Over the Counter Review Over the Counter Review Topical Management
Transcript of Over the Counter Review Over the Counter Review Topical Management
Over the Counter Review: Topical Management
© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 1
Over the Counter Review
Topical Management
Peter A. Kreckel
Adjunct Assistant Professor of Pharmacology
St Francis University, Loretto PA
With special thanks to: Gretchen M. Kreckel Garofoli Clinical Assistant Professor West Virginia University Morgantown, WV
PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education
Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support
educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all
information and data before treating patients or employing any therapies described in this educational activity.
This program has been supported by
PharmCon
Over the Counter Review
Topical Management
Accreditation:
Pharmacists: 0798-0000-11-082-L01-P
Pharmacy Technicians: 0798-0000-11-082-L01-T
Nurses: N-706
CE Credits: 1 contact hour
Target Audience: Pharmacists Technicians
& Nurses
Program Overview:
Over the counter (OTC) products are vital to the everyday existence of many individuals. This program will discuss a
number of the most commonly treatable afflictions and what the consumer can get at the pharmacy to deal with them. Each
topic is addressed briefly in terms of what causes certain afflictions before a number of products are then introduced and
discussed in how they work and of what they are composed. This program is a must for any health care professional
Objectives:
• Identify appropriate topical over-the-counter medications for self-treatable conditions
• Appropriately consult patients on proper utilization and side effects of topical OTC medications
This program has been
supported by PharmCon
Over the Counter Review
Topical Management
PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of
continuing pharmacy education
Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the
companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product
discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.
This program has been
supported by PharmCon
Speaker: Peter A. Kreckel R.Ph. is a graduate of the University of Pittsburgh, Bachelor of Science in Pharmacy,
Magna Cum Laude, Class of 1981. He served as the President of the Pharmacy School Class of 1981 for 3 years,
and President of the Pharmacy School Student Council for 2 years. During this time he received the Upjohn
Achievement Award for leadership and academic achievement. In addition to managing a retail pharmacy,
pharmacist Kreckel is an Adjunct Assistant Professor of Pharmacology, Department of Physicians Assistant
Sciences, St. Francis University. His assignments include teaching a HIV pharmacotherapy course for Physician
Assistant students, currently doing their clinical rotations, that are pursuing a Masters of Medical Science Degree
from St. Francis University.
Speaker Disclosure: Mr. Kreckel has no actual or potential conflicts of interest in relation to this
program.
Goals and Objectives
Goal:
The goal of this program is to educate fellow pharmacists regarding the selection process of appropriate topical over-the-counter medications
Objectives:
Identify appropriate topical over-the-counter medications for self-treatable conditions
Appropriately consult patients on proper utilization and side effects of topical OTC medications.
Disclaimer: The speaker reports no conflicts of interest in the preparation and presentation of this review program
Over the Counter Review: Topical Management
© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 2
Back in the old days……..
Diphenhydramine, Chlorpheniramine,
Clemastine, Ketotifen drops
Loratadine, Fexofenadine, Cetirizine
Cimetidine, Famotidine, Ranitidine
Omeprazole, Lansoprazole
Hydrocortisone
Terbinifine, Miconazole, Clotrimazole
Ibuprofen, Naproxen
PEG-3350
Dermatophytes: is there a fungus
among us??
Topical fungal infections affect scalp, skin, nails, such as mucus membranes such as oral cavity and vagina. Superficial fungal infections are sometimes called dermatophytic. Usually treated topically due to decreased side effects of this route of administration.
Causative organisms: Trichophyton, Epidermophyton or Microsporum
Tinea cruris : “jock itch”
Tinea corporis: “ringworm”
Tinea capitas: “ringworm of the scalp”
Tinea pedis: “athletes foot”
Tinea versicolor: “sweat rash”
Treatment of Dermatophytes
(-azole antifungals)
Mechanism: impairs the synthesis of ergosterol, the
main sterol of fungi membranes, allowing increased
permeability and leakage of cellular components.
Inhibits fungal CYP 450 14-alpha-desmethylase
thereby decreasing ergosterol.
