OTC - Skin Conditions + childhood skin conditions

What are the symptoms of Acne

Whiteheads (closed comedones)

Blackheads (Open comedones)

Spots (Red Papules)

Pustules (small papules filled pus)

Common affected area = face, neck, upper back, shoulders and centre of chest

What is the referral criteria for Acne

- Children under 12 years old

- Adults over 25 for first time

- Acne rosacea (butterfly pattern) - reddening of cheeks with papules and pustules, Confined to face only, Common in middle aged - may be systemic lupus (erythematosus)

- Appears on back or chest or anywhere but face

- Medication ADR - (Lithium, Phenytoin and progestogens)

- OTC failure > 8 weeks

- Moderate - severe acne (may need antibiotics or stronger preparation)

How to tell the difference between Mild, Moderate and Severe acne

Mild Acne - confined to face, mainly blackheads, whiteheads, and small number of inflammatory lesions

Moderate Acne - many inflammatory lesions not confined to the face. Lesions can be painful and there is a possibility of scarring

Severe Acne - Also has nodules and cysts and is wide spread. Scaring is highly likely. Requires retinoids

What are the OTC products available for Acne

First line: Benzoyl peroxide (Acnecide, panoxyl) - Antibacterial, anti comedogenic, anti - inflammatory. Start at a low strength 2.5% or 5%, then gradually increase from OD to BD, then after few weeks increase up to 10%

How to apply benzoyl peroxide

Wash skin before applying with mild soap to remove excess sebum

Takes about 8 weeks for improvement - continue for 4 - 6 months for full effect

Apply to whole area affected by acne not just lesions and apply at night

What are the side effects of benzoyl peroxide

Bleaches clothes

Avoid direct sunlight - apply sunscreen

Photosensitivity - apply in evening

Stinging, dry, burning, red, peeling skin especially in initial stages - Stop for 1 -2 days and start again if side effects unbearable or reduce strength or frequency of application

What is an alternative to benzoyl peroxide

Nicotinamide (Freederm)

Has anti-inflammatory properties but evidence for use is limited

What advice can you give for acne

- There is no evidence to suggest certain food or poor hygiene can cause acne

- Use a mild antibacterial soap - Twice daily is sufficient do not over clean as it can irritate symptoms

- Do not overscrub - once daily is sufficient

- Do not squeeze spots - can lead to infections, scarring

- Avoid greasy oil based cosmetics (clogs pores - stick to water based cosmetics and remove makeup before bed

What virus causes cold sores

Herpes simplex virus 1

Once contracted it remains dominate in the body and never really goes away

What can trigger the herpes simplex virus outbreak

Night fatigue

Menstrual periods

How is the virus transmitted in cold sores

Close personal contact - kissing

What are the symptoms of cold sores

Tingling sensation or irritation (6 - 24 hours before blister)

Blisters on lips/around mouth (filled with white matter on top of sore inflammed skin) - these burst after a day or so to reveal open sores which form a yellowy brown crust - gradually disappear within 10 - 14 days

Self limiting

What is the referral criteria with cold sores

Painless (cancer?)

Babies/ Young children (more severe and potentially lethal)

Immunocompromised (risk of serious infections)

Uncertain diagnosis (impetigo)

Eye affected

Cold sores inside mouth

Cold sores > 2 weeks

Patients with atopic eczema (herpes infections more severe and widespread)

What are the OTC products available for cold Sores

At blister or tingle phase:

- Aciclovir (Zovirax Cold sore cream) - Apply 5 times daily for at least 4 days. Max 10 days - four hourly intervals

- Penciclovir 12+ (Fenistil cold sore cream) - Apply 8 times daily for 4 days. Two hourly intervals

Hydrocolloid patch (Compeed patch) - apply for 24 hours a day until it completely heals. Wound healing properties and acts as a virus shield to prevent contamination

Bland creams - Soothes and moistens skin to help reduce the risk of a secondary bacterial infection

What advice to give to patients with cold sores

HIGHLY CONTAGIOUS

No longer contagious after crusts form

Wash hands after applying cream or touching lesions

Infection is transferable to eye (avoid touching the eye or contamination to eye makeup)

Avoid kissing, oral sex, sharing cutlery

Recurrent episodes - cold sores have no cure and are for life (can be triggered by stress, sun exposure, periods)

