Over the Counter Review Over the Counter Review Topical Management

Over the Counter Review: Topical Management

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Page 1

Over the Counter Review

Topical Management

Peter A. Kreckel

Adjunct Assistant Professor of Pharmacology

St Francis University, Loretto PA

With special thanks to: Gretchen M. Kreckel Garofoli Clinical Assistant Professor West Virginia University Morgantown, WV

PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education

Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support

educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all

information and data before treating patients or employing any therapies described in this educational activity.

This program has been supported by

PharmCon


Topical Management

Accreditation:

Pharmacists: 0798-0000-11-082-L01-P

Pharmacy Technicians: 0798-0000-11-082-L01-T

Nurses: N-706

CE Credits: 1 contact hour

Target Audience: Pharmacists Technicians

& Nurses

Program Overview:

Over the counter (OTC) products are vital to the everyday existence of many individuals. This program will discuss a

number of the most commonly treatable afflictions and what the consumer can get at the pharmacy to deal with them. Each

topic is addressed briefly in terms of what causes certain afflictions before a number of products are then introduced and

discussed in how they work and of what they are composed. This program is a must for any health care professional

Objectives:

• Identify appropriate topical over-the-counter medications for self-treatable conditions

• Appropriately consult patients on proper utilization and side effects of topical OTC medications

This program has been

supported by PharmCon


Topical Management

PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of

continuing pharmacy education

Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the

companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product

discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity.

This program has been

supported by PharmCon

Speaker: Peter A. Kreckel R.Ph. is a graduate of the University of Pittsburgh, Bachelor of Science in Pharmacy,

Magna Cum Laude, Class of 1981. He served as the President of the Pharmacy School Class of 1981 for 3 years,

and President of the Pharmacy School Student Council for 2 years. During this time he received the Upjohn

Achievement Award for leadership and academic achievement. In addition to managing a retail pharmacy,

pharmacist Kreckel is an Adjunct Assistant Professor of Pharmacology, Department of Physicians Assistant

Sciences, St. Francis University. His assignments include teaching a HIV pharmacotherapy course for Physician

Assistant students, currently doing their clinical rotations, that are pursuing a Masters of Medical Science Degree

from St. Francis University.

Speaker Disclosure: Mr. Kreckel has no actual or potential conflicts of interest in relation to this

program.

Goals and Objectives

Goal:

The goal of this program is to educate fellow pharmacists regarding the selection process of appropriate topical over-the-counter medications

Objectives:

Identify appropriate topical over-the-counter medications for self-treatable conditions

Appropriately consult patients on proper utilization and side effects of topical OTC medications.

Disclaimer: The speaker reports no conflicts of interest in the preparation and presentation of this review program




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Back in the old days……..

Diphenhydramine, Chlorpheniramine,

Clemastine, Ketotifen drops

Loratadine, Fexofenadine, Cetirizine

Cimetidine, Famotidine, Ranitidine

Omeprazole, Lansoprazole

Hydrocortisone

Terbinifine, Miconazole, Clotrimazole

Ibuprofen, Naproxen

PEG-3350

Dermatophytes: is there a fungus

among us??

Topical fungal infections affect scalp, skin, nails, such as mucus membranes such as oral cavity and vagina. Superficial fungal infections are sometimes called dermatophytic. Usually treated topically due to decreased side effects of this route of administration.

Causative organisms: Trichophyton, Epidermophyton or Microsporum

Tinea cruris : “jock itch”

Tinea corporis: “ringworm”

Tinea capitas: “ringworm of the scalp”

Tinea pedis: “athletes foot”

Tinea versicolor: “sweat rash”

Treatment of Dermatophytes

(-azole antifungals)

Mechanism: impairs the synthesis of ergosterol, the

main sterol of fungi membranes, allowing increased

permeability and leakage of cellular components.

Inhibits fungal CYP 450 14-alpha-desmethylase

thereby decreasing ergosterol.

