Topical Preparation Counselling Guide (3.8.2019) (7) 1edit part 1

1ST EDITION : 2018 Topical Preparations Counselling Guide for Pharmacist.

DISCLAIMER This guide would serve as a handy reference for PHARMACIST ONLY and not as a complete drug information resource. It is NOT intended to replicate or replace the knowledge, skills and experience of trained dermatologist/ health professionals, nor is it a substitute for clinical judgement and advice. The nature of healthcare/ drug information is that it is constantly evolving with ongoing research and clinical experience and is often subject to interpretation. While best effort has been made to ensure the accuracy of the information and recommendation presented, reader is advised that the contributors, editors, reviewer and publisher cannot be responsible for the continued updates of the information, of any errors or/ and of any consequences arising from its application. Pharmaceutical Services Programme Ministry of Health Malaysia Lot 36, Jalan Universiti 46200 Petaling Jaya Selangor, Malaysia Tel: 603 - 7841 3200 Fax 603 - 7968 2222 Website: www.pharmacy.gov.my.

Advisor Dr Roshayati Mohamad Sani Director of Pharmacy Practice and Development Pharmaceutical Services Division Ministry of Health, Malaysia External Reviewer Dr Rohana Ridzwan Head of Department Dermatology Department Hospital Selayang Editorial Committee Mdm. Noraini Mohamad Deputy Director of Pharmaceutical Care Pharmaceutical Services Division Ministry of Health, Malaysia Ms Umi Kalthum binti Mohd Isa Senior Assistant Director Pharmaceutical Services Division, MOH Contributors Mdm. Mazuin Mahmud Taridi Senior Principal Assistant Director Pharmaceutical Services Division, MOH Ms Low Nam Wei Pharmacist, Hospital Serdang Ms Ng Hui Wen Pharmacist, Hospital Selayang Ms Khairul Syazwani binti Mohd Arpan Pharmacist, Hospital Selayang Mdm. Noorul Huda binti Senawi Pharmacist, Hospital Sultan Haji Ahmad Shah, Temerloh Ms Yap Cheng Hoon Pharmacist, Klinik Kesihatan Kepala Batas, Pejabat Kesihatan Daerah Seberang Perai Ms Roselyne John Han Pharmacist, Klinik Kesihatan Luyang, PKK Kota Kinabalu Ms Siti Syahirah Md Radzi Pharmacist, Hospital Tuanku Fauziah.

FOREWORD BY DIRECTOR OF PHARMACY PRACTICE AND DEVELOPMENT DIVISION, MINISTRY OF HEALTH MALAYSIA Counselling is one of the important components in pharmaceutical care, in which to ensure patients adhere to their medication. It is the responsibility of the pharmacists to provide proper counseling and patient education in order to achieve the best possible pharmacotherapy outcomes. One of the commonly counsel medication by the pharmacists is topical preparations. Skin is known to be the largest organ of our body. There are hundreds of skin conditions that affect humans and it can vary greatly in symptoms and severity. It can be temporary or permanent, and may be painless or painful. Some may be caused by external factors, while others may be genetic. Some skin conditions are minor and easily treated, and others can be life threatening. There are various types of treatment available in the Ministry of Health Malaysia (MOH) Drug Formulary for treating skin conditions, either orally or as topical treatment. This counselling guide provides information for pharmacists specifically on the topical preparations available in the MOH formulary and relevant counselling points on its usage in providing effective and accurate patient education regarding their medicines. I believe the contents of this quick guide will be helpful for pharmacists providing care for patients in ensuring proper use of medications and for patients to be aware of possible side effects. I would like to congratulate the Ambulatory Pharmacy Working Committee, Pharmaceutical Services Programme, Ministry of Health for their efforts and contributions to the development of this guideline. Thank You. DR ROSHAYATI MOHAMAD SANI DIRECTOR OF PHARMACY PRACTICE & DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA.

Introduction A. Body Anatomy B. Terminology of skin condition CHAPTER 1: INFECTIVE SKIN CONDITIONS A. Bacterial Skin Infections i) Impetigo (Superficial Skin Infection) Topical preparation for treatment: 2% Fucidic acid cream 2% Mupirocin ointment ii) Cellulitis (Deep Skin Infection) Topical preparation for treatment: Potassium Permanganate 5% B. Parasitic Skin Infections i) Scabies Topical preparation for treatment: Emulsion Benzoyl Benzoate (EBB) Permethrin 5% lotion Crotamitone 10% 6% Sulphur ini Calamine/ Petrolatum ii) Head Lice Topical preparation for treatment: Permethrin 1% lotion Gamma Benzene Hexachloride (GBH) 0.1% lotion CONTENT 1 2 3 4 4 4 4 5 5 7 7 8 10 10.

