlastseveraldays.Occasionally,therashcanbecomeblistered,normallyasaresultof
scratching,andsecondarybacterialinfectioncanoccur.Bitesoftentendtobeingroupsandare
asymmetrical.Seepage325forfurtherinformation.
Allergiccontactdermatitis
Theconditionpresentsasanareaofinflamed,itchyskinwitheitherpapulesorvesiclesbeingpresent.
However,enquiryintothepatient'shistoryshouldrevealapasthistoryofsimilarlesionsinallergiccontact
dermatitis.Forfurtherinformationondermatitisseepage239(sc0065).
Dyshidroticeczema(pompholyx)
Pompholyxsimplymeansbubble,andreferstothepresenceofintenselyitchyvesiclesorblistersonthe
palmsofthehandsandoccasionallyonthesolesofthefeet.Stressisknowntoprecipitatethecondition.
Dermatitisherpetiformis
Dermatitisherpetiformisisaconditioncharacterisedbyintenseitchyclustersofpapulesandvesicles.Itis
moreoftenseeninmiddleagedpeople,especiallymen.Itcommonlyinvolvesthebuttocks,elbows,knees
andsacralregion.Thelesionsusuallyexhibitasymmetricaldistributionandhandinvolvementisrare.On
investigationupto90%ofpatientsarefoundtohaveaglutenenteropathy.
Scabies
Symptoms/signs Possibledanger/reasonforreferral
Secondaryinfectionoftheskin Mayrequireantibiotics
Severeandextensive Outsidescopeofcommunitypharmacy.
symptoms
Institutionaloutbreaks
Suspecteddermatitis ForinstitutionaloutbreakstheHealthProtectionAgencyneedtobe
herpetiformis notified.
Theefficacyandsafetyofscabicidalagentsisdifficulttodetermineduetolimitedtrialdata.Benzyl
benzoate,crotamiton,permethrinandmalathionhaveallbeenused.ACochranereview(Strongetal2007)
foundpermethrintohavehighcureratesandmoreeffectivethananyotherscabicidalagent.
Theefficacyofmalathionisquestionableasnorandomcontrolledtrialsappeartohavebeenconducted.
However,casereportshavesuggestedmalathioniseffectiveincuringscabieswithacurerateof
approximately80%.
Benzylbenzoatehasbeenusedtotreatscabiesformanyyears.However,itsefficacyhasnotbeen
demonstratedinrandomisedcontrolledtrials.Inuncontrolledtrialsbenzylbenzoatehasbeenshownto
providecureratesofapproximately50%.Unfortunately,upto25%ofpatientsexperiencesideeffectssuch
asburning,irritationanditchingonapplication.
PrescribinginformationrelatingtospecificproductsusedtotreatscabiesinthesectionEvidencebasefor
overthecountermedicationisdiscussedandsummarisedinTable7.22(t0160)usefultipsrelatingto
patientspresentingwithscabiesaregiveninHintsandTipsBox7.8(b0090).
Table7.22
Practicalprescribing:Summaryofmedicinesforscabies
Nameof Usein Likelysideeffects Drug Patientsinwhichcare Pregnancy&

medicine children interactionsof exercised breastfeeding
note
Permethrin >2 Burning,stinging None None OK

months ortingling
Benzyl >12 Burning,irritation

benzoate years
Malathion >6 Skinirritationbut

months rare
HINTSANDTIPSBOX7.8:
Scabies
Application UKguidelinesstatethattreatmentshouldbeappliedtothewholebodyincludingthe
scalp,neck,face,andears.Thisisatoddswithsomemanufacturer'sdata
Itching Prurituscanpersistfor2to3weeksaftertreatmentandthepatientmightbenefitfrom
after crotamiton.
treatment Antihistaminesappeartohavealimitedroleinrelievingitchbuttheirsedativeeffect
(e.g.chlorphenamine)mightbeusefulfortemporaryhelpinaidingsleep
Hygiene Clothes,towels,andbedlinenshouldbemachinewashed(at50Corabove)afterthe
measures firstapplicationoftreatment,topreventreinfestationandtransmissiontoothers
Bathing Treatmentshouldnotbeappliedafterahotbathbecausethisincreasessystemic
absorptionandremovesthedrugfromitstreatmentsite
Itisimportantthatallpeopleinthesamehouseholdandclosecontactsaretreatedatthesametimeto
preventreinfectioneventhoughtheymightbeasymptomatic(latentperiodbeforeitchdevelops).
Permethrinisthedrugofchoice,althoughallproductsusedtotreatscabiescanbegiventoallpatient
groupsandhavenodruginteractions.
Permethrin(LyclearDermalCream)
Permethrinissuitableforusebyadultsandchildrenover2monthsofage,althoughthesummaryof
productcharacteristics(SPC)statesthatforchildrenundertheageof2yearsmedicalsupervisionis
required.GeneralguidanceforapplicationofLyclearisthatadultsandchildrenover12shoulduseuptoa
fulltubeasasingleapplication.Someadultsmightneedtousemorethanonetubetoensuretotalbody
coverage,butamaximumoftwotubes(60gintotal)isrecommendedforasingleapplication.Forchildren
under12themanufacturerssuggestthefollowing2monthsto1yearshoulduseupto ofatube,children
agedbetween1and5,upto ofatubeandforthoseagedbetween6and12years, atube.After
applicationthewholebodyshouldbewashedthoroughly8to12hoursaftertreatment.Treatmentshould
berepeatedafter7days.
Malathion(DerbacM)
Theliquidcanbeusedonadultsandchildrenover6monthsoldandisleftonfor24hours.Ifhands,orany
otherpartsofthebodymustbewashedduringthisperiod,thetreatmentmustbereappliedtothoseareas
immediately.Treatmentshouldberepeatedafter7days.
Benzylbenzoate
Benzylbenzoateshouldonlybeusedinadults.Dosing(asperBNF63)isthatitshouldbeappliedtothe
wholebodyandrepeatedthefollowingday.Athirdapplicationmayberequiredinsomecases.Itcauses
skinirritationandatransientburningsensation.Thisisusuallymildbutcanoccasionallybeseverein
sensitiveindividuals.Intheeventofasevereskinreactionthepreparationshouldbewashedoffusingsoap
andwarmwater.Itisalsoirritatingtotheeyes,whichshouldbeprotectedifitisappliedtothescalp.
Furtherreading
AngaranoDW,ParishLC:Comparativedermatology:parasiticdisorders.ClinDermatol199412:pp.543
550.
BuffetM,DupinN:Currenttreatmentsforscabies.FundamClinPharmacol200317:pp.217225.
BurgessI,RobinsonR,RobinsonJ,et.al.:Aqueousmalathion0.5%asascabicide:clinicaltrial.BrMedJ
1986292:pp.1172.
ChosidowO:Clinicalpractices.Scabies.NEnglJMed2006354:pp.17181727.
GlaziouP,CartelJL,AlzieuP,et.al.:Comparisonofivermectinandbenzylbenzoatefortreatmentof
scabies.TropMedParasitol199344:pp.331332.
HannaNF,ClayJC,HarrisJR:Sarcoptesscabieiinfestationtreatedwithmalathionliquid.BrJVenerDis
197854:pp.354.
HeukelbachJ,FeldmeierH:Scabies.Lancet2006367:pp.17671774.
JohnstonG,SladdenM:Scabies:diagnosisandtreatment.BrMedJ2005331:pp.619622.
Websites
Prodigyguidance.http://www.prodigy.clarity.co.uk/scabies(http://www.prodigy.clarity.co.uk/scabies)
Acnevulgaris
Background
Acnecanbedefinedasaninflammatorydiseaseofthepilosebaceousfolliclescausingcomedones,papules
andpustulesontheface(99%ofcases),chest(60%)andupperback(15%).Itaffectsvirtuallyall
adolescents,tovaryingdegreesofseverity,andusuallyappearsatthetimeofpuberty.Diagnosisisusually
straightforwardandmostpatientspresentinginthecommunitypharmacywillgenerallybeseeking
appropriateadviceoncorrectproductselectionratherthanwantingsomeonetoputanametotheirrash.
Themajorityofcasesseeninthepharmacysettingwillbemildandcanbemanagedappropriatelywithout
referraltotheGP.However,morepersistentandseverecasesneedreferralformorepotenttopicalor
systemictreatment.Acneoftencausessignificantpsychologicalimpactsuchaslackofconfidence,lowself
esteemanddepression.
Acnelesionsdevelopattheonsetofpuberty.Girlsthereforetendtodevelopacneatanearlieragethan
boys.Thepeakincidenceforgirlsisbetweentheagesof14and17comparedwith15to19yearsofagefor
boys.Recentevidenceshowsthattheaveragewhenacnedevelopshasdecreasedby1yearoverthelast30
years(from15.8yearsoldin1979to15in2007)(Goldbergetal2011).Althoughacneiscloselyassociated
withadolescenceupto5%ofwomenand1%ofmenaged25to40eithercontinuetogetacneordevelop
acne(lateonsetacne)afteradolescence.Theremightbeafamilialtendencytoacneanditisslightlymore
commoninboys,whoalsoexperiencemoresevereinvolvement.Inaddition,whitepatientsaremorelikely
