Heat rash

Summer is here! It's getting hotter around the country. Do you or people around you become sweaty easily? Does the heat become intolerable to you? Even worse, you start to develop heat rash.

Sourced form Google Image

The sweat glands attempt to produce more sweat to cool down your body. When your sweat glands are blocked and your skin struggles to dissipate the heat trapped in your body, it results in inflammation that causes heat rash. Once your body cools down, then the inflammation will eventually reduce.

The good news is heat rash can be managed easily if there is no complication. Once heat trapped in your body is dissipated through evaporation of your sweats, you will get better.

Signs and symptoms
- red bumps on the skin (especially abdomen or back area).
-itchy or prickly

If you develop fever, chills, prolonger redness and swelling, seek medical advice for further help.

Differential diagnosis
Fungal infection - usually heat rash spreads all over certain part of your body (because that part of sweat glands are blocked and cannot produce sweat efficiently). whereas for fungal infection, the affected area is confined to an area that can be differentiated easily.

Eczema/dermatitis - heat rash appears as tiny red dots or small blisters over the abdomen or back area whereas eczema is red inflamed skin found around the flexures of arms or legs. Having said that, those who have eczema may be more likely to develop heat rash during hot weather.


Treatment
(a) Antihistamine - Tt is effective in soothing the itchiness. There are two types of antihistamine - sedating and non-sedating antihistamine. If the itch is intense, sedating antihistamine such as promethazine could be a good option. (NOTE : always talk to a pharmacist or health care professional for advice if your kid is younger than 2 years old).

Sedating antihistamine - Promethazine (Sourced from Google Image)

(b) Pinetarsol solution - It's a very good anti-itching product.
For bath purpose, just add 15-30ml to a warm tepid bath (two to three capful) and bathe for 5 to 10 minutes once daily when required.
For shower use, apply solution directly to your wet skin and leave it for few minutes before rinsing them off.

Pinetarsol collection (Sourced from Google Image)

(c) Calamine cream
Calamine cream can also be used to relieve the itchiness too.

Calamine cream (Sourced from Google Image)

NOTE calamine lotion is not a good choice as calamine lotion can be quite drying and make your heat rash worse.


Hydrocortisone cream is not usually recommended as heat rash usually covers big part of your body and it is not recommended to use topical steroid over a large area.

Advice 


Wear breathable clothing and avoid tight-fitting clothes.

Shower or bath more frequently than usual to cool down your body

Use air conditioning or fan




References


Wedro B. Heat rash. [Internet] https://www.medicinenet.com/heat_rash/article.htm

Ludlam K. Types of heat rash [Internet]. https://www.healthline.com/health/heat-rash-pictures-remedies

New Zealand Formulary

What can you do to make your children to take their medicines?

"My kids loathe swallowing tablets/capsules? How?"

capsules/tablets

"How on earth my kid can swallow the tablet? My kid was afraid of swallowing capsule, especially when they are crying and anxious about taking medicines!"

Parents could get frustrated in administering medicines to their kids. It becomes even harder when trying to force their kids to swallow a capsule or tablet for an anxious sick child who refuse to take medicine. 

What could parents do? 

Most children at the age of 6 (or even earlier) are able to swallow capsule/tablet. However, effective training can allow younger children o swallow a capsule or tablet effectively.

Yes, you can train your kids to swallow capsule/tablet in a relaxed and fun way! 

Lollies training 

Lollies are most children's favourite. Train them to swallow progressive larger lollies (e.g. Cake decorating balls/sprinkles, Tic-Tacs, Mini M&M, , M&M or Smarties). 

Firstly, encourage your kids to take a few sips of water to their favourite drinks (e.g. juice) to moisten their mouth and throat ( This make swallowing much easier) 

Secondly, lead by example. Show your kids how you swallow a lolly (start with the smallest size e.g. cake sprinkles) by putting it at the middle of your tongue. Then take a big gulp of water/juice and swallow it. 

Thirdly, ask your kid to do the same thing - encourage them to try for a few times until they are comfortable swallowing the lolly. 

Fourthly, then advance the level by "challenging" your kids to swallow a bigger lolly. And, the kids would be able to swallow larger and larger lollies (pills) easily without even realising they are capable of doing it! 