C. Fungal Skin Infections i) Dermatophyte infections (Dermatophytoses) Topical preparation for treatment: Topical Imidazole (Miconazole cream/ powder, Clotrimazole cream) ii) Pityriasis Versicolor Topical preparation for treatment: Selenium Sulphide (2.5%) lotion or shampoo Ketoconazole shampoo Topical Imidazole (Miconazole cream/ powder, Clotrimazole cream) iii) Cutaneous Candidiasis Topical preparation for treatment: Topical Imidazole (Miconazole cream/ powder, Clotrimazole cream) Nystatin cream Whitfield ointment D. Viral Skin Infections i) Warts Topical preparation for treatment: Salicylic acid 1 – 20% Podophyllum 10 – 20% Imiquimod 5% cream CHAPTER 2: CHRONIC NON-INFECTIVE SKIN CONDITIONS A. Eczema and Dermatitis Topical preparation for treatment: Emollients • Aqueous cream • Emulsifying ointment • Liquid paraffin • Glycerin 25% - 50% in Aqueous cream • White/ Yellow soft paraffin • Urea cream 12 12 14 15 15 16 17 19 19 19 21 21 22.

Topical corticosteroids Topical Calcineurin Inhibitors (TCIS) • Tacrolimus 0.03% & 0.1% ointment • Silver Nitrate 0.5%, 2%, 5% & 10% solution B. Psoriasis Topical preparation for treatment: Topical corticosteroids Tar-based preparation Vitamin D analogues Dithranol (Anthralin) CHAPTER 3: ACNE VULGARIS Topical preparation for treatment: Cetrimide 1%, 2% solution Benzyl peroxide 5%; 10% Adapalene, Tretinoin Azelaic acid 20% cream References Appendix i: Carta Alir Proses Kaunseling Produk Dermatologi Topikal Appendix ii: Rajah Pendispensan Ubat Dermatologi Topikal Appendix iii: General Counselling Points for Topical Dermatology Products Index 28 29 32 33 34 37 38 40 41.

1 1. INTRODUCTION Skin is human’s largest organ, with a total area of about 2 square meters (m2) covering a human body. It acts as a waterproof, insulating shield that protects the body against dehydration, extremes temperature, damaging sunlight, and harmful chemicals. Skin also exudes an antibacterial substance that helps to prevent infection and manufactures vitamin D for converting calcium into healthy bones6. Skin is made up of three layers: 1. (Epidermis) is the outermost layer of skin, which provides a waterproof barrier and creates our skin tone. 2. (Dermis) beneath the epidermis contains tough connective tissue, hair follicles, and sweat glands. 3. (Subcutaneous tissue) (hypodermis) is made of fat and connective tissue Any damage, clog or irritation to the skin layer or certain diseases/ immune system problems can cause skin problems, presented by symptoms of redness, itchiness, burning and/or swelling. Nevertheless, there are treatments available for variety of skin conditions in the form of oral or topical preparation. This guide contains presentation of various skin conditions and its management using topical preparations with few points to remember when giving counselling. It will be useful for pharmacist who conducts counselling on the use of topical preparations available in Ministry of Health facilities. Figure 1: Skin Anatomy (National Cancer Institute).

2 A) Body Anatomy Figure 2: Diagram of Human Body for Topical Application TTrruunnkk ((BBaacckk ++ AAbbddoom meenn ++ CChheesstt)) ANTERIOR Anterior Hairline / Garis Rambut Periobital / Lilitan Mata Perioral / kawasan mulut Arm / Lengan Forearm / Lengan bawah Palm / Tapak Tangan Finger Webs / Celah Jari Knee / Lutut Shin / Tulang Kering Neck / Leher Torso / Dada Abdomen / Perut Groin / Celah Peha Perineum / Perineal Toe Web / Celah Jari Kaki Back / Belakang Gluteal / Punggung Calf / Betis Posterior Hairline / Garis Rambut Belakang Thigh / Peha Leg / Kaki Lower Limbs / Anggota bawah POSTERIOR.

3 B) Table 1: Terminology of Skin Conditions TERMINOLOGY DESCRIPTION Macule <1 cm diameter, flat lesion with change of skin color Atrophy Thin transparent epithelium or depression in the dermis Lichenified Thickened skin with exaggerated skin crease Sclerosis Indurated (hardened) skin Targetoid Pink macule with central purplish papule Annular Polycyclic pattern Papule < 0.5 cm diameter raised firm lesion Vesicle < 0.5 cm diameter raised firm lesion with clear fluid Pustule < 0.5 cm diameter raised firm lesion with yellow fluid Plaque > 1cm diameter raised flat top lesion Nodule > 0.5 cm diameter raised firm lesion Bullae/Blister > 0.5 cm diameter raised fluid filled lesion Desquamation Detachment of the superficial part of the skin Excoriations/Scratch Marks Shallow hemorrhagic excavation due to scratching Necrosis Death of skin tissue Erosions Partial loss of epithelium Ulcer Full thickness loss of epithelium Crust Dried exudates Blanchable Erythematous skin lesion appears pale on pressure Non-blanchable Skin lesion remain red purplish or pigmented on pressure.

