Yvette Terrie, BSPharm, RPh

Xerostomia, commonly known as dry mouth, is defined as a syndrome in which the flow of saliva is completely halted or limited. It is often overlooked, unrecognized, and undertreated, according to the American Dental Association.

If left untreated, xerostomia can cause discomfort and difficulty chewing, speaking, swallowing, and tasting. It can also contribute to dental caries, halitosis, periodontal disease, and other oral health issues, including candidiasis infection because of the disturbance of the balance of oral microflora resulting from diminished salivary flow.

 The effects of xerostomia can range from mild to severe, and patients with severe cases often experience a reduced quality of life.

The etiology of xerostomia is multifactorial, and contributing factors include certain disease states, medical procedures, and use of some medications.

 The exact incidence of xerostomia is unknown, but statistics indicate that xerostomia in the US population ranges widely from 0.9% to 64.8% in the general population, is in an estimated 30% of adults older than 65 years, and in 40% of those older than 80 years.

 Study results show that the incidence of xerostomia increases with age because many older individuals are likely to take multiple drugs associated with diminished salivary flow rate for the treatment of various chronic illnesses.

 Moreover, Sjögren syndrome, a chronic inflammatory autoimmune disorder in which immune cells attack and destroy the glands that produce tears and saliva, is a common cause of xerostomia.

 A host of other conditions also may contribute to the development of xerostomia, including chronic active hepatitis, Crohn disease, depression, hormonal changes related to menopause, hypertension, hypothyroidism, HIV, Parkinson disease, sarcoidosis, scleroderma, and uncontrolled diabetes.

 Individuals receiving radiation therapy to the head and neck may also develop xerostomia.

 Other possible causes may include alcohol, breathing through the mouth, caffeine, and smoking.

The American Academy of Oral Medicine indicates that more than 1100 medications have the potential to negatively alter or diminish salivary production, thus contributing to xerostomia.

 Examples of medications commonly associated with salivary dysfunction and xerostomia include those with anticholinergic effects or that cause depletion of salivary flow, such as antidepressants, antihistamines, antihypertensive medications, antipsychotics, antiseizure/antispasmodic drugs, decongestants, diuretics, and sedatives.

 Study results also show that patients who are taking multiple medications may also be at greater risk of developing xerostomia as an adverse effect of therapy.

Although many patients with COVID-19 experienced loss of smell and taste, various study results indicate that xerostomia was commonly reported among those with COVID-19 and frequently occurred before other common symptoms.

 Findings from a recent review of more than 180 published studies showed that approximately 4 in 10 patients experience impaired taste or a total loss of taste, but xerostomia affected more than 43% of those with COVID-19.

In a recent publication, authors indicated that because older adults take more medications than any other age group, this patient population is more likely to experience xerostomia. They also noted that clinicians should understand the significance of xerostomia on oral health and its negative impact on patient quality of life and that there is a need for collaborative efforts among oral health personnel and pharmacists in conjunction with general practitioners, geriatricians, and nurses to augment cognizance about xerostomia and ensure affected patients are properly advised and managed.

Findings from a recently published observational study showed that oral sensory complaints often reported during perimenopause include burning sensations in the mouth, taste disturbance, and xerostomia. The authors concluded that there are correlations among burning mouth, menopausal symptoms, taste disturbance, and xerostomia.

Pharmacists are key in identifying those individuals most susceptible to xerostomia because of chronic illnesses and/or the use of certain medications, and they can provide clinical recommendations to assist patients in the management of xerostomia and minimize its severity. Pharmacists can also educate patients about the various OTC artificial saliva substitutes and dry mouth relief products available in the form of chewing gums, gels, liquids, lozenges, mouthwashes, sprays, and toothpastes. For most patients with xerostomia, alcohol-free mouth rinses are preferred because alcohol may exacerbate xerostomia. During counseling, pharmacists can advise patients to maintain daily dental hygiene, including brushing and flossing twice a day, routine professional dental care, and the need to discuss xerostomia with their primary health care providers if symptoms do not resolve or worsen after self-treatment.