Apart from the little fun "experiment" you can carry out with your kids, there are some useful tips you can take into account : 

- use yogurt or milkshake to help your kids to swallow capsule/tablet easier

- ask your kid to tilt his/her head forward while swallowing. This act can prolong the closure of airways to prevent aspiration of the medicine, making swallowing more effective. 

Sometimes, if the kids really struggle to swallow capsule. The alternative could be emptying the content of a capsule into food or drink. On the other hand, some tablets may be crushed into powder and sprinkled onto the food or drink. Some could even compounded into a suspension. However, you may not do this for every tablet/capsule because the dose accuracy, medicine stability or bioavailability may be affected. Check with your doctor or pharmacist if you can empty, crush the tablet/capsule or ask the pharmacist to compound the formulation into a suspension. 

References 

1. Bpac, 2014. Encourage children to swallow tablets or capsules [Internet]. Available at http://www.bpac.org.nz/Supplement/2014/September/pillswallowing.aspx. 

2.Bpac, 2017. Helping patients with epilepsy adhere to their medicines [Internet]. Available at http://www.bpac.org.nz/2017/epilepsy.aspx. 

What thrust Colgate Total toothpaste into the limelight ?

Are you worried by the news headlines regarding the use of Colgate Total toothpaste on daily basis ?  Are you a loyal fan of Colgate toothpaste ? Should you worry about article written about the safety use of Colgate toothpaste? 

Image obtained from google search
One of the ingredient - triclosan (0.3%)

Image obtained from google search

Recently, the use of Colgate Total containing chemical called triclosan has raised the concern of public. Use of triclosan was prohibited by FDA in US in September 2016. Triclosan is a chemical that exhibits antimicrobial and antifungal propertiesthat was previously widely used in commercial products such as soaps, detergents, toothpaste and baby wipes. However, experts have suggested that triclosan should not be encouraged to be used in commercial products. In fact, the use of triclosan have been banned in US for soaps and detergents. Previous animal studies have proposed that high dose of triclosan can potentially affect thyroid hormones level in our body. In addition, the use of triclosan in toothpaste was not shown to be beneficial in teeth care. Despite all these, the company had claimed that the use of triclosan is safe to use. 

To date, there are no still no significant evidence that triclosan could harm to your teeth or body (when it is absorbed). The concentration is 0.3% in Colgate Total toothpaste. Daily use of toothpaste containing triclosan is not recommended by chemist expert. However, asking your dentist if the use of  toothpaste with triclosan suit you will be the best option at the moment. In fact, the use of triclosan could be useful for some patient with gingivitis or dental-related diseases. 

Worry not ! Just keep yourself up-to-date if you are concerned.  

Tips for dental care: 

1. brush your teeth twice daily [ first thing in the morning and last thing before you go to bed :) ]


2. do regular flossing or use interdental brush to remove plaques in between your teeth. 


3. choose a toothpaste is fluoride . Fluoride is important for teeth health and reduce risk of dental caries especially for kids. 

4. replace a toothbrush every three month or when toothbrush is worn. 

        

References 

1. Why experts say most people should avoid Colgate Total
http://www.newshub.co.nz/home/health/2017/07/why-experts-say-most-people-should-avoid-colgate-total.html 

2. Ingredients in Colgate Total should not be sold over the counter, says chemistry expert 
http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11892778

3. Pharmacy Today Healthcare Handbook 2015 

All images obtained from Google search.

Nappy rash

Nappy rash

Nappy rash is also known as diaper rash, diaper dermatitis or irritant contact dermatitis. 

-       It is  a red rash that occurs on the skin covered by a baby’s nappy. It is  usually the skin is irritated due to the urine and faeces touching baby’s sensitive skin for extended period of time. Could be due to yeast infection (Candida),

Common signs and symptoms of nappy rash 

Small pink spots or blotches around nappy area (mild), bright red rash get bigger (moderate), pimples, blisters, ulcers, large bumps or sore fills with pus (severe).

Baby may cry when passing urine or a bowel motion due to the stinging sensation, older infant may scratch when the diaper is removed.

Common medicines used to treat the condition and how to use the products? 

(a)    Barrier creams eg zinc and castor oil, zinc and shea butter (Vustela Vitamin Barrier Cream)

-       During each nappy change, wash the nappy area with non-soap cleanser, rinse and dry thoroughly and then apply barrier cream onto the nappy area

If nappy rash due to yeast infection,

(b) Topical antifungal medicines eg miconazole , clotrimazole

- Apply to affected are ONCE or TWICE daily. Continue to use 10-14 days when symptoms have cleared.

