Case 1: Sunblock and Skin Protection
CB is a 49-year-old male who comes to the pharmacy looking for the best OTC sunblock for skin protection. CB recently had a skin cancer check performed by his dermatologist, who identified several moles on CB’s back that should be monitored over time. CB wants to know the current recommendations for skin cancer protection and use of OTC sunscreens to prevent malignancy and prevent his suspicious moles from becoming a more serious problem. What information can you share with CB?
Broad-spectrum sunscreens protect against the sun’s ultraviolet (UV) A and B rays and have a sun protection factor (SPF) of 15 or more.1 According to the FDA’s sunscreen monograph, these products claim to reduce the risk for skin cancer and early aging of the skin as well as help to prevent sunburn when used (1) according to the manufacturers’ directions and (2) in conjunction with other measures of sun protection.1,2
CB should consider purchasing a broad-spectrum sunscreen with an SPF of 15 or higher to ensure the best protection against the sun and to prevent progression toward skin cancer. A product with only UVB radiation protection or with an SPF value less than 15 will only protect against sunburn and will not offer the same protective effects that broad-spectrum agents can.1,2 Remind CB of the best practices in sunblock application and skin protection, including application before exposure to sunlight; reapplication at least every 2 hours and after swimming, sweating, or towel drying the skin; avoidance of sun exposure when UV rays are strongest (10:00 am to 2:00 pm); and use of physical barriers (eg, shirts, umbrellas, sunglasses).1 Advise CB to consider photographing his moles to identify changes in them over time.
Case 2: Dental Care
DH is a 67-year-old female looking for a recommendation for dental cavity prevention. DH recently began radiation treatment for cancer of her neck and, in addition to experiencing bothersome dry mouth, was informed that reduced production of saliva may increase her risk for dental cavities. DH would like the pharmacist to recommend a product to ensure that her teeth are protected from this potential complication. What information can you share with DH?
For most individuals seeking to protect their teeth against cavity formation and decay, recommending a fluoride-based dentifrice in paste or gel formulation would be appropriate for self-care. A product containing any of the 3 FDA-approved anticavity active ingredients (ie, sodium fluoride, sodium monofluorophosphate, or stannous fluoride) would be appropriate.3 In addition to recommending a toothpaste, counseling DH to avoid sugary and acidic foods may help to improve her dental health.4 Furthermore, because she has dry mouth that is likely due to her radiation treatment, she could consider purchasing and using an OTC artificial saliva substitute as needed to alleviate symptoms and improve her dental health.4 Based on DH’s history of malignancy and active radiation treatment, it is imperative for the pharmacist to counsel DH to follow up with her dental care provider and have a plan for routine oral hygiene.
Case 3: Mucositis
ED is a 57-year-old male wanting a product recommendation for the treatment of oral ulcers. He reports he has recently begun treatment for non-Hodgkin’s lymphoma and was warned by his physician that one of the medications in his chemotherapy regimen could cause ulceration. Over the past several weeks, ED has begun to experience oral pain and ulceration of the mouth to the degree that he reports pain when swallowing food, causing him to avoid eating, resulting in weight loss. He is unsure whether he should look for a treatment at the pharmacy or wait to speak with his oncology nurse, but he decides to inquire at the pharmacy first. What recommendation can you give ED?
In general, only minor problems with the oral mucosa (eg, teething, aphthous ulcers, denture irritation, toothache pain) are eligible for self-care. An array of OTC agents can be used to treat and alleviate pain associated with these generally benign conditions. Useful product classes include oral wound care agents, cleansers, oral anesthetics applied locally to the affected areas, oral rinses and protectants, and systemic analgesics.4 For ED, physician referral is most appropriate at this time, given his reported weight loss, dysphagia, and severity of symptoms. Mucositis, a serious complication associated with systemic chemotherapy and local radiation therapy of the head and neck, damages the cells of the mucous membranes.5 While systemic chemotherapy can promote the development of ulcerations anywhere along the gastrointestinal tract, from the oral cavity to the anus, radiation treatment is more likely to cause primarily localized oral lesions. Treatment requires prescription therapy once the condition develops; self-care is limited to the use of oral OTC analgesics or oral topical anesthetics for mild symptom relief.5
Case 4: Oral Thrush
DM is a 69-year-old female who is undergoing chemotherapy for the treatment of ovarian cancer. She reports noticing, over the past few days, a fine whitish film on her tongue and inner cheeks and a cottonlike dryness in her mouth. These symptoms are accompanied by difficulty and pain upon swallowing. DM is allergic to penicillin and sulfa and currently takes multiple medications for hypertension, diabetes, dyslipidemia, and depression, in addition to her chemotherapy regimen. She would like to know if there is an OTC oral product for alleviating these new and bothersome symptoms.
DM’s presenting symptoms and medical history are suspicious for oral thrush, a fungal infection that can affect the mucosa of the upper and lower pharynx. This is a common complication in individuals who are immunocompromised due to HIV/AIDS while undergoing chemotherapy or radiotherapy, which can damage the mucous membranes of the head and neck. Wearing dentures, having diabetes, or using certain medications (eg, inhaled or systemic corticosteroids) can also exacerbate oral thrush.6
DM can be counseled on routine dental care (eg, seeking dental care before, during, and after cancer treatment; routinely brushing the teeth with a softbristled brush; flossing; rinsing the mouth). However, treatment of oral thrush requires medical evaluation and prescription of a topical or systemic antifungal medication.6
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. 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.
1. Labeling and effectiveness testing; sunscreen drug products for over-the-counter human use. Fed Regist. 2011;76(117):35620-35665. www.regulations.gov/#!documentDetail;D=FDA-1978-N-0018-0698. Accessed August 18, 2014.
2. Questions and answers: FDA announces new requirements for over-the-counter (OTC) sunscreen products marketed in the US. FDA website. www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandingover-the-countermedicines/ucm258468.htm. Accessed August 8, 2014.
3. Rudenko AW. Prevention of hygiene-related oral 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.
4. Albanese NP. Oral pain and discomfort. 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.
5. Managing oral mucositis. CancerCare website. www.cancercare.org/publications/133-managing_oral_mucositis. Accessed August 14, 2014.
6. Fact sheet: fungal infection of the mouth in people who have cancer or HIV/AIDS. PubMed website. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0046251. Accessed August 14, 2014.