PH508 Non-Prescription Dermatology

Learning Objectives

• Describe anatomy, pathophysiology, and immunology of the integumentary system

• Assess patients presenting with self-limited skin disorders

• Recommend appropriate non-Rx medications for treatment/prevention of self-limited skin disorders

Pharmacy & Skin Dx

• Skin dx: low mortality

• Treatments: OTC Skin Care

• Community Pharmacists Provide:

  • Patient access & Facilitate (effective) self-care

Skin Structure and Function

• Integumentary System

  • An organ system consisting of skin, hair, nails, and exocrine glands

  • Largest organ

  • Waterproof

  • Protects deeper tissues

  • Excretes wastes

  • Regulates body temperature

  • ‘Sense’ organ

Layers and Structures of the Skin

Subcut → Dermis → Epidermis

• Psoriasis & Acne occur on the top layer on the epidermis*

• A macule is a small, flat, and discolored spot on the skin that is typically less than 1 centimeter in diameter. It is characterized by a change in color or pigmentation, but does not involve any elevation or depression of the skin surface. Macules can be caused by various factors such as skin infections, allergic reactions, or certain skin conditions.

Structure of the Epidermis

• The epidermis matures progressively from the stratum basale (SB) to the stratum spinosum (SS), stratum granulosum (SG), and stratum corneum (SC)

• Important structural and metabolic proteins are produced at specific layers of the epidermis

• • The cornfield lipid envelope, lipid bilayers, & cornfied cell envelope with Involucrin, foricrin, filaggrin

    • Important for the vehicle

• TOP

  • stratum Corneum (SC)

  • stratum Granulosum (SG)

  • stratum Spinosum (SS)

  • stratum Basale (SB)

• BOTTOM

  • “Come Get Sun Burnt”

Pharmaceutics

• Skin normally acidic

  • "acid mantle" → helps repel bacteria and fungus

• Key points – Absorption

  • Rates vary by anatomical skin sites

  • Lipophilic drugs absorbed faster due to lipid bilayers*

  • Occlusion affects absorption

Factors Influencing Drug Absorption through the Skin

Age-Related Skin Differences

• Pediatric skin; Thinner

  • Barrier function not intact in pre-term baby

    • Potential for drug toxicity

      • Thinner skin → rapid absorption → potential for toxicity → new born babies

    • Systemic absorption

      • Absorbs topical drugs faster than adults*

• Geriatric skin; Drier, Thinner, MORE Fragile

  • Prolonged healing time

Skin Care Basics

• Skin health related to overall health

• Nutrition

• Fluid intake

  • Skin 10%-20% water by weight

    • If below then cracks form in skin (inflammation)

• Skin hydration

  • Fragrance-free moisturizers

  • Bathing in lukewarm water

  • Non-soap cleansers

  • Minimize astringents and alcohol-containing products

Skin Assessment: Lesions

• Macules: FLAT, distinct, discolored

• Vesicles: small, fluid-filled sac

• Bulla/Bullae: large, fluid- filled sac ; larger than vesicles

  • Caused by diaper dermatitis or severe rash, chickenpox, poison ivy

• Papules: small, raised, solid bump

• Nodules: small, solid, and abnormal growth or lump

• Plaque: thick, sticky, or flaky layer

  • caused by buildup of substances such as dead skin cells, oils, and bacteria that accumulate on the surface of the skin.

    • Can lead to acne & psoriasis

• Nevi: black/brown moles or skin growths that appear anywhere on the body

• Scale: dry, flaky, patches on skin that can appear white.

  • caused by ccumulation of dead skin cells on the surface of the skin

Macules

Vesicles & Bullae

VESICLE & BULLAE

Nodules

Papules

Psoriasis

Nevi

Xerosis

• Dry Skin

• Geriatric population

• Environmental risk (arid / cold / windy)

• Extremely dry skin

  • Skin cracks / fissures

• Pruritus (itching)

  • Promote MOSITUREZERS*

Fissue

• • Diaper Rash

  • Adults with diapers for incontinence

  • Erythematous, severe rashes w/ vesicles and secondary infections

  • Candida albicans

  • Management

    • Frequent changes, nonsoap cleansers, lukewarm water

    • Zinc oxide

    • Can use as prophylaxis

Diaper Dermatitis:

• Diaper Rash

  • Adults w/ diapers for incontinence

  • TREATMENT: Zinc oxide containing products

    • Desitin, A&D ointment

• IF…Erythematous, severe rashes w/ vesicles and secondary infections then…

  • Fungus infection caused by Candida albicans

  • TREATMENT: Antifungal

    • Nystatin, clotrimazole, miconazole

• Non-Pharmacy Management:

  • Frequent changes, non-soap cleansers, lukewarm water

• When to refer

  • If not better after a few days/week

  • Ulcerations or any systemic signs: fever, skin lesions elsewhere on body

Sun Damage

• Sunburn: 1 blistering sunburn before age 18 doubles your melanoma risk

• UV radiation: photoaging and skin cancers

• UVA – minimally filtered by ozone layer

• UVB – 90% filtered by ozone later

  • *Promote sun protection & sunscreens

    Sunscreens

    • 2 types

      • Organic (chemical)

        • Absorb UVA or UVB

      • Inorganic (mineral)

        • Broad spectrum - both UVA/UVB

        • Titanium dioxide or zinc oxide

    • AVOID sunscreen use for kids under 6 months

• FDA regulates sunscreen

  • Sunscreens that are not broad spectrum or that lack an SPF of at least 15 must carry the warning: "Skin Cancer/Skin Aging Alert: Spending time in the sun increases your risk of skin cancer and early skin aging. This product has been shown only to help prevent sunburn, not skin cancer or early skin aging.”

Non-Pharmacy Sun Protection

• Limit time in sun

• Protective clothing

• Avoid tanning salons & tanning

• Seek shade

How To Apply Sunscreen

• BEFORE sun exposure

• Reapply

• Does sunscreen expire?

  • Yes, sunscreen does expire. Most sunscreens have an expiration date printed on the packaging. It is important to check the expiration date and replace sunscreen that has expired, as the effectiveness of the product may decrease over time.

• A word about photosensitizing medications

  • Some medications lower threshold to develop sunburn

    • Antibiotics (tetracycline, minocycline, doxycycline)

    • Sulfa medications (Bactrim, HCTZ)

    • NSAID (non steroidal anti-inflammatory drugs)

Contact Dermatitis

• Definition: inflammation of skin caused by an irritant or allergic sensitizer

• 5.7 million physician visits annually

• Pharmacist consultations

  • 85,000 chemicals considered skin irritant

• Irritant Contact Dermatitis (ICD)

  • *STAYS

• Allergic Contact Dermatitis (ACD)

  • *SPREADS

ICD/ACD Pathophysiology:

• ICD: Pathophysiology

  • External substance that abrades, irritate or damages skin

  • Clinical result of direct inflammation from pro-inflammatory cytokines released from damaged skin cells

• ACD: Pathophysiology

  • Type IV (delayed hypersensitivity reaction)

  • 2 phases: initial sensitization phase then elicitation phase

  • Reactions may appear 18-24 hours after exposure

ICD: Poison Ivy

• Inflammatory reaction caused by exposure to irritant: oil resin contains Urushiol

• Symptoms:

  • Swelling

  • Weeping vesicles

  • Intense Pruritis

• 50 mcg (size of 1 grain of salt) may cause…

• Exclusion to self care * SEND TO DR

  • Face or genital contact

  • Rash severity

  

ICD: Poison Ivy Treatment

• WASH the SKIN (and clothes)

  • The longer on skin the more time for tissue penetration

  • Reactions typically develop in 12-48 hours and may be transferred to other areas

• Zanfel (Lauroyl Sarcosinate)

  • OTC detergent that binds/lifts urushiol from skin

  • Fast relief but $

• Topical Medications

  • Hydrocotisone

    • 0.5% and 1% are OTC strengths

  • Anti-Pruritics

    • Calamine Lotion, Colloidal Oatmeal

  • Astringents

    • Calamine Lotion, Aluminum Acetate

Hydrocortisone

• Topical corticosteroid

• Non prescription: Lowest potency

• Mechanism of Action:“..anti-inflammatory, antipruritic, and vasoconstrictive properties. May depress the formation, release, and activity of endogenous chemical mediators of inflammation (kinins, histamine, liposomal enzymes, prostaglandins) through the induction of phospholipase A2 inhibitory proteins (lipocortins) and sequential inhibition of the release of arachidonic acid. Hydrocortisone has low to intermediate range potency (dosage-form dependent)”

• Hydrocortisone Adverse drug reactions:

  • Acneiform eruption, atrophic striae (stretch marks), burning sensation of skin, folliculitis, hypertrichosis (excess hair growth), hypopigmentation, maceration of the skin, pruritus, secondary skin infection, skin atrophy, skin irritation, xeroderma

Anti-Pruritics (Anti-Itch)

• Calamine Lotion

  • MOA: (?)