4 CHAPTER 1: INFECTIVE SKIN CONDITIONS A. Bacterial skin infection i) Impetigo (Superficial Skin Infection) Impetigo is the most common skin infection in children. It is caused mainly by Staphylococcus aureus and sometimes by Streptococcus pyogenes (group A). Skin signs include small blisters, dark or honey-colored crust that forms after the pustules burst. Immediate antibiotic treatment is advised for most cases of impetigo, to achieve a quick cure and prevent spread of the infection to other children. Figure 3: Presentation of Impetigo around the mouth area (National Health Institute) Treatment for Impetigo • For oral and IV antibiotic treatment, please refer latest National Antibiotic Guideline (NAG). • Topical preparations for Impetigo: a) 2% Fusidic acid cream MODE OF ACTION Antibacterial activity against Staphylococci SIDE EFFECTS Contact Dermatitis COUNSELLING POINTS • 1 application every 8 - 12 hour for duration of 7 days • Do not use for more than 2 weeks. May use again if infection relapse b) 2% Mupirocin ointment MODE OF ACTION Antibacterial activity against Staphylococcus aureus and coagulase- negative Staphyloocci SIDE EFFECTS • Common: Burning • Uncommon: Itchiness,erythma,stingging, dryness • Uncommon: Contact Dermatitis COUNSELLING POINTS • 1 application every 8 - 12 hour for duration of 5 days • Do not use for more than 2 weeks. May use again if infection relapse.

5 ii) Cellulitis (Deep Skin Infection) Cellulitis is a bacterial infection of the deeper layers of the skin, the dermis and the subcutaneous tissue. Cellulitis is most often caused by Streptococcus and Staphylococcus aureus bacteria. These bacteria are able to cause an infection if they get into the skin through a break in the skin barrier. This can happen with cuts, scrapes, ulcers, macerated skin at toe webs and surgical wounds. Cellulitis may also develop in normal skin. The skin is usually painful, red, swollen, warm and tender to touch. It's often difficult to identify the border between normal and infected skin. Treatment for Cellulitis • Cellulitis requires treatment with intravenous or oral antibiotics. Refer to latest National Antibiotic Guideline (NAG) for treatment. • Topical preparation potassium permanganate solution is used to dry up lesions and blisters. Figure 4: Bilateral leg cellulitis (University of California).

6 Potassium Permanganate 5% MECHANISM OF ACTION Mild antiseptic and astringent properties which reduce the foul smell from infected wound. SIDE EFFECTS • • Can cause staining on clothing, skin and nail. It may cause a stinging sensation in some people. If it is too concentrated, it may cause severe dry skin and fissure skin. COUNSELLING POINTS To be use diluted as Figure 5 below: • Dilute 2 drops (0.1 ml) in 50 ml of normal saline/water to make 1:10,000 (Picture 5d) • Dilute 2 drops (0.1ml) in 100 ml of normal saline/water to make 1:20,000 (Picture 5c) • Use as wash (use as final rinse) / dab/ wet wrap (for 20 minutes) until there is no weeping lesions • Use immediately after diluting. Solution that are left standing can turn brown (oxidized) and is ineffective. • Advise patient to stop using this solution once skin become dry to avoid fissuring of skin. Figure 5: Potassium Permanganate at different dilution a-b: Too diluted (ineffective) e-f: Too concentrated (cause side effects) d c a b e f • •.

7 B. Parasitic skin infection i) Scabies A highly pruritic and contagious parasitic disease caused by Sarcoptes scabies. Associated with poverty and overcrowded area (nursing home, prisons and hospital wards). Scabies can be transmitted through a direct skin-to-skin contact with an infected person. Sign and symptom of scabies are not difficult to detect, patient will experience severe itchiness during night time and when sweating. Possible part of body affected by scabies are wrist, toes, finger webs, arm, buttock, breast (nipple), waist line, genitalia (as shown in Figure 7). Figure 6: Presentation of scabies (MedicineNet.com) Figure 7: Common body area afected with scabies, in red (Allstop.com).

