Lecture 22a: Minor Ailments & Responding to Symptoms in Community Pharmacy | Skin Conditions 1

Examples of skin conditions

Skin structure

Dermatology

• Lesion: single area of abnormal skin

• Rash: lesions that are widespread

• Dermatosis: disease of the skin

Terminology

Skin conditions

• Age

• Affected area

• Distribution of rash

• Appearance

• Duration of symptoms

• Occupation/contact

• Associated symptoms

• Medical conditions - asthma, hay fever

• Treatment tried

Meningitis and Septicaemia

• Meningitis - inflammation of the lining of the brain and spinal cord

• Septicaemia - blood poisoning

• Bacterial, viral, fungal

• Rare but life-threatening illnesses, can lead to sepsis

• Can affect all ages, more common in babies and children

• Symptoms rapidly worsen, can kill in hours

• Rash - may develop at later stage, sign of very severe illness, risk factor for fatal outcome

Meningitis and Septicaemia Rash

• Starts as small red pinpricks, spreads quickly to become red or purple blotches anywhere on the body

• Non-blanching rash - doesn’t fade or lose colour if pressed with the side of a clear drinking glass firmly against the rash

• Darker skin - check paler areas of the body

• Balancing rash can develop into a non-blanching rash as illness progresses

• Medical emergency - call 999 immediately

Eczema

• Eczema and dermatitis (interchangeable)

• Most common - atopic eczema, contact dermatitis

• External - irritants/allergens, Internal - genetic cause

• Emotional or environmental factors can trigger flare up

• Lipid layer that covers skin becomes thin causing water loss

• Long term relapsing condition, in children improves with time

• Symptoms - redness, dry itchy skin, localised to flexures of limbs, usually symmetrical, scratch marks, damage, thickening

• Treatments can control but no cure

Management of eczema

• Emollients/moisturisers - first line, moisturisers, smooth hydrate and protect skin barrier

• Provide an occlusive layer which reduces water loss

• Applied regularly at least 4 times a day, in a downward motion following direction of hair growth, stroke on liberally

• Use soap substitutes, bath additives are ineffective

• Available as creams, ointments, lotions, gels, sprays, bath oils/additives - ointments most effective

• Safety: risk of slipping, paraffin based products are a fire hazard

• MHRA alert - aqueous cream causes burning, stinging, itching, detrimental effect on skin barrier

Management of eczema

• Topical steroids - reduce inflammation

• Choice - severity of eczema/ flare up, patients age, affected area

• Apply 20 to 30 mins before emollients

• Available as creams, lotions, ointments, gels and foams

• Stepped up/down according to need

• OTC - Hydrocortisone 1% cream, 10 years and over, not licensed for use on the face, eumovate 0.05% cream, 12 years and over

• Atropy and thing of skin after prolonged use

Topical Corticosteriod’s

Finger Tip Units (FTU)

• 1 FTU - hands, elbows or knees

• 1.5 FTU - feet including soles

• 2 FTU - face & neck

• 4 FTU - hand and arm

• 8 FTU - one leg & foot, or chest & back

Management of eczema

Itching:

• Bandaging - paste bandages, cotton gloves

• Antihistamines - chlorophenamine, non sedating usually ineffective

• Homeopathy, herbalism, acupuncture - limited evidence

• Self-care - avoid scratching, avoid triggers, keep cool, avoid synthetic fibres, avoid detergents e.g. bubble bath

Refer

• Bacterial infection - weeping, pus, warm to touch

• Eczema herpeticum - rare but life threatening, affects children, rapidly worsens, painful eczema with clustered vesicles, fever, distress

• Systemically unwell - fever, generally unwell

Acne

• Chronic inflammatory condition

• Common in teenagers, onset at puberty, hormonal changes

• Lasts few months to several years

• Affects mainly face, back and chest

• Increased keratin and sebum causes blockages of hair follicle, causes comedowns, papules, pustules

• Complications: scarring, hyperpigmentation, depression anxiety

Severity of acne

Management of acne

• Mild acne - Treat OTC, may take at leats 8 weeks to work as prevent new lesions forming, OTC treatments likely to irritate skin initially, stinging, redness, skin peeling, will settle with time, start on worst strength, use on alternate days or once daily if occurs

• Benzoyl Peroxide (P) - most effective, first line, anti-inflammatory with antibacterial properties, reduces comedowns, available as creams, gel formulation, 2.5%, 5% or 10% strength , apply 1-2 times a day, preferable after washing with soap and water, may bleach fabrics and hair, can make skin sensitive to sun

• Nicotinamide (GSL) - anti-inflammatory, reduces swelling, redness, tenderness, available as 4% gel, apply twice daily

• Moderate to severe acne - refer to GP

Management of acne

Self-care:

• Avoid over cleaning of skin, avoid exfoliants

• Avoid oil-based products - skincare, makeup, sunscreens

• Remove makeup at the end of the day

• Avoid picking.scratching lesions - likely to scar

• Use non alkaline cleansing product twice daily

Refer

• Moderate or severe acne

• Psychological distress

• OTC treatments likely ineffective

• Acne with scarring

• Pigmentary changes

Insect bites and stings

• Rapid onset, inflammatory reaction - erythema, tenderness, swelling, itchy papules

• Can cause allergic reaction or become infected

• Allergic reaction occurs within 24 hours, infection usually develops after 24-48 hours: pus, warm to touch, fever

• Complications: urticaria, anaphylaxis, malaria

• Tend to overtreat

Management of insect bites & stings

• Usually non serious, resolves in few hours or days

• Remove stinger, wash area with soap and water

• Antihistamines oral, sedating e.g. Chlorophenamine (Piriton) (P), non sedating e.g. Loratadine (P) or topical e.g. Mepyramine (Anthisan) (P)

• Steroid cream e.g. Hydrocortisone. 1% cream (P)

• Analgesics - paracetamol or ibuprofen

• Ice wrapped in a cloth or wet cloth applied for 20 mins

• Self-care - avoid scratching to prevent infection

Refer

• Anaphylaxis, life threatening allergic reaction - call 999

• Systemically unwell

• Human or animal bite

• Severe pain from wound

• Signs of Lyme disease - bullseye rash

• Insect bites or stings that occured while travelling abroad

• Significant fluid, pus at site of insect bite or sting

Pharmacy First Service

• Advanced service in community pharmacy

• Urgent medicines supply, minor illness, management of 7 common conditions

• Infected insect bites - adults and children 1 year and over

• Signs of infection, can supply POM medicines: flucloxacillin, clarithromycin (penicillin allergy) or erythromycin (pregnant)

Warts and Verrucae

• Small skin coloured excess growths of akin cause by human papilloma virus (HPV), stimulates basal cell division

• Common in children, teenagers

• Warts can appear anywhere on the skin, usually hands and feet

• Verruca is a wart on the sole of the foot, underlying black dots

• Transmitted by skin to skin contact, contact with contaminated surfaces

Management of warts & verrucae

• Reassurance - clear spontaneously within a few months, can take years

• Topical salicylic acid +/- lactic acid, break down keratin in skin e.g. Bazuka 12% pr 26% gel (P), Salatac 12%/4% gel (P), soak the skin, abrade with emery board, protect surrounding skin with vaseline, apply to wart/ verruca daily, can take 12 weeks for full effect

• Cryotherapy - extreme cold to freeze abnormal skin

• Self-care - avoid picking, scratching of wart, waterproof plasters when swimming

Refer

• Facial warts

• Anogenital warts

• Diabetic patients

• Elderly patients

• Immunocomprimised patients

• Warts that bleed, itch, grow, change colour

• Large or painful verrucae