Miconazole (Micatin®)
Clotrimazole (Lotrimin®)
Terbinifine (Lamisil®): inhibits the fungal enzyme squalene 2,
3 epoxidase, which ultimately decreases the synthesis of ergosterol
Diaper Rash
Etiology
Two-thirds of infants experience diaper rash.
Disposable diapers have greatly decreased incidence.
Breast fed babies have less than bottle fed babies.
Causes include: moisture, bacteria, alkaline pH , mechanical disruption of the area, digestive enzymes & bile salts. Thinner skin in infants and elderly predispose them to this condition. Bacteria may include: Peptostreptococcus, streptococci, staphylococci, bacteroides, and E. coli, however 80% of the cases where symptoms have been present for at least 3 days, Candida albicans is found.
Untreated overgrowth of C. albicans leads to ulceration, maceration and UTI.
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 3
Diaper rash-
TREATMENT
Candida albicans treatment: any of the –azole antifungals are effective.
Vusion (Rx)= miconazole 0.25%, ZnO, white petrolatum
Diaper rash prevention with oral antibiotic therapy. Broad spectrum antibiotics, especially amox/clavulanate. Use protectant paste
AVOID powders: avoid all powders due to potential inhalation. Cornstarch “feeds” yeast!
AVOID RX corticosteroids
Avoid alcohol & scented baby wipes
Fresh air!
Anti- infectives
TRIPLE antibiotic: Bacitracin---polymixin---
neomycin.
MAY help speed healing, prevent infection,
and reduce the risk of scarring.
Neomycin (6%) & bacitracin (2%) can cause
allergic dermatitis.
Patients notice increasing redness or itching
with these, tell them to avoid using them.
Use plain petrolatum instead.
Anti- infectives
Itching??
Calamine (Zn oxide +ferric oxide)
Diphenhydramine (Benadryl®) topical: exert an
anesthetic effect by depressing cutaneous
receptors to relieve pain and itching.
Hydrocortisone (Cortaid®):anti-inflammatory
agent that can prevent or suppress edema,
capillary dilation, swelling, and tenderness
associated with inflammation
Aluminum acetate (Domeboro®): astringent
1 packet per pint= 1:40
2 packets per pint= 1:20
Topical anesthetics
Dermoplast spray- 20% benzocaine
Hypersensitivity common reaction
Solarcaine (gel) lidocaine
Caution with broken skin (might precipitate
arrhythmia)
Use not recommended, due to short duration of
effectiveness: max= 45 minutes.
Over the Counter Review: Topical Management
© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 4
Germ Killers!
Betadine: used to decontaminate Lunar
module after Neil Armstrong moonwalk-1969.
Povidine iodine topical antiseptic.
Hibiclens: chlorhexidine- used for MRSA
Soap and Water
Alcohol
Hand gels (62% ethanol and higher)
Alcohol based hand sanitizer
1."Caregivers should wash hands with a non-antimicrobial soap and water or an anti-microbial soap and water when hands are visibly dirty or contaminated with proteineous material, such as blood or feces" (Recommendation 1)
2."If hands are not visibly soiled, caregivers should use an alcohol-based waterless antiseptic agent for routinely decontaminating hands"
(CDC Guideline for Hand Hygiene in Healthcare Settings: Recommendation 2)
Alcohol based
hand sanitizers
Must be 62% alcohol to be effective
Are not effective against Clostridium difficile
spores. Use soap and water.
