How would you respond to these patients' concerns?
CASE 1: Atopic Dermatitis
Q: RJ is a 3-year-old girl with dryness, redness, and scaling on her arms. Her mother calls the pharmacy with questions regarding atopic dermatitis (AD). She reports that RJ has been trying to scratch the itchy rash, which appears to be making the plaques thicker. RJ’s mother reports that her daughter has asthma as well. What should the pharmacist recommend to treat AD?
A: Advise RJ’s mother to limit exposure to all potential triggers for AD, including dyes, excessive bathing, extreme temperatures, irritating detergents and soaps, and tight-fitting clothing. Preventive measures can be implemented to reduce the symptoms of AD. RJ’s clothes and sheets should be thoroughly washed with unscented detergent, and dryer sheets should be avoided. Overall, bathing is recommended to remove bacteria and hydrate the skin, but excessive bathing should be avoided, and lukewarm water and mild, hypoallergenic cleansers should be used. RJ’s skin should be moisturized with unscented emollient products immediately after bathing. The skin barrier can be hydrated and maintained using emollient moisturizers that contain oils, petrolatum, or silicone.1,2
If nonpharmacologic modalities do not provide relief, RJ should be treated with topical corticosteroids, which will suppress the cytokines involved in the inflammatory process. Hydrocortisone 0.5% and 1% topical creams are available over the counter and can be used for AD in ages >2 years. Hydrocortisone should be applied to RJ’s lesions twice daily before the application of her daily moisturizers.1-3
CASE 2: Complementary Therapy
Q: RJ’s mother returns to the pharmacy a few weeks later regarding her daughter’s AD. She mentions that she learned from friends that fish oil and evening primrose oil are helpful for AD. She asks for your input on complementary therapies and evidence for use in AD. What information can you provide to RJ’s mother?
A: There is little evidence to demonstrate the efficacy of complementary therapies for use in AD. Some studies have shown, however, that phototherapy may be effective in AD after non-pharmacologic measures and topical corticosteroid use do not work. In pediatric patients specifically, ultraviolet A and B phototherapy have demonstrated efficacy and safety for AD. The guidelines now recommend phototherapy as a treatment option for refractory AD.4,5
Other complementary therapies commonly used include borage, coconut, evening primrose, and fish oils. Despite the widespread use of oils for AD, there are insufficient data to support the use of borage, evening primrose, or fish oil. However, some data do support the use of topical coconut oil in AD.5,6
CASE 3: Diaper Dermatitis
Q: MP is a 7-month-old boy with reddened skin under the diaper area developing over the past 3 days. The area appears wet, but there is no discharge. MP is otherwise healthy and does not appear to have any changes in body temperature, bowel movements, or energy level. His diaper is typically changed frequently, but he has a new nanny who may have a different schedule. What should the pharmacist advise for MP’s condition?
A: MP’s symptoms are consistent with the common presentation of diaper dermatitis. Given that he does not have diarrhea, fever, or oozing, and he has not had had the rash for > 7 days, he is eligible for treatment at home. Diaper dermatitis can occur in the setting of occlusion from the diaper and increased exposure to moisture from gastrointestinal contents and urine. Instruct MP’s nanny to increase awareness of wet diapers and change them more frequently—a minimum of 6 times per day. A modality that may be difficult but effective includes a “diaper holiday,” where MP would not wear a diaper and therefore avoid duration of contact with a wet diaper.7,8
Additionally, the use of skin protectants with each diaper change will aid in preventing diaper dermatitis. The FDA has approved 17 skin protective ingredients for treatment of diaper dermatitis, including allantoin, calamine, cocoa butter, petrolatum, and zinc oxide. MP’s caregiver should use an OTC skin protectant after each diaper change for 7 days and observe for improvement. If the rash does not improve during that time, a medical referral is recommended. OTC antibacterial and antifungal topical agents are not recommended to treat diaper dermatitis.8,9
CASE 4: Contact Dermatitis
Q: PA is a 27-year-old woman who has a rash on her face. She visited the dentist earlier in the day and had a few cavities filled. Immediately following the appointment, PA noted a stinging, swollen rash at the outer corner of her mouth. She researched the material used during a filling and noted that the etching solution used contains phosphoric acid, which could cause contact dermatitis if skin is exposed to it. What advice should the pharmacist provide?
A: PA should first wash the exposed area with a generous amount of lukewarm water to remove the irritant and reduce skin contact time and exposure. To protect the skin from epidermal water loss, PA should apply copious amounts of petrolatum to the exposed area. In some cases, Burow’s solution (aluminum acetate) can be used for its antibacterial, antiinflammatory, and cooling effects. Unlike with atopic dermatitis, topical corticosteroids do not target the mechanism of irritant contact dermatitis. As such, OTC hydrocortisone would not be an appropriate treatment choice. Likewise, PA should avoid lactic and salicylic acids, propylene glycol, and topical anesthetics, which may cause more irritation and potentiate allergic contact dermatitis. Inform PA that the rash may become hyper- or hypopigmented and scaly. Given that the rash is on her face, the pharmacist should also refer her to a provider for evaluation.10,11
ABOUT THE AUTHORS
Rupal Patel Mansukhani, PharmD, FAPhA, NCTTP, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.
Ammie J. Patel, PharmD, BCACP, BCPS, is a clinical assistant professor of pharmacy practice and administration at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, in Piscataway, and an ambulatory care specialist at RWJBarnabas Health Primary Care in Shrewsbury and Eatontown, New Jersey.
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2. Hon KL, Leung AKC, Barankin B. Barrier repair therapy in atopic dermatitis: an overview. Am J Clin Dermatol. 2013;14(5):389-399. doi:10.1007/s40257-013-0033-9
3. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116-132. doi:10.1016/j.jaad.2014.03.023
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7. Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol. 2014;31(1):1-7. doi:10.1111/pde.1225
8. Blume-Peytavi U, Hauser M, Lünnemann L, Stamatas GN, Kottner J, Garcia Bartels N. Prevention of diaper dermatitis in infants—a literature review. Pediatr Dermatol. 2014;31(4):413-429. doi:10.1111/pde.12348
9. Food and Drug Administration, HHS. Skin protectant drug products for over-the-counter human use; final monograph. Final rule. Fed Regist. 2003;68(107):33362-33381.
10. Eberting CL, Blickenstaff N, Goldenberg A. Pathophysiologic treatment approach to irritant contact dermatitis. Curr Treat Options Allergy. 2014;1(4):317-328.
11. Corazza M, Minghetti S, Bianchi A, Virigili A, Borghi A. Barrier creams: facts and controversies. Dermatitis. 2014;25(6):327-333. doi:10.1097/DER.0000000000000078