Which OTC products should these pharmacists recommend?
CASE 1: SELF-MANAGEMENT FOR NOROVIRUS SYMPTOMSQ: A 46-year-old woman calls the pharmacy asking for the pharmacist’s recommendation for treatment of systemic symptoms she believes are due to food poisoning. She relates that she and her husband and children have had low-grade fevers, nausea, vomiting, diarrhea, and severe stomach pain for the past 12 hours. The family attended a potluck holiday celebration the evening before symptom onset, and several other attendees of this party also have this same symptoms. She reports suffering from a runny nose, sinus pressure, cough, and sore throat. She has no significant medical history. What information should the pharmacist provide regarding symptomatic self-management for this woman?
A: Acute gastroenteritis, most commonly manifested as symptoms of nausea and vomiting, diarrhea, and stomach pain but with symptoms that can also include low-grade fevers, headache, and body aches, is commonly associated with norovirus infection.1 Based on this woman’s description of symptoms and onset occurring 12 to 48 hours after likely exposure, she and her family are likely suffering from this self-limiting viral illness. Although no cure exists for the gastroenteritis associated with norovirus, it is appropriate for the pharmacist to recommend supportive care and strategies to reduce the spread of infection to others, including emphasizing the importance of frequent hand washing, avoidance of food preparation for others in the household while symptoms persist, decontamination of surfaces within the home, and careful handling and laundering of soiled clothing.1 Educating her on the selection and appropriate use of OTC agents is reasonable, as is reminding her that dehydration is one of the most serious complications associated with viral gastroenteritis. For self-management, remind her that it is necessary to keep hydrated while suffering from acute diarrhea and vomiting to reduce the risk of dehydration; nonprescription oral rehydration solutions are optimal, in that these agents contain less sugar than other electrolyte-enhanced sports drinks, which can have an osmotic effect and worsen diarrhea symptoms. Remind her that, for severe symptoms or any of her family members exhibiting signs of dehydration, medical evaluation may be required.1
CASE 2: PLANTAR WART RELIEFQ: A 35-year-old man would like the pharmacist to recommend a medication to treat a slightly painful thickened bump on the underside of the big toe on his right foot. He reports that he is frequently barefoot in the gym showers each afternoon, and first noticed a tiny, pinpoint flat bump on the underside of his foot. He has no known allergies and takes no other medications. He wants to know if an OTC product could alleviate this nodule or if a medical evaluation is necessary. What recommendations should the pharmacist provide?
A: From the patient’s description, it appears he is suffering from a plantar wart, a hard, bothersome, and sometimes painful growth usually found on the heel or ball of the foot caused by the human papillomavirus (HPV). Seeing that this patient has no contraindications to self-care, including history of use of immunosuppressive medications or other contraindications to use of topical salicylic acid, severe pain, or other medical comorbidities that can compromise lower extremity blood flow, such as diabetes or peripheral vascular disease, recommending use of a nonprescription medicine is appropriate. Numerous nonprescription wart removing preparations exist, including both salicylic acid-containing preparations, a keratolytic agent which works to slowly kill affected tissue, as well as cryotherapy formulations intended to destroy the wart by freezing the affected area.2 In this patient’s case, recommend a product he is most comfortable with self-administering given his active athletic lifestyle and that is most compatible with his budget. Remind him that, in the case of salicylic acid-containing products, the higher-strength preparations are indicated for plantar warts and may take up to 12 weeks or longer to eradicate warts on the affected area. If cryotherapy is preferential, remind him to follow instructions on the label for application and frequency of retreatment.2 Medical evaluation should be sought for warts that fail to resolve after 12 weeks of self-treatment.2
CASE 3: TREATMENT-RESISTANT HEAD LICEQ: A 37-year-old woman comes to the pharmacy looking for a recommendation for a head lice treatment. Her 2 young sons came home with a medical note from their day care center, advising that head lice were observed in their hair and that they would need to be treated prior to returning to their classes. Their mother is concerned because there has been frequent media attention on “resistant” head lice in the area, and she has heard from other mothers that their children needed to be treated with prescription-strength medications by their pediatricians. She remembers using OTC lice removal shampoos and combs in the past, when she and her siblings were younger, but she is confused with all the recent media attention to this topic. What advice would be reasonable to share with her at this time?
A: Clinical trials and recent systematic reviews have described head lice that have become resistant to nonprescription pediculocidal preparations; estimates suggest that OTC permethrin is effective in approximately just 25% of cases.3 Although resistance patterns may vary across the United States and according to geographic area, if this mother believes resistance is an issue in her community, medical referral may be the next appropriate step for managing her children’s current infestations. Remind her it is imperative that she follow the application and directions for use precisely for any preparation she may be receiving.4 Also remind her that, particularly with the newer prescription-only products, combing the hair with a nit comb may not be necessary.
CASE 4: SELF-CARE FOR ACNEQ: A 27-year-old woman is looking to speak to the pharmacist about whether or not she should see a dermatologist for acne treatment. She reports she is getting married in several months but that she is concerned that her acne will ruin her wedding day and bridal photos. She reports experiencing significant acne flares since adolescence, which she describes are exacerbated when her menstrual cycle is approaching. Since college, she hasn’t routinely followed up with a medical doctor because she is generally well and healthy, short of this cosmetic concern. She reports having tried various nonprescription face washes and creams, but her symptoms persist and no particular product has seemed to alleviate them thus far. What self-care recommendations or advice for medical referral should the pharmacist offer her at this time?
A: Acne is a common, often self-limiting, cosmetic condition that can be usually be controlled with nonprescription preparations. A good mantra for self-care that can be reiterated with this woman, given that her acne is cyclically recurrent, is that treatment and application of acne preparations must be ongoing, continuous, and consistent; intermittent use of nonprescription treatments will result in sporadic resolution and recurrence of symptoms.5 It is prudent for the pharmacist to ascertain not only what specific preparations—and active ingredients—she has previously tried, but also to confirm her patterns of usage of nonprescription formulations trialed to-date. Upon verifying which type of nonprescription medicine or class she has used, another type of preparation or active ingredient could be considered. In addition, recommending self-care strategies that may reduce symptoms, including preventing dehydration, use of a mild cleanser twice daily, and dietary modification, including reducing consumption of high-glycemic-load foods, are all nonmedication strategies that have been touted to help mitigate acne symptoms.5 If, after 6 weeks of attempting to implement these therapies and interventions her symptoms persist, advise her to follow up with a skin care specialist for further management.
Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey. Dr. Mansukhani is a clinical assistant professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.