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. 

Dermatitis

Dermatitis

- General term used for various types of skin inflammation (mostly involve superficial skin layer).

(A)   Atopic dermatitis (also known as eczema) 

-       Common in those who experience hay fever, asthma or chronic urticaria

-       Tends to run in family (genetic factor) and most common in childhood

-        Might be genetics (filaggrin protein maalfunction) + environmental factors ( e.g. allergen)  

·     Signs and symptoms : 

-       Pruritus (itchiness) , redness, inflamed, raised bumpy area(s), dry, scaling and crusted skin ;For moderate to severe conditions: bleeding, blistered or weepy patches

-       Usually happens at skin flexures at arms or legs. Often symmetrical

-       If the condition is chronic, thickening (lichenification) and hyperpigmentation of the skin 

   
·      What are some of the common medicines used to treat the condition and how to use them ? 

(a)   Emollients (ointment, creams, emulsion, lotion)

eg aqueous cream, emulsifying ointment

Apply liberally a few times daily (THREE to FOUR times daily)  to moisturise the skin and use as soap substitute

(b)  Topical corticosteroid – hydrocortisone 0.5%, 1% or clobetasone butyrate 0.05%

Apply to red/angry area ONCE or TWICE daily

(c)   Antihistamine tablet or solution (itching skin) eg cetirizine, loratadine

Take one tablet ONCE daily for itchiness.

(d)  Pinetarsol (Anti-itch solution) 

Add 15–30 mL to a warm to tepid bath (5 mL in baby’s bath or hand basin) and bathe for 5–10 minutes ONCE daily as necessary (could use more often if the itch is severe)

·      Advice 

1.      Use emollient liberally, frequently and continuously and in large quantities (up to 500g per week)

2.      Use topical steroids apprpriately (apply to red/angry area of skin)  when needed for flare up.

3.      Avoid the triggers of eczema/dermatitis  ( eg soap , detergent, some fabric ,  heat and sweating

 

 (B) Other types of dermatitis

Type of dermatitis	Signs and symptoms	Treatments/Advice
Seborrhoeic dermatitis (adult) - is common among us, and it is relatively harmless to our health.  - however, it is persistent and chronic, relapse from time to time	salmon pink scaly rash Tend to be chronic and persistent Red, mild, itchy scaly rash	Topical antifungal eg ketoconazole shampoo(a) Combinations of scalp products containing coal tar, salicylic acid , sulfur eg Coco-Scalp(b) Occasionally use of topical corticosteroid is it is inflamed
Cradle cap infantile seborrhoeic dermatitis)	Confined to the scalp of recently born babies (usually appears withon 6-weeks of life). May involve eyelid and eyebrow Scaly, crusty, greasy, yellow patches over the scalp Child is well and happy (not usually itchy)	- Use baby oil or paw paw ointment to soften the scales (NOT olive oil) - salicylic acid 6% eg Egozite Cradle Cap(b)  1. Gently massage your baby's scalp with your fingers 2. Use a soft brush to loosen the scales. 3. DO NOT peel the hard crust
Irritant contact dermatitis	Occurs when exposed to irritant substances such as soap and chemicals which remove natural oils form skin Red, itchy, dry skin Scaling, cracking and roughness upon repeated contact	Barrier cream Eg. Zinc and castor oil, dimethicone (Silic 15) Topical corticosteroid eg 0.5%; 1% hydrocortisone 1. Avoid irritant if possible  2. Wear protective gloves or use barrier cream 3.Use moisturisers eg cream, lotion
Allergic contact dermatitis	When in contact with allergen such as hair dye, nickels in jewellery, latex gloves etc Redness, swelling, water blisters confined to the area contacted by the allergen Blister may break, forming crusts and scales	Topical corticosteroid eg 0.5%; 1% hydrocortisone or clobetasone butyrate 0.05% ** 1.Identify allergen(s) and avoid them 2.Substitute products made of materials that do not cause rection 3.Use topical corticosteroid appropriately

 ** DO NOT confuse clobetasone butyrate 0.05% (mild topical corticosteroid) with clobetasonl propionate 0.05% ( VERY STRONG [potent] topical corticosteroid) 

·      How to use these products:

(a)   Ketoconazole shampoo

Apply to wet scalp TWICE weekly for up to 4-weeks leave preparation on for 3–5 minutes before rinsing.

May repeat treatment after a 4-weeks break

(b)   Coco-Scalp (coal tar, salicylic acid, sulfur)

Part hair and apply a thin ribbon to the affected area, rub in and leave for 1 hour before rinsing

For mild condition, use ONCE weekly. For severe scaly condition, use ONCE daily for 3-7days)

(c)   Egozite Cradle Cap (salicylic acid 6%)

Ensure scalp is dry. Apply carefully to crusts only, avoiding non-crusted areas. Wipe away any lotion from non-crusted areas with dry cotton wool. Do not comb or remove crusts forcibly.

Apply twice daily for 3 – 5 days without washing hair, then wash hair with gentle Hairscience Nourishing Shampoo.

·      Red flags / referral points 

-       Signs of secondary bacteria infection

-       Not responding to OTC treatment

-       Uncertainty over diagnosis

References

1.     Pharmacy Today Healthcare Guidebook

2.     American Osteopathic College of Dermatology http://www.aocd.org/

3.     Bpac website – contact dermatitis:” a working diagnosis; managing eczema; topical corticosteroid treatment for skin conditions;

4.     Dermnet.nz

5.     NZF

6.     http://www.babycenter.com/0_cradle-cap-infantile-seborrheic-dermatitis_80.bc

All images or photos obtained from Google Image Search.