Comprehensive Guide to Common Skin Conditions in Community Pharmacy

Learning Outcomes for Skin Condition Management in Pharmacy

• Differentiate between common skin conditions based on specific symptoms and clinical presentations.

• Determine appropriate management strategies for various common skin conditions.

• Recognize specific clinical red flags and criteria that necessitate referral to other healthcare providers.

• Identify how the Pharmacy First service facilitates the provision of additional treatments, specifically for conditions like impetigo and shingles.

Fungal Infections: Pathophysiology and Clinical Presentation

• Fungal infections are primarily caused by either Candida yeast or dermatophytes.

• Dermatophytes are specialized fungi that invade the stratum corneum and proliferate within the keratinocytes of the epidermis.

• Infections caused by dermatophytes are highly contagious.

• Clinical presentation on the skin includes eczema-like patches that are itchy and feature a scaly, inflamed edge. The central area of the lesion may appear normal. These can occur anywhere on the body, including toe webs, the groin, and under the breasts.

• Clinical presentation on nails (onychomycosis) involves thickening and discoloration. The infection typically starts at the edge of the nail and spreads inwards.

• Classification of dermatophyte infections by location:

  • Foot: Tinea pedis (Athlete's foot).
  • Groin: Tinea cruris (Jock itch).
  • Body: Tinea corporis (Ringworm).
  • Scalp: Tinea capitis (Ringworm of the scalp).
  • Nails: Tinea unguium or onychomycosis.

Management and Referral for Fungal Infections

• Topical Imidazoles: These antifungals include clotrimazole ($GSL/P$), miconazole ($GSL/P$), and ketoconazole ($GSL/P$).

• Combined Therapies: Antifungals may be combined with hydrocortisone for patients over $10$ years of age, such as clotrimazole (Canesten Hydrocortisone, $P$) or miconazole (Daktacort Hydrocortisone, $P$).

• Available Formulations: Creams, solutions, sprays, and powders.

• Usage Guidelines: Frequency and duration vary by specific product; however, treatment should be continued even after the visible lesion has cleared.

• Other Agents: Terbinafine, tolnaftate, and undecenoates.

• Fungal Nail Management: Treatment is suitable for mild infections involving up to $2$ nails in adults aged $18$ years and over.

  • Amorolfine $5\%$ nail lacquer ($GSL$): A broad-spectrum antifungal applied weekly.
  • Procedure: File down the affected nail, cleanse with an alcohol wipe, and apply the lacquer to the nail to dry.
  • Duration: Fingernails require approximately $6$ months; toenails require $9$ to $12$ months.

• Criteria for Referral:

  • Involvement of the face or scalp.
  • Ringworm covering a large area of the skin.
  • Nail infections in diabetic or immunocompromised patients.
  • Nail infections involving more than $2$ nails.
  • Situations where over-the-counter (OTC) treatment has been ineffective.

Impetigo: Symptoms and Diagnostic Classification

• Impetigo is a superficial bacterial infection of the skin caused by Staphylococcus or Streptococcus species.

• Non-bullous Impetigo: Accounts for $70\%$ of cases and presents as sores.

• Bullous Impetigo: Characterized by fluid-filled lesions or blisters measuring approximately $2\,\text{cm}$.

• Size Classification:

  • Localised: $\le 3$ lesions.
  • Widespread: $\ge 4$ lesions.

• Epidemiology: Most common in young children aged $0$ to $4$ years. It is highly contagious and usually occurs on the face, specifically around the mouth and nose.

• Progression: It starts as thin-walled vesicles (clear, fluid-filled lesions less than $1\,\text{cm}$ in diameter that last a few days). These rupture to release exudate, which dries to form a golden/brown crust.

Pharmacy First Service and Management of Impetigo

• General Course: If untreated, impetigo is usually self-limiting and clears within $2$ to $3$ weeks.

• Self-Care: Crusts should be washed off with soapy water.

• Pharmacy First Service Eligibility: For non-bullous impetigo in adults and children aged $1\,\text{year}$ and over. Prescription-only medicines ($POM$) can be supplied.

• Topical Management for Localised Cases: Hydrogen peroxide $1\,\%$ cream ($P$). If hydrogen peroxide is unsuitable (e.g., around the eyes) or ineffective, fusidic acid $2\,\%$ cream ($POM$) is used.

• Systemic Management for Widespread Cases: Oral antibiotics are prescribed for $5$ days.

  • Flucloxacillin: First-line if no allergy.
  • Clarithromycin: Alternative for penicillin allergy.
  • Erythromycin: Recommended for pregnant patients.

• Pharmacy First Exclusions and Workflow:

  • Exclude bullous impetigo, recurrent impetigo (defined as $\ge 2$ episodes in the same year), and pregnant individuals under $16$ years.
  • Diagnosis is confirmed via visual examination.
  • Risk assessment: Consider NEWS2 score for deterioration. Refer to A&E if patient is immunosuppressed and infection is widespread or if severe complications (e.g., deep soft tissue infection) are suspected.