If nappy rash is inflamed,

(c)   Combination of topical antifungal and corticosteroid eg miconazole + hydrocortisone Resolve Plus or Micreme H 

-       Apply to red/angry area ONCE or TWICE daily. Maximum use of 14 days.

-       Continue to use topical antifungal only (eg miconazole) for 1-week after the rash has cleared up

Resolve pLus 1%

(d)  Healing or soothing preparations

Eg Bepanthen Ointment, Kiwiherb Baby Balm, Lucas Pawpaw Ointment,

-       To reduce redness, soothe, heal and protect the skin

-       Rinse affected area with lukewarm water and apply to affected area after nappy change

Bepanthen is good for skin healing (can be used for treatment and prevention) 

 Referral points  or red flags 

-       Suspected secondary bacterial infection

-       Baby becomes very grumpy and develop a fever

-       The rash get worse or does not go away in 2-3 days

-       The rash spreads to the abdomen, back, arms or face

-       Develops a rash during the first 6-weeks after birth

Advice for the customer (parents or caregivers) 

-       Change cloth or disposable diapers nappies frequently and as soon as possible when wet or soiled and use barrier cream  

-       Keep the skin clean and dry

-       Put diaper on loosely (too tight restrict airflow and irritate the baby’s skin

References

1.     Pharmacy Today Healthcare Guidebook

2.     https://medlineplus.gov/ency/article/000964.htm

3.     http://www.kidshealth.org.nz/nappy-rash

NSAID (Non-Steroid Anti-inflammatory Drug) - A friend or foe for acute pain ?

From 1 to 10 , please scale your level of pain.

Pain is a very subjective sensation.

There are many drugs being developed and marketed for pain. Apart from paracetamol (also known as acetaminophen), NSAIDs are the drugs that most commonly used to treat pain and/or inflammation. For example, NSAIDs could be used for osteoarthritis (eg. knee pain),  sprains, strains, period pain (dysmenorrhoea), gout pain, headache, migraine.

Some of the examples for NSAIDs include ibuprofen,  diclofenac, naproxen, mefenamic acid, celecoxib, meloxicam. The list goes on.

What NSAIDs do ? 

NSAIDs works by inhibiting COX  (either selective or non-selective) , thereby stopping the production of prostaglandins (pro-inflammatory factors). This can then reduce the inflammation and pain, giving us the pain relief we need.

NSAIDs are "nasty" drugs with adverse side effects? 

 We all know that nothing comes with no cost. In medical field, we used drugs (medicines) to treat ailments and diseases. Yet, medicine, itself, can bring side effects. This applies to all medicines, from causing common side effects - nausea, vomiting, diarrhoea to some even more serious ones such as agranulocytosis, heart attack, renal failure.

So do NSAIDs.

Therefore, I would say correct and proper use of medicines are much more important in preventing side effects. Even so, side effects may still occur.

Let's look at some of the common side effects of NSAIDs and how we deal with them when it does happen. 

1.  GI side effects

Most of drugs can cause stomach upset. NSAIDs can cause stomach upset, diarrhoea,  gastrointestinal bleeding or ulceration.

Selective COX-2 inhibitors are believed to reduce risk of GI side effects, however,  studies have not shown significant differences of GI side effects between non-selective and selective COX inhibitors.

If the patient has acute pain and need a short course of NSAIDs, can consider giving gastro protective agents such as proton pump inhibitor (e.g. omeprazole) or H2 antagonist (e.g. ranitidine) at the same time to reduce the risk of bleeding or ulceration.

Alternatively, can give paracetamol plus codeine (such as Panadeine) to alleviate the pain.

Diclofenac and ibuprofen appears to be the NSAIDs that cause less GI effects (5). 


2. Cardiovascular side effects
- blood pressure increases (because of NSAIDs can cause sodium and water retention), may exacerbate pre-existing hypertension 
-increase risk of cardiovascular events such as heart attack (myocardial infarction) and stroke.

If the patient has had recent cardiovascular events (heart attack or stroke), AOVID taking NSAIDs. Use alternative pain killer such as paracetamol, or add in codeine phosphate if needed.