What are the symptoms of corns and calluses

Yellow hyperkeratinised skin - caused by excessive pressure or friction on the skin. Common cause is wearing poor fitting shoes or high heels

Can be painful

What is the referral criteria for corns and calluses

Diabetes

Impaired circulations

Treatment failure

Soft corns

What are the OTC products available for corns and calluses

Padding or shielding -helps to relieve pressure

What advice to give to patients with corns and calluses

Wear appropriate well fitting shoes (high heels and poor fitting shoes cause them)

Use a pumice stone to gently remove hard skin

Dry you feet thoroughly after washing them

What is dermatitis

Inflammation of the skin

What is eczema and what are the symptoms

Eczema is atopic dermatitis - Genetic tendency to be hyperallergic

- Sore and inflammed rash

- Very dry and flaky skin

- Irritated and itchy skin

Commonly affected areas is the face, Hands and limb flexures e.g: behind the knees or inner elbows

What is contact dermatitis and what are the symptoms

Response to external factors

- Irritant - substance directly damages outer layer of skin e.g: soap detergent

- Allergic - substance causes immune response e.g: nickel allergy

The typically affected areas is where skin comes into contact with the offending substance

What is the referral criteria for dermatitis

Infected skin - weeping, crusty and spreading rash

Severe rash - widespread, bleeding, cracked skin

Broken skin

Face

Anogenital areas

OTC failure > 7 days

Undiagnosed eczema or no known cause

Symptoms > 2 weeks

What OTC products are available for dermatitis

Emollients: Hydrates and soothes - Apply as often as needed

- Lotions (e.g: dermol 500)

- Cream (e.g: aveeno, cetraben, E45)

- Ointment (e.g. Epaderm ointment) - Most lipid content and most hydrating

- Soap subsititues (e.g: Aqeuous cream)

- Bath additives (e.g: Oilatum bath oil)

Topical Steroids: reduces inflammation. Mild to moderate eczema/rashes

Apply thinly once or twice a day.

10+ Hydrocortisone - Mild potency

12+ Clobetasone - Moderate potency

Itch relief

- Calamine/ Crotamiton (Eurax)

What is the OTC licensing for steroid creams

Max, 15g pack size. Max use 7 days.

Not for broken or infected skin

Not for face or anogenital areas

Not for pregnancy

C/I in acne, rosacea, skin infections e.g: cold sores, athletes foot, impetigo, ringworm

What advice to give to patient OTC for dermatitis

Apply steroid sparingly - can cause skin thinning

Apply Emollient first - Wait 30 minutes to apply steroids

Use soap substitutes

Eliminate aggravating factors (Cold, harsh weathers, stress, central heating, house dust, pet fur, soaps, perfumed cosmetics, synthetic clothing, dairy and red meat

What are the symptoms of psoriasis

Plaque psoriasis

Red plaques

Well defined edges

Slivery scales

Areas affected include elbows, knees and scalp

What is the referral criterial of psoriasis

Undiagnosed

Moderate to severe

What are the OTC products for psoriasis

Emollients

12+ coal tar solution - Exorex, T/Gel shampoo, polytar

Can stain clothes and has an unpleasant smell.

Side effects: Photosensitivity and skin irritation

POM = Vitamin D (Calcipotriol), steroids, Dithranol

What advice can you give OTC for psoriasis

Limit stress

Not contagious

Sun exposure - can improve psoriasis

Give examples of tinea fungal infections

Athlete's foot - tinea pedis

Body ringworm - tinea corporis

Jock itch - tinea cruris

Scalp ringworm - tinea capatis

What are the symptoms of tinea pedis - athletes foot

White

Itchy

Flaky

Possibly macerated skin in web spaces between toes - looks soggy

Smelly

What are the symptoms of tinea corporis - body ringworm

Flat

Slightly raised circular rings with a distinctive red scaly border and can have a central clearing

What are the symptoms of tinea cruris - Jock itch

Fungal groin infection

Red brown rash with well defined edge on inner thighs and buttocks

What are the symptoms of tinea capatis - Scalp ringworm

Distinctive ring shaped rash with associated hair loss

Refer requires oral antifungal

What is the referral criteria for all tinea fungal infections

Ring worm that affects the face or scalp

Toenails also affected in athletes foot

Large area affected or with broken skin

Secondary bacterial infections

Diabetic/ immunocompromised

OTC Failure after 2 weeks

What are the OTC products available

Topical Imidazoles can be used to treat tinea infections:

