Self Care Exam 1

seborrheic dermatitis

-chronic inflammatory dermatitis of the scalp, face, and/or trunk

-occurs in areas of greatest sebaceous activity

-red, scaly, itchy rash, yellow, greasy scales with erythema

-hyperproliferation with 3x normal turnover rate d/t Malassezia

Infant SD Presentation

-infantile cradle cap

-usually self limiting

-massage scalp with baby oil

-nonmedicated shampoos

-emollients/moisturizers for face

Adult SD Presentation

-dull, yellowish, oily scales on red skin

-well demarcated on pruritus is common

-common on scalp and middle face

-may have exudation and crusting

SD Self Care Treatment

-medicated shampoo (pyrithione zinc 1-2%, selenium sulfide 1%, ketoconazole 1%, coal tar 0.5-5%, salicylic acid or sulfur as alternative)

-emollients/moisturizers

-hydrocortisone (applied to affected area NTE 7 days)

Medicated Shampoos

-more aggressive

-apply daily to 1-2 weeks, then at least 2-3 times/week x 4 weeks, then weekly once controlled

-exception: ketoconazole 2x/week for up to 8 week with >3 days between uses, then weekly

-use regardless of symptom location as shampoo and on affected areas

Alternatives

-salicylic acid or sulfur products

-keratolytic: normalizes proliferation

-slower acting than other products

-nonmedicated shampoo/dish soap: soften crusts and scales

-topical antifungal creams

Psoriasis

-chronic inflammatory disease

-plaque psoriasis most common

-unpredictable relapsing and remitting course

-hyperproliferation with 6-8 x normal turnover rate

-unknown cause but environmental, infections, Rx drugs, stress, alcohol, and tobacco play a role

Psoriasis Presentation

-thick scales on well defined, raised plaques

-pinpoint bleeding when scale is removed

-common on extensor surfaces, lumbar back, scalp, ears, and genitals

Psoriasis self care treatment

-only for mild (few isolated lesions < size of a quarter)

-regular use of moisturizers

-hydrocortisone: ointment usually preferred ( more occlusive), wait 30 min then apply emollient

-medicated shampoo: coal tar, salicylic acid

-contact PCP if no improvement in 1-2 weeks

Nonpharm treatment for Psoriasis

-bathe 2-3 times per week with lubr bath products in tepid water

-emollient 4x daily

-remove scales with soft cloth

-reduce stress

-avoid injury

-weight loss

-smoking cessation

-avoid EtOH

Exclusions to Self Care for Psoriasis

-children < 2 years

-involvement of >5% of BSA

-more than a few lesions or any one lesion larger than a quarter

-associated with joint pain

Irritant Contact Dermatitis

-direct tissue damage

-itching, erythema, stinging/burning, edema

-occurs in min-hours possibly after 1st exposure

Allergic Contact Dermatitis

-immune response to antigen

-itching, erythema, vesicles, papules, edema

-occurs in days, most often in sensitized pts

-type IV hypersensitivity

Causative Agents ICD

-detergents

-hand sanitizer

-soap

-alkalis or acids

-urine/feces

ICD Presentation (Irritant Contact Dermatitis)

-dry, cracked skin, or inflamed, erythematous skin

-often with pruritus', burning, or stinging

ICD Treatment (Skin)

-avoid exposure

-wash with hypoallergenic soap

-colloidal oatmeal baths

-emollients/moisturizers

-urea or glycerin is benifical

-petrolatum is gold standard for preventing epidermal water loss

-do not use hydrocortisone

-protective clothing

-contact PCP if no improvement after 1 week

Causative Agents ACD

-poison ivy/oak/sumac

-nickel

-latex

-fragrances

-cosmetics

Urushiol

-oleoresin in Toxicodendron plants

-black tarry lacquer released with plant damage

-enters skin within 10 min

-80% pop is sensitive

ACD presentation (Allergic Contact Dermatitis)

pruritus, erythema, papules, vesicles/bullae (vesicle fluid does not contain antigen)

Mild ACD (Allergic Contact Dermatitis)

linear streaks in distinct patches

Moderate ACD (Allergic Contact Dermatitis)

vesicles and erythematous swelling

Severe ACD (Allergic Contact Dermatitis)

extensive involvement with edema of face and/or extremities

ACD Treatment

-remove antigen from skin and clothing ASAP

-symptomatic treatment: hydrocortisone cream, antihistamines, astringent compresses, colloidal oatmeal baths, calamine lotion