  • converts to zinc oxide, astringent properties

  • Commonly used to relieve itching and irritation caused by minor skin conditions such as poison ivy, insect bites, and sunburn.

    • Brands: Caladryl & CVS Calamine Plus.

• Colloidal Oatmeal

  • High concentration in starches & beta-glucan is responsible for the protective & water-holding functions of oat

    • Different types of phenols confer antioxidant and anti-inflammatory activity

    • Some oat phenols are strong ultraviolet absorbers

    • Cleansing activity of oat is mostly dye to Saponins

  • Avenanthramides inhibit activity of nuclear factor kappaB and release of pro-inflammatory cytokines and histamine

    • Key mechanisms in pathophysiology of inflammatory dermatoses

  • Used for: treating various skin conditions such as eczema, dry skin, and itching

  • Brands: Aveeno

Astringents

• MOA: constricts blood vessels, relieves inflammation

  • “TRING” → “CONSTRICT”

• Aluminum acetate (Burow solution)

  • Produced when aluminum sulfate & calcium acetate are mixed in water

  • Topical solution acts astringent by constricting blood vessels

    • Relieves inflammation & itching: cools & dries skin & wet or weeping skin lesions

  • Brand: Domeboro Soak

Allergic Contact Dermatitis

• Difficult to distinguish from ICD

• Common reasons for ACD:

  • Fragrance & Nickels

• Testing for allergies

Atopic Dermatitis

• Chronic skin disorder involving inflammation and intense pruritis

  • Itching is responsible for disease burden

• Often referred to as eczema

• “The itch that rashes”

• The Atopic Triad:

  • Atopic dermatitis

  • Allergic Rhinitis

  • Asthma

AD: Epidemiology

• Most cases manifest before age of 1 year

• 85%-95% of patients develop symptoms before 5 years of age

• 10%-30% will continue with symptoms through adulthood

• Periods of exacerbations (flare ups) and remission

• Prevalence: 15-30% of children; 2-10% of adults

• $5 billion dollar health care burden

AD: Etiology

• Clinical diagnosis

  • No biomarker / no lab test

• Genetic predisposition

  • T-helper predominance (Th2)

  • Mutation in Filaggrin (FLG) gene (key structural protein in epidermal differentiation)

• AD = epidermal barrier dysfunction / enhanced allergen absorption through the skin

AD: Pathophysiology

• Unknown MOA, trigger inflammatory changes in the skin

• Predisposing factors: climate, infection, genetics diet, family history

AD: Clinical Presentation

• Infancy: Erythematous papular skin eruption on cheeks/chin, patchy facial areas

• Lesions on flexor surfaces (Antecubital & Popliteal fossa)

• Dry, flaky, rough, cracked skin

• Lichenification: occurs from repeated rubbing of the skin

• Prone to skin infections: Staphylococci aureus

  • Impetigo

Non-Rx Therapy

• Apply Moisturizer

  • Standard of care

  • May reduce disease severity and need for RX

  • Improves AD associated xerosis

  • May be steroid sparing

• Lukewarm bath with application of moisturizer after bathing once or twice daily

• Keep humidity at home at or above 50%, cool room temps

• Nonsoap cleansers like Cetaphil

• Stress relief

• Cotton sheets

• Wear loose fitting clothing

• Aviod high heat

Moisturizers

• Occlusives: form a film to reduce the loss of water from the skin

  • Petrolatum, mineral oil

• Humectants: attract and bind water from surroundings

  • Urea, alpha hydroxy acid

• Emolients: lubricate the skin

  • Lanolin, glyceryl stearate, soy sterols

Moisturizers Formulation Characteristics

• Cream: less greasy than ointment, preferred for AD

• Lotion: less greasy than cream, quicker to be absorbed

• Ointment: best for thick/extremely dry areas (lichenified)

• Gel: quick drying

• Solutions: quick drying

• Foams: use for scalp

Hydrocortisone

• Topical corticosteroid

• Non prescription: Lowest potency

• Mechanism of Action:

  • Anti-inflammatory, antipruritic, and vasoconstrictive properties

  • May depress the formation, release, and activity of endogenous chemical mediators of inflammation

  • Hydrocortisone has low to intermediate range potency

• Hydrocortisone Adverse drug reactions:

  • Acneiform eruption, atrophic striae, burning sensation of skin, folliculitis, hypertrichosis, hypopigmentation, maceration of the skin, pruritus, secondary skin infection, skin atrophy, skin irritation, xeroderma

  • At increased risk of adrenal suppression with higher potency

• Administration

  • Fingertip rule

  • Only thin layer necessary

  • Squeeze a ribbon of medication onto index finger

  • Amount should cover both palms of hand

• Length of treatment

  • Use for short duration: AD

• What goes first?

  • general guideline is to apply products from thinnest to thickest consistency.

    • foam, solution, gel, lotion, cream, & ointment

Topical Corticosteroids

• Class 1: Superpotent

  • Betamethasone dipropionate 0.05% ointment (Diprolene and Diprosone ointment)

  • Clobetasol propionate 0.05% lotion/spray/shampoo/foam (Clobex lotion/spray/shampoo, OLUX-E foam)

  • Clobetasol propionate 0.05% cream and ointment (Cormax, Temovate, Dermovate)

  • Desoximetasone 0.25% spray (Topicort)

  • Fluocinonide 0.1% cream (Vanos)

  • Halobetasol propionate 0.05% cream, lotion, and ointment (Ultravate)

  • Flurandrenolide tape 4 mcg/cm2 (Cordran)

• Class 2: Potent

  • Amcinonide 0.1% ointment (Cyclocort ointment)

  • Betamethasone dipropionate 0.05% cream/gel (Diprolene cream, gel, and Diprosone cream)

  • Desoximetasone 0.25% cream, ointment (Topicort)

  • Diflorasone diacetate 0.05% ointment (Florone, Psorcon)

  • Fluocinonide 0.05% cream, gel, ointment (Lidex)

  • Halcinonide 0.1% cream (Halog)

• Class 3: Upper mid-strength

  • Amcinonide 0.1% cream (Cyclocort cream)

  • Betamethasone valerate 0.1% ointment (Betnovate/Valisone ointment)

  • Diflorasone diacetate 0.05% cream (Psorcon cream)

  • Fluticasone propionate 0.005% ointment (Cutivate ointment)

  • Mometasone furoate 0.1% ointment (Elocon ointment)

  • Triamcinolone acetonide 0.5% cream and ointment (Aristocort)

• Class 4: Mid-strength

  • Betamethasone valerate 0.12% foam (Luxiq)

  • Clocortolone pivalate 0.1% cream (Cloderm)

  • Desoximetasone 0.05% cream, ointment, and gel (Topicort LP)

  • Fluocinolone acetonide 0.025% ointment (Synalar ointment)

  • Fluocinolone acetonide 0.2% cream (Synalar-HP)

  • Flurandrenolide 0.05% ointment (Cordran)

  • Hydrocortisone valerate 0.2% ointment (Westcort ointment)

  • Mometasone furoate 0.1% cream (Elocon cream)

  • Triamcinolone acetonide 0.1% ointment (Kenalog)

• Class 5: Lower mid-strength

  • Betamethasone dipropionate 0.05% lotion (Diprosone lotion)

  • Betamethasone valerate 0.1% cream and lotion (Betnovate/Valisone cream & lotion)

  • Desonide 0.05% lotion (DesOwen)

  • Fluocinolone acetonide 0.01% shampoo (Capex shampoo)

  • Fluocinolone acetonide 0.025%, 0.03% cream (Synalar cream)

  • Flurandrenolide 0.05% cream and lotion (Cordran)

  • Fluticasone propionate 0.05% cream and lotion (Cutivate cream and lotion)

  • Hydrocortisone butyrate 0.1% cream (Locoid)

  • Hydrocortisone valerate 0.2% cream (Westcort cream)

  • Prednicarbate 0.1% cream (Dermatop)

  • Triamcinolone acetonide 0.1% cream and lotion (Ke

• Class 6: Mild

  • Alclometasone dipropionate 0.05% cream and ointment (Aclovate)

