Topical Preparation Counselling Guide (3.8.2019) (7) 1edit part 2

29 Treatment of Psoriasis • Principles of therapy: o Choice of therapy should be individualized. o Mild psoriasis can usually be treated by topical therapy. o In moderate to severe psoriasis, adequate control of skin lesion is not achieved using topical agents alone. • The following considerations will influence the choice & frequency of therapy: o Severity, body surface area (BSA) and site of lesion o Effect of psoriasis on quality of life o Degree of psychological impairment caused by the disease o Risk versus benefit ratio must be considered for each treatment regimen o Co-morbidities (e.g.: diabetes, hypertension) o Patient’s preference o Cost of therapy • Topical therapy : Erythrodermic psoriasis (PAPAA.org, 2016) • Severe generalised erythema affecting 80%-90% of the body surface area with various degrees of scaling • Skin’s protection function is lost, patient is more susceptible to infections, loss of fluids and nutrients. • Can be life threatening Inverse Psoriasis (PsoriasisSPEAKS) • Lesions consist of erythematous plaques with minimal scales • Located in the skin folds such as axillary, genitalia, perineal, inter-gluteal, inframmary areas a) Emollients (First-line treatment for all types of psoriasis) (Aqueous cream, Ung emulsificant ointment, 25% glycerine in Aqueous cream, 50% glycerine in aqueous cream, white/yellow soft paraffin and liquid paraffin) – refer to Eczema-Emollient section.

30 b) Tar-based preparation:  Coal Tar in Vaseline 1%, 3%, 6% (Liquor Picis Carbonis, LPC)  Coal Tar and Salicylic Acid shampoo,  Coal Tar Solution 20%  UngCocois Co MODE OF ACTION • Anti-inflammatory properties • Anti-scaling properties • Inhibits DNA replication in cells, which slows down cell division and stops the cells from multiplying excessively. Hence, reducing thickening and scaling of the skin. • Breaks down keratin, helping the skin cells shed from the treated area, thus reducing thickening and scaling. SIDE EFFECTS Stain and irritate skin, folliculitis COUNSELLING POINTS Coal tar in Vaseline 1%, 3%, 6% (LPC) • Start with coal tar in vaseline 1% and slowly titrate to higher strength if needed. • Test dose: To apply onto the affected area (small amount). If patient experienced irritation to LPC, please ask patient to see doctor immediately • Usually apply at night due to the unpleasant smell Coal tar and Salicylic acid shampoo • Use as shampoo for 2-3 times a week. • Apply for 5 minutes then wash off • Do not scratch the scalp as it will worsened the psoriasis Coal tar solution 20% • 1 cap (15 ml) added to 10L of water in a pail • Soak diluted solution for 20 minutes • Do not rinse again with tap water UngCocois Co • Separate hair • Apply to scalp once at night • Wrap scalp with towel or shower cap • Cover pillow (can stain pillow) • Shampoo off the next morning All tar-based preparation should not be used on body-folds, face and genitalia..

31 c) Topical Corticosteroids - refer to Eczema- topical Corticosteroids section d) Vitamin D Analogues MODE OF ACTION Regulates proliferation and differentiation of keratinocytes after binding to vitamin D receptors SIDE EFFECTS Itching, rash, thinning of the skin, skin burning COUNSELLING POINTS • Do not use more than recommended dose because of the risk of hypercalcaemia. Recommended dose:  Adult: 100gm/week  Children (2-14 years) : 50 gm/ week • Not recommended for use on face and flexures • Avoid excessive exposure to sunlight • Avoid in erythrodermic and generalised pustular psoriasis Calcipotriol + Betamethasone Ointment • Once daily application (usually at night) Calcipotriol + Betamethasone Gel • To be used on scalp once a day after shampoo e) Dithranol (Anthralin) MODE OF ACTION Reduce proliferation of stem cells & prevents T-lymphocyte activation so that normal keratinization may occur SIDE EFFECTS Skin irritation, burning sensation, staining of skin and clothing COUNSELLING POINTS • Apply on the skin lesion for 30 minutes and wash off • Not suitable for flexural areas and face • Start by applying a low-strength preparation (such as 0.1% dithranol) for a week, and then increase the strength gradually over the next few weeks until the best suitable strength. It should be possible to clear the patches within about 4-6 weeks of treatment..