Reports of alcohol ingestion from “licking”
hands
Ophthalmic Disorders
Eye surface Dry eyes
Allergic conjunctivitis
Diagnosed viral conjunctivitis
Diagnosed corneal edema
Presence of loose foreign debris
Minor ocular irritation
Chemical burns
Clean or lubricating of artificial eyes
Diagnosed age-related macular degeneration
Over the Counter Review: Topical Management
© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
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Exclusions to Self Care
Blunt trauma
Foreign particles trapped or embedded in the eye
Ocular abrasions
Infections of the eyelid/eye surface
Eye exposure to chemical splash, solid chemical, or chemical fumes
Thermal injury to eye
Bacterial conjunctivitis
Chlamydial conjunctivitis
Dry Eye
Most common anterior eye disorder
Common Causes Aging
Lid defects
Loss of lid tissue turgor
Sjögren’s syndrome
Bell’s palsy
Thyroid eye disease
Collagen diseases
Systemic medication
Environmental factors
Dry Eyes Treatment Goals
Alleviate and control dryness
Relieve symptoms of irritation
Prevent possible tissue and corneal damage
Nonpharmacologic Therapy
Avoid environmental triggers
Avoid prolonged viewing of computer screens
Symptoms
White or mildly red eye
Sandy, gritty feeling
Sensation of something in the eye
May initially present with excessive tearing
Dry Eyes
Pharmacologic Therapy
Artificial Tear Solutions
Ocular Lubricants
Prevent tear evaporation through stabilization of tear film
Use at least twice per day
Numerous products available
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
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Dry Eyes
Pharmacologic Therapy
Ophthalmic Ointment
Contains
White petrolatum
Mineral oil
Lanolin
Advantage is that it is retained longer in the eye
Administered twice daily
Most common side effect
Blurry vision
Allergic Conjunctivitis
Treatment Goals: Remove or avoid allergen
Provide symptomatic relief-limit allergy reaction
Protect the ocular surface
Nonpharmacologic Therapy
Do not wear contact lenses until resolved
Apply cold compresses 3-4 times a day
Causes: Pollen, Animal dander, topical eye preps
Symptoms: Red eye with watery discharge, Itching
Allergic Conjunctivitis
Pharmacologic Therapy
1st line
Artificial tears
If symptoms persist
Ophthalmic antihistamine/mast cell stabilizer
If symptoms do not resolve within 72 hours from
starting therapy patient should see eye care
practitioner
Allergic Conjunctivitis
Ophthalmic Decongestants
Constrict conjunctival vessels reducing
redness
Phenylephrine
Works on alpha-adrenergic receptors of ophthalmic
vasculature
Oxymetazoline
Naphazoline
Tetrahydrozoline
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 7
Allergic Conjunctivitis
Ocular decongestant side effects
Generally do not have ocular or systemic side
effects
Long-term use leads to potential for:
Rebound conjunctival hyperemia
Allergic conjunctivitis
Allergic blephariits
Abnormal dryness
Allergic Conjunctivitis
Ocular Decongestants
Do NOT use in patients with
Systemic hypertension
Arteriosclerosis
Other cardiovascular diseases
Diabetes
Hyperthyroidism
Use sparingly if at all in pregnancy
Allergic Conjunctivitis
Ophthalmic Antihistamines
MOA: histamine1- receptor antagonists
Pheniramine maleate
Antazoline Phosphate
Available in combination with decongestants
Pheniramine/naphazoline
Antazoline/naphazoline
More effective than using either agent alone
Allergic Conjunctivitis
Ophthalmic antihistamine and mast cell
stabilizer
Zaditor ® (ketotifen fumarate)
Potent H1-receptor antagonist
Mast cell degranulation inhibited, release of
inflammatory mediators inhibited
Relief in minutes
Lasts for 12 hours
Can use in children 3 years of age and older
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 8
Viral Conjunctivitis- “Pink
Eye”
Most common form of conjunctivitis. In adults
80% of pink eye is of viral etiology. In
Children 50% of pink eye cases are viral.
