Case 1: Lutein
MG is a 39-year-old female who comes to the pharmacy looking for a natural supplement called lutein. She says her mother and father both have age-related macular degeneration (AMD). Her parents are having trouble with their vision and were advised years ago by their ophthalmologist to take a vitamin containing lutein. Because her parents have AMD, MG is concerned about losing her vision and thought that a lutein supplement might help prevent AMD. Upon questioning, she says she has smoked 1 pack per day for the past 10 years and does not exercise regularly. She has no medical conditions and does not take any medications regularly. What recommendations would you have for MG regarding AMD and the use of lutein supplements?
AMD is a common eye condition and the leading cause of blindness among patients 50 years and older. It typically causes damage to the macula in the retina, leading to blindness. MG’s risk of developing AMD is higher because she has a first-degree relative with AMD. Many studies show that diets poor in antioxidants and omega-3 fatty acids are associated with AMD.1
Like MG, many patients choose to take lutein daily to prevent AMD. Evidence suggests that patients who consume high amounts of lutein in their diet can reduce their chances of developing AMD.2
However, some data show that lutein may have no benefit in preventing AMD. Currently, it is difficult to say whether lutein is beneficial in preventing AMD because no large, well-controlled clinical trials have been conducted. However, if MG wants to try using lutein to prevent AMD, she can take 6 mg per day. Other lifestyle changes that may help prevent AMD are to quit smoking and to exercise for 30 minutes most days of the week. Studies have shown that avoiding smoking can decrease the risk for developing AMD. MG can use smoking cessation products, such as nicotine patches, or speak to her physician about how to stop smoking. She can also modify her diet to include lots of fish and leafy green vegetables.
Case 2: Sunscreen
RM is a 24-year-old female who comes to the pharmacy looking for sunblock. She is going on vacation with her friends to Mexico. She says she plans on being on the beach from sunrise to sunset. She is looking for something waterproof because she will be going in the water. She says she prefers a high sun protection factor (SPF) so she only has to apply sunblock once daily. She has no chronic conditions and does not take any medication daily. What recommendations do you have for RM?
Ultraviolet (UV) radiation has a cumulative effect and can cause serious adverse effects, such as burns, skin aging, and cancers. UVA is primarily responsible for skin aging and wrinkling, and UVB is responsible for sunburns and cancers. RM should be educated on using a broad-spectrum sunscreen that includes oxybenzone, sulisobenzone, dioxybenzone, titanium dioxide, meradimate, or avobenzone in combination with padimate O and/or octocrylene. RM should be educated that SPFs ≥15 provide the greatest protection against sunburn. However, a higher SPF does not allow for longer periods of time between applications, and SPFs >15 are not more beneficial than SPF 15.
RM should be told to apply 1 ounce of sunscreen 15 minutes before she goes into the sun. No currently available sunscreens are waterproof; however, water-resistant products are available and should be reapplied every 40 to 80 minutes as directed in the instructions for use. If RM does not go in the water and is not sweating, she can reapply a water-resistant product every 2 hours. RM should be made aware that UV rays are still present on cloudy days, so she should wear sunscreen even when the sun is not out. The sun’s rays are most damaging between 10:00 am and 4:00 pm, so she should avoid the sun during this time if possible. Finally, she can use beach umbrellas or wear protective clothing to minimize exposure to UV rays.
Case 3: Self-Care for Pink Eye
BP is a 32-year-old male who comes to the pharmacy seeking a recommendation for treatment of a red, watery eye. BP reports waking up this morning and noticing his right eye was swollen, with mucus and crusting. He reports this eye seems to be more sensitive to light, and it feels like something is on the lens, but upon inspection, he doesn’t see anything in the eye. He has no allergies to medications, and he reports using OTC pain relievers only as needed for occasional headaches. He recently reported having a cold that resolved several days ago without medical intervention. What recommendations for self-care can you share with BP?