toexperiencemoderatetosevereacnethanblackpatientsalthoughblackskinispronetoworsescarring.
Aetiology
Attheonsetofpubertyacascadeofeventstakesplaceresultingintheformationofnoninflammatoryand
inflammatorylesions.Inresponsetoincreasedtestosteronelevels,thepilosebaceousglandbeginsto
producesebum(ifthesebaceousglandsbecomeoversensitivetotestosteronetheyproduceexcessoiland
theskinbecomesgreasyahallmarkofacne).Atthesametimeepithelialcellsliningthefollicleundergo
change.Priortopubertydeadcellsareshedsmoothlyoutoftheductalopeningbutatpubertythisprocess
isdisruptedandinpatientswithacnethesecellsdevelopabnormalcohesionandpartiallyblockthe
openingandeffectivelyreducesebumoutflow.Overtimetheopeningoftheductbecomesblockedtrapping
oilinthehairfollicle.Bacteria,particularlyPropionibacteriumacnes,proliferateinthestagnantoil
stimulatingcytokineproduction,whichinturnproduceslocalinflammationleadingtotheappearanceofa
spot.Inresponsetotheproliferationofbacteriawhitebloodcellsinfiltratetheareatokillthebacteriaand
inturndieleadingtopusformation.Thepustuleeventuallyburstsontheskinsurface,carryingtheplug
away.Thewholeprocessthenstartsagain.
Upto60%ofaffectedpeopleseektreatmentforacnewithasubstantialproportionselfmedicatingrather
thanconsultingtheirGP.Differentialdiagnosisofacneisroutineandshouldnotbedifficult.The
pharmacistwill,however,needtoassesstheseverityoftheacne.Severalratingscaleshavebeendeveloped
withtheaimoftryingtogradetheseverityofanindividual'scondition.Nonehavegaineduniversal
acceptancealthoughmostdermatologytextssimplygradetheseverityofacneintomild,moderateor
severe.Askingsymptomspecificquestionswillhelpthepharmacisttodetermineifreferralisneeded(Table
7.23(t0170)).
Table7.23
Specificquestionstoaskthepatient:Acnevulgaris
Question Relevance
Severity Mildacneconsistsmainlyofnoninflammatorycomedones.
Moderateacnecanbedescribedashavingmanyinflammatoryspotsthatarenotconfined
totheface.Lesionsareoftenpainfulandthereisarealpossibilityofscarring.
Severeacnehasallthecharacteristicsofmoderateacneplusthedevelopmentofnodules
andcysts.Lesionsareoftenwidespreadinvolvingtheupperbackandchest.Scarringwill
usuallyresult.
Ageof Patientspresentingwithacnetypelesionswhofalloutsidethenormalagerangeshouldbe
onset closelyquestionedasanalternativediagnosisismorelikely.
Occupation Certainjobscanpredisposepatientstoacnelikelesionsandiscommonlyassociatedwith
longtermcontactwithoils
Clinicalfeaturesofmildacnevulgaris
Clinicalfeaturesofmildacnevulgaris
Patientssufferingfrommildacnecharacteristicallyhavepredominatelyopenandclosedcomedoneswitha
smallnumberofactivelesionsnormallyconfinedtotheface(Fig.7.21(f0110)).Mildacnewillnotcause
permanentscarring.Acnecansometimesconsistpredominatelyofblackheadsandwhiteheadswithvery
fewinflammatorylesions.ThisistermedcomedonalacneandoccursmostcommonlyinAsianandAfro
Caribbeanpatients.
Fig.7.21
Mildacne.
ReproducedfromABFleischeretal,2000,20CommonProblemsinDermatology,withpermissionoftheMcGrawHill
Companies.
Rosacea
Rosaceaisaninflammatorydiseaseoftheskinfollicles.Itisuncertainwhatcausesrosaceaalthough
successfultreatmentwithantibioticssuggeststhatbacterialpathogensplayasignificantroleinthedisease.
Itisnormallyseeninpatientsover40yearsofageandisclassicallycharacterisedbyrecurrentflushingand
blushingofthecentralfaceespeciallythenoseandmedialcheeks.Cropsofinflammatorypapulesand
pustulesarealsoacommonfeature,althoughcomedonesarenotpresent(Fig.7.22(f0115)).Eyeirritation
andblepharitisispresentinabout20%ofrosaceapatients.
Fig.7.22
Rosacea.
Medicinescausingacnelikeskineruptions
Anumberofmedicinescanproduceacnelikelesionsandincludelithium,oralcontraceptives(especially
thosewithhighprogestogenlevels),phenytoin,azathioprine,rifampicinandsteroids.
Perioraldermatitis
Perioraldermatitistendstoaffectyoungwomenagedbetween25and40andexhibitsanacnelikerash
generallyaroundthemouthandnasolabialfolds(Fig.7.23(f0120)).Itchingandburningcanalsobepresent
andtherashcantakeonadermatitislikequality.
Fig.7.23
Perioraldermatitis.
Polycysticovarysyndrome
Aclinicalmanifestationofthisconditioncanbeacnevulgaris.Anypatientthatalsoexhibitshirsuitism,is
overweightandhasmenstrualirregularitymustbereferredforfurtherinvestigation.
Acne
Moderateorsevereacne
Occupationalacne
OTCtreatmentfailure
Patientsover25yearsoldpresentingforthefirsttime
Rosacea
Theaimoftreatmentmustbetoclearthelesionsandpreventscarring.MildacnecanbemanagedOTCbut
itisimportanttoshowunderstandingandempathywhenadvisingpatients.Acneispredominantlya
conditionthataffectsadolescentsatimewhenappearanceisallimportant.Itisworthtakingafew
minutestocounselpatientsabouttheircondition,allyfearsandmakesuretheirexpectationsoftreatment
arerealistic.
OTCacnetreatmentscontaineitherbenzoylperoxide,salicylicacid,sulphur,nicotinamideoran
antibacterial.
Benzoylperoxide
BenzoylperoxideexertsitsmaineffectbyreducingtheconcentrationofPropionibacteriumacnes.
Additionally,ithasslightantiinflammatoryandmildanticomedogeniceffects.Manystudieshave
investigatedtheefficacyofbenzoylperoxide.Ithasbeenproventobeeffective,especiallyinmildto
moderateacne.However,thereisnoevidencetosuggestthat10%benzoylperoxideismoreeffectivethan
lowerstrengths.Therefore,becauseofitspotentialtocauseerythemaandirritation,concentrationsof10%
shouldprobablybeavoided.
Avarietyofotheragentshavebeencomparedagainstorincombinationwithbenzoylperoxide.Noneof
theseproductshasbeenshowntobesignificantlybetterthanbenzoylperoxidealone.Forexample,the
additionofmiconazole2%(AcnidazilnowdiscontinuedintheUK)wasshowntobenomoreeffective
thanbenzoylperoxide.Likewise,whenQuinodermwascomparedtoQuinodermHC(benzoylperoxideand
hydrocortisone)nosignificantdifferencesinefficacywereobserved.
Evidenceofefficacyforsalicylicacidandsulphurispoor.Bothagentshavebeenusedformanyyearsonthe
basisoftheirkeratolyticactionbutoncurrentevidencetheyarebestavoided.Nicontinamide(Nicam,
Freederm),isamorerecentadditiontotheOTCmarket.Datafromcohortstudiesfornicotinamidesuggest
itisaseffectiveasclindamycin1%gelbutbecauseofthelackofrandomisedcontrolledtrialsUKguidance
currentlydoesnotrecommenditsuse.
Complementaryandalternativemedicine(CAM)treatments
EvidenceislackingtosupporttheuseofCAM.ReviewsofCAMtotreatacnereportstudies,whichwere
smallinsizeandpoorquality.Inonetrial,theherbOcimumgratissimumwascomparedwithbenzoyl
peroxideandplacebo.However,becausevariousconcentrationswereinvestigated,thenumberofpatients
ineachgroupwastoosmalltoallowanyfirmconclusions.Afurthertrialthatcomparedteatreeoilwith
benzoylperoxidelackedaplacebogroupandwasunderpowered,yetbenzoylperoxidewasmoreeffective
thanteatreeoil.Anotherstudy,whichcomparedgluconolactoneversusbenzoylperoxide,found
gluconolactonetobebetterthanplacebobutnotsignificantlydifferentthanbenzoylperoxide.
Summary
Firstlinetreatmentofacneshouldbebenzoylperoxide2.5or5%.Patientsshouldseeanimprovementin
theirsymptomsafter6weeks.Ifthepatient'ssymptomsfailtoimproveinthistimethenreferraltotheGP
wouldbeappropriate.However,ifbeneficial,treatmentshouldbecontinuedforatleast4to6months.
PrescribinginformationrelatingtobenzoylperoxideisdiscussedandsummarisedinTable7.24(t0175)and
Table7.25(t0180)usefultipsrelatingtopatientspresentingwithacnearegiveninHintsandTipsBox7.9
(b0100).
Table7.24
Practicalprescribing:Summaryofmedicinesforacne
Nameof Usein Likelysideeffects Drug Patientsinwhich Pregnancy&