• Infection Control Measures:

  • Practice good hygiene: frequent hand washing, separate flannels/towels, and washing bedding at high temperatures.
  • Clean toys and avoid scratching lesions.
  • School/work exclusion: Stay off until $48$ hours after treatment has started or until lesions are dry and healed.
  • Legal requirement: Food handlers must inform their employers.

• Impetigo Referral Criteria:

  • Bullous impetigo.
  • Patient appearing systemically unwell.
  • Recurrent impetigo ($\ge 2$ episodes in one year).
  • Immunocompromised status.
  • Rapid or significant worsening of symptoms.

Cold Sores: Presentation and Treatment

• Pathology: Caused by the Herpes Simplex Virus, specifically $HSV-1$.

• Presentation: Small blisters or vesicles (clear, fluid-filled, $< 1\,\text{cm}$ diameter) on or around the mouth, typically the lower lip.

• Early Signs (Prodrome): Pain, tingling, burning, or itching up to $48$ hours before the sore appears. The condition is contagious from these early signs until fully healed.

• Triggers for Recurrence: Stress, ultraviolet (UV) light, premenstruation, minor trauma, and the common cold.

• Management:

  • Resolves naturally in $7$ to $10$ days.
  • Aciclovir $5\,\%$ cream ($GSL$): Most effective if started at the first sign of symptoms. Apply $5$ times a day for $5$ to $10$ days.

• Self-Care and Prevention: Wash hands after touching the area; avoid kissing or sharing items like towels/cutlery; avoid contact with babies under $4$ weeks; use sunblock on lips.

• Criteria for Referral: Large, painful, or recurrent sores; cases involving babies, pregnant women, or immunocompromised patients.

Hand, Foot and Mouth Disease

• Pathology: Viral infection caused by the Coxsackie $A16$ virus.

• Epidemiology: Common childhood illness affecting those under $10$ years.

• Progression: Initial symptoms include fever, sore throat, and reduced appetite. A few days later, painful ulcers develop on the mouth and tongue, followed by a rash of pink/red vesicles on the hands, feet, thighs, and buttocks.

• Management: Symptoms resolve in $7$ to $10$ days. No specific antiviral treatment exists.

  • Analgesia: Paracetamol or ibuprofen.
  • Supportive care: Hydration and soft foods (e.g., yoghurts).
  • Infection control: Hand washing and using tissues; school exclusion is only necessary if the child feels too unwell to attend.

• Referral: Pregnant women and patients showing signs of dehydration (e.g., thirst, dark urine, dry mouth/lips, sunken eyes).

Chickenpox (Varicella Zoster Infection)

• Pathology: Viral infection caused by the Varicella virus (Herpes Zoster).

• Infection Timeline: Incubation period is $10$ to $21$ days. Patients are most contagious $48$ hours before the rash appears and remain so until all lesions have crusted over (usually $5$ days).

• Symptoms: Fever, headache, malaise. The rash consists of extremely itchy papules (raised, solid, $< 1\,\text{cm}$) that become vesicles and then scabs. In adults, the rash is more widespread and fever is prolonged.

• Management:

  • Resolves in $1$ to $2$ weeks.
  • Itch relief: Crotamiton cream, calamine aqueous cream, or calamine lotion (drying effect).
  • Antihistamines: Sedating (chlorphenamine) or non-sedating (loratadine); note these may be less effective.
  • Analgesia: Paracetamol. Avoid ibuprofen as it can increase the risk of secondary bacterial skin infections.

• Referral: Increased warmth, redness, or pain around lesions; immunocompromised patients; pregnant women; and babies under $4$ weeks.

Shingles (Herpes Zoster Reactivation)

• Pathology: Reactivation of the Varicella Zoster virus that has been dormant in the nervous system following a chickenpox infection. It affects a single nerve and the skin surface (dermatome) served by it.

• Clinical Features: Incidence increases with age. Initially presents as tingling, pain, or headache. A rash of macules (flat, $< 1\,\text{cm}$) and papules develops $2$ to $3$ days later into painful vesicles that weep infectious fluid before crusting. It typically affects one side of the body, often the chest.

• Pharmacy First Service for Shingles: Adults over $18$ years can be supplied with $POM$ medications.

  • Aciclovir $800\,mg$ tablets ($POM$): Taken $5$ times a day for $7$ days. Most effective within $72$ hours of the rash to reduce the risk of post-herpetic neuralgia.
  • Valaciclovir ($POM$): For immunocompromised patients or when aciclovir is unsuitable.

• Management Support: Analgesia such as paracetamol, ibuprofen, or co-codamol. Keep the rash dry and avoid using creams or dressings.

• Criteria for Referral:

  • Systemically unwell or severe pain.
  • Pregnant women.
  • New blisters forming after $7$ days of treatment.
  • Recurrence of shingles.
  • Rapid symptoms worsening or ophthalmic involvement (eye area).

Questions & Discussion

• The presenter concludes by inviting any questions regarding the skin conditions and treatment pathways discussed.

• Further reading on the Pharmacy First clinical pathways is available via the NHS England documentation, specifically version $1.6$.