Miconazole (Micatin®)

Clotrimazole (Lotrimin®)

Terbinifine (Lamisil®): inhibits the fungal enzyme squalene 2,

3 epoxidase, which ultimately decreases the synthesis of ergosterol

Diaper Rash

Etiology

Two-thirds of infants experience diaper rash.

Disposable diapers have greatly decreased incidence.

Breast fed babies have less than bottle fed babies.

Causes include: moisture, bacteria, alkaline pH , mechanical disruption of the area, digestive enzymes & bile salts. Thinner skin in infants and elderly predispose them to this condition. Bacteria may include: Peptostreptococcus, streptococci, staphylococci, bacteroides, and E. coli, however 80% of the cases where symptoms have been present for at least 3 days, Candida albicans is found.

Untreated overgrowth of C. albicans leads to ulceration, maceration and UTI.




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Diaper rash-

TREATMENT

Candida albicans treatment: any of the –azole antifungals are effective.

Vusion (Rx)= miconazole 0.25%, ZnO, white petrolatum

Diaper rash prevention with oral antibiotic therapy. Broad spectrum antibiotics, especially amox/clavulanate. Use protectant paste

AVOID powders: avoid all powders due to potential inhalation. Cornstarch “feeds” yeast!

AVOID RX corticosteroids

Avoid alcohol & scented baby wipes

Fresh air!

Anti- infectives

TRIPLE antibiotic: Bacitracin---polymixin---

neomycin.

MAY help speed healing, prevent infection,

and reduce the risk of scarring.

Neomycin (6%) & bacitracin (2%) can cause

allergic dermatitis.

Patients notice increasing redness or itching

with these, tell them to avoid using them.

Use plain petrolatum instead.

Anti- infectives

Itching??

Calamine (Zn oxide +ferric oxide)

Diphenhydramine (Benadryl®) topical: exert an

anesthetic effect by depressing cutaneous

receptors to relieve pain and itching.

Hydrocortisone (Cortaid®):anti-inflammatory

agent that can prevent or suppress edema,

capillary dilation, swelling, and tenderness

associated with inflammation

Aluminum acetate (Domeboro®): astringent

1 packet per pint= 1:40

2 packets per pint= 1:20

Topical anesthetics

Dermoplast spray- 20% benzocaine

Hypersensitivity common reaction

Solarcaine (gel) lidocaine

Caution with broken skin (might precipitate

arrhythmia)

Use not recommended, due to short duration of

effectiveness: max= 45 minutes.




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Germ Killers!

Betadine: used to decontaminate Lunar

module after Neil Armstrong moonwalk-1969.

Povidine iodine topical antiseptic.

Hibiclens: chlorhexidine- used for MRSA

Soap and Water

Alcohol

Hand gels (62% ethanol and higher)

Alcohol based hand sanitizer

1."Caregivers should wash hands with a non-antimicrobial soap and water or an anti-microbial soap and water when hands are visibly dirty or contaminated with proteineous material, such as blood or feces" (Recommendation 1)

2."If hands are not visibly soiled, caregivers should use an alcohol-based waterless antiseptic agent for routinely decontaminating hands"

(CDC Guideline for Hand Hygiene in Healthcare Settings: Recommendation 2)

Alcohol based

hand sanitizers

Must be 62% alcohol to be effective

Are not effective against Clostridium difficile

spores. Use soap and water.

Reports of alcohol ingestion from “licking”

