Impetigo, folliculitis/furuncles/carbuncles, acne, fungal skin infections, Athlete's foot

Impetigo

What are pustules?

opaque fluid filled blister

What are vesicles

clear fluid filled blisters, small

What are bullae?

large clear fluid blisters

Which of bullous and non-bullous impetigo is more common?

non-bullous

Describe bullous impetifo

large bullae

trunk, extremities, skin folds

more painful w/ systemic features

Describe non-bullous impetigo

clusters of vesicles with red surround skin

face or extremities

itchy or tender

How long does it take non-bullous impetigo to resolve?

2-4 weeks without scarring

If a patient comes in with bullous impetigo what should you do?

refer

How does impetigo occur?

break in skin allows bacteria to colonize (strep and s. aureus)

What are red flags for referral?

<1y

fever/chills

malaise/fatigue

3+ small patches or large patch (>2% BSA)

recurrent episodes (>=3/6 months)

What are the goals of therapy?

cure infection

reduce symptoms

prevent spread and recurrence

What are some nonpharm strats?

soaked cloth in saline or warm H2O 10-15 mins

stay home from school until 24-48h of therapy

keep nails short

wash cuts/scrapes

T/F a patient NEEDS ABX to cure impetigo

F, self limiting

What are benefits to using ABX?

faster recovery

decrease spread (go back to school)

What are the topical antimicrobial therapy options for non-bullous impetigo?

mupirocin 2% (cheapest)

fusidic acid 2%

ozenoxacin 1% (most expensive)

What should you do before applying the topical antimicrobial?

remove crust with warm soapy water

Can you use oral ABX?

only if topical did not work

T/F you can rec polysporin or a combo product for impetigo

F, dont!

Can you use antiseptics?

yes! can try using 1st

hydrogen peroxide 1% cream > ABX (no resistance)

When should you followup?

depend on patient (no ABX = take longer)

T/F if a child uses an antiseptic such as hydrogen peroxide they can go back to school within 24h

F, only applies to ABX use

Folliculitis, Furuncles, and Carbuncles

What is folliculitis?

itis of hair follicle, pustules + red papules, itchy, usually infection

What can cause non-infectious folliculitis?

drugs, chemicals, shavin

What can cause infectious folliculitis?

bacteria (S aureus)

How do caruncles form?

papule → pustule

if extend into subcutaneous = furuncle

multiple furuncles combine = caruncle

T/F furuncles and carbuncles are often associated with pruritis

F

How to differ between furuncle and carbuncle?

furuncle: warm, tender, moveable, single white spot

carbuncle: multiple yellow/white spots, fever & malaise

T/F folliculitis can self resolve if its mild

T

Can furuncles and carbuncles scar?

yes if they are deep

What are non pharm strats?

warm H2O or saline 3-4x day for 10-15 mins

loose clothing

minimize sweating

avoid occlusive

What should you remind patients?

DONT pick

When should you consider pharm options for folliculitis?

after 1 week of non pharm

What pharm options are there for folliculitis?

mupirocin 2%

fusidic acid 2%

3x day for 7 days

Should you recommend triple ABX products for faster resolution?

no

Who can use oral ABX for folliculits?

by physician

immunocompromised, recurrent folliculitis, systemic symptoms

How can you treat caruncles and furuncles?

need to drain

apply warm comrpess and wash area 3-4x/day

T/F you can use oral analgesics for folliculitis and caruncles/faruncles

T

When should a pharm follow up?

1-2 weeks, take while for complete resolution

What are red flags that should be referred?

fever

caruncles

multiple lesions

recurrence or reform after drainage

no improve after 72h of drainage

immunocompromised

Acne

What is acne?

inflammatory, affect hair follicles and oil glands

usually on face

genetic component

How prevalent is acne?

1 in 5 Canadians

Is acne acute or chronic condition?

chronic, relapses, need long term maintenance

early intervention crucial

T/F acne has a small impact on QOL

F, big

What are the 4 pathophysiology factors for acne?

increased sebum

increased keratin

increased bacteria (C acnes)

itis

What causes increased sebum production?

androgens

stress

impaired skin barrier

What causes increased keratin?

microcomedone (sticky skin = blockage)

How does bacteria proliferation occur?

bacteria colonize blocked core, form nodule

What are the earliest signs of acne?

closed comedones

What are the 2 types of comedones?

closed (white head)

open (black head)

T/F preventing closed comedone will prevent worse lesions in the future

T

Why are black heads dark colour?

comedone oxidized (lipid and melanin)

T/F both closed and open comedones are inflammatory

F, non itis but can quickly progress to itis

What are examples of inflammatory lesions?

papule

pustule

nodule

cyst

T/F a nodule that is <5mm needs referral

F, >5mm

What is a scar?

permanent change in tissue

atrophic (local) or hypertrophic

What scar types are common in all skin types?

rolling and ice pick scars

(keloid is common in coloured skin)

How can you differentiate mild, moderate and severe acne? Which one(s) do you refer?

mild: comedones, papules, pustules

mod: many papules and pustules

severe: few to several cysts present (REFER)

What is the main difference between comedonal, papulopustular and nodulocystic acne?

comedonal: non itis, comedones

papulopustular: papules and pustules

nodulocystic: papules, pustules, cysts, lead to scarring and erythema; severe

How long does it take for a pimple to form?

