Counseling Patients About Common Skin Disorders: A Guide for the Community Pharmacist

Patients consult their community pharmacist more than any other health care professional. Therefore, it is crucial to be familiar with over-the-counter (OTC) treatments for several common skin disorders, including dry skin, acne, psoriasis, fungal infections, and dermatitis⁽¹⁾ (atopic, seborrheic, and contact) (Table 1).

Dry SkinDry skin has become a major focus for pharmacists as the size of the aging population increases. Dry skin is caused by a decrease in water retention by the stratum corneum and is characterized by roughness, scaling, inflammation, and itching. It is especially prevalent during the winter months and

may be due to excessive showering with hot water or excessive use of soap.⁽¹⁾ To prevent dry skin, patients should be counseled to maintain skin hydration through adequate fluid intake (3 to 4 L daily), avoid hygiene products that dry out the skin, reduce full-body bathing to every other day, and avoid long, hot showers. To treat dry skin, there are several suggestions pharmacists can offer. Patients can apply oil-based emollients (eg, petrolatum and mineral oil) after bathing, or they may use colloidal oatmeal (Aveeno) or bath oil while bathing to enhance skin hydration. Humectants, such as glycerin, draw water into the skin. More serious cases of dry skin may require a urea- or lactic acid?containing product. If areas of inflammation and redness exist, the patient may try hydrocortisone applied three to four times daily for 1 week. If skin dryness does not resolve within 1 week of treatment, patients should be encouraged to seek consultation with their physician. ⁽¹⁾

Acne

An OTC consultation request for an acne product should be approached with empathy, as well as clinical knowledge, since acne is associated with significant psychological effects, including low self-esteem, social phobia, and depression.⁽²⁾ It is important when counseling a patient to dispel the myths associated with acne. It is not a condition of poor hygiene or diet, nor is it caused by stress, ⁽³⁾ although severe stress may exacerbate the problem. It is just as important, though, to inform the patient that there are several factors that may cause or exacerbate acne^(2,3):

Environmental and Physical Factors

• Hydration (high humidity, excessive sweating)
• Occlusive clothing, headbands, helmets
• Touching the face
• Dirt, cooking oil, coal tar, petroleum
• Oil-based cosmetics (those containing lanolin, mineral oil, and cocoa butter); also hair dressings used by African Americans

Emotional Factor

• Severe or prolonged stress

Hormonal Factors

• Premenstrual flare-ups
• Some progestins used in oral contraceptives

Medication Use

• Systemic and topical steroids

It is also important to educate patients with acne on how to care for their skin. Initially, nonpharmacologic therapy should be addressed. Patients should cleanse their skin twice daily with warm water, which will remove excess sebum from the surface of the skin.^(2,3) Discourage vigorous washing and the use of soaps that contain oil or medications such as benzoyl peroxide. Medicated soaps spend very little time on the surface of the skin and are of little clinical value.⁽²⁾ Patients should also minimize exacerbating factors, including preventing friction-induced irritation by using water-based cosmetics and/or shampoos and by avoiding picking or squeezing lesions.(2)When assisting a patient in selecting an acne product, the various treatment vehicles available should be considered. Creams are suitable for patients with sensitive or dry skin; gels are more appropriate for patients with oily skin. Lotions may be used on any skin type and spread well over hair-bearing areas. ⁽³⁾ Several OTC therapies are available, including benzoyl peroxide, salicylic acid, and sulfur preparations. ⁽³⁾ When selecting an appropriate product for the patient, keep in mind efficacy, adverse effects, and compliance.

PsoriasisPsoriasis, a chronic condition often associated with silvery scales over pink or red lesions, ⁽⁴⁾ typically must be treated with prescription medications; however, mild cases may be self-treated. Self-treatment should involve the use of emollients and lubricating bath products formulated for dry, itchy skin. Topical hydrocor-tisone, coal tar products, and/or kera-tolytic agents (such as those with salicylic acid) also may be required. ⁽⁴⁾

Topical corticosteroids remain the most widely used treatment for psori-asis due to their anti-inflammatory, immunosuppressive, and antipro-liferative properties. ⁽⁵⁾ If hydrocortisone is used, the patient may apply it sparingly to the affected area two to three times daily. ⁽⁴⁾ When a salicylic acid product is used, the patient should soak the affected area in warm water for 10 to 20 minutes before application. In addition, patients should use a nonmedicated, nonresidue shampoo (eg, Prell, Breck, or J&J Baby Shampoo) before using a medicated shampoo.