8 Treatment for Scabies • Immediate treatment for the patient (treat secondary infection first, as most scabicides are irritant). • Treatment of patient and any household contacts who may or may not be symptomatic. Decontaminate all linens, towel and clothing use in the previous 4 days by hot water washing (60°C) or put under the sun. Table 2: Treatment for Scabies according to patient’s category • Topical preparations for treating scabies: Patient Category Recommended Therapy Newborn to 2 months of age • Crotamitone 10% cream Children (2 months to 2 years old) • Permethrin 5% • Crotamitone 10% • 6% sulphur in calamine / petrolatum Children (2-12 years old) • Emulsion benzyl benzoate 12.5% • Permethrin 5% Adult • Emulsion benzyl benzoate 25% • Permethrin 5% Pregnant women • Permethrin 5% • 6% sulphur in calamine/ petrolatum a) Emulsion Benzoyl Benzoate (EBB) 12.5% & 25% MODE OF ACTION Benzyl benzoate exerts toxic effects on the nervous system of the parasite, resulting in its death. It is also toxic to mite ova, though its exact mechanism of action is unknown. In vitro, benzyl benzoate kills the Sarcoptes mite within 5 minutes. SIDE EFFECTS Burning sensation, rashes, skin irritation COUNSELLING POINTS • Apply from neck to soles, avoid head and face area • Apply on the skin surface continously for 24 hours for 2-3 days. • Rinse off after 24 hours and then reapply, with a bath taken in between each application. • A third application may be required in some cases i.e. HIV/ immunocompromised patients • Wash off thoroughly after the recommended time period • Use of EBB is contraindicated in pregnancy, breast feeding woman and infant of <2 years old..

9 b) Permethrin 5% Lotion MODE OF ACTION Pyrethroid insecticide SIDE EFFECTS Burning, itching, rash, redness, stinging, swelling, numbness COUNSELLING POINTS • Apply over whole body include face, neck, scalp and ears in infants & HIV patients who has scabietic lesions on the head. Otherwise in normal adults, apply from neck to soles. • Wash off after 8 - 12 hours • Repeat 1 week later c) Crotamitone 10% MODE OF ACTION Scabicidal agent SIDE EFFECTS Burning, itching, rash, redness, stinging, swelling, numbness COUNSELLING POINTS • Bathe and dab dry before applying crotamitone. • Apply over whole body except face and scalp; once daily, up to 7 days. • Avoid any contact with eyes or mucous membrane • Avoid massive, prolonged use in pregnant woman and infant • For nodular scabies; Apply to the nodules 3 times a day for 7-14 days. d) 6% sulphur in calamine/ petrolatum MODE OF ACTION Parasiticidal SIDE EFFECTS Irritation COUNSELLING POINT Rinse off after 24 hours and then reapply every day for the next 3 days (with a bath taken in between each application)..

10 ii) Head Lice Head lice (Pediculushumanus capitis) are whitish to grey-brown in colour and smaller than the size of a pinhead when first hatched. When fully grown, they are about the size of a sesame seed. They cannot fly, jump or swim and are spread by head-to-head contact, climbing from the hair of an infected person to the hair of someone else. A head lice infestation is not the result of dirty hair or poor hygiene. All types of hair can be affected, regardless of its length and condition. Head lice only affect humans and cannot be passed on to animals or be caught from them. Treatment for Head Lice • Topical preparations for treating head lice: Figure 6: Presentation of scabies (MedicineNet.com) a) Permethrin 1% Lotion MODE OF ACTION Pyrethroid insecticide SIDE EFFECTS Mild skin irritation, burning COUNSELLING POINTS • Apply lotion onto clean towel-dried hair, ensuring every strand comes in contact with lotion for at least 10 minutes. • Rinse completely • Re-apply after 7-10 days (to ensure total recovery).

11 b) Gamma Benzene Hexachloride (GBH) 0.1% Lotion MODE OF ACTIONS • Parasiticidal action by being directly absorbed through the parasite's exoskeleton and their ova. • Blockage of the GABA-gated Chloride (Cl-) Channel reduces neuronal inhibition, which leads to hyper-excitation of the Central Nervous System. This results in paralysis, convulsions, and death of lice. SIDE EFFECTS • CNS effects (Dizziness, Headache, Nausea, Vomiting), Skin Irritation, Contact Dermatitis. • Not for use by infant as it can cause toxic encephalopathy. COUNSELLING POINTS • Before using the GBH shampoo, make sure hair is clean by using regular shampoo without conditioner and dry it. However, do not wash hair within 1 hour before using GBH shampoo. • Shake the GBH shampoo bottle well. • Use 1 ounce (30ml) or not more than 2 ounces (60ml) of GBH shampoo on dry hair to wet the hair and scalp. • Do not add water to the hair at this time • Also, put GBH Shampoo on the short hairs at the back of neck and sideburns. • Keep GBH Shampoo on hair for 4 minutes • Do not wear a shower cap or any covering on head while waiting for the 4 minutes to pass. • Rinse thoroughly with warm water and towel dry briskly. • Remove the dead lice, nits and nit-shells using a fine-toothed comb Additional Information: • Boil/ wash/ dry-clean used clothes, bed linen and get all the household members treated simultaneously in order to avoid re- infection. • On evidence of re-infection, may advice for a second application only after 7 days following the first. • Risk of neurologic toxicity (seizures and death) with prolonged or repeated exposure.