hands

Ophthalmic Disorders

Eye surface Dry eyes

Allergic conjunctivitis

Diagnosed viral conjunctivitis

Diagnosed corneal edema

Presence of loose foreign debris

Minor ocular irritation

Chemical burns

Clean or lubricating of artificial eyes

Diagnosed age-related macular degeneration




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Exclusions to Self Care

Blunt trauma

Foreign particles trapped or embedded in the eye

Ocular abrasions

Infections of the eyelid/eye surface

Eye exposure to chemical splash, solid chemical, or chemical fumes

Thermal injury to eye

Bacterial conjunctivitis

Chlamydial conjunctivitis

Dry Eye

Most common anterior eye disorder

Common Causes Aging

Lid defects

Loss of lid tissue turgor

Sjögren’s syndrome

Bell’s palsy

Thyroid eye disease

Collagen diseases

Systemic medication

Environmental factors

Dry Eyes Treatment Goals

Alleviate and control dryness

Relieve symptoms of irritation

Prevent possible tissue and corneal damage

Nonpharmacologic Therapy

Avoid environmental triggers

Avoid prolonged viewing of computer screens

Symptoms

White or mildly red eye

Sandy, gritty feeling

Sensation of something in the eye

May initially present with excessive tearing

Dry Eyes

Pharmacologic Therapy

Artificial Tear Solutions

Ocular Lubricants

Prevent tear evaporation through stabilization of tear film

Use at least twice per day

Numerous products available




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Dry Eyes


Ophthalmic Ointment

Contains

White petrolatum

Mineral oil

Lanolin

Advantage is that it is retained longer in the eye

Administered twice daily

Most common side effect

Blurry vision

Allergic Conjunctivitis

Treatment Goals: Remove or avoid allergen

Provide symptomatic relief-limit allergy reaction

Protect the ocular surface

Nonpharmacologic Therapy

Do not wear contact lenses until resolved

Apply cold compresses 3-4 times a day

Causes: Pollen, Animal dander, topical eye preps

Symptoms: Red eye with watery discharge, Itching



1st line

Artificial tears

If symptoms persist

Ophthalmic antihistamine/mast cell stabilizer

If symptoms do not resolve within 72 hours from

starting therapy patient should see eye care

practitioner


Ophthalmic Decongestants

Constrict conjunctival vessels reducing

redness

Phenylephrine

Works on alpha-adrenergic receptors of ophthalmic

vasculature

Oxymetazoline

Naphazoline

Tetrahydrozoline




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Ocular decongestant side effects

Generally do not have ocular or systemic side

effects

Long-term use leads to potential for:

Rebound conjunctival hyperemia

Allergic conjunctivitis

Allergic blephariits

Abnormal dryness


Ocular Decongestants

Do NOT use in patients with

Systemic hypertension

Arteriosclerosis

Other cardiovascular diseases

Diabetes

Hyperthyroidism

Use sparingly if at all in pregnancy


Ophthalmic Antihistamines

MOA: histamine1- receptor antagonists

Pheniramine maleate

Antazoline Phosphate

Available in combination with decongestants

Pheniramine/naphazoline

Antazoline/naphazoline

More effective than using either agent alone


Ophthalmic antihistamine and mast cell

stabilizer

Zaditor ® (ketotifen fumarate)

Potent H1-receptor antagonist

Mast cell degranulation inhibited, release of

inflammatory mediators inhibited

Relief in minutes

Lasts for 12 hours

Can use in children 3 years of age and older




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Viral Conjunctivitis- “Pink

Eye”

Most common form of conjunctivitis. In adults

80% of pink eye is of viral etiology. In

Children 50% of pink eye cases are viral.

Highly contagious- for one week

Precursors- Recent cold

Sore throat

Exposure to someone with “pink eye”


Eye”

Goal of therapy- relieve symptoms while

infection runs its course. Symptoms

Watery discharge, conjunctival redness and swelling

Ocular discomfort, with mild-to-moderate sensation of

foreign object in eye

Photophobia and blurred vision

Self-limiting:symptoms resolve in 1-3 weeks

For symptomatic relief: use artificial tear

preparations or ocular decongestants


Eye”