, is a consulting pharmacist and medical writer in Haymarket, Virginia.

1. Albanese N, Donaldson M. Orofacial pain and discomfort. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 20th ed. 

2. Xerostomia. American Dental Association. Updated February 22, 2021. Accessed April 18, 2022. https://www.ada.org/resources/research/ science-and-research-institute/oral-health-topics/xerostomia

3. Wolff A, Joshi RK, Ekström J, et al. A guide to medications inducing salivary gland dysfunction, xerostomia, and subjective sialorrhea: a systematic review sponsored by the World Workshop on Oral Medicine VI. 

. 2017;17(1):1-28. doi:10.1007/s40268-016-0153-9

4. Villa A, Connell CL, Abati S. Diagnosis and management of xerostomia and hyposalivation. 

5. Orellana MF, Lagravère MO, Boychuk DG, Major PW, Flores-Mir C. Prevalence of xerostomia in population-based samples: a systematic review. 

. 2006;66(2);152-158. doi:10.1111/j.1752-7325.2006.tb02572.x

6. Xerostomia. American Academy of Oral Medicine. Updated October 15, 2015. Accessed April 18, 2022. https://www.aaom.com/index.php%3Foption=com_content&view=article&id=107:xerostomia&-catid=22:patient-condition-information&Itemid=120

7. Dawes C, Pedersen AM, Villa A, et al. The functions of human saliva: a review sponsored by the World Workshop on Oral Medicine VI. 

. 2015;60(6):863-874. doi:10.1016/j.archoralbio.2015.03.004

8. Agostini BA, Cericato GO, Silveira ERD, et al. How common is dry mouth? Systematic review and meta-regression analysis of prevalence estimates. 

 2018;29(6):606-618. doi:10.1590/0103-6440201802302

9. Fathi Y, Hoseini EG, Atoof F, Mottaghi R. Xerostomia (dry mouth) in patients with COVID-19: a case series. 

. 2021;10.2217/fvl-2020-0334. doi:10.2217/fvl-2020-0334

10. Tsuchiya H. Characterization and pathogenic speculation of xerostomia associated with COVID-19: a narrative review. 

11. Huang N, Pérez P, Kato T, et al. SARS-CoV-2 infection of the oral cavity and saliva. 

. 2021;27(5):892-903. doi:10.1038/s41591-021-01296-8

12. Mozes A. Here’s how COVID-19 can affect your mouth. HealthDay. September 8, 2021. Accessed April 20, 2022. https://consumer.healthday. com/9-3-here-s-how-covid-19-can-affect-your-mouth-2654773518.html

13. Amorim Dos Santos J, Normando AGC, Carvalho da Silva RL, et al. Oral manifestations in patients with COVID-19: a 6-month update. 

. 2021;100(12):1321-1329. doi:10.1177/00220345211029637

14. Thomson WM, Smith MB, Ferguson CA, Moses G. The challenge of medication-induced dry mouth in residential aged care. 

. 2021;9(4):162. doi:10.3390/pharmacy9040162

15. Taga T, Ito K, Takamatsu K, et al. Menopausal symptoms are associated with oral sensory complaints in perimenopausal women: an observational study. 

. 2021;21(1):262. doi:10.1186/s12905-021-01401-6

Articles

Pharmacists can help select nonprescription products to treat xerostomia and recommend further medical care when warranted.

Understand the Significance of Identifying and Treating Dry Mouth

 is one of the most common conditions for which patients seek medical care, and its effects vary in terms of duration and severity.

The most recent statistics from the Sleep Foundation indicate that between 10% and 30% of adults experience frequent insomnia, including between 30% and 48% of older adults.

Approximately one-third of adults in the United States occasionally experience insomnia. Ten percent to 15% report problems with functioning during the daytime, and 6% to 10% have symptoms severe enough to meet the criteria for an insomnia disorder, according to the American Psychiatric Association.

The Sleep Foundation classifies insomnia into 2 main types:

: long-term patterns of sleep issues. Patients have challenges falling asleep or staying asleep. Insomnia symptoms occur at least 3 times per week and persist for at least 3 months.

