MANAGEMENT OF SKIN DISEASEA CASE STUDY BY

EMMANUEL OBIRI BAKAI(AN INTERN PHARMACIST AT KATH)

OUTLINE

• Patient’s demographics• Laboratory tests• Pharmaceutical care plan• Patient counseling• Conclusion• References

PATIENT’S DEMOGRAPHICS

Name: SLAge: 35yrsGender: maleAddress: AkwatialineReligion: MoslemMarital status: SingleOccupation: Businessman

12/05/2015

• SL was referred from Manhyia District Hospital to the accident and emergency unit of KATH.

• With rashes all over the body and face diagnosed as Stephen Johnson syndrome, for further investigation and management .

13/05/2015

• PC: Generalised body rash for the past six days• HPC: No history of chronic disease or allergy. Patient noticed rash at the antecubital region of the upper limb. Seek medical attention at a pharmacy and was given Cap Amoxycillin.

Presented same condition to another Pharmacy two days after and given Cap Flucloxacillin, tab cetrizine and Tab greseofulvin.Start- flucloxacillin, experinced generalised body rash of varying sizes. Some fluid filled associated with severe purities , some raptured producing milky exudates.

ODQ

• No fever and chill• No bleeding from lesions• No ulceration at the bucal mucosa and lip • Genital ulceration +

• PMHx: No previous admission or surgery• No chronic disease and no haemotransfused.

DHx: Cap Amoxycillin – stopped after a day• Cap Flucloxacillin 500mg qid for 5 day.• Tab cetrizine 10mg dly for 5 days.• Tab griseofulvin 250mg bd for 5 days.

FHx: No Chronic disease.SHx: Single, work as a businessman (sells motocycles).

O/E

• Young man with facial puffiness and generalized (body) rashes (scaly).

• Majority of rash- bullae• Some are hyper pigmented lesions especially

on scalp• Yellowish exudates from nose and mouth.• Ulceration on gland penis +

VITALS ON ADIMISSION

• Spo2- 100%• Temp- 37.9oC• PR – 112 bpm-regular• RR – 28pm• RBS- 7.5mmol/l• HS –s1+s2+0

Review of systems

• CVS: JVP not raised• R/s: A/E- bilaterally adequate• B/S : Viscular no added sound• Abdomen: full, soft, and non-tender• CNS: Conscious and alert.

LAB TEST 13/05/2015Electrolytes

TEST RESULT REFERENCE

Sodium 131 mmol/L low 135 - 150

Potassium 4.5 mmol/L 3.5 - 5.1

Chloride 94 mmol/L low 98 - 107

TOT. CO2 (bicarbonate) 29 mmol/L 23 - 29

Urea 5.1 mmol/L 2.1 - 7.1

Creatinine, serum 113 mmol/L 60 - 120

eGFR- (CKD-EPI) 72 ml/min

LIVER FUNCTION TESTTEST RESULT REFERENCE

Bilirubin (total) 5 umol/L 2 - 26

Bilirubin conjugated 1 umol/L 1 - 7

Alkaline Phosphatase 81 IU/L 32 - 93

G-Glutanyl Tranferase 21 IU/L 0 - 50

ALT (GPT) 13 IU/L 10 - 40

AST ( GOT) 18 IU/L 15 - 40

Total Protein 61 g/l 60 - 80

Albumin 32 g/l low 35 - 48

Impression

• Idiosyncratic drug reactionPLAN: Stop all previous medication IV Hydrocortisone 200mg Start IV Dextrose saline 1.0 L startTo be seen by Dermatologist and Ophthalmologist.

14/05/2015

• Patient condition generally satisfactoryPlan: IV hydrocortisone 200mg start 15/05/2015• All parameters were same.• PR – 92• BP – 100/72• CNS – gcs 15/15• Plan: Encourage to take more fluid.

16/05/2015 Reviewed by Dermatologist

• O/E : A 35 yr old previously well male who developed some lesions over the antecubital area.

• It was said to be chicken pox and went to buy some drugs.(?).

• Shortly after taking drug he started developing papulovescular rash on the face which later spread.

• They were pruritic and the face became eodematous.

Dermatologist review cont

• ODQ : no mucosal lesions• S|L : Scalp – studded with crusted scale - face - oedematous and covered crusted squamous - eye and bucal mucosa - uninvolved - arms - oedematous and weepy

Review cont

- trunk - studded with crusted scales - legs - bullons , eruptous on dorsal (esp feet), aspect of feet hot to touch - palm - deep scaled blisters - hair and nail - normal

Impression and Plan

• Impression: Drug induced exfoliative dermatitis.

• ??? Impertiginised Dermatitis

• Plan: Punch for biopsy , FBC, Urine R/E, HIV test, Blood c/s

Goal of Therapy

• To relieve symptoms ( pruritis , malaise and chills)

• Keep the Skin in good condition• Minimize flare-ups• Prevent opportunist infections(bacterial

infection with stphylococus and or streptocococus and fungal infection)

Drugs

• - Ketopine Shampoo (Ketoconazole)(wash off after 6mins use on alternate days)• - Potassium Permanganate for dly bath• - Neomycin-p cream (apply tds over denuded

area)• - Petroluem jelly (apply over total skin six

times daily.

DRUGS

• Tab Valupack one daily for 30 days• Tab prednisolone 20mg tds for 4 days.• Puncture bullae without deroofing.

• 17/05/2015• Patient yet to receive drugs from relatives• PLAN : Cap Dalacin C 300mg tds for 7 days

(added)

18/05/2015 – 20/05/2015

• Patient general condition remain stable• Yet to receive some of the drug from relatives• Diagnosis: Drug induced exfoliative dermatitis Drug: -Prednisolone 20mg tid for 5 days. - Bactroban cream (apply tds on sore area) -to continue other medications

Images

Images

Images

Images

Dermatologist Review21/05/2015

• Patient remains stable and has started all medications

• PLAN: To be discharged to continue domicile care

• Next review date 12/06/2015 at Dermatology clinic.

Images of SL after discharge

Pharmaceutical care planMedicine Indication

IV Hyrocortisone For managing the inflammation and allergy

IV Dextrose Saline For managing the Glucose and Electolyte lost

Tab Prednisolne For managing the inflammation and itching

Tab intavita Serves as a multivitamin

Cap Dalacin C For managing any bacterial infection that may ensue

Pharmaceutical care planMedicine Indication

Ketopine Shampoo (Ketoconazole) For managing Mycosis

Petroleum Jelly Serves as emollient for managing the dry and scaly skin

Bactroban Cream For managing any superficial bacterial infection

Neomycin – P Cream For managing any bacterial infections

Pottasium Permanganate Serves as antiseptic- containing product to reduce the bacterial load.

Pharmaceutical care Issues

Counseling

• Comply with given medication to ensure complete cure

• Avoid purchasing non prescription medication• Reassure that condition not infectious• On application of medication (emollient)

Conclusion

• Exfoliative dermatitis also known as erythroderma, is an uncommon but serious skin disorder.

• The etiology is often unknown, but may be the result of a drug reaction or an underlying malignancy.

• The approach to treatment therefore include discontinuation of any potential causative medication and a search for any underling malignancy

• Thank you

References

• The Merch Manual Eighteenth edition Merch reserch lab, 2006

page 932-1027• British National Formulary, 68th edition