12 C. Fungal infections Superficial Mycoses The common fungi that cause superficial fungal infections are Dermatophytes, Malassezia furfur and Candida spp. i) Dermatophyte infections (Dermatophytoses) Dermatophytes are fungi that requires keratin for growth. These fungi can cause superficial infections of the skin, hair, and nails. Dermatophytes are spread by direct contact from other people, animals and soil. Most common fungi that cause dermatophyte infection or dermatophytoses are Epidermophyton, Microsporum and Trichophyton. Dermatophytoses are referred to as “tinea” infections or ringworm. They are also named based on the body site involved. Table 3: Clinical feature of the various Dermatophytoses TYPES OF DERMATOPHYTOSES CLINICAL FEATURES Tinea pedis (foot) (Access Medicine.com) 1. Interdigital type: • Dry scaling type or • Moist (macerated) type 2. Moccasin type: • Chronic dry hyperkeratotic appearance 3. Inflammatory or bullous (vesicular) type: • Blister formation 4. Ulcerative type: • An extension of interdigital type into dermis due to maceration.

13 Tinea unguium (nail) ( Clinical Advisor.com) 1. Toenails more often infected than fingernails. 2. First and fifth toenails most commonly infected, probably due to traumatic damage by ill-fitting footwear. 3. White or yellow irregular lesion appears first at free end of nail and spreads slowly to cause entire nail to become thickened, opaque and yellow in colour, and it may crumble. Tinea Cruris (groin) (www.nursingfile.com) 1. Scaly, well-demarcated dull red/ tan/ brown patch with central clearing. 2. Papules, pustules may be seen at the rash margin. Tinea Capitis (Scalp) (Mddk.com.) 1. Localised scales lesions to widespread patches of alopecia. 2. Kerion: Localised swollen, tender red bald patch that contain pus. 3. Black dot noted on hair. 4. Favus is a distinctive infection with grey, crusting lesions Tinea Corporis (Body) (Candida Hub) Scaly, sharply marginated annular, concentric rings or arcuate patch with central clearing..

14 Treatment for Dermatophytoses infection • Topical preparation for treating Dermatophytoses infection: Topical Imidazole (miconazole cream/powder, clotrimazole cream) MODE OF ACTION Inhibits biosynthesis of ergosterol, damaging the fungal cell wall membrane, which increases permeability causing leaking of nutrients. SIDE EFFECTS Contact dermatitis in sensitized patients COUNSELLING POINTS • Apply twice daily to affected area optimally for 4 weeks including 2 weeks after lesions have cleared. • Apply 2-3 cm beyond advancing margin of lesion..

15 ii) Pityriasis Versicolor A common fungal infection of the skin caused by the dimorphic lipophilic yeast Pityrosporumorbiclare (round form) and Pityrosporumovale (oval form). Both were previously called Malassezia furfur. Pityriasis Versicolor is sometimes known as tinea versicolour. Clinical features of Pityriasis Versicolor: • More common in adolescence and young adulthood. • Macules, sharply marginated, round or oval in shape, varying in size with fine scales. • In untanned skin, lesions are light brown whereas it is white on tanned skin. • In immunocompromised individuals, the rash may be extensive and appeared red. Treatment for Pityriasis Versicolor • Topical preparation for treating Pityriasis Versicolor: Figure 9: Presentation of Pityriasis Versicolor infection (Merck Manual) a) Selenium Sulphide (2.5%) lotion or shampoo MODE OF ACTION Anti-mitotic action, resulting in a reduction in the turnover of epidermal cells. SIDE EFFECTS Burning, contact dermatitis COUNSELLING POINTS Apply daily for 1 week to affected areas for 10-15 minutes followed by a shower & rinse off,. Then apply 2-3 times per week..