Short-term (acute or adjustment insomnia)

: often caused by prolonged anxiety or stress over the death of a loved one, financial problems, job loss, or relationship changes. This type may last for days or weeks, typically for fewer than 3 months; it can occur in adults and children and frequently occurs during menopause and pregnancy.

Chronic insomnia can adversely affect academic performance, health, and quality of life. It can cause irritability and daytime sleepiness, decreases work productivity, and increases the risk of motor vehicle accidents. Statistics show that just 5% of individuals with chronic insomnia sought care from their primary care physician, specifically for insomnia, and just 26% of those patients discussed insomnia during a visit for another medical issue.

Factors contributing to insomnia can be classified as environmental, physical, or psychological and include the following

Anxiety, depression, stress, and other mental health issues

Life stressors, such as financial and job worries

Changes in environment, routine, or schedule

Medical conditions, such as chronic pain, congestive heart failure, gastroesophageal reflux disease, hormone fluctuations, hyperthyroidism, nocturia, obstructive sleep apnea, respiratory disorders, and restless legs syndrome

Recent Clinical Publications and Product News

Nature’s Bounty recently announced its new line of jelly bean supplements, including Sleep Jelly Beans that contain melatonin.

In a recent study, investigators surveyed health care professionals in specialties considered to put them at high risk for exposure to COVID-19.

The investigators found that longer sleep duration was linked to lower odds of COVID-19 and that greater burnout and other factors were strongly correlated with greater odds of contracting COVID-19. They also found that for each additional hour of sleep at night, the risk of contracting COVID-19 plummeted by 12% in the study population of frontline health care practitioners. Further, those who reported experiencing work-related burnout every day were 2.6 times more likely to report having COVID-19, have it for a longer time, and experience more severe COVID-19.

 show that insomnia may be one of the most common neurological and psychiatric outcomes of COVID-19.

In addition, according to results of a randomized clinical trial published in 

, cognitive behavioral therapy for insomnia may help thwart major depression among older adults with insomnia disorder.

At the 2021 SLEEP annual meeting, investigators indicated that difficulty getting to sleep had the greatest impact on cognition later in life compared with other symptoms of insomnia.

 The findings were published in the journal 

A recent news story on the Cleveland Clinic website evaluated various OTC sleep aids. The article postulat- ed that after careful patient assessment for appropriateness, the use of OTC sleep aids diphenhydramine and doxylamine and complementary therapies such as melatonin and valerian root may be a helpful short-term remedy for those who experience an occasional sleep issue. The article also recommended other strategies to help resolve insomnia, such as good sleep hygiene, including maintaining a regular bedtime and wake-up routine, as well as avoiding alcohol, electronic devices, stimulants, and tobacco before bedtime. Other strategies recommended included establishing a regular exercise routine, keeping a sleep journal, and seeking advice from a primary health care provider about a drug-free therapy to improve sleep, such as cognitive behavioral therapy for insomnia.

During counseling, inform patients that OTC sleep aids are indicated for the treatment of short-term insomnia. Advise them about recommended dosage, duration of use, potential drug interactions, and adverse effects, as well as precautions and warnings. Due to their drug expertise, pharmacists are in a pivotal position to identify those medical conditions or pharmacologic agents that may be correlated with and/or exacerbate episodes of insomnia. Pharmacists can also be instrumental in educating patients about the efficacy and safety of OTC sleep aids, including supplements marketed for sleep health, and recommending nonpharmacological measures to combat insomnia. This will enable patients to make informed decisions regarding the management and treatment of insomnia. Moreover, pharmacists can encourage patients experiencing chronic insomnia and/or those with preexisting medical conditions to seek further medical evaluation from their primary health care providers when warranted. The CDC website offers several valuable patient education resources about insomnia.

, is a consulting pharmacist and a medical writer in Haymarket, Virginia.