3. Renal side effects

- If you have renal problems,
OR
-If you are taking blood pressure pills (such as diuretics or ACEI (angiotensin converting enzyme inhibitor) or ARB(angiotensin II receptor blocker),

You need to be extra careful , as NSAIDs may predispose or increase the risk of acute renal failure.  Please do let your doctor or pharmacist know.

4. Hypersensitivity reactions

Some of the patients may develop allergic reactions such as angioedema (swelling), difficulty in breathing (because of swollen airways) or skin reactions such as rashes upon taking NSAIDs.

Stop taking NSAIDs immediately if hypersensitive reaction develops. And, tell a doctor or a pharmacist when you are needing something for pain treatment next time. Tell them you are allergy to NSAIDs and describe what happened.


All NSAIDs have the risks of inducing all these side effects - to certain extent depending on the particular NSAID . For example, diclofenac poses highest risk of cardiovascular events.


Have you ever heard of stories about patients suffer from acute renal failure after having few doses of ibuprofen (NSAIDs). I heard about one and I was not too sure the exact cause behind the story, however, I want to make a point that the side effects of NSAIDs could get serious!

****Triple whammy ***

One of the factors we need to consider when it comes to taking NSAIDs is the interactions with other medications the patient is taking.


Combination use of NSAIDs (or selective COX-2 inhibitor)  AND diuretics  AND  ACEI/ARB
should be avoided.

Using these three classes of medicines at the same time increase the risk of acute renal failure. That's the last thing we wanted for the patient.

Do remember this when a customer come in and ask for pain killer (NSAIDs), especially the elderly or when the customer is dehydrated.

In short,

If the patient is taking diuretics and ACEIs (or ARBS) for their blood pressure control, avoid use of NSAIDs, if possible, or use lowest effective dose for shortest period.

DO NOT take NSAIDs when you are dehydrated.


Patient advice 


Take NSAIDs following the dosing regime. Take them with a large glass of water and food.

(Do inform the patient the importance of drinking enough water while taking NSAIDs to reduce risk of kidney side effects.)

Example of normal dosing regime for adult dose :

Ibuprofen - ONE or TWO tablets (200mg to 400 mg) up to THREE or FOUR times daily. Maximum of 2.4g in 24 hours.

Diclofenac - 75-150 mg daily in TWO or THREE divided doses. Maximum of 200mg in 24 hours.

Naproxen sodium - 250-500 mg TWO or THREE times daily.Maximum of 1250 mg in 24 hours.

Meloxicam - 7.5 - 15 mg ONCE daily. Maximum use of 15mg in 24 hours.

NOTE: the dosing regime above is only a reference. Always talk to a doctor or a pharmacist regarding your condition.

In short, 

NSAIDs are ubiquitous medicines on the market. You can get NSAIDs easily. However, use NSAIDs wisely. For acute pain, NSAIDs are useful in reducing the pain and inflammation and keep you going in your daily activities.


However, always be aware of the possibilities of the side effects.

For long term management, always bear in mind the possibilities of GI side effects e.g. bleeding and risk of cardiovascular events. (A NSAID with a longer half life such as naproxen can be considered for easily daily ONCE or TWICE daily dosing,which can increase patient compliance and adherence. 

Watch out for the side effects and do remember that NSAIDs (e.g. ibuprofen or diclofenac) can interact with some of the medicines you are taking. If you are on long term medications, talk to a pharmacist or a doctor to seek for advice.

AVOID NSAIDs while someone is pregnant, especially during the third trimester.  ( Paracetamol is always the safer option).

References 

1. http://www.bpac.org.nz/BPJ/2013/October/nsaids.aspx

2. Australian Medicines Handbook 2016

3. New Zealand Formulary

4. http://www.saferx.co.nz/full/triplewhammy.pdf

5. AMH handbook

FIVE points about eye conditions (Conjunctivitis, Stye, Chalazion)

Often, customers come into the pharmacy, asking for eye antibiotics for their eye infections. Is that a real necessity ?

1. Ask a pharmacist or an optometrist or a doctor to work out what kind of eye condition you have

Usually, talking to a pharmacist is the easiest and cheapest way (their advice are free ! ^^ ). Talk to a pharmacist and figure out what kind of eye conditions you are experiencing. If the pharmacist could offer treatment or refer you to someone for further investigation. Often, patient thought they have bacterial conjunctivitis ( also known as "pink eye"), however, often it is not the case.