CHAPTER 3: ACNE VULGARIS Acne Vulgaris (Acne) is a common skin condition that occurs when hair follicles become clogged with dead skins and oil, and eventually become inflamed. Acne sign includes whiteheads, blackheads, red pimples, nodules and cyst. It can occur on the face, neck, shoulders, back, or chest. Acne can be classified as: • Non-inflammatory: Characterised by comedones • Inflammatory: Characterised by papules, pustules, nodules, and cysts Acne Vulgaris has a multifactorial pathogenesis in which the key factor is genetics. Acne develops as a result of interplay of the following 4 factors: i. Follicular epidermal hyper-proliferation with subsequent plugging of the follicle ii. Excess sebum production iii. The presence and activity of the commercial bacteria Propionibacterium Acnes iv. Inflammation 32 Figure 17: Diferent presentations of Acne Vulgaris (Acne.com).

33 a) Cetrimide 1%, 2% solution MODE OF ACTION Bactericidal activity against gram-positive bacteria SIDE EFFECTS Burning sensation COUNSELLING POINTS • Apply solution onto the face twice daily • Cetrimide mix with water on palms, rub hand together until froth • Apply froth on face • Then rinse off with water • Dap dry b) Benzyl Peroxide 5%; 10% MODE OF ACTION • Antibacterial activity against Propionibacteria Acnes • It decomposes to release free oxygen radicals, which have potent bactericidal activity in the sebaceous follicles and anti-inflammatory action SIDE EFFECTS Dryness, skin irritation, bleaching or discoloration of fabrics (e.g. clothing, bed linen, towels) COUNSELLING POINTS • Apply on the acne spot after washing skin. May apply twice/ thrice a day if needed. • Start on night for a week, if no irritation, then can apply twice a day. • Stop if skin irritation occurs. c) Adapalene, Tretinoin Cream/Gel MODE OF ACTIONS • Normalisation or differentiation of follicular epithelial cells resulting in decreased micromedone formation • Reducing inflammatory components of acne (papules and pustules) SIDE EFFECTS Erythema, scaling, dryness, pruritus, burning, photosensitivity COUNSELLING POINTS • Apply thin layer to the entire face or other affected area at night after washing. • Wash well in the morning. • Protect face from direct sunlight. • Pregnancy should be avoided during treatment & at least 4 weeks after stopping treatment for Tretinoin cream/gel. d) Azelaic Acid 20% cream MODE OF ACTION Inhibit the growth of susceptible organism (Propionibacterial acnes) on the skin surface and inhibits follicular keratinisation. This restricts the development of comedone. SIDE EFFECTS Local skin irritation (erythema, scaling, burning, itching), photosensitivity COUNSELLING POINTS Massage a thin layer onto the affected area on the face twice a day. Treatment of Acne vulgaris • Topical therapy:.