  • Betamethasone valerate 0.05% cream and ointment

  • Desonide 0.05% cream, ointment, gel (DesOwen, Desonate, Tridesilon)

  • Desonide 0.05% foam (Verdeso)

  • Fluocinolone acetonide 0.01% cream and solution (Synalar)

  • Fluocinolone acetonide 0.01% FS oil (Derma-Smoothe)

Antipruritics

• Calamine lotion

  • MOA: (?), converts to zinc oxide, astringent properties

• Colloidal oatmeal

  • High concentration in starches and beta-glucan is responsible for the protective and water-holding functions of oat

  • Different types of phenols confers antioxidant and anti-inflammatory activity

  • Some of the oat phenols are also strong ultraviolet absorbers

  • The cleansing activity of oat is mostly due to saponins

  • “Avenanthramides” inhibit activity of nuclear factor kappaB and release of proinflammatory cytokines and histamine

    • well known key mechanisms in the pathophysiology of inflammatory dermatoses

• Antihistamines

  • MOA: block histamine (H1)

  • Oral formulations

    • Diphenhydramine

    • Loratadine

    • Cetirizine

  • Topical antihistamines should be avoided

  • Yes, an antihistamine can have antipruritic properties. Antihistamines work by blocking the effects of histamine, a chemical released during an allergic reaction that can cause itching (pruritus) and other symptoms. By reducing histamine activity, antihistamines can help relieve itching and provide antipruritic effects.

Atopic Dermatitis: Exclusions to Self Care:

• Infants less than 1 year old

• Signs of active infection

• Large body surface area involvement

• Face

• Atopic Dermatitis Case

  • A parent comes to your community pharmacy complaining “My child constantly wants to scratch her skin, and she can’t sleep well during the night.” What information would you collect from the parent?

  • To properly assess the situation, you would collect the following information from the parent:

    1. Age of the child: This helps determine if the symptoms are age-related or if they could be due to a specific condition.

    2. Duration of symptoms: Knowing how long the child has been experiencing these symptoms can provide insights into the possible causes.

    3. Any known allergies: Allergies can often cause skin itching and disrupt sleep, so it's important to inquire about any known allergies.

    4. Recent changes in environment or routine: Changes in detergents, soaps, or other environmental factors can trigger skin irritation.

    5. Other accompanying symptoms: Inquire about any other symptoms the child may be experiencing, such as redness, rash, or fever.

    6. Family history: Ask if there is a history of skin conditions or allergies in the family, as these can be hereditary.

• Atopic Dermatitis Case

  • What are the clinical signs and symptoms of AD

    • Clinical signs and symptoms of Atopic Dermatitis (AD):

      1. Itchy skin: Intense itching is a hallmark symptom of atopic dermatitis.

      2. Dry skin: Skin may appear dry, rough, and scaly.

      3. Redness and inflammation: Affected areas of the skin may be red, swollen, and inflamed.

      4. Rash: A rash may develop, typically in the folds of the skin, such as behind the knees or in the crook of the elbows.

      5. Cracked and thickened skin: Over time, the skin may become thickened, cracked, and leathery.

      6. Blisters or oozing: In severe cases, blisters or oozing may occur, leading to crusting and weeping of the skin.

      7. Skin discoloration: The affected skin may become lighter or darker in color.

      8. Sleep disturbances: Itching can disrupt sleep, leading to fatigue and irritability.

      9. Emotional distress: The chronic nature of atopic dermatitis can cause emotional distress, including anxiety and depression.

      10. Secondary infections: Scratching can lead to open sores, increasing the risk of bacterial or viral infections.

• AD: Case

  • What non-pharmacologic therapy would you recommend?What moisturizer would you recommend? How often to apply? What is best time to apply?

    • Non-pharmacologic therapy for atopic dermatitis includes:

      1. Moisturizing regularly: Use a fragrance-free moisturizer to hydrate the skin and prevent dryness.

      2. Avoiding triggers: Identify and avoid irritants or allergens that can worsen symptoms.

      3. Gentle skincare routine: Use mild, non-irritating cleansers and avoid excessive scrubbing or hot water.

      4. Moisturizer recommendation: A thick, emollient moisturizer with ingredients like ceramides or petrolatum is often recommended.

      5. Frequency of application: Apply moisturizer at least twice daily, or as directed by a healthcare professional.

      6. Best time to apply: Apply moisturizer immediately after bathing or showering to lock in moisture.