1. Sleep statistics. Sleep Foundation. Updated November 12, 2021. Accessed January 26, 2022. https://www.sleepfoundation.org/how-sleep-works/sleep-facts-statistics

2. What are sleep disorders? American Psychiatric Association. August 2020. Accessed January 26, 2022. https://www.psychiatry.org/ patients-families/sleep-disorders/what-are-sleep-disorders

3. What are the different types of insomnia? Sleep Foundation. Updated June 24, 2021. Accessed January 26, 2022. https://www.sleepfoundation.org/insomnia/types-of-insomnia

4. Chawla J. Insomnia. Medscape. Updated January 27, 2022. Accessed February 21, 2022. https://emedicine.medscape.com/ article/1187829-overview#a6

5. Insomnia. Cleveland Clinic. Updated October 15, 2020. Accessed January 26, 2022. https://my.clevelandclinic.org/health/diseases/12119-insomnia

6. Kim H, Hegde S, LaFiura C, et al. COVID-19 illness in relation to sleep and burnout. 

. 2021;4(1):132-139. doi:10.1136/bmjnph-2021-000228

7. Taquet M, Geddes JR, Husain M, Luciano S, Harrison PJ. 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records. 

. 2021;8(5):416-427. doi:10.1016/S2215- 0366(21)00084-5

8. Irwin MR, Carrillo C, Sadeghi N, Bjurstrom MF, Breen EC, Olmstead R. Prevention of incident and recurrent major depression in older adults with insomnia: a randomized clinical trial. 

. 2022;79(1):33-41. doi:10.1001/jamapsychiatry.2021.3422

9. Zaheed AB, Spira AP, Chervin R, Zahodne L. Insomnia symptoms and subsequent cognitive performance in older adults: are depressive symptoms and vascular disease mediators? 

. 2021;44(suppl 2):A212. doi:10.1093/sleep/zsab072.535

10. What to know about over-the-counter sleep aids. Cleveland Clinic. July 1, 2021. Accessed January 26, 2022. https://health.clevelandclinic.org/what-to-know-about-over-the-counter-sleep-aids/

11. Sleep and sleep disorders. CDC. Updated May 4, 2017. Accessed February 21, 2022. https://www.cdc.gov/sleep/resources.html

Sleeplessness Is prevalent, and many Individuals struggle to find effective relief and treatment.

Help Patients Prevent and Reduce Insomnia

The skin is considered the first line of defense for protecting the human body against external factors that may affect or damage the skin, such as allergens, chemicals, exposure to ultraviolet (UV) radiation, infections, and stress.

Internally, the skin helps sustain homeostasis and protects the body from increased loss of water.

 Moreover, the skin barrier is responsible for filtering 60% to 70% of UVB rays.

 Essential components of the skin barrier are ceramides, which comprise approximately 50% of the lipids found within the skin barrier.

Ceramides, which are the major lipids in the outermost layer of the epidermis, known as the stratum corneum, contribute to the intercellular lipid bilayer, which is involved directly in regulation of transepidermal water loss.

The 3 major functions of ceramides in the skin barrier and in skin care are improving hydration, prevention or treatment of dermatological conditions, and skin barrier homeostasis.

 Research has clearly demonstrated that alterations of stratum corneum lipid composition, barrier disruption, and low levels of skin ceramides may result in the manifestation of skin disorders associated with barrier defects, including acne, atopic dermatitis, photosensitivity, rosacea, UV damage, and xeroderma.

Establishing a skin care regimen is essential for promoting and maintaining dermatological health and in the prevention and treatment of common skin conditions.

Pharmacists can assist patients seeking guidance on the selection of the various OTC skin care products on the market and provide them with pertinent clinical information about the essential roles of ceramides in dermatological health.

The results of numerous studies have shown that the using products containing ceramides improves moisture and resilience, supports the health of the skin’s natural skin barriers, and thwarts dry skin. These are all factors that may contribute to or exacerbate the manifestation of many common dermatological issues. Various publications have indicated that ceramide levels are reduced or are structurally abnormal in skin conditions, such as acne, atopic dermatitis, ichthyosis, psoriasis, rosacea, and skin damaged by surfactants.

 Research has also shown that use of ceramide-containing skin care products diminishes the disease severity of many common skin conditions and enhances skin function.