34 References Koning, S et al. 2002. Fusidic acid cream in the treatment of impetigo in general practice: double blind randomized placebo controlled trial. BMJ 324: pp 1 - 5 Micromedex Drug Information 2016 MIMS: Pharmacotherapy Guide to Atopic Dermatitis & Psoriasis. Singapore, Malaysia, Hong Kong 2014 Ministry of Health Malaysia. 2014. National Antibiotic Guidelines Ministry of Health Malaysia. 2015. Guideline for Management of Scabies in adult & Children. National Geographic. (n.d.) Skin. <http://science.nationalgeographic.com/science/ health-and-human-body/human-body/skin-article/> [Accessed 20 Sept 2016] National Institute for Health and Clinical Excellence (NICE). 2007Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. London: National Collaborating Centre for Women's and Children's Health. Ng HW et. al. 2013. Dermatology Counselling Pharmacist 1st Edition. Pharmacy Department, Selayang Hospital. NHS Choices. 2016. Head lice and nits. <http://www.nhs.uk/conditions/Head-lice/ Pages/introduction.aspx> [Accessed March 31, 2016] Product Information Leaflet, Crotamiton Product Information Leaflet, Emulsion benzoyl benzoate Product Information Leaflet, Fusidic acid cream Product Information Leaflet, Pemethrin Product Insert Lindane Shampoo, USP 1% Richardson M. et al. 2005. The Pocket Guide to Fungal Infection Second Edition. Blackwell Publishing. Available through Wiley Online library website <http://onlinelibrary.wiley.com/book/10.1002/9780470757734> [Accessed March 31, 2016] Royal Pharmaceutical Society. British National Formulary (BNF) 70. September 2015-March 2016 Rutter Paul. 2009. Community Pharmacy: Symptoms, Diagnosis and Treatment. 2nd Edition. Churchill Livingston. Sabeera B and Leong K.F. 2014. Atlas of Paediatric Diseases: Dermatitis & Psoriasis. Tang JJ, Tan WC, Chan LC, Leong KF. 2016. Atlas of Paediatric Diseases: Skin Infections Therapeutic Guidelines: Dermatology Version 1. 1999. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20..

2, 3. 4. 5. 6. 8. 9. 10. 11. 12. 13. 14. 15. 13. 17. Na+jonal Cancer Institute, SEER Training Modules. (n.d) Anatomy of the skin. <https:/fraining.seer.cancer.gov/melanoma/anatomy/> Na+jonal I-lez_th Institute. (n.d.) Impel' University of (1k nomia, San Diego. (n.d.) A Pæctic-BI Guide to Clf nicel MedicineNet.com. (n.d.) Bintas and <hff'.p://www.medieinenet.corrvim- aue-co- A" gtop. (n.d.) Index of btzs-body-d-. FliGkr.Crom. 2010. Mele human head louse. toxlsanma Access medicines.cono (n.d.) Chapter 140. Tinea Pedis. Clinical Advisor.com. 2012. Onychomycosis. <hlffp://www.clinic;z-advi- sor.com/dermatologyfonychomycosis-tinea-unguium-nail-fungal Nursir•gFiIe.com, 201B. Nursing Interventions for Tinea Cruris. M.el<fk.com. 2017. Tinea Cawit(s Pictures. Hub. (n.d) Ringworm (Tinea Corporis) Symptoms. hub.com/ac.v/Funæl-lfiTe$tion-Synvot.oms» NielCk Manual Profer,si.-znal ver. 2017. Tinea versicolor. <hitp://www.merckmanua's.com/- protegsiona-.idarmatolcoic-disordersffurv- Mack Manual Profer,si.-znal ver. 2017. Candidi4tis (DK vsr rash). <hfbt;,•s://www.merck- Mectce•.pe. 2016. Thrush clinical present%tfan, 2017. Plantar watts. <httns:}/www.a±'podiatist.ca'-iantar-wart-la- ser-treatment> 2017. watts. <h-;tp://www.webmd.comkkin-prot,lems-and-teatment&'fiic- ture-of-watts> PAPA.A.ocg. 2016. A emo -tent therapy routjne, <http://www.papaa.orr.;ect-:esee- fault i Pharmaceutical Services Programme, Ministry of Health Malaysia 35.

36 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. The Medicines Box.2007. Fingertip units for body surfaces. <https://vitualis.word- press.com/2007/02/26/the-fingertip-unit-of-topical-steroids/> Veterans MATES. 2012. How much topical corticosteroid should I use? <https://www.veter- ansmates.net.au/topic-33-therapeutic-brief> The Medicines Box. 2007. The fingertip unit. <https://vitualis.word- press.com/2007/02/26/the-fingertip-unit-of-topical-steroids/> Medical Box. 2018. Wooden stick applicators. <http://www.medicalbox.org.uk> National Psoriasis Foundation. (n.d.) Plaque psoriasis. <https://www.psoria- sis.org/about-psoriasis/types/plaque> Noskinproblems.com. (n.d.) Guttate Psoriasis Treatment and Causes. <https://noskinprob- lems.com/guttate-psoriasis-treatment-and-causes/> PsoriasisFreeTips.com. (n.d.) Pustular psoriasis. <http://psoriasisfreetips.com/psoria- sis-photos/pustular-psoriasis-photos/> PAPAA.org. 2016. About psoriasis- Erythrodermic psoriasis. <http://www.papaa.org/re- sources/about-psoriasis> PsoriasisSPEAKS. (n.d.) Psoriasis Types and Pictures- Inverse Psoriasis. <https://ww- w.psoriasis.com/psoriasis-types-pictures> Acne.com. (n.d.) Types of Acne. < https://www.acne.com/types-of-acne/acne-signs/> American Academy of Dermatology Psoriasis: Recommendations for Vitamin D analogues. h t t p s : / / w w w . a a d . o r g / p r a c t i c e c e n t e r / q u a l i t y / c l i n i c a l - g u i d e - lines/psoriasis/topical-therapy/recommendations-for-vitamin-d-analogues.

