Symptoms In The Pharmacy - Skin

Skin Conditions in Pharmacy Practice

Learning Outcomes

  • Recognize symptoms related to common skin conditions.
  • Identify red flags and when to refer patients.
  • Identify suitable options for over-the-counter (OTC) supply.

General Information

  • Skin conditions can affect patients of all ages.
  • Community pharmacies encounter a wide variety of skin conditions.
  • Images are courtesy of DermNet NZ.

Skin Anatomy

  • Skin anatomy details are covered in the "Routes of Administration: Topical and Transdermal" lecture.

Community Pharmacy Common Ailments Service

  • Pharmacists can offer advice and/or treatment for 26 agreed conditions.
  • Examples include:
    • Acne
    • Athlete’s Foot
    • Cold sores (*advice only on NHS)
    • Conjunctivitis (bacterial)
    • Dermatitis (acute)
    • Hay fever
    • Head lice
    • Nappy rash
    • Oral thrush
    • Scabies
    • Threadworm
    • Verruca
      Conditions marked with () are advice-only, with no NHS treatment available due to insufficient evidence supporting the use of medicines.*.

Eczema & Dermatitis

  • Terms often used interchangeably.
  • Eczema is often reserved for atopic eczema, and dermatitis for contact dermatitis.
Atopic Eczema
  • Chronic, itchy skin condition, common in children.
  • Often accompanies other "atopic" conditions.
  • Rash is dry, flaky, and inflamed.
  • Aetiology unclear with trigger factors.
Contact Dermatitis
  • Commonly on the hands.
  • Consider patient history and occupation.
  • Nappy rash is a type of contact dermatitis.
Eczema & Dermatitis - Treatments
  • Treatments for atopic eczema and contact dermatitis can be similar despite different aetiologies.
  • Emollients are the mainstay of treatment to soothe the skin and form a waterproof barrier to prevent drying and can also be used as soaps or bath additives.
  • Topical corticosteroids (e.g., hydrocortisone 1% w/v) are available as Pharmacy (P) medicines; more potent corticosteroids are also available.
  • Antipruritics to prevent itching are available but generally not recommended (Doxepin Cream is Prescription Only Medicine).
When to Refer
  • Infected rashes (e.g., weeping).
  • Suspected Adverse Drug Reaction (ADR) or unidentifiable cause.
  • Failed medication (e.g., >1 week of topical corticosteroid use).
  • Always consider meningitis/septicaemia.

Seborrhoeic Dermatitis

  • Affects sebaceous gland-rich regions of the skin (e.g., scalp).
  • Can also occur at other hairy sites (e.g., under arms, chest).
  • Dandruff is an (uninflamed) form of seborrhoeic dermatitis.
  • Presents as scaly patches which typically do not itch.
  • May be referred to as "cradle cap" in babies.
  • Treatment may involve the use of keratolytics such as salicylic acid.
  • Antifungals may also be required.
  • For infants: mild shampoos +/- baby oil.

Psoriasis

  • Skin condition sometimes confused with eczema.
  • Characterized by inflamed skin topped with silver or white "plaques."
  • Cause unclear but immune system believed to be involved.
  • Mild psoriasis typically treated with topical agents:
    • Emollients
    • Coal tar preparations
    • Dithranol and salicylic acid
    • Topical corticosteroids
  • Phototherapy is an option for treatment.
  • Non-Caucasians tend to have greater areas of skin affected.

Skin Infections (Fungal)

  • Ringworm is a fungal infection that presents as a circular rash.
  • Spread by person-person / person-animal contact.
  • Ringworm of the scalp is rare and should be referred.
  • Fungal nail infections should be referred as systemic antibiotics are usually required.
  • Athlete’s foot is a fungal foot infection usually spread by person-person contact or from shared towels, changing rooms, etc.
Skin Infections (Fungal) – Treatment
  • Ringworm and athlete’s foot can be treated OTC with topical antifungals.
  • Imidazoles (e.g., miconazole cream - Daktarin®) are the usual first-line treatment for ringworm and are also used for athlete’s foot.
  • Itraconazole and terbinafine (an allylamine) are also used OTC in athlete’s foot treatment.
  • Powder and spray formulations are commonly used for athlete’s foot.
When to Refer
  • Treatment failure (>2 weeks).
  • Bacterial infection.
  • Diabetic patients.
  • Involvement of the nail.