-zanfel to remove resin

-protective clothing

ACD (Allergic Contact Dermatitis) Exclusions to Self-Care

-age < 2

-mucous membrane or genital involvement

-extensive involvement >20% BSA

-numerous large bullae

-signs of infection

-symptoms developing after sun exposure

-failure of self treatment after 1-2 weeks

Cleansing

-most effective within 10 min of exposure

-Tecnu Outdoor Skin Cleanser: can use up to 8hrs after exposure, cleanse for > 2 min, can be used without water

-Ivarest Cleansing Foam

-Dial Ultra dishwashing soap

Hydrocortisone

-effective for mild-moderate ACD

-helps with inflammation, pruritus and erythema

-avoid on eyes/eyelids

-cream preferred over ointment if weeping

-apply 2-4 times daily for up to 7 days

Astringents

-useful if weeping

-Burow's solution (aluminum acetate 5%): mic tablet/packet with 1 pt of water, soak 15-30min 3-4 times daily

-witch hazel

-wet dressings or cool compresses

-20-30min, 4-6 times daily

Calamine

-astringent, protectant, and soothing agent

-apply 3-4 times daily (shake prior to sue, avoid on large areas/mucous membranes)

Zanfel (R)

-only product known to remove urushiol (oil from poison ivy) from skin

-may relieve itching and pain within 30 seconds

-can use any time after exposure

-later 1.5" to paste in hands rub on area up to 3 min, rinse

-may to 2nd treatment if needed

Barrier Products

-Ivy Block Lotion (bentoquatam 5%): effective when applies >15 min before, apply generously and reapply q4h or prn, not currently available in US

-IvyX Pre Contact Solution: claims to tighten skin pores, not sticky, greasy, or clay like, not well studied but may be effective in combo with post exposure cleansing

Salivary Glands

-responsible for secreting saliva

-normal function promotes good oral health

Tongue

-muscular organ

-vital for chewing and swallowing food

Root

below gum line

Crown

above gums, surface for affective chewing

Enamel

hard Ca P salts, protection

Dentin

softer, largest part of structure

Pulp

vasculature neural tissue, continuous with surroundings

Cementum

hard tissue, helps ligament attach

Gum (gingiva)

Firm but soft tissue surrounding the alveolar process, when attached =pink

Dental Caries

Cavities

Dental Caries Risks

poor oral hygiene , xerostomia, tobacco, alcohol, diabetes, medication (anticholinergic), orthodontic devices, high cariogenic foods, head and neck radiation

Dental Caries Pathophysiology

plaque bacteria generate acid from dietary carbohydrates which demineralizes tooth enamel and dentin, leading to the formation of soft carious lesions, plaque

Dental Caries Prevention Nonpharm

-food choices: low cariogenic food (< 15% sugar), eating fresh fruit, high protein, and fibrous food

-plaque removal devices

Dental Caries Prevention Pharmacologic

fluoride (incorporated into growing teeth makes more resistant to break down, interferes with bacterial growth), dentifrices, mouth rinse

Whitening Products

-available: toothpastes (surface abrasives), strips (low hydrogen peroxide then professional), activated charcoal and other home based methods (abrasive, thought to absorb stains, don't recommend

-concerns: tooth sensitivity, irritated gums, painful for those with cracks, not appropriate for those with cavities or dental work being done

Gingivitis

inflammation of the gums

gingivitis pathophysiology

- accumulation of bacterial plaque

-drugs: Ca2+ channel blockers, anticholinergic, antidepressants

-smoking

-hormones: pregnant

Gingivitis Clinical Presentation

-erythema (redness), enlarged gingiva, inflammation

-common, reversible, mild but can escalate into periodontitis (ligament/bone attachment compromised/lost, tooth unprotected)

Gingivitis Prevention

-calculus prevention

-plaque control

Halitosis

bad breath

Halitosis Pathophysiology

-oral and systemic conditions

-impacted food

-cavities, infection

-tobacco products

-certain food: high sulfur (volatile sulfur compounds)

Halitosis Prevention

-physical: hydration, brushing teeth (fluoride), get back of tongue, mouth wash, flossing, tongue scrapper