Counseling points

Proper hygiene

Wash hands after touching eyes

Avoid sharing towels

Discard used tissues

Cold compress use

Avoid wearing contact lenses

Replace after having pink eye

Otic Disorders

Exclusions for Self-Care Signs of infection

Pain associated with discharge

Bleeding or signs of trauma

Presence of ruptured tympanic membrane

Ear surgery within previous 6 weeks

Tympanostomy tubes present

Not able to follow proper instructions

Hypersensitivity to recommended agents

Less than 12 years of age




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Excessive/Impacted Cerumen

Predisposing causes

narrow or misshapen external auditory canal

Excessive hair growth in the canal

hearing aids, earplugs or sound attenuators are

also at a higher risk for developing

Sense of fullness or pressure, gradual hearing

loss, dull pain, vertigo, tinnitus, chronic cough

Nonpharmacologic Treatment

Damp washcloth draped over a finger

Irrigation with an otic bulb syringe- warm water

Excessive/Impacted Cerumen

Pharmacologic Treatment

Carbamide peroxide 6.5%

Used in adults and children 12 yrs and older

Cerumen softening agent

Softens, Loosens, Removes

Used twice daily up to 4 days

Warm water irrigation after treatment

OTHER treatments are not FDA

recommended.

Water-Clogged Ears

Nonpharmacologic Treatment Tilt affected ear downwards

Use a blow-dryer on a low setting around the ear after swimming or bathing

Pharmacologic Treatment Isopropyl alcohol 95% in anhydrous glycerin 5%

50:50 mixture if acetic acid 5% and isopropyl alcohol 95%

Refer if no relief after 4 days of treatment

Topical Nasal Products

Nasalcrom: Cromolyn sodium- mast cell

stabilizer, use before allergen exposure.

Prevention rather than treatment. May take 2

weeks if severe.

Oxymetazoline: 3 days max. After 10 days see

“rhinitis medicamentosa” .

Normal saline: can relieve nasal congestion and

dryness. For infants, suggest using saline drops

first to loosen the mucus, then suctioning it

gently with a bulb syringe.




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Neti Pot

Advise patients to keep their neti pots and irrigation bottles clean to reduce contamination. Wash after every use. Do not share!

If patients who irrigate get frequent nasal infections, review their cleaning methods or suggest a trial off irrigation.

Limit nasal irrigation to once or twice daily. More frequently can be overly drying and irritating.

No difference between isotonic (0.9%) or hypertonic saline solutions. The range of concentrations of hypertonic saline used in the various studies was from 2% to 3.5%.4

Hemorrhoids –Stage I and II

goal is to reduce straining and downward

pressure.

Avoid straining, and sitting on toilet longer than

necessary.

Treat with high fiber diet, and bulk laxatives.

Increase bulk intake and water intake.

Stool softeners will also reduce straining.

OTC creams, ointments and foams will provide

relief

Hemorrhoids DRUG PROTECTANT ANESTHETIC VASOCON-

STRICTOR

ASTRINGENT ANTI-INFLAMMATORY

Nupercainal Dibucaine

Preparation-H Mineral oil,

Petroatum,

Shark oil

Phenyl

ephrine

Prep-H cooling gel Phenyl

ephrine

Witch hazel

Prep-H anti-itch Hydrocortisone 1%

Tucks (former-

Anusol)

Hydrocortisone 1%

Tronolane Zinc oxide Pramoxine Zinc oxide

Calmol-4 Cocoa

butter

Zinc oxide

Tucks-Pads Witch hazel

Prep-H Wipes Witch Hazel

Personal

Lubricants

Basic formula: (are NON-petroleum based)

Lubricants: glycerin, hydroxyethyl cellulose,

propylene glycol, Polysorbate-60, purified water

Preservatives: chlorhexidine gluconate, glucono

delta-lactone, methylparaben and sodium hydroxide

or benzoic acid

INDICATIONS: enhances the comfort and ease of

intimate activity and acts as a moisturizer for vaginal

dryness.

Nonoxynol-9 : Spermicide may INCREASE the

spread of HIV




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Unwanted Hair Removal

Depilatories use a chemical called thioglycolate mixed

with sodium hydroxide or calcium hydroxide to

literally melt the hair away. Thioglycolate disrupts

disulfide bonds, which are chemical bonds that hold

skin and hair cells together. The disulfide bonds that

hold hair together contain more of the protein cystine

than do the disulfide bonds that hold skin cells

together. Thioglycolate is more effective on disulfide

bonds that contain cystine. The major side effect of a

depilatory is skin irritation because the chemical can

melt away skin cells.