medicine children interactionsof careexercised breastfeeding
note
Benzoyl Not Skinirritation, None None OK

peroxide appropriate burningorpeeling
Table7.25
ProductsavailableintheUKcontainingbenzoylperoxide
Name Form Strength Otheringredients
Acnecide Gel&wash 5%
Brevoxyl Cream 4%
PanOxyl Aquagel 2.5%,5%,10%,
Cream 5%
Gel&wash 10%
Quinoderm Cream 5,10% Antimicrobialhydroxyquinolinesulphate0.5%,
Oxy10 Lotion 10%
HINTSANDTIPSBOX7.9:
Acne

Myths Sunshinehelpsreduceacnethereisnoconvincingevidencethatthisisthecase
surrounding Chocolatecausesspots.Thereisnoproofthatanyfoodcausesacne
acne Stresscausesacne.Stresscannotcauseacnealthoughitcanmakeitworse
Applying Benzoylperoxidehasapotentbleachingeffect.Ithastheabilitytopermanently
benzoyl bleachclothingandbedlinen.Patientsshouldbeadvisedtoalwayswashtheirhands
peroxide afterapplyingtheproduct
Benzoylperoxide
Benzoylperoxideislicensedforuseinadultsandchildren(forproductsseeTable7.25(t0180)).However,
acneisveryuncommoninchildrenunder12andshouldnotbegiventothisagegroup.Benzoylperoxideis
usuallyappliedonceortwicedailydependingonpatientresponse,althoughoncedailyapplicationisoften
sufficient.Itshouldbeappliedtoallareasoftheskinwhereacneoccursandnotjusttotheactivelesions.It
cancausedrying,burningandpeelingoninitialapplication.Ifthisoccursthepatientshouldbetoldtostop
usingtheproductforadayortwobeforestartingagain.Patientsshouldthereforestartonthelowest
strengthcommerciallyavailable,especiallyifthepatientsuffersfromsensitiveorfairskin.Occasionally,
patientswillexperiencecontactdermatitis,althoughithasbeenreportedtoaffectonly1to2%ofpatients.
Apartfromlocaladverseeffectsbenzoylperoxideissafe.
Furtherreading
BassettIB,PannowitzDL,BarnetsonRS:Acomparativestudyofteatreeoilversusbenzoylperoxideinthe
treatmentofacne.MedJAust1990153:pp.455458.
BurkeB,EadyEA,CunliffeWJ:Benzoylperoxideversustopicalerythromycininthetreatmentofacne
vulgaris.BrJDermatol1983108:pp.199204.
FluckigerR,FurrerHJ,RufliT:Efficacyandtoleranceofamiconazolebenzoylperoxidecream
combinationversusabenzoylperoxidegelinthetopicaltreatmentofacnevulgaris.Dermatologica1988
177:pp.109114.
HuntMJ,BarnetsonRS:Acomparativestudyofgluconolactoneversusbenzoylperoxideinthetreatmentof
acne.AustJDermatol199233:pp.131134.
JohnsonBA,NunleyJR:Topicaltherapyforacnevulgaris.Howdoyouchoosethebestdrugforeach
patient?.PostgradMed2000107:pp.6970.7376,7980
KligmanAM:Acnevulgaris:tricksandtreatments.PartII:Thebenzoylperoxidesaga.Cutis199556:pp.
260261.
MaginP,PondD,SmithW,et.al.:Asystematicreviewoftheevidenceformythsandmisconceptionsin
acnemanagement:diet,facewashingandsunlight.FamPract200522:pp.6270.
MaginPJ,AdamsJ,PondCD,et.al.:TopicalandoralCAMinacne:Areviewoftheempiricalevidenceand
aconsiderationofitscontext.ComplementTherMed200614:pp.6276.
MarksR:Theenigmaofrosacea.JDermatolTreat200718:pp.326328.
PurdyS,deBerkerD:Clinicalreview:Acne.BrMedJ2006333:pp.949953.
SagranskyM,YentzerBA,FeldmanSR:2009Benzoylperoxide:areviewofitscurrentuseinthetreatment
ofacnevulgaris.ExpOpinPharmacother200910:pp.25552562.
ShalitaAR,SmithJG,ParishLC,et.al.:Topicalnicotinamidecomparedwithclindamycingelinthe
treatmentofinflammatoryacnevulgaris.IntJDermatol199534:pp.434437.
Websites
AcneSupportGroups:http://www.m2w3.com/acne/(http://www.m2w3.com/acne/)
Coldsores
Background
Acoldsoreisaninfectioncausedbytheherpessimplexvirus(HSV).Therearetwomainsubtypesofthe
virus:HSV1andHSV2.ColdsoresarecausedbyHSV1,whereasHSV2ismostcommonlyimplicatedin
genitallesions.
Herpessimplexvirusinfectionisoneofthemostcommonlyencounteredhumanviralinfections.Itis
estimatedthatmorethan50%ofadultsintheWesternworldshowserologicevidenceofhavingbeen
infectedbyHSV1,althoughthismightnotmanifestassymptoms.Whenfirstcontracted,thevirusisknown
astheprimaryinfection.Thisisoftenasymptomatic,andismostcommonlycontractedbypreschool
children.Itisreportedthat20to40%ofpeoplehaveexperiencedcoldsoresatsometime.
Aetiology
Infectionisspreadbyviralsheddingintosalivaandresultsfromdirectmucousmembrane(e.g.kissing)
contactatsitesofabradedskinbetweenaninfectedandanuninfectedindividual.Thevirustheninfects
epidermalanddermalcells,causingskinvesicles.Atthesametime,nerveendingsarealsoinfectedwiththe
virus,whichtravelstothesensorygangliawhereitliesdormantinthedorsalrootgangliaofthetrigeminal
nerveuntilreactivation.Thevirusremainsdormantuntiltriggeredbyastimulus(Table7.26(t0190)).
Duringreactivationthevirusactivelyreplicates,leadingtolesionsinthedistributionoftheaffectednerve.
Oncecontractedtheinfectionlaststhelifetimeofthehost.
Table7.26
Specificquestionstoaskthepatient:Coldsores
Question Relevance
Appearance Patientswithcoldsoreswilloftenexperienceprodromalsymptomspriortotheskineruption
whereasnowarningsymptomsarepresentwithimpetigoorangularcheilitis.
Location Coldsorestypicallyoccuraroundthemouthandforthisreasonareknownasherpes
simplexlabialis.Theycanalsooccuraroundandinsidethenose,butthisislesscommon
Impetigoalsooccursinthesameareasbutismorepronetospreadtootherareasofthe
faceormovetootherpartsofthebody,forexamplethearms.
Angularcheilitisoccursatthecornersofthemouthandcanbemistakenforcoldsoresdue
totheirsimilarlocations.
Trigger Stress,illhealth,sunlight,viralinfection(e.g.thecommoncold)andmenstruationareall
factors implicatedintriggeringcoldsoreattacks.Thesetriggersarenotassociatedwithother
similarconditionsandthepatientshouldbeaskediftheycanidentifywhatbroughtonthe
lesions.
Coldsoresshouldnotbetoodifficulttodiagnose,althoughconditionssuchasimpetigocanlooksimilarto
coldsores.Askingsymptomspecificquestionswillhelpthepharmacisttodetermineifreferralisneeded(
Table7.26(t0190)).
Clinicalfeaturesofcoldsores
Patientswithcoldsorestypicallyexperienceprodromalsymptomsofitching,burning,painortingling
symptomspriortovesicleeruption.Thesesymptomsmightbenoticedfromafewhourstoacoupleofdays
beforethelesionsdevelop.Thelesionsappearasblistersandvesicleswithassociatedredness(Fig.7.24
(f0125)).Thesecrustoverusuallywithin24hoursandtendtoitchandbepainful.Thelesions
spontaneouslyresolvein7to10days,thereforemostoutbreakslast14daysfromtherecognitionof
prodromalsymptomstotheresolutionoflesions.
Fig.7.24
Coldsore.
ReproducedfromGWhite,2004,ColorAtlasofDermatology3rdedition,ChurchillLivingstone,withpermission.
Manypatientscanidentifyacauseoftheircoldsore,withsunlight(UVlight)reportedtoinducecoldsores
in20%ofsufferers.Recurrenceiscommonandlesionstendtooccurinthesamelocation.Patientswill
oftenexperiencetwoorthreeepisodeseachyear.Immunocompromisedpatients,orpatientstaking
immunosuppressivemedicationcanexperienceseveresymptomsandshouldbereferred.
Impetigo
Impetigousuallystartsasasmall,red,itchypatchofinflamedskinthatquicklydevelopsintovesiclesthat
ruptureandweep.Theexudatedriestoabrown,yellowstickycrust.Currently,referralisneededforeither
topical(e.g.fusidicacid)orsystemic(flucloxacillin)therapy.However,patientgroupdirectionsforsupply
oftopicalantibioticsbycommunitypharmacistsareinuseincertainareasoftheUK.Itispossiblethat
deregulationoftopicalantibioticswilloccurinthefuture.
Angularcheilitis
Angularcheilitiscanoccuratanyage.Itismorecommoninpatientswhoweardentures.Thecornersofthe
mouthbecomecracked,fissuredandred.Thelesionscanbecomeboggyandmaceratedandareslowtoheal
becausemovementofthemouthhindershealingofthelesions(Fig.7.25(f0130)).Itispainfulbutgenerally
doesnotitchorcrustoverasistypicalwithcoldsores.
Coldsores
Symptoms/signs Possibledanger/reasonforreferral
Durationlongerthan14days Unlikelytobecoldsores
Coldsoreslocatedwithinthemouth Outsidescopeofcommunitypharmacy
Severeandwidespreadlesions
Lesionsthatspreadrapidlyovertheface Impetigomorelikely
Patientswhoareimmunocompromisedor Generallytheyexperiencemoreseveresymptoms
takeimmunosuppressivemedicines andshouldbemanagedbytheirdoctor
Fig.7.25
Angularcheilitis.
ReproducedfromRCawsonetal2002,EssentialsofOralPathologyandOralMedicine,ChurchillLivingstone,with
permission.
Anumberofproductsaremarketedforthereliefandtreatmentofcoldsores.Nonehaveshown
conclusivelytobeeffectiveinbothitspreventionandtreatment.Productscontainingammonia,zincand
phenolappeartohavenoevidenceofefficacy.However,theymightbeusefulindryinglesionsand
preventingsecondarybacterialinfections.Localanaesthetics(e.g.lidocaine)andcholinesalicylatemight
alsobeusefulformildlypainfullesions.Forinformationontheseproductsseepage138.
Onlytheantivirals,aciclovirandpenciclovirwhichworkbyinhibitingtheherpesvirusDNApolymerase
havedemonstratedclinicaleffectivenessagainsttheherpesvirus.Orally,antiviralssuchasaciclovirare
highlyeffectivebuttheevidencefortopicaladministrationislessconclusive.Trialdatahavefailedtoshow
anysignificanteffectsonspeedingtheresolutionofestablishedcoldsoreswhenusingaciclovir,although
thereissomedatatosupportitsuseasaprophylacticagent.Ifappliedintheprodromalstagethetotal
healingtimeofsubsequentlesionsisreducedbya to1day.However,theresultsofthestudiesinthis
reviewweremixed,withseveralfailingtofindanydifferencecomparedtoplacebo.
Ahydrocolloidpatchhasbeenreleasedforthetreatmentofcoldsores(CompeedColdSorePatch).
Hydrocolloiddressingsareavailableforwounds,andenhancehealingbyprovidingamoistenvironment.A
studycomparingCompeedpatchwithaciclovir5%creamfoundsimilarefficacyintermsofselfreported
globalassessmentofefficacyandtimeuntilhealing(7.57daysforCompeedvs7.03daysforaciclovirp
=0.37)( Karlsmarketal2008).However,thestudywasnotblindedfortheprimaryoutcome(selfreported
globalassessment),castingsomedoubtsonthefindings.Further,thestudywasnotsetupasan
equivalencestudy,andthereforethelackofdifferenceintheoutcomescouldbeduetotoosmallasample
size.Giventheuncertaintyinthebenefitofaciclovir,thesmalladditionalhealingtimeseenwithCompeed
inthistrial(approximately aday)couldmeanCompeedisnobetterthanplacebo.
Summary
Aciclovirandpenciclovirarefirstlinetherapyforthetreatmentandpreventionofcoldsores.However,
theyshouldbeusedassoonasthepatientexperiencessymptomsforthemtohaveanyeffect.
PrescribinginformationrelatingtoantiviralsisdiscussedandsummarisedinTable7.27(t0200).For
completenessthetablealsocontainssomeoftheothercommonlyusedcoldsoreproductsusefultips
relatingtopatientspresentingwithcoldsolesaregiveninHintsandTipsBox7.10(b0110).
Table7.27
Practicalprescribing:Summaryofmedicinesforcoldsores
Nameof Useinchildren Likely Drug Patientsin Pregnancy&

medicine side interactions whichcare breastfeeding
effects ofnote exercised
Aciclovir All(exceptLypsylproduct)statecan Stinging None OK OK

beusedinchildrenbutnolowerage
Lypsyl
limitstated
coldsore
cream
Cymex
Ultra
Virasorb
Zovirax
Nameof Useinchildren Likely Drug Patientsin Pregnancy&
medicine side interactions whichcare breastfeeding
effects ofnote exercised
Penciclovir >12years None None None Manufacturers