- All ages: Clotrimazole (Canesten)

- Adults: Ketoconazole (Daktarin GOLD, Intensiv)

- All ages: Miconazole (Daktarin, Daktacort - 15g) - Daktacort licensing: 10+ 7 days use only. Thinly BD

Terbinafine (Lamisil 16+ Lamisil Once 18+)

OTC Licensing:

Spray, cream = Jock itch and athlete's foot

Gell = Jock itch, athlete's foot and body ringworm

Cutaneous solution (Lamisil Once) = Athlete's foot

Powders (Mycota, mycil)

- Can be used prophylactically for athletes foot

What advice can you give for Tinea fungal infections

Continue until at least 7 days after symptoms disappear

Contagious - Easily transferred from pets and animals

Avoid sharing towels - Avoid tight shoes, clothing and accumulation of sweat and heat

In athletes foot:

- Change socks regularly, Dry skin thoroughly, Wear flip flops in communal areas

What are the symptoms of fungal nail infection

Dull, yellow opaque (appearance starts at side of nail or beneath the tip and mainly affects toe nails)

Nail thickens and distorts

Brittle and crumbles away

What are the referral criteria for fungal nail infection

Other fungal nail infections - OTC treatment for mild DLSO

Nail breaking away (severe need systemic treatment with terbinafine)

Pre disposing patient groups

- Immunocompromised

- Peripheral circulatory disease

- Diabetes

What is the OTC Product available

POM to P swtich

Amorolfine 18+ (Curanail 5% nail lacquer)

For mild DLSO

Distal (beneath the nail tip)

Lateral (sides of nail)

Subungal (under nail plate)

Onchomycosis (fungal nail infection)

OTC Licensing: 18+

- No more than 2 nails affected.

- Only beneath tips or sides of nails affected

C/I in pregnancy and breastfeeding

What advice to give to patients with fungal nail infection

Keep using until all the affected nail tissue grows out

- Toenails take 9 - 12 months, Fingernails take 6 months

- One pack give 3 months supply

1. Apply Once weekly to affected nails

2. File down nail surface (use disposable nail file to prevent infection to healthy nails

3. Clean using disposable cleaning pads provided

4. Apply nail lacquer evenly and leave to dry. (Lacquer can be removed by solvents )

What virus causes Warts and verrucae

Human papilloma virus

What are the symptoms of Warts

Flesh colour

Raised

Cauliflower surface

Commonly occurs on the hands and fingers

Disappears naturally within 6 months to 2 years

What are the symptoms of verrucae (plantar warts)

Flat

Occur on sole of feet with black dots (blackened capillaries) in he middle

Can be painful if on weight bearing part of foot

Disappears naturally within 6 months to 2 years

What is the referral criteria for warts and verrucae

Facial warts (OTC products destructive, scarring)

Multiple warts

Anogenital warts (STI)

Diabetic patient - impaired circulation = delayed healing

Immunocompromised patients Itching/ bleeding warts

Change in appearance of wart: size and colour (skin cancer)

OTC Failure > 3 months - warts can take up to 12 weeks to disappear

What are the OTC products for Warts and verrucae

Salcyclic acid (Bazuka, verrugon, salactol)

- Treatment of choice. Softens + destory skin

- Some products contain lactic acid (keratolytic) enhances the availability of salicyclic acid

Cryotherapy (Wartner):

- Freezes warts, verrucae; comes off in 10 days

- Contain dimethyl ether propane

- Thought not to work as well as salicylic acid

Glutaralyydehyde (Glutatrol)

- More suited to treat verrucae

- Not first line ; useful in resistant cases

What advice to give to patients with warts and verrucae

Take up to 12 weeks to disappear with salicyclic acid or glutaraldehyde

Take steps to prevent spreading to others e.g: cover with plaster

When applying salicylic acid:

1. First soak affected area in warm water for 5 minutes to soften it

2. Apply daily, protect healthy skin using petroleum jelly i.e: vaseline

3. Remove dead skin every week with pumice stone/ emery board.

What virus causes chicken pox

varicella zoster virus

What are the symptoms of chicken pox

Small red spots --> very itchy and infectious blisters --> crusts

Small red spots first appear on chest or face before spreading to the limbs/ other body parts