The results of a study published in the Journal of Drugs in Dermatology showed that implementing a ceramide-containing moisturizer and sunscreen skin care routine protects against UV-induced skin surface barrier changes by improving skin hydration, preserving normal superficial skin cells morphology and turnover, and thwarting erythema and hyperpigmentation.

In addition to enhancing the appearance of lesions and minimizing skin irritation, the study results showed that delivering skin-identical stratum corneum lipids could add benefits to patients’ daily routines by strengthening the barrier and improving skin health against chronic sun exposure.

In another study published in the Journal of Drugs in Dermatology, the authors indicated that restoration of the skin barrier, especially the role of topically applied mixtures of ceramides, cholesterol, and essential/nonessential free fatty acids strengthens the compromised skin barrier and alleviates symptoms and discomfort linked with skin barrier disorders.

The results of another study indicated that moisturizers containing ceramides have clinically demonstrated the capacity to support the management of skin conditions, such as atopic dermatitis, by decreasing the severity of the disease and recurrence and enhancing patients’ perception of overall skin health and quality.

Pharmacists can expand awareness about the clinical benefits associated with the use of ceramide-containing skin care cleansers, moisturizers, and sunscreen products. Ceramides commonly found in OTC products may be listed as ceramide AP, ceramide EOP, ceramide NG, ceramide NP, ceramide NS, phytosphingosine, and sphingosine. Pharmacists can educate patients about avoiding skin care products that exacerbate or irritate common skin conditions, and they also are in a pivotal position to identify patients at risk for possible hyperpigmentation, photosensitivity, and xerosis reactions because of
the use of certain pharmacological agents, such as loop diuretics, nonsteroidal anti-inflammatory drugs, phenothiazines, quinine, statins, tetracyclines, thiazides, vemurafenib, and voriconazole.

 Advise patients who use these pharmacological agents to always use a sunscreen product with a sunscreen protection factor of 30 or higher when going outdoors, especially for extended periods of time.

Establishing a skin care regimen is critical to maintaining healthy, hydrated skin, and incorporating preventive measures can also aid in diminishing or eliminating common dermatological issues. Pharmacists can help educate and remind patients to use OTC skin care products that contain ceramides, which can maintain, protect, and restore the natural skin barrier and overall dermatological health. Pharmacists should also be familiar with guidelines for the management and treatment of common dermatological conditions as outlined by the American Academy of Dermatology Association.

Anatomy, Skin (Integument), Epidermis. StatPearls

. 2018;147(1):117-118. doi:10.4103/0971-5916.232013

3. New research reveals the impact of UV exposure on the skin barrier & the benefits of ceramides. CeraVe. July 8, 2021. Accessed November 30, 2021. https://www.prnewswire.com/news-releases/ new-research-reveals-the-impact-of-uv-exposure-on-the-skin-barrier-the-benefits-of-ceramides-301327759.html

4. Del Rosso JQ. Ceramide-and keratolytic-containing body cleanser and cream application in patients with psoriasis: outcomes from a consumer usage study. 

5. Li Q, Fang H, Dang E, Wang G. The role of ceramides in skin homeostasis and inflammatory skin diseases. 

. 2020;97(1):2-8. doi:10.1016/j.jdermsci.2019.12.002

6. Purnamawati S, Indrastuti N, Danarti R, Saefudin T. The role of moisturizers in addressing various kinds of dermatitis: a review. 

. 2017;15(3-4):75-87. doi:10.3121/cmr.2017.1363

7. Zeichner JA, Del Rosso JQ. Multivesicular emulsion ceramide-containing moisturizers: an evaluation of their role in the management of common skin disorders. 

8. Kahraman E, Kaykın M, Şahin Bektay H, Güngör S. Recent advances on topical application of ceramides to restore barrier function of skin. 

. 2019;6(3):52. doi:10.3390/cosmetics6030052

9. Baldwin H, Alexis AF, Andriessen A, et al. Evidence of barrier deficiency in rosacea and the importance of integrating OTC skincare products into treatment regimens. 