(Fenistil) recommend
avoidance
Ammonia Yes,butnoloweragestated None None None OK

Blistex
Phenol Yes,butnoloweragestated None None None OK

Colsor
Zinc& >12years Stinging None None OK

lidocaine
Lypsyl
coldsore
gel
Urea Yes,butnoloweragestated None None None OK

Cymex
HINTSANDTIPSBOX7.10:
Coldsores
Suninduced Forthosepatientsinwhomthesuntriggerscoldsores,asunblockwouldbethe
coldsores mosteffectiveprophylacticmeasure
Applying Patientsshouldbeencouragedtouseaseparatetowelandwashtheirhandsafter
products applyingproductsbecauseviralparticlesareshedfromthecoldsoreandcanbe
transferredtoothers
Decrease Riskoftransmissionishighestduringthefirst14daysofsymptomsandpeople
transmission shouldbeadvisednottokissothers
Aciclovir(e.g.CymexUltra,Lypsylcoldsorecream,Virasorb,Zovirax)
Aciclovircanbeusedtopicallybyallpatientgroups,includingpregnantandbreastfeedingwomen,although
themanufacturersadvisecautionbecauseoflimiteddataregardingtheexposureofpregnantwomento
aciclovir.Ithasnodruginteractionsandcausesonlytransientstingingafterfirstapplicationinthe
minorityofpatients.Aciclovirshouldbeappliedfivetimesdailyatapproximately4hourlyintervalsand
treatmentshouldbecontinuedfor5days.
Penciclovir(Fenistilcoldsorecream)
Penciclovir,likeaciclovir,hasthesamesideeffectprofile,cautionsandcontraindicationsalthoughthe
manufacturersadviseavoidanceinpregnancyandbreastfeeding,presumablyonlackofsafetydata.
However,thereappearstobenoevidencetosuggestitcausesanyproblemsinthesegroups.Forpeople
agedover12yearsitshouldbeappliedevery2hoursandtreatmentcontinuedfor4days.
Furtherreading
EmmertDH:Treatmentofcommoncutaneousherpessimplexvirusinfections.AmFamPhysician2000
61:pp.16971704.
RabornQW,McGawWT,GraceM,et.al.:TreatmentofHerpesLabialiswithacyclovir.AmJMed198885:
pp.3942.
SpruanceSL,NettR,MarburyT,et.al.:Acyclovircreamfortreatmentofherpessimplexlabialis:resultsof
tworandomized,doubleblind,vehiclecontrolled,multicenterclinicaltrials.AntimicrobAgentsChemother
200246:pp.22382243.
ScullyC,GorskyM,LozadaNurF:Thediagnosisandmanagementofrecurrentaphthousstomatitis:a
consensusapproach.JAmDentAssoc2003134:pp.200207.
WhitleyRJ,KimberlinDW,RoizmanB:Herpessimplexviruses.ClinInfectDis199826:pp.541555.
Websites
MayoFoundationforMedicalEducationandResearch:http://www.mayoclinic.com/invoke.cfm?id=DS00358
(http://www.mayoclinic.com/invoke.cfm?id=DS00358)
Eczemaanddermatitis
Background
Thetermseczemaanddermatitisareoftenusedinterchangeably.Dermatitissimplymeansinflammation
oftheskinwhereaseczemahasnouniversallyagreeddefinitionbutinsomecountriesindicatesamore
acutecondition.Manyauthoritiessubdivideeczemaanddermatitisintoeitherexogenous(duetoan
obviousexternalcause)orendogenous(assumedtobeofageneticcause),however,thedistinctionisnot
clear.Theconditionisalsoreferredtoaseitheracuteasingleexposuretoanirritant,orchronic
repeatedexposure.Inthissection,forconsistency,thetermdermatitiswillbeused.
Dermatitisischaracterisedbysore,red,itchingskin.Inprimarycare,thetwocommonestformsof
dermatitisareirritantandallergicdermatitis.
Theexactprevalenceandincidenceofirritantandallergiccontactdermatitis(ICDandACD)isunclear,
althoughICDismuchmorecommonthanACDandhasbeenreportedtoaccountfor80%ofall
occupationalskindisorders.ACDissaidtoaffect1to2%ofthepopulationwithcertainpatientgroups,such
aspatientswithlegulcersathigherriskofdevelopingACD.
Aetiology
DifferentphysiologicalmechanismsareresponsibleforICDandACD.InICD,anagentmustpenetratethe
outerlayerofskinthestratumcorneumtoinvokeaphysiologicalresponse.Thetypeofirritant,the
concentration,quantityinvolvedandlengthofexposurewillaffecttheseverityofreaction.Thiscanoccur
withasingleexposure,ormorecommonly,withfrequentexposureswhentheirritantaccumulatesinthe
stratumcorneum.Forexamplestrongacidsandalkalinesubstancescanproduceulcerationonasingle
exposure,whereasotheragents(e.g.zincoxidetape)potentiallyrequiremultipleexposureandtendto
invokeaweakerreactionandcauseapricklyheattypeofdermatitis.
ACDfirstrequiressensitisationtooccur.Thisleadstospecificcellmediatedsensitisation.Oncetheskin
hasbecomesensitisedtoanallergen,reexposuretotheallergentriggersmemoryTcellstoinitiatean
inflammatoryresponse24to48hoursafterreexposure.BecausetheseTcellsaredistributedthroughout
thebodythereactionisnotlimitedtothesiteofexposureandexplainswhylesionsareseenawayfromthe
siteofexposure.Theriskofsensitisationcandependontheindividual'ssusceptibilityaswellasthe
particularallergen'sconcentrationandquantity.Reexposurecanoccurdaysandsometimesyearsafter
initialexposure.AlistofcommonirritantsandallergensisshowninTable7.28(t0210).
Table7.28
Irritantsandallergensknowntoprecipitatedermatitis
IrritantsthatcanprecipitateICD AllergensthatcanprecipitateACD
Detergentsandsoaps Nickel(especiallyjewelleryinwomen)
Chromateincement
Solventsandabrasives Topicalcorticosteroids(5%ofpatients)
Oils Cosmeticsparticularlyfragrances,hairdyes,preservatives,andnail
varnishresin.
Acidsandalkalis,including Rubber,includinglatex
cement
Reducingagentsandoxidizing Dyes,formaldehydeandepoxyresins
agents
Manycausesofdermatitisareoccupationallyrelated.Questionsaboutexposuretoirritantsandallergensat
workcanoftenidentifythecauseofsymptoms.
Manypatientswillpresentinthepharmacywithanitchyredrash.Gaininganaccuratediagnosiscanbe
difficultasidentificationofthecauseisdifficultandclinicalfeaturesaresimilar.Generallyspeaking
treatmentisthesameforbothformsofdermatitissomakingadefinitivediagnosisislessimportant.
However,askingsymptomspecificquestionswillhelpthepharmacisttodetermineifreferralisneeded(
Table7.29(t0215)).
Table7.29
Specificquestionstoaskthepatient:Dermatitis
Question Relevance
Location Thedistributionofrashforcontactdermatitisiscloselyassociatedwithclothingandjewellery(
Fig.7.26(f0135))
Exposure Ahistoryofwhentherashoccursgivesausefulindicationastothecause,e.g.aconstruction
workermightcomplainofsorehandswhilstatworkbutwhenonholidaythecondition
improvesonlyforittoworsenwhentheygobacktowork
Fig.7.26
Distributionofcontactdermatitis.
ClinicalfeaturesofACDandICD
Inbothcasesrashdevelopsatthesiteofexposure.Intheacutephase,lesionsappearrapidlywithin6to
12hoursofcontact.Theskinappearsred,itchy,inflamedandmightshowpapulesandvesicles.Itchingis
aprominentfeatureandoftencausesthepatienttoscratch,whichresultsinbrokenskinwithsubsequent
weeping.Inchronicexposure,theskinbecomesdry,scalyandcancrackandfissure(Fig.7.27(f0140)).The
rashinICDtendstobewelldemarcated.InACD,therashtendstobelesswelldefinedmilderinvolvement
awayfromthesiteofexposureisseenonrepeatedexposureandcanreactivateatpreviouslyexposedsites.
Fig.7.27
Irritantdermatitis.
ReproducedfromGWhite,2004,ColorAtlasofDermatology,3rdedition,ChurchillLivingstone,withpermission.
Psoriasis
Isolatedlesionsofpsoriasiscanbesuperficiallysimilartodermatitistheyappearredandscaly,althougha
keydifferenceisthegenerallackofitchinpsoriasis.Thedistributionoflesionsisalsousuallydifferent,and
psoriasisisnotprecipitatedbyexposuretocertainirritantsorallergens.Forfurtherinformationon
psoriasisseepage197(s0050).
Fungalinfections
Fungalinfectionsexhibittheclassicaldermatitistypesymptomsofitchyredrashandcanthereforebe
easilyconfused.Veryclearlesiondemarcationalongwithdifferinglocation,andcentralclearingallpoint
towardfungalinfection.Forfurtherinformationonfungalinfectionsseepage210.
Discoiddermatitis
Thisdiffersfromotherformsofeczemaasthelesionshaveclearlydemarcatededgesandarecircularor
oval.Lesionstendtoaffectthearmsandlegsandareoftendistributedsymmetrically.Itismorecommonin
middleagedpeople.
Dyshidroticeczema(pompholyx)
Pompholyxsimplymeansbubbleandreferstothepresenceofintenselyitchyvesiclesorblistersonthe
palmsofthehandsandoccasionallyonthesolesofthefeet.Stressandheatareknowntoprecipitatethe
condition.
Urticaria
Urticarialrashescanresultfrommanycauses,mostnotablyduetofoodallergies,foodadditives(Table7.30
(t0220))andmedicines.Likedermatitis,therashisitchyandredbutresemblestherashseenwhenstungby
astingingnettle(Fig.7.28(f0145)).Inaddition,theskincanbeoedematousandblancheswhenpressed.
Urticarialreactionsoftenrespondwelltosystemicantihistamines.
Table7.30
Foodadditivesknowntocauseallergicreaction
Sulphites Sulphitesareusedtopreservesmokedandprocessedmeats,driedfruit(apricots)and
(E220 salads.Theyarecommonlyfoundinliquidformincolddrinksandfruitjuiceconcentrates,
E227) andwineandsprayedontofoodstokeepthemfreshandpreventdiscolourationor
browning.
Benzoicacid Benzoatesandparabenshaveantibacterialandantifungalpropertiesforpreventionoffood
and spoilage.Theseagentsareaddedtopharmaceuticalandfoodproductsandoccur
parabens naturallyinprunes,cinnamon,teaandberries.
(E210
E219)
Antioxidants Fatandoilsinfoodturnrancidwhenexposedtoair.Syntheticphenolicantioxidants
(E320 butylatedhydroxyanisoleandbutylatedhydroxytoluenepreventthisspoilagehappening
E321) butcantriggerasthma,rhinitisandurticaria.
Flavour Theseareusedtoenhancefoodpalatability,mostnotablyaspartamewhichcantrigger
enhancers urticariaandswellingandmonosodiumglutamate(E620)whichcantriggertheChinese
(E620 restaurantsyndromeofheadacheandburningplustightnessinthechest,neckandface.
E635)
Colourings Colouringsareusedtomakefoodvisuallymoreattractive,theazodyes(Tartrazine,E102,
(E100 SunsetYellow,E110)andnonazodyes(erythrocine)havebeenassociatedwithtriggering
E180) urticaria,asthmaandgeneralisedallergicreactions.
Fig.7.28
Urticarialreactiontograss.
Figure7.29(f0150)willaidthedifferentiationofdermatitis.
Dermatitis
Childrenunder10inneedofcorticosteroids
Lesionsonthefaceunresponsivetoemoillients
OTCtreatmentfailure
Widespreadorseveredermatitis
Fig.7.29
Primerfordifferentialdiagnosisofdermatitis.
Allformsofdermatitiscauseredness,dryingoftheskinandirritation/pruritustovaryingdegrees.
Treatmentshouldincludethreesteps:managingtheitch,avoidingirritantsandmaintainingskinintegrity.
Nonpharmacologicalinterventionsincludeavoidanceofthecausativeagent,howeverdeterminingthe
causeisoftendifficultandavoidanceissometimesimpractical.Sweatingintensifiestheitchingsostrategies
tokeepthepersoncoolwillhelpcottonandloosefittingclothingcanbeworn.
Pharmacologicaltreatmentofdermatitisshouldbemanagedwithacombinationofemollientsandsteroid
basedproducts.
Emollients
Emollientsshouldbeusedonaregularbasistokeeptheconditionundercontrolandflareupscanthenbe
treatedwithcorticosteroids.Choosingthemostefficaciousemollientforanindividualisdifficultduetothe
lackofcomparativetrialdatabetweenproductsandthevariablenatureofpatientresponse.Ingeneral,
patientsrespondtoathickeremollientratherthananelegantcosmeticbrandbecausetheseallowgreater
retentionofwater,forexample50%liquidparaffinand50%whitesoftparaffin.However,patient
acceptabilityofsuchproductsneedstobeconsidered.Creamformulationsratherthanointmentstendtobe
morereadilyacceptedbypatients,astheyareeasierandlessmessytouse.Ingeneral,skinwhichis
moderatelydrytoverydrywillrespondbesttoanointmentandskinwhichismildlydry,acream.Ifthe
skinisbrokenorweepingthenawatersolublecreamcanbeuseful.Toavoidthedryingeffectsofsoap,a
soapsubstituteshouldbeused.
Steroids
IntheUK,twosteroidsarecommerciallyavailableOTChydrocortisoneandclobetasone.Bothhaveproven
efficacyintreatingdermatitisandshouldbeconsideredfirstlinetreatmentforacutedermatitis.Once
symptomsarecontrolledthenthepatientshouldbeinstructedtorevertbacktoemollienttherapy.
Prescribinginformationrelatingtospecificproductsusedtotreatdermatitisdiscussedinthesection
EvidencebaseforoverthecountermedicationissummarisedinTable7.31(t0225)usefultipsrelatingto
usingproductstotreatdermatitisaregiveninHintsandTipsBox7.11(b0120).
Table7.31
Practicalprescribing:Summaryofmedicinesfordermatitis
Nameof Usein Likelyside Drug Patientsinwhich Pregnancy&

medicine children effects interactionsof careexercised breastfeeding
note
Emollients Frombirth None None None OK

onwards
Corticosteroids
Hydrocortisone >10years None None None OK
Clobetasone >12years
Dermatitis