16 iii) Cutaneous Candidiasis Our skin normally hosts variety of bacterial and fungal. Most of them are useful for our body function; however there are some that are harmful to our health especially when it multiplies uncontrollably such as fungi-like Candida sp. Overgrowth of Candida fungi causes a condition known as candidiasis of the skin, or cutenous candidiasis. Cutaneous candidiasis are commonly caused by Candida albicans and mostly occurs in areas such as the armpit, groin, and gluteal folds (e.g. diaper rash), in digital web spaces, on the glans penis or beneath the breasts. Candidiasis can cause a wide spectrum of clinical syndromes, as described below. The clinical presentation varies, depending on the type of infection and the degree of immunosuppression. Clinical Features of Cutaneous Candidiasis: • Primary lesion is a pustule on erythematous base that becomes eroded and confluent • Subsequently, fairly sharply demarcated, polycyclic, erythematous, eroded patches with small pustular lesions at the periphery (satellite pustulosis) • The advancing infected border usually stops when it reaches dry skin b) Ketoconazole Shampoo MODE OF ACTION Inhibits biosynthesis of ergosterol, damaging the fungal cell wall membrane, which increases permeability causing leaking of nutrients. SIDE EFFECTS • Burning, contact dermatitis in sensitized patient. • Safety and efficacy not established in <12 years old. COUNSELLING POINTS Apply onto skin/hair and leave it for 3-5 minutes before rinsing, use it once daily for 5 days. c) Topical Imidazole (miconazole cream/powder, clotrimazole cream) MODE OF ACTION Inhibits biosynthesis of ergosterol, damaging the fungal cell wall membrane, which increases permeability causing leaking of nutrients. SIDE EFFECTS Contact dermatitis in sensitized patients COUNSELLING POINTS • Applied twice daily to affected area optimally for 4 weeks including 2 weeks after lesions have cleared. • Apply 2-3 cm beyond advancing margin of lesion..

17 Types of candida infections include: • Athlete’s foot • Oral thrush • Vaginal yeast infection • Nail fungus • Diaper rash Presentations of Candidiasis at different parts of body: Treatment for Cutaneous Candidiasis: • Topical preparations for treating Cutaneous Candidiasis: Figure 10 : Diaper rash around the groin area (Merck Manual) Figure 11 : Oropharyngeal (Medscape) a) Topical Imidazole (miconazole cream/powder, clotrimazole cream) MODE OF ACTION Inhibits biosynthesis of ergosterol, damaging the fungal cell wall membrane, which increases permeability causing leaking of nutrients. SIDE EFFECTS Skin irritation or sensitivity, Contact dermatitis, vaginal burning due to cream base COUNSELLING POINTS • Apply twice daily to affected area, optimally for 4 weeks including 2 weeks after lesions have cleared. • Apply 2-3 cm beyond advancing margin of lesion..

18 b) Nystatin cream MODE OF ACTION Fungistatic activity against Candida spp SIDE EFFECTS • Irritation and sensitisation are reported but are rare • When sensitisation or severe irritation reactions develop, stop using this preparation and do not use it again. COUNSELLING POINTS • Apply liberally to affected area twice daily or as required. • After lesion has disappeared, continue treatment for 10 days to prevent relapses. • For nail infection, cut nails as short as possible. Apply cream once daily until growth of new nail has set in. c) Whitfield Ointment MODE OF ACTION Fungistatic activity combines with keratolytic properties. Useful for superficial skin infections caused by fungi such as ringworm and athlete’s foot. SIDE EFFECTS Local irritation COUNSELLING POINTS • The cream should be applied twice daily in a thin layer to the affected parts of the skin. Treatment may take several weeks. • Wash the skin with water and soap. Apply the cream in a thin layer and rub it into the skin. Whitfield’s cream should only be applied to affected parts of the skin. • Contact with the eyes, mouth and other mucous membranes should be avoided..

19 D. Viral skin infections i) Warts Warts are benign proliferations of skin and mucosa caused by human papillomavirus (HPV). It usually affects the hands, feet (plantar warts) and the anogenital area. It is contagious and can spread through contact Treatment of Warts Figure 13: Plantar Warts (Askpodiatrist) Figure 12: Warts on hand (WebMD) a) Salicylic Acid 1-20% INDICATION Warts other than genital warts MODE OF ACTION Potent keratolytic action and antiseptic action. Soften and destroy the stratum corneum. SIDE EFFECTS • Skin irritation • Skin ulceration (with higher concentration) COUNSELLING POINT • Apply carefully onto wart • Advise to protect surrounding skin with soft paraffin. b) Podophyllum 10- 20% paint INDICATION External genital warts MODE OF ACTION Prevents growth of wart tissue. SIDE EFFECT Local irritation COUNSELLING POINTS • Application must be done by trained personnel. • Avoid normal skin and open wound • Strong irritant to the skin and mucous membrane. Special care must be taken to ensure application is restricted to the wart itself..

20 c) Imiquimod 5% cream INDICATION External genital warts MODE OF ACTION Immune response modifier SIDE EFFECTS • Burning sensation • Erosion • Erythema • Itching • Excoriation COUNSELLING POINTS • Apply three times weekly up to 16 weeks. • Apply thin layer of cream to the wart and rub it until the cream vanishes • Leave the cream for 6-10 hours then wash the area with mild soap and water.