37 Appendix i CARTA ALIR PROSES KAUNSELING PRODUK DERMATOLOGI TOPIKAL TANGGUNGJAWAB CARTA ALIR Pegawai Farmasi Pegawai Farmasi Pegawai Farmasi Pegawai Farmasi Pegawai Farmasi Pegawai Farmasi Pegawai Farmasi Terima pesakit Perkenalkan diri dan jelaskan tujuan kaunseling Jalankan penilaian (jika berkaitan) Beri kaunseling & dispens ubat kepada pesakit Tetapkan temujanji susulan jika perlu Lengkapkan borang kaunseling Failkan borang kaunseling a) rekod dalam borang kaunseling b) Ubat dilabel dengan kod yang ditentukan seperti dalam Rajah Pendispensan Ubat Dermatologi Topikal.

38 ITEM CODE ITEM CODE ITEM CODE Aqueous Cream Clobetasol Propionate 0.05% Ointment Magnesium Sulphate 45% Paste Adapalene 0.1% Cream/Gel Castellani's Paint Neomycin 0.5% Cream Amorolfine 5% Nail Lacquer Coal Tar 20% Solu�on Nysta�n 100,000 units/g Cream Benzoic Acid Compound Ointment Coal Tar 1% with Vaseline Paraffin, White so� Benzyl Benzoate Emulsion 12.5 % (Child) / 25% (Adult) Coal Tar 3% with Vaseline Permethrin 5% w/v Lo�on Benzoyl Peroxide 5% Gel Coal Tar 6% with Vaseline Podophyllum 10% Paint BVC 0.01% (1:10) Clotrimazole 1% Cream Pot. Permanganat 0.1% Solu�on BVC 0.05% (1:2) Emulsifying Ointment Pot. Permanganat 5% Solu�on BVC 0.025% (1:4) Fusidic acid 2% Ointment Salicylic acid 2% Ointment BVC 0.1% Fusidic acid 2% in BVC 0.1% Salicylic acid 5% Ointment BVO 0.1% Gamma Benzene Hexa 1% Lo�on Salicylic acid 10% Ointment BVO 0.05% (1:2) Gentamicin 0.1% Cream Salicylic acid 20% Ointment BVO 0.25% (1:4) Glycerin 25% in Aqueous Cream Salicylic acid 2% in BVO 0.025%(1:4) Calamine + 6% Sulphur Lo�on Glycerin 50% in Aqueous Cream Selenium Sulphide 2.5% Shampoo Calamine with 0.5% Menthol Lo�on Hydrocor�sone 1% Cream Silver Nitrate 0.5% Lo�on Calcipotriol 50mcg/g Cream Hydrocor�sone 1% Ointment Sod. Chloride 0.9% (For Irriga�on) Calcipotriol 50mcg/g + Betamet. 0.5mg/g Gel (Xamiol) Hydroquinone Comb Depigmenta�on Cream Sulfacetamide 15% Solu�on Calcipotriol 50mcg/g + Betamet. 0.5mg/g Ointment (Daivobet) Ketoconazole 2% Shampoo Tar, Coal Tar, and Salicylic Acid Liquid (Sebitar) Carbamide (urea) 10% Cream Methoxsalen 0.01% Ointment Tre�noin 0.05% Cream / Gel Cetrimide 2% Lo�on Methoxsalen 0.05% Ointment Zinc Oxide Cream Clobetasone Butyrate 0.05% Cream Miconazole cream Clobetasone Butyrate 0.05% Ointment Mometasone Furoate 0.1% Cream Clobetasol Propionate 0.05% cream Mupirocin 2% Ointment Appendix ii RAJAH PENDISPENSAN UBAT DERMATOLOGI TOPIKAL Nama: MRN: Tarikh: SENARAI UBAT SAPU / LIST OF TOPICAL MEDICATION (adapted from: My Skin Diary (Jan 2015), Projek Inovasi Jabatan Farmasi Hospital Serdang) NOTA:.