Blisters form over the next 12 hours and then burst and scab over the next few days

Prodromal symptoms: up to 3 days before chickenpx erupts there may be fever, headahce, sore throat, myalgia and malaise

What is the referral criteria for chicken pox

Adults

Pregnant women

Weakened immune system

Infants under 4 weeks old - dangerous at risk of severe chickenpox

What is shingles

Reinfection of the varicella zoster virus and it is a nerve infection - immune system is low

It needs to be referred as it can be treated with possible antivirals (espically if over 50 years, pregnant, immunocompromised, severe rash or severe pain, eye involved, non truncal involvement)

What is the symptoms of shingles

Blisters appear on one side of the body usually the trunk and does not cross over the midline

Nerve pain - can last a month and up to a year after infection

What are the OTC products available for chickenpox

Itching:

Calamine lotion

Crotamiton (Eurax)

1+ Chlorphenamine (piriton)

Fever:

Paracetamol

AVOID IBUPROFEN - can cause serious skin reactions

What advice can you give OTC for chickenpox

Don not scratch lesion (cut nails short and clean to reduce risk of secondary bacterial infection and scarring)

Very contagious

- Infectious until lesions have crusted over.

(Chickenpox spreads through direct contact with blister exudates and air droplets e.g: coughing or sneezing)

Shingles spreads through direct contact only. cover rash with non adhesive dressing

Can catch chickenpox from someone with shingles if you haven't had it before

What is impetigo

Highly infectious bacterial infection that causes sores and blisters

What bacteria causes impetigo

Staphylococcus aureus

Streptococcus pyogenes

What are the symptoms of impetigo

Golden crust lesions in both

Non - bullous impetigo

- Starts as small red sores around the nose and mouth

- Quickly develops into blisters and bursts

- Can be itchy but otherwise asymptomatic; not painful

Bullous impetigo

- Common in neonates

- Starts as fluid filled blisters on trunk or arms/legs

- Quickly spreads before bursting

- Can be painful and itchy

- Fever and swollen lymph glands is more common

What is the referral criteria for impetigo

ALL CASES needs to be referred

They need antibiotics

- Topical fusidic acid cream for mild cases in small areas

- Oral flucloxacillin if severe or widespread

What are the OTC Products for impetigo

No OTC treatment for impetigo

Symptomatic treatment: if required e.g: paracetamol for fever or antihistamines for itching e.g: chlorpheniramine

What OTC advice can be given for impetigo

Contagious

- Stay away from school until rash clears

Hygiene measures

- Do not share towels. Do not touch lesions

- Cut nails short, scratching causes secondary infection and scarring

What is Meningitis and what bacteria causes meningitis

Infection of meninges which are protective membranes that surround the brain and spinal cord

Can cause life threatening septicemia and can lead to permanent damage to the brain or nerves

Neisseria meningitides - life threatening

Streptococcus pneumoniae

Viral meningitis is caused by the HSV virus - more common and less serious and a spontaneous recovery

When is the peak time for meningitis to occur

6 to 12 months

However can happen in children and adults

What are the symptoms meningitis

- Non blanching rash (pale, blotchy skin with widespread bruises which does not fade when pressed against a glass tumbler) - refer immediately

Non specific symptoms:

- Worsening flu like symptoms

- High fever

- Severe muscle ache

- Nausea and vomiting

More specific:

- Stiff neck

- Severe Headache

- Cold hand and feet

- Confusion, drowsiness

- Photophobia - dislike bright lights

- Seizures

What are specific symptoms specific to infants for meningitis

- Floppiness/ unresponsive

- Dislike being handled

- Refuse feeds

- Difficult to wake

- Rapid breathing/ Grunting

- Unusual cry or moan

- Bulging fontanelle

What should be done to all suspected meningitis cases

BE REFERRED

As required immediate hospital admission

What are the OTC products for viral meningitis

Usually mild, can be treated at home and has spontaneous recovery

Symptomatic relief:

- Paracetamol

- Ibuprofen

What advice can you give for meningitis

TRUST GUT INSTINCT - dont wait until rash develops

Bacterial meningitis is life threatening and may cause septicemia and necessitate limb amputations