Patchtesting Iftherashpersistsdespiteavoidinglikelyirritantsandallergensthenpatch
testingcouldbetried
Howmuchto Patientsshouldbeinstructedtouseafingertipunit.Thisisthedistancefromthe
apply? tipoftheadultindexfingertothefirstcrease.Oneunitissufficienttocoveran
areatwicethesizeofanadultflathand
Quantity TheBNFgivesthefollowingguidanceforaweeksuse:
required? Bothhands,15to30g
Botharms,30to60g
Bothlegsortrunk,100g
Whentoapply Afterusingacorticosteroidanemollientcanbeappliedtothesamearea30
emollientsand minuteslater
corticosteroids?
Emollients
Emollients
Therearealargenumberofemollientsonthemarket.Theycomeinarangeofformulationstosuitallskin
typesandpatientpreference(Table7.32(t0235)).Patientsshouldbeinstructedtoapplyemollientsboth
liberallyandwheneverneeded.Theyarepharmacologicallyinactiveandsocanbeusedbyallpatients
regardlessofageormedicalstatus.Anumberofingredientsincorporatedintoemollientsdohavethe
potentialtosensitiseskinandpatientsshouldbeadvisedtopatchtesttheproductonthebackofthehand
beforestartingtoroutinelyuseit.
Table7.32
Summaryofproprietaryemollientproducts
Productname Formulation Combination Containspotentialsensitising

product agents
Aveeno Cream,bathoil,andlotion Yes
Aquadrate Cream Urea No
Aquamol Cream Yes
Balneum Bathoil Yes
BalneunPlus Bathoil,cream Urea(cream) Yes
Calmurid Cream Urea,lacticacid No
Cetraben Cream,bathoil Yes
DermatonicsHeel Cream Urea Yes

Balm
Dermamist Spray No
Dermalo Bathoil No
Dermol showerandbathemollient,wash Antimicrobials Yes

emulsion
Diprobase Cream,ointment Yes(cream)
Diprobath Bathoil No
Doublebase Bathoil,gel No
E45 Cream,lotion,bathoil,emollient Yes(creamandlotiononly)

washcream
E45Itchrelief Cream Urea Yes
Emollin Spray No
Emulsiderm Bathemulsion Antimicrobials Yes
Epaderm Cream,ointment Yes

Productname Formulation Combination Containspotentialsensitising
product agents
Eucerin Cream,lotion Urea Yes
Hewletts Cream Yes
Hydromol Cream Urea No

Intensive
Hydromol Cream,ointment,bathandshower Yes(creamandointment)

emollient
Imuderm Bathoil Yes
LinolaGamma Cream Yes
Lipobase Cream Yes
Neutrogena Cream Yes
Nutraplus Cream Urea Yes
Oilatum Cream,junior,showeremollient, Yes

bathoil
OilatumPlus Bathoil Antimicrobials Yes
QV Cream,ointment,lotion,wash,bath Yes(exceptoil)
oil
Ultrabase Cream Yes
UnguentumM Cream Yes
Vaseline Cream,lotion Yes

Dermacare
ZeroAQS Cream Yes
Zerobase Cream Yes
Zerocream Cream Yes
Zeroguent Cream Yes
Zerolatum Bathoil No
ZerolatumPlus Bathoil Yes
Zeroneum Bathoil Yes
Cortiocsteroids
AlthoughcorticosteroidscanbesoldtopatientsOTC,thereareanumberofrestrictionstotheirsale.Inthe
UKtheseare:
thepatientmustbeover10forhydrocortisone(over2yearsinAustralia)and12forclobetasone
durationoftreatmentislimitedtoamaximumof1week
amaximumof15gcanbesoldatanyonetime
theycannotbeusedonfacialskin,theanogenitalregion,brokenorinfectedskin.
Intheopinionoftheauthor,theserestrictionslimittheirusefulnessandmeanthatmanypatients,who
couldbeotherwisetreatedsuccessfullyiftheproductlicenseswerenotsoprohibitive,mustbereferredtoa
GP.Forexample,1%hydrocortisonecream,ifusedshortterm,isanidealsteroidtouseonthefacewithno
adverseeventsalso,15gofproductisofteninsufficientforsurfaceareassuchaslimbsandthebody,even
ifusedonlyforaweek.
Hydrocortisone
Hydrocortisonecaneitherbeboughtalone(e.g.Hc45,)orincombinationwithotheringredients(e.g.Eurax
HC,CanestenHydrocortisone).Itisprudenttouseproductssolelycontaininghydrocortisonefor
dermatitis,applyingthemtwiceadayforamaximumof7days.Ifsecondaryinfectionissuspected,for
examplewithafungalinfection,thenproductssuchasCanestenHydrocortisonecanbeused.
Clobetasone(Eumovateeczemaanddermatitiscream)
Clobetasoneisclassedasmoderatelypotent,whereashydrocortisoneisclassedasmild.Thisaffordsthe
pharmacistchoiceintailoringtreatmenttotheseverityofthecondition.Itwouldseemreasonableto
reserveclobetasoneformoresevereflareupsofdermatitis,orthosepatientsinwhichhydrocortisonehas
inthepastfailedtocontrolsymptoms.Likehydrocortisone,itshouldbeappliedtwiceaday.
Furtherreading
BellinghamC:Properuseoftopicalcorticosteroids.PharmJ2001267:pp.377.
ClarkC,HoareC:Makingthemostofemollients.PharmJ2001266:pp.277279.
CunliffeB:Eczema.PharmJ2001267:pp.855856.
Websites
NationalEczemaSociety:http://www.eczema.org/(http://www.eczema.org/)
NationalEczemaAssociation:http://www.nationaleczema.org/(http://www.nationaleczema.org/)
Sunexposureandmelanomarisk
Background
Theultravioletspectrumissubdividedintothreeregions:UVA(320to400nm)UVB(290to320nm)
andUVC(200to290nm).LightfromtheUVAspectrumcausesskintanningandUVBlightsunburn,
whereasUVClightiseffectivelyfilteredoutbytheozonelayer.Itisnowwellrecognisedthatexcessiveor
prolongedexposuretothesun'sraysandinadequateskinprotectioncanresultinprecancerousand
cancerousneoplasms.Therearemanytypesofskincancer,butthreetypesareassociatedwithsun
exposuresquamouscellcarcinoma(SCC),basalcellcarcinoma(BCC)andmalignantmelanoma(MM)
andareresponsibleformorethan95%ofallskincancers.SCCandBCCresultfromchroniclongterm
exposuretosunlightwhereasMMisassociatedwithacute,intense,andintermittentblisteringsunburns.
BCCandSCCareoftengroupedtogetherasnonmelanomaskincancer(NMSC).
Theincidenceofcancersrelatedtoskindamagehasdramaticallyincreasedsincethe1980s,andare
greatestinwhiteskinnedpeoplelivinginequatorialregions.In2010,therewerejustunder13000new
casesofMMintheUK.MMsareslightlymorecommoninwomen,althoughtheincidenceinbothsexeshas
beensteadilyincreasing.AffluentwomenappeartobeathighestriskofdevelopingMM,whereasmenfrom
lowersocioeconomicgroupsareatgreatestriskofdevelopingNMSC.
Aetiology
Thebody'sresponsetotheeffectsofUVAandUVBlightisprotective.Onexposuretoultravioletlight
melanocytesincreaseproductionofmelanin,thuscausingadarkeningoftheskin,theallimportant
suntan!MelaninabsorbsbothUVAandUVBandeffectivelyprotectstheskinfromdamage,unfortunately
melaninsynthesisisslowandskindamagemightwellhavealreadyoccurredmanifestedassunburn.
Sunburnisaninflammatoryresponsetoexcessiveexposuretoultravioletlightwherebyanincreasein
inflammatorymediatorsresultsincapillaryvasodilatationandincreasedcapillarypermeability.Inaddition
tomelaninproduction,epidermalhyperplasiaoccurs,causingtheskintothickenthisprovidesfurther
protectionagainsttheskin.
Pharmacistshaveamajorroletoplayindealingwithpatientswhohavebeenexposedtoexcessiveamounts
ofsunlight.Theycanpromotesunsafetymessages,bothpassivelyandactively(whendealingwithrequests
forsunburn)andmakeappropriatereferralswithregardtosuspiciouslesions.Pharmacistsmustbeableto
recognisesuspiciouslesions,especiallythoseresemblingMMbecauseithasthehighestmortalityofskin
cancers,butiftreatedearlyiscurable.
Clinicalfeaturesofmalignantmelanoma
MMisoneofthefewcancerswhichisassociatedwithyoungadults.Itcanappearonallbodysitesyettheir
distributionbetweenmenandwomendoesdiffer(Fig.7.30(f0155)).IntheUKpopulationthemost
commonsiteisthelowerleginwomen,andonthebackinmen.Riskfactorsincludeearlychildhoodsun
exposure,peoplewithmultiplemolesandthosewithsusceptiblesunburnskintypes.Thefirstsignof
melanomaisoftenachangeinthesize,shape,orcolourofamole,althoughmelanomacanalsoappearon
thebodyasanewmole(Fig.7.31(f0160)).Earlyidentificationisessentialandtwocommonlyused
checklistsareusedtoaiddiagnosisthe7pointchecklistandtheABCDElist.
Fig.7.30
Distributionofmalignantmelanoma.
Fig.7.31
Superficialspreadingmelanoma.
Irregularincolourandshape.ReproducedfromJWilkinsonetal2004,DermatologyinFocus,ChurchillLivingstone,
withpermission.
1 The7pointlist
Thischecklistconsistsof3majorand4minorpoints:
Major(scores2)
1.Changeinshape
2.Changeinsize
3.Changeincolour
Minor(scores1)
1.Largestdiameter7mmormore
2.Inflammation
3.Oozing
4.Changeinsensation(e.g.itchorirritation)
AnylesionshouldbesuspectedasMMwithascoreof3ormore.
2 TheABCDERule
Inthischecklist5pointsareused:
AsymmetryOrdinarymolesareusuallysymmetricalinshape.Melanomasarelikelytobeirregular
orasymmetrical.
BorderMolesusuallyhaveawelldefinedregularborder.Melanomasaremorelikelytohavean
irregularborderwithjaggededges.
ColourMolesareusuallyauniformbrown.Melanomastendtohavemorethanonecolour.They
maybevaryingshadesofbrownmixedwithblack,red,pink,whiteorabluishtint.
DiameterMolesarenormallynobiggerthanthebluntendofapencil(about6mmacross).
Melanomasareusuallymorethan7mmindiameter.
Evolutionthesymmetry,border,colour,ordiameterofamolehaschangedovertime.
Itislikelythatpatientswillaskforadviceandreassuranceonskinlesionswhichtheyareconcernedcould
bemelanoma.Itisessentialthatthesepeoplearegiveninformation,ideallybothorallyandwritten,
regardingthechangesthatmightsubsequentlysuggestMMandinstructedtoseekmedicalhelpassoonas
theynoticechanges.
NMSC
NMSCarethemostcommoncancersintheUK.Theyareassociatedwitholderpeople,withtheaverageage
ofdiagnosisintheearly70s.Thecancersarerarelyfatalbutcancausesubstantialmorbidity.Bothcancers
commonlyoccuronskinsurfacesthatareexposedtoalifetimeaccumulationofUVradiationsuchasthe
hands,faceandscalp.Theyaremorecommoninpeoplewhohaveworkedoutdoors,infairskinnedpeople
andthoselivingintropicalandsubtropicalclimates.BCCandSCCvaryintheirappearance.SCCinitially
presentasraisedlesionsthatexhibitahornyorscalyappearancethatlaterbecomenonhealinglesions
oftenlargerthan1cmwhichcanulcerateBCCstartsassmalltranslucentpapulewithobvious
telangiectasiaoverthesurface.Overtime(growthcanbeveryslow)thesizeofthepapuleincreasesandcan
ulcerateandcrustover.
Actinickeratoses
Actinickeratosesisthemostcommonpremalignantskinconditionandaffectsthesamegroupofpeopleas
SCC,withapproximately1in1000casesprogressingtoSCC.Lesionsoccuronpartsofthebodythatare
exposedtolongtermsunexposure(e.g.head,forearms,hands).Theybeginassmallroughspots.
Roughnessisakeyfeatureoftenreferredtoasfeelinglikerubbingsandpaper.Theyaregenerallyflatand
brownandhavewelldemarcatededges.Overaperiodofyearstheyenlargeandoftenbecomeredandscaly.
Seborrhoeicwarts
Thesearebenignflatorraisedlesionsthatvaryincolour.Initially,theytakeonthecolouroftheperson's
skinbutgraduallydarken.Theyrangeincolourfromlightbrowntojetblack(Fig.7.20(f0105)).Theyare
moreusualonthetrunkandincreaseinincidencefrom40yearsonwards.Overtimetheycanbecomewart
likeandhaveastuckonwaxyappearance.Occasionally,theycanbecomeinflamed,itchyorbleedbutthisis
normallybecausetheyhavebeencaughtonclothing.
Sunburn/damage
Faciallesions,especiallyinpeopleover40
Lesionsthathavebecomeitchy,irritatedorarepronetobleeding
Molesthathavechangedinsize,shapeorcolour
Avoidancemeasures
Themosteffectivestrategyforpreventingskindamage/sunburnandreducingthechanceofdeveloping
cancersisavoidanceofUVlight.CancerresearchUKhaspromotedaSunSMARTcancerprevention
programmewhichhighlightsthekeysunavoidancemeasuresthatshouldbepromotedtothepublic:
SSpendtimeintheshadebetween11amand3pm
MMakesureyouneverburn
AAimtocoverupwithaTshirt,hatandsunglasses
RRemembertotakeextracarewithchildren
TThenusefactor15+sunscreen
Itisalsoworthstressingtopeoplethatpeoplecanstillburnoncloudydays.
Sunscreens
Whilesunscreensplayanimportantroleinsunburnprotection,theyshouldneverreplaceminimisingsun
exposure.Sunscreensusethesunprotectionfactor(SPF)systemtoindicatethelevelofprotectionagainst
UVradiation.ItisameasureoftheprotectionfromUVBradiation.Thisiscalculatedunderexperimental
conditionsusingfourtimestheamountofsunscreenusuallyappliedbyconsumers.Itisimportantthat
patientsandconsumersdonotassumealinearincreaseinprotectionastheSPFincreases.Forexample,a
sunscreenwithanSPFof15blocks93%ofUVB,whereasadoublingtoSPF30onlyincreasesprotectionby
4to97%.
IntheUKacontroversialstarratingalsoexiststoindicatethelevelofprotectionofferedagainstUVA
relativetoprotectionagainstUVB.AfivestarratingindicatestheproducthasabalancedamountofUVA
andUVBprotection.ThelowerthestarratingthenthegreatertheprotectionofferedagainstUVB
comparedtoUVA.
PrescribinginformationrelatingtosunscreenproductsreviewedinthesectionEvidencebaseforoverthe
countermedicationisdiscussedandsummarisedinTable7.33(t0240)usefultipsrelatingtopatients
askingforadviceaboutprotectionfromthesunaregiveninHintsandTipsBox7.12(b0130).
Table7.33
Practicalprescribing:Summaryofsunprotectionproducts
Nameof Useinchildren Likelysideeffects Drug Patients Pregnancy&

