Author: Mary Barna Bridgeman, PharmD, BCPS, CGP, and Rupal Patel Mansukhani, PharmD
Case 1—Prickly Heat
JL brings her 4-year-old granddaughter to the pharmacy for evaluation. JL reports that during the last 2 days of a week-long family vacation in Florida, she noticed her granddaughter had developed a fine, pinpoint, red-colored, itchy, patchy rash on her chest, neck, and back. The whole family wore sunscreen for the entire vacation, but it was very warm throughout the week, and their lodging facilities did not have a good air-conditioning system. The child has no known allergies to medications and does not take any chronic medications. JL would like the pharmacist’s recommendation for self-treatment of her grandchild’s rash.
JL’s granddaughter is likely suffering from prickly heat, an often benign skin rash associated with exposure to heat and humidity. Prickly heat rash usually resolves on its own without treatment when the cause is removed.1
JL should be offered nonpharmacologic counseling on removing the causative condition and protecting the skin to allow for symptom resolution as well as recommendations of pharmacologic agents to relieve irritation, pruritus, and rash.
Prickly heat usually occurs due to blocked pores and sweat glands in areas subject to occlusion (eg, axillae, chest, upper back, neck, and groin). It usually presents as clusters of red-colored, pinpoint-sized lesions that occur when occluded sweat pores rupture. To resolve symptoms, counsel JL to wash the skin of the affected area and to dry thoroughly before applying any nonprescription product. she should also dress the child in loose-fitting, breathable fabrics for a few days until symptoms resolve.
Instruct JL to use water-soluble emollient lotions and creams rather than oil-based products, which may occlude damaged pores. Products containing dimethicone may be soothing and provide relief. Also consider recommending colloidal oatmeal products as either bath soaks or lotions for itch relief. For more severe pruritus, topical hydrocortisone can be applied sparingly to affected areas. Instruct JL that her granddaughter’s symptoms should resolve quickly; for symptoms that worsen or persist longer than a week, recommend physician attention.
Case 2—Foreign Body in the Eye
CD, a 28-year-old woman, says something is irritating her right eye. She was out jogging when a particle of dust or pollen flew into her face, and the pharmacy was on her way home. Upon inspection, you notice her right eye is tearing and bloodshot. She is looking for an OTC product she can use to flush the affected area. Is CD a candidate for self-care? What are potential strategies for addressing CD’s complaint?
Eye injuries, specifically foreign substances in the eye, are common complaints. In most cases, the tearing and blinking reflexes will cause small irritants (dust, eyelashes, or sand) to be washed from the eye rather quickly.2,3
For more bothersome symptoms, patients should wash their hands thoroughly before touching the eye or using an OTC ocular irrigant, the product of choice for this indication.
Ocular irrigants mimic the effects of the tearing reflex to flush the irritant and lubricate the eye.2
These products contain a pH-balanced, isosmotic saline solution and are indicated for short-term, symptomatic relief. CD should flush the eye thoroughly with the selected product. If that doesn’t provide adequate relief, she should inspect the eye and inner eyelids in a well-lit area to try to locate the irritant. If it is on the eyelid, she should try to gently remove it by flushing the area with the irrigant. If this doesn’t work, she should brush the lid with a cotton-tipped swab and flush the area again, keeping the swab from touching the eye.3
Localized irritation may persist for a day or so, but if CD’s symptoms worsen or she notices vision changes, she should see a physician. CD is a candidate for self-treatment since a small, dust-like particle is likely causing her symptoms. However, patients who may have wood or metal particles in the eye require immediate medical attention as these can cause permanent damage to the cornea.3
Case 3—Self-Treatment of Eczema in Children
BK comes to the pharmacy with her 8-month-old daughter, who has patchy, chapped skin on her cheeks and forehead and on the inner aspect of her elbows. BK says she has not recently changed detergents or introduced new foods into her child’s diet. She reports the child has no known allergies to foods or medications and that she takes a daily vitamin d liquid supplement since she is still being breast-fed. BK says she first noticed the lesions a month or so ago, but they seem to have gotten worse despite use of a topical colloidal oatmeal lotion. What can you recommend for BK’s daughter?
BK’s daughter may be experiencing the skin disorder known as atopic dermatitis, a chronic and recurrent immune-mediated disorder of the skin that often presents in infancy and may affect 10% to 20% of children.4,5
The condition usually affects the cheeks, face, and extremities.5
Flares of this condition can be triggered by exposure to allergens, including certain soaps or detergents, animal dander, and cigarette smoke. To minimize the potential for irritation due to allergens, remind BK to wash the child’s clothing with unscented detergent and to avoid use of fabric softeners. BK should also continue to use a gentle soap indicated for infant skin when bathing her daughter, and should consider bathing the child every other day to minimize the effects of bathing on over-drying the child’s skin.
Treatment of atopic dermatitis usually consists of use of topical products to promote hydration of the skin and to reduce itching; emollient creams or lotions can help rehydrate the skin and minimize the appearance of dryness.4
These topical products work best when applied immediately after a bath. Hydrocortisone is the nonprescription product of choice used to treat this inflammatory condition. However, given the daughter’s age, BK should not be counseled to use topical hydrocortisone at this time.4
Case 4—Allergic Conjunctivitis
CK is a 42-year-old man who reports experiencing bad seasonal allergies during the spring, including symptoms of red, itchy, watery eyes and nasal congestion. His physician prescribed an ocular antihistamine product for him, but he reports that it is too expensive for him; if possible, he would like to try something OTC before using this type of medication. He has no known allergies and takes rosuvastatin 10 mg daily, methylphenidate 36 mg daily, and cetirizine 10 mg daily as needed. What type of product can CK use for self-treatment?
CK’s symptoms and presentation are consistent with allergic conjunctivitis, a common ocular complaint that often occurs concomitantly with seasonal allergic rhinitis. Allergic conjunctivitis is usually triggered by exposure to allergens, such as pollen or animal dander, and can be associated with the use and local application of ophthalmic products to the eye. Symptoms of allergic conjunctivitis often include itchy, red, or bloodshot eyes and are often accompanied by a watery discharge that may cause blurring of the individual’s vision.2
In terms of nonpharmacologic interventions, recommend CK avoid exposure to known allergens, including monitoring pollen counts and avoiding spending time outdoors when counts are high, closing windows, and using air filters to help mitigate symptoms. For very irritated eyes, tell him to apply cold compresses to relieve itching and redness.2
As an alternative to the histamine antagonist/mast cell-stabilizing agent his physician prescribed, consider recommending an OTC topical eye drop containing ketotifen fumarate (Alaway or Zaditor). Instruct CK that the selected product should be instilled twice daily into both eyes and can be used concomitantly with the oral antihistamine product, cetirizine, that he is currently taking. Other less expensive nonprescription alternative antihistamine/decongestant combination products also are available. However, these products need to be administered 3 to 4 times per day. Further, the long-term use of ocular decongestants may result in rebound vasodilation and worsening redness of the eye and should be avoided.
Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
Hagemeier NE. Diaper dermatitis and prickly heat. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:661-674.
Fiscella RG, Jensen MK. Ophthalmic disorders. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:509-530.
Eye emergencies. Medline Plus. www.nlm.nih.gov/medlineplus/ency/article/000054.htm. Accessed April 2, 2013.
Scott SA. Atopic dermatitis and dry skin. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:615-630.
Pediatric atopic dermatitis. Medscape. http://emedicine.medscape.com/article/911574-overview. Accessed April 1, 2013.