What virus that cause MMR

Measles - Paramyxo virus

Mumps - paramyxo virus

Rubella - RNA virus

What are the symptoms for measles

Measles - Initial symptoms develop 1 - 2 weeks after infection with the paramyxo virus - these symptoms include cold like symptoms, red sore eyes, fever and classically koplick spots (greyish white spots that develop on the inside of the cheek)

Measle characteristics:

- Rash starts behind the ears and then spreads to the face, trunks and limbs. Red - brown confluent and blotchy rash

What are the symptoms of mumps

Initial symptoms of mumps develop 2 - 3 weeks after infection with the paramyxo virus

- General symptoms of fever, headache and malaise occur

Mumps characteristics:

Painful swelling on one or both sides of face given a person a distinctive hamster face appearance. - inflammation of the parotid glands

What are the symptoms of rubella

The initial symptoms of rubella develop 2 - 3 weeks after infection with the RNA virus

Symptoms: Swollen lymph glands at the back of neck is a tell tell symptom

Characteristics:

Pink - red macular non confluent rash - Rash starts on the face then spreads to trunks and limbs

What is the referral criteria for MMR

All cases of measles, mumps and rubella for confirmed diagnosis

MMR are notifiable disease

What are the OTC products for MMR

Symptomatic relief after seeing a doctor

- Paracetamol or ibuprofen

What OTC advice can you give for MMR

Plenty of bed rest

Keep hydrated

Keep children off school during contagious period

Avoid acidic drinks in mumps (irritates parotid glands)

Children with rubella should keep away from pregnant women

How long to keep children of school for in measles

Contagious for 4 days after rash appears

Most dangerous childhood illness: complications: otitis media, pneumonia, encephalitis

How long to keep children of school for in mumps

Contagious for 5 days after swelling appears

In adults risk of meningitis and sterility

How long to keep children of school for in rubella

Contagious for 6 days after rash appears

STAY AWAY FROM PREGNANT WOMEN - FETAL DAMAGE

What virus causes slapped cheek

Parvovirus

What are the symptoms of slapped cheek

Bright red rash on cheeks

Light pink, lace like itchy rash on trunk and milbs

Initial cold like symptoms - most contagious period

- Occurs a few days before the rash appears. The patient may have a slight fever, sore throat, headache, runny nose and malaise

What is the referral criteria

Mild infection that usually clears up by itself in 1 to 3 weeks and therefore referral is not required

Refer exposed patient groups urgently if they show symptoms

- Pregnant women - causes miscarriage or stillbirth

- Blood disorders - thalassaemia, weakened immune system, sickle cell anaemia = risk of severe anaemia

- Symptoms of severe anaemia - fainting, severe shortness of breath, ery pale skin, extreme tiredness

What OTC products can be used for slapped cheek

Symptomatic relief:

- Paracetamol or ibuprofen - helps with fever, headaches etc

- Antihistamines - eases itchy rash e.g: piriton

What advice can be given OTC for slapped cheek

Rest and plenty of fluid

Once rash appears it is no longer contagious - there is no need to stay away from school unless the child is feeling unwell

What bacterial causes scarlet fever

Group A streptococcus pyogenes

Usually affects under 10

What are the symptoms of scarlet fever

Follows a sore throat or impetigo

Initial symptoms before rash:

- Sore throat

- Headache

- High temperature

- Flushed cheeks

- Swollen tongue

Pink red itchy sandpaper rash - develops 12 to 48 hours after initial symptoms. First appears on the chest and stomach before spreading to other areas of the body

Other symptoms:

Red and swollen tongue (strawberry tongue)

Swollen lymph glands

Malaise

Loss of appetite

What is the referral criteria for scarlet fever

All cases of scarlet fever as they require antibiotics

Amoxicillin for 10 days - fever goes 24 hours after starting an antibiotic

What OTC products that can be used for scarlet fever

Symptomatic relief as GP referral

- Paracetamol - relieves high fever

- Antihistamine/ calamine lotion - relieves itching

What OTC advice can you give for scarlet fever

Scarlet fever is very contagious

Keep children off for at least 24 hours after starting antibiotic

Avoid sharing towels, clothes, bed linen, cups - spread through touching the skin of a person with streptococcal skin infection, such as impetigo

Cover mouth when sneezing, coughing - spread through air droplets