medicine interactions inwhich breastfeeding
ofnote care
exercised
Chemical Infantupwardsbut Allergicreactionsbutmay None None OK

sunscreens somemanufacturers belinkedtothevehicleand
dohavelowerage nottheactiveingredients
limits
Physical None,butmaybe
sunscreens cosmeticallyunacceptable
Sundamage

Waterresistant Theseareclaimedtobeeffectiveafterimmersioninwater.However,studieshave
sunscreens shownthatsunscreeneffectivenessdecreasesafterwaterexposure.Itwouldbe
prudentthereforetoreapplysunscreensafterswimming
Eyeprotection Prolonged(overyears)sunexposurecancontributetoagerelatedmacular
degeneration.Thereforewraparoundsunglassesandlensesthateffectivelyfilter
UVlightshouldbeworn
Treatmentof Mildsunburncanbemanagedwithacombinationoftopicalcoolingpreparations,
sunburn? suchascalamine,moisturisersandsystemicanalgesia
Medicine Piroxicam,tetracyclines,chlorpromazine,phenothiazinesandamiodaronecan
induced causepruritusandskinrashwhentheskinisexposedtonaturalsunlight,primarily
photosensitivity duetoUVAradiation.Patientsonphotosensitivedrugsshoulduseabroad
spectrumsunscreenasthesefilterbothUVAandUVBradiation
Sunprotection InFebruary2012theDoHissuedguidancetohealthcareprofessionalsonthe
andvitaminD dangerofvitaminDdeficiency.This,inpart,hasbeencausedbytheuseof
deficiency sunscreens.Guidanceisnottostopusingsunscreenbutcertainpatientgroups
shouldtakesupplements
http://www.dh.gov.uk/health/2012/02/vitamind/
(http://http://www.dh.gov.uk/health/2012/02/vitamind/)(accessed22November2012)
http://www.npa.co.uk/resources/informationleafletsandfactsheets/clinical/preventing
vitaminddeficiencyinatriskgroups/(http://www.npa.co.uk/resources/informationleaflets
andfactsheets/clinical/preventingvitaminddeficiencyinatriskgroups/)(accessed22
November2012)
Allproductsshouldbeapplied20minutesbeforeexposuretothesun,andreappliedevery2to4hoursand
afterswimmingtoensuremaximumprotection.Standardpracticeuntilrecentlywastomatchskintype
withthelevelofSPFprotectionthepersonrequired.However,thisapproachwhilstpreventingsunburn
doesnotpreventlongtermskindamage.Ratherthanselectingaspecificsunscreenforskintypeitis
advocatedthatallwhiteskinnedpeopleshoulduseasunscreenwithanSPFofatleast15becausethislevel
ofprotectioniseffectivelyasunblock.
Chemicalsunscreens
ChemicalsunscreensworkbyabsorbingUVenergyandgiveprotectionagainsteitherUVAorUVB,
althoughtheytendtobemoreeffectiveagainstUVBradiation.Themajorityofmarketedproductscontaina
combinationofagentsincludingbenzophenones,cinnamates,dibenzoylmethanesandparaaminobenzoic
acid.Thelatterisnowinfrequentlyused,asparaaminobenzoicacidwasfrequentlyassociatedwithcontact
sensitivity.
Physicalsunscreens
PhysicalsunscreensareopaquereflectiveagentsandofferprotectionagainstUVAandUVBradiation.
Examplesofphysicalsunscreensincludezincandtitaniumoxide.
Websites
Charities
http://www.skincancer.org/(http://www.skincancer.org/)(TheSkinCancerFoundation)
http://www.cancerresearchuk.org/home/(http://www.cancerresearchuk.org/home/)(CancerResearchUK)
Guidance
Prodigyguidance.http://www.prodigy.clarity.co.uk/melanoma_and_pigmented_lesions
(http://www.prodigy.clarity.co.uk/melanoma_and_pigmented_lesions)
NICEguidanceonskintumoursincludingmelanoma.http://www.nice.org.uk/guidance/csgstim/?c=91528
(http://www.nice.org.uk/guidance/csgstim/?c=91528)
http://www.sign.ac.uk/guidelines/fulltext/72/index.html(http://www.sign.ac.uk/guidelines/fulltext/72/index.html)
2007.BritishAssociationofDermatologistsguidelinesonTheprevention,diagnosis,referraland
managementofmelanomaoftheskin.
http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/RCP%20Melanoma%20Guidelines%202007.pdf
(http://www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/RCP%20Melanoma%20Guidelines%202007.pdf)
Generalsites
http://www.sunsmart.com.au/(http://www.sunsmart.com.au/)(Sunsmartwebsite)
http://www.cancer.org.au/(http://www.cancer.org.au/)(CancerCouncilAustralia)
http://www.melanoma.org/(http://www.melanoma.org/)(MelanomaResearchFoundation)
http://www.melanoma.com/(http://www.melanoma.com/)
Selfassessmentquestions
Thefollowingquestionsareintendedtosupplementthetext.Twolevelsofquestionsare
providedmultiplechoicequestionsandcasestudies.Themultiplechoicequestionsare
designedtotestfactualrecallandthecasestudiesallowknowledgetobeappliedtoa
practicesetting.
Multiplechoicequestions
7.1Whichmedicinehasnotbeenproventobeefficaciousintreatingdandruff?
a.Coaltar
b.Cetrimide
c.Ketoconazole
d.Zincpyrithione
e.Seleniumsulphide
7.2.WhichformofpsoriasiscanbemanagedOTC?
a.Guttate
b.Pustular
c.Plaque
d.Seborrhoeic
e.Erythrodermic
7.3.Whichmedicineisknowntocausehairloss?
a.Nifedipine
b.Simvastatin
c.Ranitidine
d.Ibuprofen
e.Warfarin
7.4.Whatsymptomisleastassociatedwithpsoriasis?
a.Itch
b.Redness
c.Scaling
d.Papules
e.Raisedplaques
7.5.Whichformoftineainfectionareimidazolesineffective?
a.Athlete'sfoot
b.Jockitch
c.Infectioninvolvingthebody
d.Infectioninvolvingthenail
e.Infectiononthehand
7.6.Acorniscausedby?
a.Sweatingfeet
b.Excessivepressurecausedbyillfittingshoes
c.Toomuchpressurecausedbyanatomicaldeformity
d.Humanpapillomavirus
e.Noneoftheabove
7.7.Inwhichconditionisitchingtheleastprominent?
a.Allergicdermatitis
b.Scabies
c.Fungalinfection
d.Psoriasis
e.Lichenplanus
7.8.Whatskinconditionischaracterisedbysilverywhitescalylesionsofsalmonpinkappearance
withwelldefinedboundaries?
a.Contactdermatitis
b.Rosacea
c.Plaquepsoriasis
d.Seborrhoeicdermatitis
e.Pityriasisversicolor
Questions7.9to7.11concernthefollowingconditions:
A.Dermatitis
B.Plaquepsoriasis
C.Fungalinfection
D.Acne
E.Coldsores
Select,fromAtoE,whichoftheaboveconditions:
7.9.Ischaracterisedbyitchingandscaling
7.10.Oftenhasprodromalsymptomspriortotherashappearing
7.11.Hasastronggeneticlink
Questions7.12to7.14concernthefollowingmedicinesforfungalinfection:
A.Hydrocortisone
B.Clotrimazole
C.Amorolfine
D.Tolnaftate
E.Bifonazole
Select,fromAtoE,whichoftheabovemedicines:
7.12.Isappliedoncedaily
7.13.Isappliedonceweekly
7.14.Shouldbeusedfornolongerthan1week
Questions7.15to7.17:foreachofthesequestionsoneormoreoftheresponsesis(are)correct.Decide
whichoftheresponsesis(are)correct.Thenchoose:
A.Ifa,bandcarecorrect
B.Ifaandbonlyarecorrect
C.Ifbandconlyarecorrect
D.Ifaonlyiscorrect
E.Ifconlyiscorrect
Directionssummarised
A B C D E
a,bandc aandbonly bandconly aonly conly
7.15.Forthefollowingstatementsaboutcradlecapwhichis/aretrue?
a.Thereisnormallyafamilyhistory
b.Earandeyeinvolvementiscommon
c.Therashtendsnottoitch
7.16.Wartsandverrucasare:
a.Causedbythehumanpapillomavirus
b.Infectionsthatneveraffectadults
c.Candevelopintoprecancerousgrowthsifleftuntreated
7.17.Whensupplyingaciclovir,patientsshouldbetoldto:
a.Usetheproduct5timesaday
b.Applyassoonassymptomsareexperienced
c.Washtheirhandsafterapplication
Questions7.18to7.20:thesequestionsconsistofastatementinthelefthandcolumnfollowedbya
statementintherighthandcolumn.Youneedto:
decidewhetherthefirststatementistrueorfalse
decidewhetherthesecondstatementistrueorfalse
Thenchoose:
A.Ifbothstatementsaretrueandthesecondstatementisacorrectexplanationofthefirststatement
B.IfbothstatementsaretruebutthesecondstatementisNOTacorrectexplanationofthefirst
statement
C.Ifthefirststatementistruebutthesecondstatementisfalse