-chemical: zinc salts, chloride dioxides

Denture Related Problems Pathophysiology

-similar to natural teeth

-fungal and bacterial growth

-chronic atrophic candidiasis (yeast infection of mouth)

-angular cheilitis (cracking of corner of mouth): terbinafine cream

Denture Related Problems Prevention

-regular cleaning

-brushing

-soaking in alkaline peroxide or sodium hypochlorite

-brush again to remove products

Exclusions for Self Treatment of Hygiene Related Oral Disorders

-symptoms of toothache

-development of a mottled appearance to the teeth

-bleeding, swelling, or reddened gums

-persistent mouth odor despite regular hygiene

tooth hypersensitivity pathophysiology

-dentin exposure

-dentin tubules open

Tooth Hypersensitivity clinical presentation

pain when exposes to certain stimuli (heat, cold, acid, sweet, sour)

Tooth Hypersensitivity Nonpharm

-avoid predisposing factors

Sensodyne fresh impact

-Crest Pro-Health

Tooth Hypersensitivity Pharmacologic Treatment

-Potassium Salts: depolarize the excited nerves in pulp

-Arginine: minimize the flow of fluid

-treat as long as needed but if not relieved in 4-6 weeks refer to dentist

Tooth Hypersensitivity Exclusions for Self Treatment

-toothache

-mouth soreness associated with poor fitting dentures

-presence of fever or swelling

-loose gums

-bleeding gums in the absence of trauma

-broken/knocked out teeth

-severe tooth pain triggered or worsened by hot, cold, or chewing

-trauma to mouth

Teething

-very young, when new teeth come in

-irritable, pain, redness, drooling

Teething Nonpharm.

-gum massage

-teeth ring

Teething Pharmacologic

-topical oral anesthetics (not FDA recommended): oral benzocaine, oral lidocaine, can cause toxicity

-homeopathic remedies (don't recommend): teething tablets, toxicity

-Analgesics: Acetaminophen 10-15mg/kg every 4-6 hrs and Ibuprofen 5-10 mg/kg every 6-8 hrs

Aphthous Stomatitis

canker sore

Aphthous Stomatitis Pathophysiology

-cause unknown

-precipitating factors: genetic, trauma, diet, HIV/AIDS, neutrophil dysfunction, vitamin deficiency

Aphthous Stomatitis Clinical Presentation

-epithelial ulceration in mucosal surface of movable mouth parts

-round/oval

-flat/crateriform

-gray to grayish yellow

Aphthous Stomatitis Nonpharm

-fix nutrition deficiency

-avoid certain foods

-ice (NO HEAT)

Aphthous Stomatitis Pharmacologic

-carbamide peroxide (10-15%) or hydrogen peroxide (1.5%) applied to affected area and allowed to remain for 1 min before expectorating, use up to 7 days: cleanse and soothe

-topical oral protectants: canker covers, reduces friction

Exclusion for Self Care of Aphthous Stomatitis

-lesions associated with underlying pathology

-lesions present for > 14 days

-frequently recurring lesions'-symptoms of systemic illness

-failure of prior appropriate self treatment

Herpes Simplex Labialis Pathophysiology

-infection is contagious

-transmitted by direct contain

-fluid in pustules contains virus

-reactivation criteria: stress, fatigue, infection, mensuration, fever

Herpes Simplex Labialis Clinical Presentation

-affects the lip or areas bordering the lips

-onset often preceded by prodromal symptoms

-small red papules of fluid containing vesicles

-lesions can coalesce

-crust

Exclusion of Self Treatment of Herpes Simplex Labialis

-lesions present for > 14 days

-increased frequency of outbreaks

-compromised immunity

-symptoms of infection (fever, swollen glands, rash)

-no previous diagnosis of cold sores

-recurrence

Herpes Simplex Labialis Nonpharm

-gentle cleansing and hand hygiene

-avoiding precipitating factors

-SPF

Herpes Simplex Labialis Pharmacologic

-topical skin protectants: after meals, avoiding eating/drinking for 30 min after

-external anesthetics and analgesics: benzocaine, relieve itching/burning

-Docosanol 10% (Abreva): apply at first sign of an outbreak, 5 times a day, until healed for max of 10 days, decrease healing time by 1 day, spendy

-campho-phenique: cheaper, pain relief, antiseptic

-antivirals: Acyclovir, Valacyclovir, and Famciclovir (prescription)

Xerostomia

dry mouth, decreased salivation

Xerostomia Pathophysiology

-Sjogren syndrome: autoimmune condition, salivary gland dysfunction

-diabetes mellitus

-radiation therapy

Xerostomia Clinical Presentation

-difficulty talking and swallowing

-stomatitis, burning tongue, and halitosis

-unmoistened food can't be tasted

-sensitive teeth

-caries around the root surfaces of teeth and tooth decay

Xerostomia Nonpharm.