21 CHAPTER 2: CHRONIC NON-INFECTION SKIN CONDITION A. Eczema and Dermatitis The terms eczema and dermatitis are often used interchangeably. In some cases, the term eczematous dermatitis is sometimes used. Dermatitis can be acute or chronic or both. Dermatitis means inflammation of the skin which is characterised by sore, red, itching skin. In primary care, the two commonest forms of dermatitis are irritant and allergic dermatitis. • Acute eczema (or dermatitis) refers to a rapidly evolving red rash which may be weepy and swollen. • Chronic eczema (or dermatitis) refers to a longstanding irritable area. It is often darker than the surrounding skin, thickened (lichenified) and scaly. Pathophysiologic features: • Heredity (80% in monozygous twins, 20% in heterozygous twins) • Increased IgE production • Lack of skin barrier producing dry skin due to abnormalities in lipid metabolism & protein formation • Susceptibility to infections caused by Staphylococcus aureus/epidermidis & Malassezia furfur • Common causes include allergens such as fragrance product, food, soaps, detergents, inhalant allergens and skin infections. Common body areas for eczema and dermatitis by ages: Infants 0 – 2 years:  Extensor surfaces of extremities  Face (forehead, cheeks, chin)  Neck  Scalp  Trunk 2 -12 years old:  Flexural surfaces of extremities  Neck  Wrists, ankles 12 years old – adulthood:  Flexural surfaces of extremities  Hands, feet.

22 Treatment for Eczema and Dermatitis • Non-Pharmacological Therapy: • Patient education: Discuss the chronic nature of the disease in ome patients, the importance of adherence to treatment and convey the goal of treatment rather than cure, avoiding triggering factors. • Skin care: Hydration of skin with emollients, regular bathing, wet dressing • Clothing: Wear cotton or soft fabrics. Avoid rough, scratchy fibres and tight clothing. • Pharmacological Therapy: i. Emollients • Soften and smoothen the stratum corneum by a trapping mechanism that decreases the rate of trans-epidermal water loss. • Often use to manage dry or scaly skin. a) Aqueous cream b) Emulsifying ointment c) Liquid paraffin d) Glycerin 25% - 50% in Aqueous cream e) White/ Yellow soft paraffin f) Urea cream MODE OF ACTIONS • Standard adjunctive therapeutic approach to the treatment of chronic inflammatory skin condition. • Emollients either as soap substitutes or moisturizers are routinely used. • It has steroid-sparing effect when used in combination with topical corticosteroids as it restore normal hydration and epidermal barrier function & increase the efficacy of corticosteroids. • Soften & smoothen the stratum corneum, achieved by a trapping mechanism that decreases the rate of trans- epidermal water loss. SIDE EFFECTS Contact dermatitis in sensitized patients, itching It may cause the floor to be slippery and increase risk of patient fall..

23 COUNSELLING POINTS As a soap: • To apply cream/ ointment on cotton wool. Then wet the body, smear the cotton wool onto the skin. Wash and then use the dry cotton wool to remove excess oil. Precaution: To prevent fall in bathroom, have a stool in bathroom, anti-slip mat, wall-hand railing. Caretaker to accompany elderly patient in bathroom. As an emollient: • To apply after taking a bath or showering when the skin is moist. • To apply emollients liberally (at least 2-4 times a day). • To be applied smoothly in the general direction of growth of body hair in order to prevent accumulation at hair bases which might predispose to folliculitis (as Figure 14 below) Figure 14 : Emollient application (PAPAA.org) ii. Topical corticosteroids • Anti-inflammatory & anti-pruritic activity through several mechanism: a) Alteration in leucocyte number and activity b) Suppression of mediator release (histamine, prostaglandin) c) Enhanced response to agents that increase cyclic adenosine monophosphate.

24 • Used as 1st line treatment for mild to severe eczema to provide symptomatic relief. • Types of topical corticosteroids use dependent on: • Disease condition • Area of application • Age of the patient • Systemic effects of Topical Corticosteroid: a) Prolonged absorption through the skin can cause pituitary-adrenal-axis suppression, growth retardation, hypertension & Cushing`s syndrome b) Absorption is increased if skin is by thin and/or raw skin applied on intertriginous areas or occluded skin c) Absorption is more likely when used over very large areas and in children • Suggested potencies and preparations for long term use of topical corticosteroids for chronic dermatoses are as Table 3 below: Table 4: Selections of topical Corticosteroid according to potency POTENCY CLASS DRUG FREQUENCY SITES Very Potent  Clobetasol propionate** cream/ointment Once daily Thick lichenified, palm or sole and scalp Potent  Mometasone furoate** (Elomet) (short term only)  Betamethasone valerate cream/ointment full strength (0.1%)  Bethamethasone valerate cream/oint 1:2 (0.05%) Once daily Body and limbs Moderate Potency  Betamethasone valerate cream/ ointment 1:4 (0.025%)  Clobetasone butyrate cream/ ointment Three times daily (3x) Two times daily (2x) Any site Mild Potency  Hydrocortisone cream/ ointment 1%  Bethamethasone valerate cream/ ointment1:8 (0.0125%) Three times daily (3x) Three times daily (3x) Face, ear or flexural, elderly with thin skin.