. 2021;20(4):384-392. doi:10.36849/JDD.2021.5861

10. Tan J, Schöfer H, Araviiskaia E, et al. The RISE study group. Prevalence of rosacea in the general population of Germany and Russia—the RISE study. 

. 2016;30(3):428- 434. doi:10.1111/jdv.13556

11. Lueangarun S, Tragulplaingam P, Sugkraroek S, Tempark T. The 24-hr, 28-day, and 7-day post-moisturizing efficacy of ceramides 1, 3, 6-II containing moisturizing cream compared with hydrophilic cream on skin dryness and barrier disruption in senile xerosis treatment. 

. 2019;32(6):e13090. doi:10.1111/dth.13090

12. Draelos ZD, Baalbaki NH, Raab S, Colón G. The effect of a ceramide-containing product on stratum corneum lipid levels in dry legs. 

. 2020;19(4):372-376. doi:10.36849/ JDD.2020.4796

13. Dumbuya H, Yan X, Chen Y, et al. ARTICLE: efficacy of ceramide-containing formulations on UV-induced skin surface barrier alterations. 

. 2021;20(4):s29-s35. doi:10.36849/JDD.2021.589E

14. Wu Y, Wangari-Olivero J, Zhen Y. ARTICLE: compromised skin barrier and sensitive skin in diverse populations. 

. 2021;20(4):s17-s22. doi:10.36849/JDD.2021.589c

15. Haftek M, Roy DC, Liao IC. ARTICLE: evolution of skin barrier science for healthy and compromised skin. 

. 2021;20(4):s3-s9. doi:10.36849/JDD.2021.589a

17. CrosbyK.Preventionofsun-inducedskindisorders.In:KrinskyD,Ferreri S, et al, eds. 

Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed

. American Pharmacists Association; 2020.

18. Clinical guidelines. American Academy of Dermatology Association. Accessed December 15, 2021. https://www.aad.org/member/clinical- quality/guidelines

Educate and remind patients to use appropriate OTC products to help protect, restore, and maintain the natural skin barrier.

Ceramides Help Prevent and Treat Dermatological Conditions

Tinea unguium, also referred to as onychomycosis, is a fungal infection that affects the fingernails and toenails and may involve any component of the nail unit, including the bed, matrix, or plate.

The incidence fo onychomycosis is increasing. Statistics show that an estimated 35 million Americans suffer from the condition, which primarily affects men aged 50 to 70 years, although women also can experience it.

 In adolescents or children, onychomycosis is observed most often in those aged 12 to 18 years, is uncommon in children younger than 12 years, and is extremely rare in those younger than 6 years.

 Onychomycosis characteristically begins as a small white or yellow spot beneath the nail and causes detachment of the nail bed, distortion, nail discoloration, irregular surface changes, pain, and/or thickening.

 Risk factors for onychomycosis include diabetes; obesity; older age; peripheral vascular disease; preexisting nail dystrophy such as in a patient with psoriasis, or tinea pedis; and a weakened immune system.

Individuals with diabetes account for an estimated 33% of those presenting with onychomycosis.

 Several nonclinical risk factors also affect an individual's chance of developing fungal nail infections. The prevalence of toenail onychomycosis has increased in recent years, and contributing factors may include the increasing use of occlusive footwear, which consists of boots or shoes that enclose the feet.

Nail trauma can also expand the risk of fungal infection of the affected nail, especially in the geriatric population.

 The American Dermatology Association indicates that healthy individuals typically are at greater risk of nail infections when visiting beauty nail salons that use poorly sanitized instruments, public whirlpool baths, saunas, and swimming pools; and shower facilities in dormitories, gyms, etc.

 the authors attempted to expand the public's understanding of the potential for disease transmission via the common tools and products used in beauty salons.

 They reviewed the results of several studies and found that there is a need to expand salon standards of care used in sterilizing beauty tools and products and storing them properly. In addition, they highly recommended the use of individual cosmetic kids and noted that all these recommendations, if employed, should contribute considerably to a decline in the spread of bacterial and fungal infections in these establishments.