Cara Mengisi Rajah Pendispensan Ubat Dermatologi Topikal i. Ubat yang dipreskrib diberikan Kod pada Senarai Ubat Sapu. (kod ditentukan oleh pegawai yang memberikan kaunseling) Contoh: Hydrocortisone Ointment = A Aqueous Cream = B ii. Labelkan pada label ubat kod yang telah ditentukan. iii. Tandakan Kod tersebut pada nama ubat disenaraikan dalam RAJAH PENDISPENSAN UBAT DERMATOLOGI TOPIKAL iv. Jika terdapat maklumat tambahan, sila isikan di ruang nota yang disediakan. v. Berikan RAJAH PENDISPENSAN UBAT DERMATOLOGI TOPIKAL kepada pesakit untuk rujukan. vi. Sekiranya ubat pesakit tidak tersenarai dalam jadual ubat tersebut, mohon tambah pada ruang kosong yang ada. 39.

General Counselling Points for Topical Dermatology Products • Ensure that the patient knows which product to apply to which part of the body; and the difference in potencies. • If both emollient & topical corticosteroid to be use at the same area, apply emollient first and wait for several minutes before applying topical corticosteroid. • Always apply cream based preparation prior to ointment based preparation. • Do not scratch the affected area as it will worsened the condition. • Remind Patient to practice hand hygiene before & after applying topical preparation and to Cut nails as short as possible. • Provide information on storage. • Always apply ‘wet the dry’’and ‘dry the wet’ concept when counselling patient. ‘wet the dry’ – use emollient to moisten the dry area ‘dry the wet’ – use KMNO4 on weepy area 40 Appendix iii.

Index 2% Fucidic acid cream 4 2% Mupirocin ointment 4 6% Sulphur ini Calamine/ Petrolatum 8, 9 Adapalene, Tretinoin 32 Azelaic acid 20% cream 32 Benzyl peroxide 5%; 10% 32 Cetrimide 1%, 2% solution 32 Crotamitone 10% 8, 9 Dithranol (Anthralin) 30 Emollients 21, 22, 24, 28 Aqueous cream 21, 28 Emulsifying ointment 21, 28 Liquid paraffin 21, 28 Glycerin 25% - 50% in Aqueous cream 21, 28 White/ Yellow soft paraffin 18, 21, 28 Urea cream 21 Emulsion Benzoyl Benzoate (EBB) 12.5% 8 Emulsion Benzoyl Benzoate (EBB) 25% 8 Gamma Benzene Hexachloride (GBH) 0.1% lotion 10 Imiquimod 5% cream 18 Ketoconazole shampoo 14 Nystatin cream 16 Permethrin 1% lotion 10 Permethrin 5% lotion 8, 9 Podophyllum 10 – 20% 18 Potassium Permanganate 5% 5, 6 Salicylic acid 1 – 20% 18 Selenium Sulphide (2.5%) lotion or shampoo 14 Tar-based preparation 29 Topical corticosteroids 21, 22, 23, 24, 30 Topical Calcineurin Inhibitors (TCIS) 26 Tacrolimus 0.03% & 0.1% ointment 26 Silver Nitrate 0.5%, 2%, 5% & 10% solution 26 Topical Imidazole (Miconazole cream/ powder, Clotrimazole cream) 13, 15, 16 Vitamin D analogues 1, 30 Whitfield ointment 17 41.

ii.