Highly contagious- for one week
Precursors- Recent cold
Sore throat
Exposure to someone with “pink eye”
Viral Conjunctivitis- “Pink
Eye”
Goal of therapy- relieve symptoms while
infection runs its course. Symptoms
Watery discharge, conjunctival redness and swelling
Ocular discomfort, with mild-to-moderate sensation of
foreign object in eye
Photophobia and blurred vision
Self-limiting:symptoms resolve in 1-3 weeks
For symptomatic relief: use artificial tear
preparations or ocular decongestants
Viral Conjunctivitis- “Pink
Eye”
Counseling points
Proper hygiene
Wash hands after touching eyes
Avoid sharing towels
Discard used tissues
Cold compress use
Avoid wearing contact lenses
Replace after having pink eye
Otic Disorders
Exclusions for Self-Care Signs of infection
Pain associated with discharge
Bleeding or signs of trauma
Presence of ruptured tympanic membrane
Ear surgery within previous 6 weeks
Tympanostomy tubes present
Not able to follow proper instructions
Hypersensitivity to recommended agents
Less than 12 years of age
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 9
Excessive/Impacted Cerumen
Predisposing causes
narrow or misshapen external auditory canal
Excessive hair growth in the canal
hearing aids, earplugs or sound attenuators are
also at a higher risk for developing
Sense of fullness or pressure, gradual hearing
loss, dull pain, vertigo, tinnitus, chronic cough
Nonpharmacologic Treatment
Damp washcloth draped over a finger
Irrigation with an otic bulb syringe- warm water
Excessive/Impacted Cerumen
Pharmacologic Treatment
Carbamide peroxide 6.5%
Used in adults and children 12 yrs and older
Cerumen softening agent
Softens, Loosens, Removes
Used twice daily up to 4 days
Warm water irrigation after treatment
OTHER treatments are not FDA
recommended.
Water-Clogged Ears
Nonpharmacologic Treatment Tilt affected ear downwards
Use a blow-dryer on a low setting around the ear after swimming or bathing
Pharmacologic Treatment Isopropyl alcohol 95% in anhydrous glycerin 5%
50:50 mixture if acetic acid 5% and isopropyl alcohol 95%
Refer if no relief after 4 days of treatment
Topical Nasal Products
Nasalcrom: Cromolyn sodium- mast cell
stabilizer, use before allergen exposure.
Prevention rather than treatment. May take 2
weeks if severe.
Oxymetazoline: 3 days max. After 10 days see
“rhinitis medicamentosa” .
Normal saline: can relieve nasal congestion and
dryness. For infants, suggest using saline drops
first to loosen the mucus, then suctioning it
gently with a bulb syringe.
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 10
Neti Pot
Advise patients to keep their neti pots and irrigation bottles clean to reduce contamination. Wash after every use. Do not share!
If patients who irrigate get frequent nasal infections, review their cleaning methods or suggest a trial off irrigation.
Limit nasal irrigation to once or twice daily. More frequently can be overly drying and irritating.
No difference between isotonic (0.9%) or hypertonic saline solutions. The range of concentrations of hypertonic saline used in the various studies was from 2% to 3.5%.4
Hemorrhoids –Stage I and II
goal is to reduce straining and downward
pressure.
Avoid straining, and sitting on toilet longer than
necessary.
Treat with high fiber diet, and bulk laxatives.
Increase bulk intake and water intake.
Stool softeners will also reduce straining.
OTC creams, ointments and foams will provide
relief
Hemorrhoids DRUG PROTECTANT ANESTHETIC VASOCON-
STRICTOR
ASTRINGENT ANTI-INFLAMMATORY
Nupercainal Dibucaine
Preparation-H Mineral oil,
Petroatum,
Shark oil
Phenyl
ephrine
Prep-H cooling gel Phenyl
ephrine
Witch hazel
Prep-H anti-itch Hydrocortisone 1%
Tucks (former-
Anusol)
Hydrocortisone 1%
Tronolane Zinc oxide Pramoxine Zinc oxide
Calmol-4 Cocoa
butter
Zinc oxide
Tucks-Pads Witch hazel
Prep-H Wipes Witch Hazel
Personal
Lubricants
Basic formula: (are NON-petroleum based)
Lubricants: glycerin, hydroxyethyl cellulose,
propylene glycol, Polysorbate-60, purified water
Preservatives: chlorhexidine gluconate, glucono
delta-lactone, methylparaben and sodium hydroxide
or benzoic acid
INDICATIONS: enhances the comfort and ease of
intimate activity and acts as a moisturizer for vaginal
dryness.
Nonoxynol-9 : Spermicide may INCREASE the
spread of HIV
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 11
Unwanted Hair Removal
Depilatories use a chemical called thioglycolate mixed
with sodium hydroxide or calcium hydroxide to
literally melt the hair away. Thioglycolate disrupts
disulfide bonds, which are chemical bonds that hold
skin and hair cells together. The disulfide bonds that
hold hair together contain more of the protein cystine
than do the disulfide bonds that hold skin cells
together. Thioglycolate is more effective on disulfide
bonds that contain cystine. The major side effect of a
depilatory is skin irritation because the chemical can
melt away skin cells.