7-8 weeks

What is the life cycle of a spot?

trigger → microcomedone → comedone (open/closed) → inflamed lesion

When collecting information about a patient who has acne, what should you do?

History: did you apply properly? nonadherence due to dryness (#1 side effect)

Aggravating factors: ask patient what products they use

Remitting factors

Explanatory model: how does it impact patient (if negative → refer)

If a 55y female patient comes into the pharmacy concerned about acne, what should you do?

most likely rosacea (acne >50y is rare)

When does acne typically occur in females?

puberty to menopause

How can you differentiate from rosacea?

central on face, redness

How can you differentiate from perioral dermatitis?

around mouth, topical steroids can cause it

How can you differentiate from keratosis pilaris?

insufficient exfoliation, chicken bumps, common in coloured skin

What is neonatal acne?

peaks at 2 months, disappears spontaneously at 4-6 months, usually closed comedones, avoid OTCs

reassure caregiver (not a predictor for future acne, use warm water and mild cleanser)

What is acne conglobata?

very severe

cysts fuse and go deep in skin

common in teen boys

REFER

When assessing a patient, what should you look for?

anabolic steroid use

COCs high in progestin

coal tar (clog pores)

whey protein (worsen acne, interfere w/ insulin)

According to the Fitzpatrick skin colour rating scale, what is considered skin of colour? Why is this significant?

types 3 to 6

higher risk of PIH

What can you recommend for acne in deeper skin tones?

sunscreen >30spf (50 ideal)

retinoid (azelaic acid)

What are red flags that need referral?

<12y (may be PCOS)

onset at age >30y

widespread

severe acne and scarring

fever

unresponsive to therapy and no clear diagnosis

What are goals of therapy?

clear lesions and prevent new ones

lessen discomfort

improve appearance

minimize scarring or pigmentation

What is the main factor for not achieving full treatment benefit?

poor adherence (not applying properly)

What products should you recommend in….

dry skin?

oily skin?

combo skin?

dry: cream/lotion

oily: gel or H2O base

combo: lotion

What types of therapy are available?

topical (can RX in pharm, mild to mod, less AEs, maintenance therapy)

systemic (need referral, severe, failed topical)

How should you treat comedonal acne?

retinoids (tretinoin, adapalene), SA, benzoyl peroxide

How should you treat mixed or papulopustular acne?

combo clindamycin/retinoids, clindamycin/BPO or BPO adapalene, dapsone, azaleic acid

How is hormonal acne treated?

clascloterone (topical)

OCP, spironolactone (oral)

What should you use to treat hyperpigmentation?

topical retinoids (1st line), azaleic acid, glycolic acid, SA

What should you use to treat scarring, cystic or refractory acne?

isotretinoin

What is 1st line for mild/mod acne?

BPO (antibacterial, keratolytic, anti itis)

2.5-5% (>5% = more side effects)

8-12 weeks onset

When should pharm follow up for BPO?

1 week (check efficacy)

8 weeks

What are important instructions for BPO for patients?

apply to entire affected area (NOT spot treatment)

AEs peeling

use sunscreen

opt for cream > cleanser (stays on face longer)

If a patient cannot tolerate BPO, what can they use?

SA

mildly comedolytic, keratolytic and antibacterial

0.5-3.5%

8-12 weeks

T/F many products contain 0.25% SA which is beneficial for patients

F, does nothing, need 0.5% or more

T/F proactive is a great option for a patient worried about cost

F, very expensive, main ingredient is 2.5% BPO + SA + glycolic acid (can get for cheaper)

When should azelaic acid be used?

RX needed

good for PIH (BPO makes PIH worse)

What is an AE for dapsone?

skin discolouration

What is 1st line for all acne types?

topical retinoids

max response at 12 weeks

need sunscreen (Sun sensitivity)

Which topical retinoid has the highest potency?

tazarotene < tretinoin < adapalene (differin)

When should topical ABX be used?

lots of inflammatory acne

clindamycin and erythromycis

improvements in 8-12 weeks

How should clindamycin and erythromycin be used?

applied 2x day with BPO (decrease resistance and increase antibacterial)

Which products are safe in pregnancy?

BPO

azelaic acid

clindamycin and erythromycin

Which products are not recommended in pregnancy?

dapsone (need more evidence)

topical retinoids

When should combo topical products be used?

for maintenance, ex: BPO/retinoid

NEVER use ABX for maintenance

What are important counseling notes for patients?

oil free makeup

avoid overcleansing

sunscreen!!

keep a diary/record (take pics)