International Journal of Women's Dermatology,

 the authors indicated that gentle nail care and the sanitization of nail tools are crucial in thwarting the transmission and spread of onychomycosis.

Treatment of onychomycosis depends on its clinical type, the number of affected nails, and the severity of nail involvement.

 The self-treatment of onychomycosis with topical nonprescription antifungals is not approved by the FDA.

 states that when no contraindications are present, the affected nail can be treated with prescription topical agents (ciclopirox olamine 8% or efinaconazole 10% nail solutions), systemic prescription agents (itraconazole or terbinafine), a combination of oral and topical agents, or surgical removal of the affected area.

Patients exhibiting signs of onychomycosis should never self-treat and should always seek medical care from their primary health care providers, especially if they have risk factors for developing onychomycosis or other comorbidities, according to the American Dermatology Association.

Although available OTC products are not FDA-approved treatments for onychomycosis, there are a few topical products that are marketed for the management of fungal nail infections, and some marketed to improve the appearance of nails damaged by fungal infections. These products are available in various formulations, including ointments and topical liquids, and may include ingredients such as propylene glycol, tea tree oil, and undecylenic acid.

When encountering patients seeking guidance on the treatment of onychomycosis, pharmacists should encourage them to consult their primary health care providers for further assessment and treatment. They should also remind patients that onychomycosis cannot be effectively managed with the use of topical nonprescription agents. They can, however, use nonprescription agents sometimes in conjunction with prescribed agents to reduce nail discoloration and smooth out rough or thick nails. It is also imperative that pharmacists remind patients that therapy is usually long term, and adherence is essential for effective treatment.

1. Tosti A. Onychomycosis. Medscape. Updated October 5, 2020. Accessed April 7, 2021. https://emedicine.medscape.com/article/1105828-overview

2. Adigun CG. Onychomycosis. Merck Manual, Professional Version. Updated August 2019. Accessed April 7, 2021. http://www.merckmanuals.com/professional/dermatologic-disorders/nail-disorders/onychomycosis

3. Brooks M. FDA OKs first topical triazole antifungal for onychomycosis (Jublia). Medscape. June 10, 2014. Accessed April 7, 2021. https://www.medscape.com/viewarticle/826480

4. Feldstein S, Totri C, Friedlander SF. Antifungal therapy for onychomycosis in children. Clin Dermatol. 2015;33(3):333-339. doi:10.1016/j.clindermatol.2014.12.010

5. Piraccini BM, Starace M. Nail disorders in infants and children. Curr Opin Pediatr. 2014;26(4):440-445. doi:10.1097/MOP.0000000000000116

6. Westerberg DP, Voyack MJ. Onychomycosis: current trends in diagnosis and treatment. Am Fam Physician. 2013;88(11):762-770.

7. Tan JS, Joseph WS. Common fungal infections of the feet in patients with diabetes mellitus. Drugs Aging. 2004;21(2):101-112. doi:10.2165/00002512-200421020-00003

8. Ghannoum M, Isham N. Fungal nail infections (onychomycosis): a never-ending story? PLoS Pathog. 2014;10(6):e1004105. doi:10.1371/journal.ppat.1004105

9. Onychomycosis (fungal nail infection). Ada Health GmbH. Updated December 14, 2018. Accessed April 7, 2021. https://ada.com/conditions/onychomycosis-fungal-nail-infection/

10. Alharbi NM, Alhashim HM. Beauty salons are key potential sources of disease spread. Infect Drug Resist. 2021;14:1247-1253. doi:10.2147/IDR.S303461

11. Reinecke JK, Hinshaw MA. Nail health in women. Int J Womens Dermatol. 2020;6(2):73-79. doi:10.1016/j.ijwd.2020.01.006

12. Gardner A, Walkup N. Fungal skin infections. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 19th ed. American Pharmacists Association; 2018.

Pharmacists can educate patients about recommended treatment strategies to manage onychomycosis.

Prevent and Reduce Fungal Nail Infections

Ms. Terrie is a clinical pharmacy writerbased in Haymarket, Virginia.

Check the expiration date of testing kitsbefore use.

Read the instructions before testing andadhere to the step-by-step directions.