25 COUNSELLING POINTS FOR TOPICAL CORTICOSTEROID APPLICATION • Topical corticosteroids should not be used to provide emollient effect, but ideally applied shortly after bath/shower. • Length of cream/ ointment squeezed from tube can be measured by Fingertip units (FTU). o 0.5 g steroid cream = 1 finger tip unit (FTU) o 1 FTU steroid cream to be applied to skin lesion as large as 1 side of the hand • Short term therapy with potent and very potent topical corticosteroids may be used to gain rapid clearance. These preparations should be avoided on the face, genitalia and skin folds. o Limit use of super potent corticosteroids to less than 30g/ week. Refer to dermatologist’s order. o Limit use of potent corticosteroids to less than 60mg/ week. o Continuous use of potent corticosteroids should not exceed two weeks. o Continuous use of super potent corticosteroids should not exceed two weeks. • Mild potency corticosteroids may be use for face, genitalia and body folds. SIDE EFFECTS • Local effects: Skin damage (skin thinning, redness and dilated surface blood vessel, easy bruising, striae) • Skin infections such as acne or fungal.

26 Table 5: Fingertip units for different areas of the body FTU Area 2.5 Neck & Face 7 Front 3 Per arm 7 Back & Buttocks 1 Per hand 6 Per leg 2 Per foot Figure 15: Fingertip Unit (Veterans’ MATES) (The Medicing Box).

27 iii. Topical Calcineurin Inhibitors (TCIS) a) Tacrolimus 0.03% & 0.1% ointment MODE OF ACTIONS • Immunosuppressant that has been shown to be effective for the treatment of atopic dermatitis. • Inhibits inflammatory cytokine transcription in activated T-cells & other inflammatory cells through inhibition of calcineurin. • Steroid-free ointment for patients aged 2 years and older who have moderate to severe eczema. • Improvement is seen within 1 week of therapy & sustained for at least 12 month SIDE EFFECTS • Local effects: Burning, stinging, pruritus which usually decrease with continued use COUNSELLING POINTS • Apply a thin layer of the affected skin, rub in gently & completely • Do not apply to areas of acute cutaneous viral infections • Continue treatment for another one week after sign & symptoms of atopic dermatitis has cleared. b) Silver Nitrate 0.5%, 2% 5% and 10% solution MODE OF ACTIONS Bactericidal agent SIDE EFFECTS Stinging and burning sensation at the site of application COUNSELLING POINTS Apply using aid of sharpen orange stick, dip in solution, touch the side of the bottle to remove drips of solution and then apply the moistened sharpen tip on macerated or fissured skin moistened caustic pencil tip for 1-2 minutes once daily at night. Maximum for 3 days. Figure 16: Orange stick (wooden stick applicator) (Medical Box).

28 B. Psoriasis Psoriasis is a common chronic non-contagious inflammatory skin condition that develops when a person's immune system send faulty signals that tell skin cells to grow too quickly. New skin cells form in days rather than weeks. The body does not shed these excess skin cells causing the skin cells to pile up on the surface of the skin, resulting in patches of psoriasis to appear. Psoriasis is characterized by thickened patches of inflamed, red skin covered with thick, silvery scales. Psoriasis can be exacerbated by drugs such as lithium, chloroquine, hydroxychloroquine, beta-blockers, NSAIDs, and ACE inhibitors. The reaction can occur within weeks until months after initiation of the medication. Other triggering factors may include stress, dry, smoking, alcohol consumption and injury to skin. There are many types of psoriasis, as described below: Table 6: Types of Psoriasis Plaque psoriasis (National Psoriasis Foundation) • The most common form of psoriasis, affecting 80-90% of patients • Irregular, round to oval in shape & tends to be symmetrically distributed • Site of lessions: elbows, knees, scalp, trunks, inter-gluteal cleft, buttocks, soles, palms and on the genitalia Guttate psoriasis (No Skin Problems.com) • Affects < 2% of psoriasis patients • Teardrop-shaped, salmon-pink flat top scaly plaque measuring 1-10mm • Found on trunk and proximal extremities • Usually occurs after upper respiratory infection Pustular psoriasis (PsoriasisFreeTips.com) • Characterized by white sterile pustules surrounded by red skin. In extensive skin involvement, skin protection functions may be lost rendering patient more susceptible to infections, loss of fluids and nutrients. • Can be life threatening.