D.Ifthefirststatementisfalsebutthesecondstatementistrue
E.Ifbothstatementsarefalse
Directionssummarised
1ststatement 2ndstatement
A True True 2ndexplanationisacorrectexplanationofthefirst
B True True 2ndstatementisnotacorrectexplanationofthefirst
C True False
D False True
E False False
Firststatement Secondstatement
7.18Benzoylperoxideshouldbeusedtotreatmild Itshouldbeusedforatleast6weeks
acne
7.19Scabiesisintenselyitchy Themite'sfaecescauseahypersensitivity
reaction
7.20Minoxidilisusedtotreathairloss Itworksonover80%ofpatients
Casestudy
CASESTUDY7.1
MrRJandhis9yearoldsonJimmywanttobuysomethingforJimmy'sverruca.MrRJ
thinksthatJimmyhashadtheverrucaforabout4to6weeks.Hedescribesitasa
circulardiscolouredpieceofskinthatlooksliketheverrucasheusedtoget.
a.Whatcourseofactionareyougoingtotake?TryanddirectlyquestionJimmy.Seeif
Jimmyknowshowlongthesuspectedverrucahasbeenthere.Askifthelesioniscausingany
painwhenwalking.Insteadofaskingforfurtherdescriptionsofwhatthelesionlookslikeand
whereitispositionedaskifyoucanactuallylookatthelesion.Remembertowashyourhands
beforeandafterinspectingthefoot.Onfurtherquestioningandexaminationyouconcurwith
theselfdiagnosisofaverruca.Thelesionissmall(lessthan0.5cmindiameter)andcausesno
painwhendirectpressureisapplied.
b.Whatareyougoingtorecommend?Asalicylicacidbasedproductisthemostsuitable
product,andyourecommendBazukaafterfirstmakingsureJimmyisnotdiabetic.Sixweeks
laterMrsJreturnswithJimmyanddemandstoseethepharmacist.Shesaysthestuffyou
recommendedisrubbishandJimmy'sverrucaisbiggerthanitwasbefore!
c.Howareyougoingtorespond?First,youmuststaycalmandnotbedefensive.Askopen
questionstofindoutwhyMrsJisunhappythisapproachwillgenerallyrevealwhatthe
problemis.Second,ifthereasonisnotobviousthenyoumustfindoutaboutcompliance.Who
hasbeenresponsibleforapplyingtheproduct?IftheparentshavetoldJimmytouseit,hashe
beenusingtheproductcorrectlyandatthecorrectdosagefrequency?Inaddition,many
patientshaveunrealisticexpectationsonhowquicklytheverrucawillresolvewiththerapy.
Didyoutellthemhowlongitwouldtakebeforeanaffectwillbeseen?Thisisavitalpieceof
informationtoensurepatientsrealisethattreatmentisnotaquickcure.YoufindoutthatMrs
JhasbeenapplyingtheBazukaanddoingeverythingtheinstructionleafletsays.Youinspect
Jimmy'sfeetagainandfromwhatyoucanrememberthelesiondoeslookslightlylarger.
d.Whymightthisbethecase?Salicylicacidisdestructiveinnatureandiftheproduct
comesintocontactwithnonaffectedskinthenitcandamageskinandappeartothepatient
thatthelesionhasindeedgotbigger.MrsJwantstotryBazukaExtraStrengthsincethe
normalBazukaisn'thelping.
e.Whatareyougoingtodo?YoumusttrytostresstoMrsJthatshecontinueswiththe
normalBazukabecause6weeksoftherapyisnotlongenoughtomakeadecisiontoalter
therapy.Reluctantly,MrsJacceptsyouradviceandleavesthepharmacypromisingshewill
tryforabitlonger.OneweeklatershepresentsaprescriptionforCuplexgelforJimmy.
f.Whatareyougoingtodo?ItappearsthatMrsJwasnotsatisfiedorconvincedwithyour
adviceandhasdecidedtoseetheGP.YoudonotknowwhetherMrsJtoldtheGPaboutusing
anOTCproduct.YoucouldringtheGPtotellhimorherthatMrsJhasbeenusingasalicylic
acidbasedproductalready,however,thisislikelytohavelittlebearingontheoutcomeof
productselectionasJimmywillstillneedtocontinuetreatmentwithsomethingforafewmore
weeks.TheprescriptionshouldbedispensedandMrsJcounselledappropriately.Itwouldbe
unprofessionaltopointoutthatCuplexisunlikelytobeanybetterthanBazuka.Whenyou
handMrsJtheCuplexshementionsthatthedoctorsaidthiswasstrongerthanBazukaand
shoulddothetrick.
g.Howdoyoureply?Bediplomaticandnonjudgemental.ItislikelythattheGPknowsthat
CuplexisnobetterthanBazukabutiftheparentisconvincedthatwhatsheisnowgettingis
superiortothepreviousproductthenhermotivationtocomplywithdirectionsmightbebetter
andhencetheoutcomeforJimmywillbeeradicationoftheverruca.Itmightbeworthasking
theGP,nexttimeyouhaveaconversation,whathisorherrationaleforprescribingCuplex
was.
CASESTUDY7.2
MsAHisthemotherofaninfantsonaged4months.Sheasksforyourhelpintreating
herson'sflakyskinonhisscalp.Shesayshehashadtheproblemonandoffforthelast
6weeks.Shehasn'tyettriedanythingexceptbabyshampoo,asrecommendedbythe
healthvisitor.However,shenowwantsacreamorsomethingtogetridoftheproblem
onceandforall.
a.Whatfurtherinformationdoyourequiretobeinapositiontohelpher?Youneed
toknowmoreabouttheseverityoftheproblem,forexamplewhetheranyotherpartsofthe
baby'sskinisaffected.Doesthebabyappeartoscratchattherashandwhatweretheprevious
episodeslike?Weretheythesameasthistimeordifferent?Alsoisthereafamilyhistoryof
atopyorotherdermatologicalconditionsinthefamily.Youdecidethechildhascradlecap.
b.Whattreatmentareyougoingtorecommend?Theuseofamildtarbasedproduct
everyotherdayuntilthescalpclearswouldbeappropriate.Inbetweenusingthetarbased
productthemothershouldbeinstructedtousethebabyshampoo.MsAHreturnstothe
pharmacy2weekslaterwithanotherofherchildren.Impressedthatherson'sscalpisnow
clearshenowwantssomeadviceforher7yearolddaughter.Shehasasoreonthecornerof
hermouth.
c.Whatfurtherinformationdoyourequiretobeinapositiontohelpher?Youneed
toknow:
Howlonghasthesorebeenpresent
Howthesorefirstdeveloped
Whatsymptomsareassociatedwiththesore
Theprogressionofthesore.Hasitspread?
Previoushistoryoftherashandafamilyhistory
Youfindoutthesoreappearedovernightandisnowitchy.Oninspectionthelesionappearsto
beweepingaclearexudate.
d.Whatisthemostlikelydiagnosis?Basedonthisinformationthelikelydiagnosisisa
coldsore.
e.Whattreatment,ifany,areyougoingtorecommend?Notreatmentnecessarybutif
theparentinsistsontherapythenanyproductcouldbegiven,althoughantiviraltherapyis
expensiveandthecostdifficulttojustify.Inaddition,adviceonminimisingtransmissioncould
begivensuchasnotsharingtowelsandtryingtoavoidkissing(e.g.mumanddad).
CASESTUDY7.3
MrRT,anelderlymanasksforsomecreamtohelpgetridofarashhehasoverpartof
hischest.Thefollowingquestionsareasked,andresponsesreceived.
Informationgathering Datagenerated
Presentingcomplaint
Howlonghadthe Rashstarted3daysago
symptoms
Whatdoesitlooklike Redandangry
Whereexactly Startedonhisleftsidebelowhisarmpitandnowspreadunderthearm
pit.
Other Feltabitunwell,slightlossofappetite&headache.
symptoms/provokes
Anyitchingorpain? Somepainratedas4onscaleof110
Additionalquestions
Previoushistoryof Nonesimilar
presentingcomplaint
Pastmedicalhistory Slightstroke1yearago.Hypertensioncontrolledwithmedication
Eczema,Contactdermatitis,urticariatosomeplants
Drugs(OTC,Rx,and Warfarin,Bendroflumethiazide,AdalatLA
compliance)
DoubleBasecream
Occasionaluseofclobetasone(Eumovate)fordermatitis
Allergies Unknown
Socialhistory Wifedied6monthsago,findingitdifficulttocopeattimes.Doesnotlike
Smoking tobotherchildrenwholivelocally.Feelsverylow
Alcohol
Drugs
Employment
Relationships
Familyhistory Notasked
Onexamination Clustersofpapules&vesiclesunilaterallyalongdermatomeaffectingleft
chestandback.
Diagnosticpointerswithregardtosymptompresentation
Forskinrashseenonthetrunkintheareaobservedthenherpeszosterseemslikely.Theexpected
findingsforquestionswhenrelatedtothepossibleconditionsthatcouldbeconfusedwithherpes
zosterthatareseenbycommunitypharmacistsaresummarisedbelow.
Vesicles Unilateral Recurrent Pain Othersymptoms