Understand the testing procedure andfactors that may interfere with theaccuracy of the selected test.

If unsure about the testing procedure orresults, contact the primary care provideror the manufacturer.

Use an accurate timing device whenperforming the tests.

If using collection testing kits thatrequire mailing, proper collection, storage,and shipment are critical to obtainingaccurate results.

Report positive test results immediatelyto the primary care provider to confirmresults and obtain further medicalevaluation.

Question negative test results andconfer with the primary care provider,especially if experiencing any symptomsor have any concerns.

Patients with visual impairments orproblems with dexterity-ask forassistance when performing tests or bereferred to their primary care providerfor testing.

Patients with bleeding disorders ortaking anticoagulants-because excessivebleeding may occur with tests thatrequire a finger stick blood sample-confer with the primary care providerbefore using.

Pharmacists can be a patient'sbest resource with regard to theproper selection of the variousat-home diagnostic and monitoring testscurrently on the market. These productsfall into the personal diagnostics category.At-home diagnostic tests may assistpatients in detecting or monitoring certainmedical conditions, according tothe FDA's Office of In Vitro DiagnosticDevice Evaluation and Safety.

 At-hometesting provides various advantages,such as privacy, convenience, ease ofuse, and low cost. The FDA classifies athometest kits into 2 categories

&#8212;the patient collects thesample, performs the test, and readsthe results.

&#8212;the patient collectsthe sample, mails it to a laboratory,and obtains the results via phone.

Self-diagnostic kits provide patientswith information about their currenthealth condition, which enables themto make informed decisions. Althoughthe use of diagnostic kits may be convenient,the kits should never replace afollow-up visit with a physician. Properuse of these tests and adhering to themanufacturer's directions regardingtesting protocol are crucial to obtainingaccurate results.

 At-home diagnostictests may provide a patient with valuableinformation and enable patients toseek medical intervention earlier, preventingfurther medical complications.The Table lists some of the varioustypes of at-home tests available.

	.clsTableBorderedCells{		border: 1px solid black;		float: right;		width: 50%;		background-color: #DDDDDD;		border-spacing: 0px;		margin: 12px 0px 8px 8px;		border-collapse: collapse;	}	.clsTableBorderedCells td{		border: 1px solid black;		border-collapse: collapse;	}

The FDA requires that at-home testsperform as well as those used by healthcare professionals; however, thesetests must be used properly to ensureaccurate results.

 Pharmacists can bea fundamental source of informationfor patients seeking the use of at-homediagnostic test kits, as well as makingcertain that patients are adequatelycounseled on their proper use. Oftenthe selection of appropriate at-hometests may be based on ease of use, easeof interpreting results, presence of acontrol, and cost.

During counseling, pharmacists alsomay assess the patient's symptoms andascertain if immediate medical evaluationis warranted. It is important forpatients to consult with a health careprofessional, if needed, as well as thepatient information hotlines found inmost kits, if patients are unsure abouttest results or testing procedure. Patientsalso should be reminded thatalthough these testing kits may be beneficial,patients should always maintainroutine visits to their primary healthcare provider.

	.clsFunkyMonkey {		margin: 10px auto 10px auto;		border-collapse: collapse;	}	.clsFunkyMonkey td{		border: 1px solid red;	}	.clsFunkyMonkey p, ul{		margin: 2px 0px 2px 5px;	}

Examples of Available At-Home Diagnostic Tests

MyAllergyTest Tests for Airborne and Food Allergens (ImmuneTech)

BIOSAFE Anemia Meter (BIOSAFE Medical Technologies Inc)

BIOSAFE Cholesterol Panel (BIOSAFE Medical Technologies Inc)

CardioChek HDL Cholesterol Test Strips (Polymer TechnologySystems Inc)

EarlyDETECT Cholesterol Test (EarlyDETECT)

First Check Home Cholesterol Test (First Check Diagnostics LLC)

Home Access Full Cholesterol Panel (Home Access Health Corp)

When used correctly, at-home diagnostic tests can prompt patients to seek early medical intervention, which is why proper counseling is important.