Deodorants and

Antiperspirants

Certain Dri Anti-Perspirant: 12 percent

aluminum chloride (water base). (Drysol Rx is

20% alcohol based)

Dermatologists/podiatrists recommend use

for feet to prevent onychomycosis, that has

been treated by Terbinifine (Lamisil) or

Itraconazole (Sporanox).

Remember fungi love: Warm, Dark, Moist!

Vaginal

candidiasis

Clotrimizole (Lotrimin): 7 day & 3 day

Vag tabs: 100, 200mg; Cream: 1%, 2%

Miconazole: (Monistat) 7 day & 3 day & 1 day

Supps: 100,200,1200; Cream: 2%, 4%

Tioconazole (Vagistat-1) 1 day

Ointment: 6.5%

1-day vaginal antifungals don’t work faster than 3-

or 7-day products. Shorter regimen products are

more concentrated but they don't relieve symptoms

faster.

Clinical pearls

Candidiasis

Avoid miconazole with warfarin- vaginal use might increase an INR

Recommend any of the vaginal antifungals. All work well

Single dose of oral fluconazole 150 mg for uncomplicated yeast infections. OTC??

Nonalbicans Candida infections are more common in diabetes patients and are usually resistant to topical or oral azoles. (Tx: Boric acid 600mg supps)

Women are at higher risk if pregnant or diabetic

Pregnant women should be given a vaginal azole for 7 days.




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Topical Pain reliever

“rubefacients”

Also known as counter irritants- cause

redness of skin, caused by capillary dilation,

producing warm sensation. Works to distract

pain messages to the surface, rather than the

deep seated source.

Most common: methyl salicylate.

Apply no more frequently than 3-4 times

daily for 7 days.

Examples: Ben-Gay, Icy Hot Chill stick;

and Mentholatum

Topical Pain relievers-

Salicylate products

Not a counter irritant. Salicylate is absorbed

through skin. Salicylate levels in synovial

fluids are slightly below levels achieved with

oral aspirin.

Same drug interactions seen with aspirin

FDA led studies show no better than placebo.

Is odor free

Examples: Aspercreme, Myoflex,

Sportscreme

Topical Pain relievers-

Capsaicin products

Major ingredient in hot chili peppers

Mechanism: Depletes substance –P

which transmits pain messages.

This depletion of Substances-P is similar to

cutting a nerve. Burning and stinging occurs in

40-70% of all patients.

Pain relief is noted within 14 days of therapy.

Will cause a 50% reduction in 1 out of 8 patients

treated.

Concentration of over 0.025% associated with a

cough.

Cold Sores

Docasanol: use 5 times daily. Shortens

duration by 18 hours. (Rx: less than 1 day)

Protectants: keep lesion from drying and

cracking

Best option:

Rx: Valacyclovir 2gm BID for 1 day

Rx: Famcyclovir: 1500mg as a single dose

START ALL THERAPIES AT FIRST SIGN

OF TINGLING!

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Page 13

Brand name extensions: drives us

Pharmacists and Techs “CRAZY”

Monistat: we think “Miconazole”: Monistat Itch

Relief Cream contains hydrocortisone and

Monistat Uristat contains phenazopyridine for

UTI symptoms. Monistat-1 vaginal ointment

contains tioconazole.

Lotrimin: we think clotrimazole: Lotrimin Ultra

contains butenafine. Lotrimin AF powder and

sprays contain miconazole.

More Examples of Product

extensions

Dulcolax softner = docusate

Kaopectate =bismuth subsalicylate

Maalox Total Relief =bismuth subsalicylate

PeptoBismol childrens= calcium carbonate

Notes

Notes

Documents

Over the Counter Review Over the Counter Review Topical Management