Herpeszoster Yes Yes Unusual Yes Tingling/burningpriortoeruption
Generalmalaise
Contactdermatitis Possible Yes Yes Possible Itch
Herpessimplex Yes Yes Yes Yes Noneofnote
Eczema Possible Possible Yes Possible Itch
Trauma No Possible No Yes Shouldbeanobviouscause
Whenthisinformationisappliedtothatgainedfromourpatient(below)weseethathissymptomsfit
withherpeszoster.
Vesicles Unilateral Recurrent Pain Othersymptoms
Herpeszoster
Contactdermatitis ?
Herpessimplex
Eczema
Trauma X
Shinglesinformation
Shinglesisanacuteinfectioncausedbyreactivationoflatentvaricellazostervirus.Followingprimary
chickenpoxinfection,thevirusliesdormantinthedorsalrootgangliaofthespinalcord.When
reactivated,ittravelsalongthesensorynervetoaffectoneormoredermatomes,causingthe
characteristicshinglesrash.Reactivationofthevirusprobablyoccursfollowingadecreaseincell
mediatedimmunity(e.g.withincreasingage,HIVinfection,illness).Adiagnosticquestiontoaskis
previoushistoryofchickenpox.Ifthepatienthasneverhadchickenpoxthentheycannotdevelop
shingles.
Courseofaction
Thepatientcouldbegivenanalgesicstohelpwithpainbutreferredforpossibleantivirals.(e.g.
Famciclovir250mgtdsfor7days)andwarnedaboutpostherpeticneuralgia.Thepatientalsoseems
tobeshowingsignsofdepressionwhichneedsfurtherinvestigation.Itwouldbegoodpractice,inthis
case,totryandspeakwiththeGPtoarrangeanurgentappointmentforthepatienttotreattherash
butalsomentionyourconcernsoverthepatientexhibitingsignsofdepressiveillness.
CASESTUDY7.4
MrAC,amaninhislate20s/early30spresentswithaveryitchyrashonhislefthand.
Heasksifyoucangivehimacreamtostoptheitching.Thefollowingquestionsare
asked,andresponsesreceived.
Informationgathering Datagenerated
Presentingcomplaint(possiblequestions)
Howlonghadthe Fewdays
symptoms
Rashanywhereelse No
Other Notreallyjustreallyitchy!
symptoms/provokes
Additionalquestions Noexposuretochemicalsornewtasksinvolvinghandwork
Previoushistoryof No
presentingcomplaint
Pastmedicalhistory Epileptic
Drugs(OTC,Rx,and Na.valproate500mgbd.Wellcontrolled.
compliance)
Allergies None
Socialhistory WorksfortheNHSdoingpatienttransports
Smoking
Alcohol
Drugs
Employment
Relationships
Familyhistory Dadhaseczema
Onexamination Lefthandandwristverysore.Obviousredpapulesinplacesbutlooklike
theyhavebeenscratched(thisisconfirmedbypatient)
Markeditchinginvolvingthehandsismostlikelytobescabies.However,otherconditionsare
possibleandarenotedbelow:
Probability Cause
MostLikely Scabies
Likely Dermatitis,insectbites,pompholyx
Veryunlikely Dermatitisherpetiformis
Usingtheinformationgainedfromquestioningandlinkingthiswithknownepidemiology,itshould
bepossibletomakeadifferentialdiagnosis.
Diagnosticpointerswithregardtosymptompresentation
Theexpectedfindingsforquestionswhenrelatedtothedifferentconditionsthatcanbeseenby
communitypharmacistsaresummarisedbelow.
Locationotherthan Lesionappearance Itch Positivefamilyor

hands&wrists socialhistory
Scabies Unusual Redpapulesthroughto Intense Yes

vesicles
Dermatitis Often(dependson Redscalingrashthatmight Moderate No

typeofdermatitis) crustoverduetoscratching tointense
Insectbites Often Redpapulesthroughto Moderate Possible

vesicles tointense
Pompholyx Unusual Vesicles Intense No
Dermatitis Usual Redpapulesthroughto Intense No

herpetiformis vesicles
Whenthisinformationisappliedtothatgainedfromourpatient(below)weseethathissymptoms
mostcloselymatchscabies.
Locationother Lesion Itch Positivefamilyor

thanhands& appearance socialhistory
wrists
Scabies
(intensitypointsmoreto (occupationexposes
scabiesthanother persontohigherrisk)
conditions)
Dermatitis ?
Insectbites ?
Pompholyx ?
Dermatitis
herpetiformis
Therapycouldbestartedwithpermethrincream,althoughitisexpensiveandreferraltotheGPmight
beconsidered.Itisalsoimportanttotryandtracethecontactfromwhichhehascontractedscabies
fromandalsoinformwork.
Dangersymptoms/signs(triggerpointsforreferral)
Asafinaldoublecheckitmightbeworthmakingsurethepersonhasnoneofthereferralsignsor
symptomsthisisthecasewiththispatient.
Severeandextensivesymptoms
Suspecteddermatitisherpetiformis
Answers
1=b 2=c 3=e 4=d 5=d 6=b 7=d 8=c 9=c 10=e 11
=b 12=e 13=c 14=a 15=c 16=d 17=a 18=b 19=a 20=c
References
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Masonetal,2009.MasonAR,MasonJ,CorkM,etal:Topicaltreatmentsforchronicplaque
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ointmentandtarinchronicplaquepsoriasis.BrJDermatol1994131:pp.673677
Guptaetal,2004.GuptaAK,BatraR,BluhmR,etal:SkindiseasesassociatedwithMalassezia
species.JAmAcadDermatol200451:pp.785798
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Manriquez,Uribe,2007.ManriquezJJ,andUribeP:Seborrhoeicdermatitis.ClinicalEvidence.
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dermatophytoses.ClinExpDermatol199419:pp.4346
Crawford,Hollis,2007.CrawfordF,andHollisS:Topicaltreatmentsforfungalinfectionsofthe
skinandnailsofthefoot.CochraneDatabaseofSystematicReviews2007undefined:
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BOOKCHAPTER

Scalp,Skinor Salicylic Sulphur Other Children Application

Alphosyl2in1 Scalp No No No Allages Every2to3days

Capasal Scalp Yes No Coconutoil Allages Daily

CarboDome Cream No No No Allages Twoorthreetimesa

Cocois Scalp Yes Yes No >6 Weekly

Exorex Scalp No No No >12 2to3timesaday

Pentraxshampoo Scalp No No No Allages Twiceweekly

Pinetarsol Skin No No No Allages Canbeusedasasoap

Polytar&Polytar Scalp No No No Allages Onceortwiceweekly

Psoriderm Both No No No Allages Onceortwiceaday

SebCo Scalp Yes Yes No >6 Dailywhenneeded

T/Gel Scalp No No No Allages 2to3timesaweek

Nameof Usein Likelyside Drug Patients Pregnancy&Breastfeeding

Coaltar Allages Localirritation None None OK

Nameofmedicine Usein Likelyside Drug Patientsinwhich Pregnancy&

DentinoxCradle Birth None None None Notapplicable

Nameofmedicine Useinchildren Likelyside Drug Patientsin Pregnancy&

Bifonazole Allages Mild None None OK

Mycil Nolowerage None None None OK

Mycota Nolowerage None None None OK

Whitfield'sOintment Nolowerage None None None OK

Lamisilrange&Scholl >16years(>18 Redness, None None OK

Griseofulvin(GrisolAF) Nolowerage Stinging None None OK

Activeingredient Brand Formulations

Bifonazole CanestenBifonazoleOnceDaily Cream

Clotrimazole1% CanestenAF Cream,spray

Clotrimazole1%&Hydrocortisone1% CanestenHydrocortisone Cream

Miconazole2% DaktarinActiv Cream,spray,powder

Miconazole2%&hydrocortisone1% DaktacortHydrocortisone Cream

Ketoconazole DaktarinGold Cream

Terbinafine LamisilAT Spray,cream,gel

Tolnaftate Mycil Ointment,spray,powder

Undecenoicacid Mycota Cream,spray,powder

Type Keycharacteristics Spreadofinfection

DLSO Mainlybigtoe Noteyellowingstartsatdistalpartoftoeor

Proximalsubungual Immunocompromisedpatients Yellowspotsappearatthebaseofthenail

Superficialwhite Oftenoccursinpreviouslydamaged Locatedonthesurfaceofthenail

Nameof Usein Likely Drug Patientsinwhich Pregnancy&breastfeeding

Amorolfine >18 Skin None None Manufacturersstateavoid,although

Nameof Usein Likelyside Drug Patientsinwhichcare Pregnancy&

Minoxidil Not Skinirritation, None Avoidinhypertensive Avoid

Nameof Usein Likelysideeffects Drug Patientsin Pregnancy&breastfeeding

Compound >6 Localskinirritation None Avoidin OK

Bazuka No Localskinirritation None Avoidin OK

Glutarol No Localskinirritation. None Avoidin OK

Veracur No Nolocalaffects None Avoidin Pregnancy

Silver No Localskinirritation None Avoidin OK

Nameof Usein Likelysideeffects Drug Patientsinwhichcare Pregnancy&

Permethrin >2 Burning,stinging None None OK

Benzyl >12 Burning,irritation

Malathion >6 Skinirritationbut

Nameof Usein Likelysideeffects Drug Patientsinwhich Pregnancy&

Benzoyl Not Skinirritation, None None OK

Name Form Strength Otheringredients

PanOxyl Aquagel 2.5%,5%,10%,

Quinoderm Cream 5,10% Antimicrobialhydroxyquinolinesulphate0.5%,

Oxy10 Lotion 10%

Nameof Useinchildren Likely Drug Patientsin Pregnancy&

Aciclovir All(exceptLypsylproduct)statecan Stinging None OK OK

Penciclovir >12years None None None Manufacturers

Ammonia Yes,butnoloweragestated None None None OK

Phenol Yes,butnoloweragestated None None None OK

Zinc& >12years Stinging None None OK