-avoid drying substances like tobacco, caffeine, hot spicy food, and alcohol

-modify medication schedules of drying meds (antidepressants)

-limit sugar, starch, and acid intake

-Xylitol: stimulate salivary flow but GI side effects

-stay hydrated

Xerostomia Pharmacologics

artificial saliva

Xerostomia Exclusions for Self Care

-tooth erosion, decalcification and decay

-candidiasis, gingivitis, and periodontitis

-moth soreness associated with poor fitting dentures

-presence of fever or swelling

-bleeding gums in the absence of trauma

-loose teeth

-severe tooth pain triggered or worsened by hot, cold, or chewing

-Sjogren syndrome

-salivary gland stones

Levocetirizine (Xyzal)

second generation antihistamine

Oxymetazoline (Afrin)

nasal decongestant

Budesonide (Rhinocort)

intranasal corticosteroid

Chlorpheniramine (Clor Trimenton)

first generation antihistamine

Azelastine (Astepro)

intranasal antihistamine

Anticholinergic effects

can't see, can't pee, can't spit, can't shit

A patient, HS comes into your pharmacy with a bottle of Robitussin DM with a curious/confused look on her face. She asks "What can I do to help me with this cough?". After motioning toward you with the bottle, she states, "I'll try anything, I can't sleep because of all this gunk in my chest that I keep coughing up." What counseling points can you provide:

- Robitussin Dm contains a pro and anti tussive and this is not a product I would recommend

- SCHOLAR MAC to gain a better insight into patients clinical picture

-Drink plenty of water as this will allow for the cough to become more productive

Water is just as effective as guaifenesin making a cough productive.

True

Patient BG presents to your pharmacy stating "this cough won't let me sleep". He shares further complaints of a sore throat that is improving with some congestion and headache after his return from vacation yesterday.

recommend pseudoephedrine (sudafed)

BG is wondering if his wife can take the same medication since she is having a similar experience after returning. After going through SCHOLAR MAC you learn that BG's wife is taking losartan and amlodipine. Would you give the same recommendation to BG's wife that you gave to him?

-no I would not

-hypertension medication indicates hypertension

-contraindicated with decongestant, contracts blood vessels

BG returns to your pharmacy a few weeks later. He says "Now if only I could get my eyes and nose to stop watering." He goes on to say this happens every year and gets worse when he goes outside in the spring or fall. What is a non pharm recommendation you can give?

-check AQI before going outside, avoidance

-HEPA filter

What is first line pharm treatment would you give?

intranasal corticosteroids

Dermatitis

inflammatory reaction pattern involving epidermis and dermis

Dermatitis Treatment Goals

-control symptoms

-decrease number and severity of flares

-increase disease free periods

-minimize exacerbating factors

-minimize adverse effects from therapy

-educate on trigger avoidance and hydration of the skin

Atopic Dermatitis

-chronic, pruritic inflammatory skin disease (follows relapsing course, usually with early age of onset and xerosis)

-dysfunctional skin barrier and dysregulation of immune system (often w/ increase in CD4 T helper cells & cytokines, filaggrin gene mutation, increased TEWL, deficient skin barrier)

atopic triad

AD, asthma, allergic rhinitis

AD Presentation Infants

face, neck, trunk, and extensor extremities

AD Presentation Young Children

neck, flexor extremities, wrists, hands, ankles, feet, inside elbows, behind knees

AD Presentation Older Children and Adults

neck, flexor extremities, and hands

thickened hyperkeratotic plaques with lichenification

Exacerbating Factors AD

-temperature extremes

-low humidity

-irritants and allergens

-infections

-food

-emotional stress

-excessive bathing