The pharmacist can check with you, in case there is serious underlying causes of your eye condition.

Referral points: 

1. Sensitive to light (photophobia)
2. Painful eye ball
3. Recent eye surgery
4. Different pupil size
5. Vision loss or sudden vision change 

2. Bacterial conjunctivitis - Do you really need topical eye antibiotics such as chloramphenicol eye drop or ointment? 

Bacterial conjunctivitis is self limiting. This means it will go away even if you DO NOTHING at all.

The sign and symptoms of bacterial conjunctivitis - green/yellow/greenish-yellow discharge, sticky eye lid (especially when you wake up in the morning) 

When the patient comes in the pharmacy, the eyes may not have sticky green-yellowish discharge as they may have wiped it already. Therefore, asking questions to probe further is important.

3. How to use topical antibiotic eye drops or ointment? 

For chloramphenicol eye drop - Instil 1-2 drops into affected eye(s) every 2-6 hours for the first 2-days and then reduce to FOUR times daily. Continue to use for 48 hours after the symptoms has cleared.

Do not touch the tip of the eye drop container to your eye to prevent contamination.

For chloramphenicol ointment - Apply a thin ribbon ( ~1.5cm - one fingertip unit) to the lower eyelids of affected eye(s) THREE times daily or ONCE daily at night (in addition to chloramphenicol eye drop).

Eye ointment can make your vision blurry. Do not drive or handle heavy machines if your vision is blurred.

4.  You DO NOT need topical antibiotic to treat your stye or chalazion !

Stye and chalazion are very similar to each other. It is hard for the patient to tell. For stye (medically known as hordeolum), it is a painful lump (yellow pus could be seen) inside or outside your eyelids.  On the other hand, chalazion is a small raised bump and usually not painful that caused by blocked oil gland at your upper or lower eyelid.  

Chalazion 

Stye 

Both eye conditions are self-limiting. NO topical eye antibiotics are needed. Even though you use topical eye antibiotics, the drug would not be able to get into the affected area. Therefore, there is no reason you should use topical eye antibiotics to treat these conditions. In addition, it increases the chance of antibiotic resistance - that is the last thing we wanted it to happen. 

Warm compression is the way to alleviate the symptoms (alleviate painful stye and make the pus burst faster) or fasten the healing process (clear the blocked oil gland). Soaking a face cloth in warm water and compress it at the affected area for 10-15 minutes several times a day (THREE to FOUR times daily). 

One more thing you can do for chalazion is to massage your eye gently. Rubbing the eyes can drain away oil accumulated at the blocked gland. 

For stye, do not try to squeeze or rub the stye and make it burst. Usually, stye will be there for few days and burst and release pus inside. Once the pus inside is drained, stye will heal.

If the stye makes you feel painful, oral painkiller such as paracetamol or ibuprofen can be taken to alleviate the pain. (Not to forget to do warm compress at the same time) 

Maintain good personal hygiene is important. Wash your hands before and after touching your eyes.

If the customer wants something from your pharmacy to help , recommending eye rinse may be a good choice such as Optrex. Otherwise, any artificial eye drops could be used for relieving eye pain or dryness. 

5. If you are contact lens wearer , BE CAREFUL when you have an eye condition! 

For contact lens (CL) wearer, it is important to maintain good eye hygiene. If you are experiencing red eyes or bacterial conjunctivitis, see a doctor or an optometrist. This is because CL wearers have higher risk of getting bacterial keratitis. Sometimes, it could be severe and cause visual loss or even blindness. Even though you use topical antibiotic eye drops such as chloramphenicol, it might not be effective as the bacteria that infect your eye might be Psuedomonas species, in which beyond chloramphenicol antibacterial spectrum.

If you are experiencing red eyes or conjunctivitis, do not wear your contact lenses!

Wear glasses instead until the eye condition is resolved.

In short, it is better to see a doctor or optometrist to have an eye check - just in case.

References 

1. http://www.healthline.com/health/chalazion

2. http://www.healthline.com/health/stye#Treatment5

3. http://www.nhs.uk/conditions/stye/Pages/introduction.aspx

4. New Zealand Formulary

5. http://www.webmd.com/eye-health/common-eye-problems#1

All photos obtained from google image search.