Skin Infections (Herpes)

  • Herpes simplex labialis or cold sores can usually be managed OTC.
  • Skin infection – usually around lips/nose caused by the herpes simplex virus (HSV-1 in most cases).
  • Triggered by various factors (sunlight, other infections (colds/flu), menstrual cycle).
  • Treatment OTC with aciclovir 5% cream (apply 5 × 5 daily).
When to Refer
  • Eyes/genital regions affected.
  • Age of patient? (Zovirax® cream has no age restrictions).
  • Painless, in the mouth, or lasting >2 weeks.
  • Immunocompromised.

Warts & Verrucae

  • Small growths on the skin caused by human papillomavirus (HPV).
  • Peak incidence in secondary school children.
  • A verruca (plantar wart) is just a wart on the plantar region, i.e., sole of foot.
  • Warts/verrucae contain a network of capillaries.
  • Warts and verruca will eventually resolve without treatment, but the appearance can be distressing for patients.
  • Corns are unrelated to warts but can look similar.
Warts & Verrucae – Treatments
  • Treatment options typically use keratolytics.
  • Salicylic acid-based products are commonly used; this active ingredient gradually destroys the affected area.
  • Care to ensure that the formulation is only applied to the wart/verruca (protect surrounding skin with white soft paraffin).
  • Emphasise that successful treatment may take >3 months.
  • Cryotherapy used to freeze off wart (10-14 days) – home kits available.
When to Refer
  • Suspicious changes in shape or colour +/- bleeding and itching.
  • (A) Asymmetrical – melanomas usually irregular shape
  • (B) Border – melanoma border often “ragged”
  • (C) Colours – at least 2 colours
  • (D) Diameter – most melanomas >6mm in diameter
  • (E) Evolving – moles that change in size may be a melanoma
  • Diabetic and immunocompromised patients.
  • Anogenital warts in children.
  • Failed treatment.

Acne

  • Acne vulgaris = common acne.
  • Hair follicles and sebaceous glands become blocked.
  • High incidence in teenagers, largely affects the face, but back and chest are other common sites.
  • Classified as mild/moderate/severe.
Acne – Treatments
  • Mild to moderate acne can be managed without referral.
  • Many OTC products are available.
  • Benzoyl peroxide is usually the first-line treatment (2.5%, 5%, and 10% strengths available – start with lowest).
  • Treatment required for at least 6-8 weeks.
  • Antibiotics and retinoids are POMs and require referral.
  • Sunlight may help; avoid greasy foundation.
When to Refer
  • Severe acne.
  • Treatment failure.
  • Suspected ADR.
  • ABCDE concerns.
  • Causing mental health issues.

Scabies

  • Scabies is an intensely itchy skin condition caused by a mite that burrows through the skin → rash.
  • Burrows are often seen on the palms of the hands, but rash and itching can be at other sites.
  • Passed on through close personal contact – common in schools, universities, care homes.
  • Can be up to 2 months before symptoms start to appear.
Scabies treatments
  • Two applications of a topical acaricide are required 7 days apart.
  • Must be left on for 12-24 hours depending on the acaricide used.
  • Other household members should be treated simultaneously.
  • Treatment can worsen the itch initially.
When to Refer
  • Age: young children and elderly.
  • Outbreaks suspected, e.g., in a school.
  • Crusted scabies (hyper-infection with mites).
  • Infected rash.
  • Treatment failure.
  • Acquired through sexual activity?

Communicable Diseases

  • Many (typically childhood) communicable diseases present with skin rashes.
  • Details will not be covered in this lecture.
  • Shingles are more likely in elderly individuals.
  • If fever and/or malaise, then unlikely to be a simple skin condition → consider communicable diseases.
  • Referral required if suspected bacterial skin infection (particularly in diabetic patients, respiratory symptoms).

Red Flags

  • Skin cancer (ABCDE).
  • Meningitis – petechial rash.
  • Erythroderma (>90% of skin affected).
  • Bullous disorders.
  • Suspected ADR.

Spiral Curriculum

  • Skin conditions will be revisited in much more detail in the Skin “Integrated Study Unit” in PMP202 Patient-Centred Learning II.

Directed Study

  • Minor Illness or Major Disease. Addison, Brian; Brown, Alyson; Edwards, Ruth; and Gray, Gwen 6th Edition - Pages: 213 – 241
  • Symptoms in the Pharmacy. Blenkinsop, Alison; Duerden, Martin; Blenkinsopp, John (8th Edition - Pages: 127 – 185