BP is likely suffering from viral conjunctivitis (pink eye), an acute, benign, and self-limiting medical condition often associated with adenovirus. As in BP’s case, a recent cold is a common precursor to viral conjunctivitis, as is a history of contact with an infected individual. Symptoms of viral conjunctivitis often include acute reddening of the eyes, watery discharge, conjunctivitis, swelling, and light sensitivity affecting 1 or both eyes; the symptoms tend to resolve on their own within 1 to 3 weeks.4,5
This highly contagious condition warrants vigilant attention to hygiene for 10 to 14 days to avoid spreading it to others.
BP should be counseled to take proper precautions in the workplace, avoid touching his eyes, properly wash his hands after touching his face, and avoid sharing towels or tissues, as these objects may harbor the virus.4,5 Options for symptomatic relief include use of OTC artificial tears to alleviate irritation and pruritus. For relief of burning or irritation, cold compresses can be applied to the affected eyes several times per day. Topical vasoconstrictors and antihistamines can be recommended for severe cases but are not indicated for all individuals with this condition.4,5
If BP usually wears contact lenses, he should not wear them while he has this condition and should consider replacing them after his symptoms resolve.
Case 4: Self-Treatment of Acne
DD is a 16-year-old female who stops by the pharmacy with her mother while out shopping. DD’s mother wants to know which OTC face wash would be best for helping DD treat and prevent blackheads on her forehead, nose, and cheeks. DD’s mother reports that her daughter suffers from occasional acne flares that seem to worsen with the onset of menses; however, her blackheads are a constant problem that seem to make DD anxious and self-conscious about her appearance. DD has not yet seen a dermatologist for evaluation of her condition, but her mother is hoping to improve DD’s condition with self-care. What products and self-care recommendations can you share with DD?
DD’s acne vulgaris is a common problem in adolescents and in some adults. This bothersome skin condition is thought to result from genetic, hormonal, and environmental influences, although the exact cause remains unknown.6
DD’s self-identified blackheads represent a type of noninflammatory lesion; papules, pustules, and nodules are inflammatory lesions associated with this condition. The goals of self-care for this often self-limiting condition include reducing the appearance of lesions and minimizing scarring.6
Topical retinoids are considered the gold standard treatment for moderate to severe acne, although their availability is limited by their prescription-only status.6
In the case of DD, consider recommending that she use an OTC face wash containing benzoyl peroxide in a concentration of 2.5% to 10%. The concentration does not seem to affect product efficacy; higher-strength formulations have similar antimicrobial effects and greater potential for causing adverse effects compared with their lower-strength counterparts.6,7
Counsel DD that topical application of benzoyl peroxide may result in redness and scaling of the skin that should subside within 1 to 2 weeks with continued use. If severe redness or suspected allergic reaction occurs, recommend discontinuation of the product and prompt physician follow-up for further evaluation.
Dr. Mansukhani is clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University, and transitions of care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey. Dr. Bridgeman is clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University, and internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.
Pinazo-Durán MD, Gómez-Ulla F, Arias L. Do nutritional supplements have a role in age macular degeneration prevention [published online January 23, 2014] J Ophthalmol. 2014;2014:901686.
Seddon JM, Ajani UA, Sperduto RD, et al; Eye Disease Case-Control Study Group. Dietary carotenoids, vitamins A, C, and E, and advanced age-related macular degeneration. JAMA. 1994;272:1413-1420.
Crosby KM, O'Neal KS. Prevention of sun-induced skin disorders. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 17th edition. Washington, DC: American Pharmacists Association, 2011.
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; 2011.
Viral conjunctivitis. Medscape website. http://emedicine.medscape.com/article/1191370-overview. Accessed April 1, 2014.
Foster KT, Coffey CW. Acne. 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; 2011.
Federman DG, Kirsner RS. Acne vulgaris: pathogenesis and therapeutic approach. Am J Managed Care. 2000;6:78-87.