Deodorants and
Antiperspirants
Certain Dri Anti-Perspirant: 12 percent
aluminum chloride (water base). (Drysol Rx is
20% alcohol based)
Dermatologists/podiatrists recommend use
for feet to prevent onychomycosis, that has
been treated by Terbinifine (Lamisil) or
Itraconazole (Sporanox).
Remember fungi love: Warm, Dark, Moist!
Vaginal
candidiasis
Clotrimizole (Lotrimin): 7 day & 3 day
Vag tabs: 100, 200mg; Cream: 1%, 2%
Miconazole: (Monistat) 7 day & 3 day & 1 day
Supps: 100,200,1200; Cream: 2%, 4%
Tioconazole (Vagistat-1) 1 day
Ointment: 6.5%
1-day vaginal antifungals don’t work faster than 3-
or 7-day products. Shorter regimen products are
more concentrated but they don't relieve symptoms
faster.
Clinical pearls
Candidiasis
Avoid miconazole with warfarin- vaginal use might increase an INR
Recommend any of the vaginal antifungals. All work well
Single dose of oral fluconazole 150 mg for uncomplicated yeast infections. OTC??
Nonalbicans Candida infections are more common in diabetes patients and are usually resistant to topical or oral azoles. (Tx: Boric acid 600mg supps)
Women are at higher risk if pregnant or diabetic
Pregnant women should be given a vaginal azole for 7 days.
Over the Counter Review: Topical Management
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Reproduction in whole or in part without permission is prohibited.
Page 12
Topical Pain reliever
“rubefacients”
Also known as counter irritants- cause
redness of skin, caused by capillary dilation,
producing warm sensation. Works to distract
pain messages to the surface, rather than the
deep seated source.
Most common: methyl salicylate.
Apply no more frequently than 3-4 times
daily for 7 days.
Examples: Ben-Gay, Icy Hot Chill stick;
and Mentholatum
Topical Pain relievers-
Salicylate products
Not a counter irritant. Salicylate is absorbed
through skin. Salicylate levels in synovial
fluids are slightly below levels achieved with
oral aspirin.
Same drug interactions seen with aspirin
FDA led studies show no better than placebo.
Is odor free
Examples: Aspercreme, Myoflex,
Sportscreme
Topical Pain relievers-
Capsaicin products
Major ingredient in hot chili peppers
Mechanism: Depletes substance –P
which transmits pain messages.
This depletion of Substances-P is similar to
cutting a nerve. Burning and stinging occurs in
40-70% of all patients.
Pain relief is noted within 14 days of therapy.
Will cause a 50% reduction in 1 out of 8 patients
treated.
Concentration of over 0.025% associated with a
cough.
Cold Sores
Docasanol: use 5 times daily. Shortens
duration by 18 hours. (Rx: less than 1 day)
Protectants: keep lesion from drying and
cracking
Best option:
Rx: Valacyclovir 2gm BID for 1 day
Rx: Famcyclovir: 1500mg as a single dose
START ALL THERAPIES AT FIRST SIGN
OF TINGLING!
Over the Counter Review: Topical Management
© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.
Reproduction in whole or in part without permission is prohibited.
Page 13
Brand name extensions: drives us
Pharmacists and Techs “CRAZY”
Monistat: we think “Miconazole”: Monistat Itch
Relief Cream contains hydrocortisone and
Monistat Uristat contains phenazopyridine for
UTI symptoms. Monistat-1 vaginal ointment
contains tioconazole.
Lotrimin: we think clotrimazole: Lotrimin Ultra
contains butenafine. Lotrimin AF powder and
sprays contain miconazole.
More Examples of Product
extensions
Dulcolax softner = docusate
Kaopectate =bismuth subsalicylate
Maalox Total Relief =bismuth subsalicylate
PeptoBismol childrens= calcium carbonate
Notes
Notes