Tinea Infections

Pharmacists often encounter questions about superficial fungal infections, as many are easily treated with OTC medications. Tinea infections are classified according to their location on the body.(6,7)

Tinea CapitisThis fungal infection of the scalp most often occurs in infants and children. Lesions are diffuse and hairless and must be treated with a prescription medication.

Tinea BarbaeTinea barbae commonly affects men who work with animals. Symptoms consist of inflammation of the follicle of the whiskers and will often subside without treatment. If treatment is required, oral therapy is preferred to topical therapy.

Tinea Corporis (Ringworm)Symptoms of ringworm are red circular lesions with central clearing. Ringworm can easily be treated with a topical imidazole, such as clotrima-zole, although oral treatment may be required if more than a few lesions are present.

Tinea Cruris (Jock Itch)

Patients with jock itch experience an itchy, discolored rash on their groin and inner thigh areas. In addition to recommending a topical imid-azole cream for treatment, the pharmacist should counsel patients to wash the area with soap and water and wear loose-fitting clothing to expedite healing.

Candidal VulvovaginitisCandidal vulvovaginitis presents as vaginal itching and discharge accompanied by dysuria and painful intercourse. Treatment may include a topical imida-zole, such as miconazole, which is available without a prescription.

Tinea Pedis (Athlete?s Foot)

Symptoms of athlete?s foot include cracking between the toes and itchy, vesicular lesions. A topical imidazole cream will treat the infection, but patients should also be counseled to keep their feet dry, change socks frequently, avoid occlusive footwear, and apply an antiperspirant to the soles of the feet to prevent reinfection.

Tinea Unguium (Onychomycosis)

Onychomycosis causes nails to thicken and a brownish-yellow debris to form beneath the nail. Despite the availability of products such as FungiNail, successful treatment requires an oral prescription. Remember, when choosing a product for the treatment of any tinea infection, it is important to consider route of delivery, efficacy, patient compliance, and cost. ⁽⁶⁾

DermatitisAtopicAtopic dermatitis is a recurrent, symmetric inflammatory condition often experienced by infants, children, and young adults.^(1,8) It begins on the cheeks and may extend to the rest of the face, neck, wrists, and hands.⁽⁸⁾ The most common symptoms include intense itching and skin so dry that patients often will complain that moisturizer is ineffective.^(1,8) To control their condition, patients must be educated about proper bathing habits. Bathing in warm (not hot) water should last no more than 5 to 10 minutes, and a mild cleanser, such as Dove, Neutrogena, Aveeno, Basis, or Cetaphil, should be used. ^(8,9) Immediately after bathing, apply generous amounts of a moisturizer, such as Aquaphor, Eucerin, Moisturel, mineral oil, or baby oil.^(8,9) In addition to proper bathing and moisturizers, wet compresses may be applied to the affected area for 20 minutes four to six times daily.⁽¹⁾ Pharmacotherapy for atopic dermatitis may include hydro-cortisone cream (1% or 2.5%) or tar preparations.⁽⁸⁾ When recommending an OTC tar preparation, consider a shampoo or cream, as they may cause less irritation. Tar preparations have a strong odor and, due to their dark color, may stain.

Although some health care practitioners recommend antihistamines, they have limited value in the treatment of atopic dermatitis. ⁽¹⁾ Topical diphenhydramine also should be avoided as it may cause allergic contact dermatitis. ⁽⁹⁾ Referral to a physician should be considered if a large area of the body is affected or if the patient is a child less than 2 years old. ⁽¹⁾

Seborrheic

Seborrheic dermatitis is a chronic inflammatory skin disorder that is usually confined to areas of the head and trunk where sebaceous glands are prominent. ⁽¹⁰⁾ Symptoms often include dull yellow/red lesions, oily/yellow scales, and itching. ⁽⁴⁾ General treatment should consist of frequent cleansing with soap, which will remove oil from the affected areas. In addition, outdoor recreation, especially during the summer months, may improve the condition. ⁽¹⁰⁾

Pharmacologic options include antifungal preparations (selenium sulfide, pyrithione zinc, azole agents, and topical terbinafine) and anti-inflammatory agents (topical steroids). Many cases may be effectively treated by shampooing daily or every other day with an antidandruff shampoo containing selenium sulfide, sulfur, salicylic acid, coal tar, or pyrithione zinc. ^(4,10) Ketoconazole and topical terbinafine may also be used. ⁽¹⁰⁾ Patients should be instructed to leave the shampoo on for 5 to 10 minutes before rinsing to achieve maximum efficacy. If erythema persists despite treatment with medicated shampoos, use hydrocortisone lotion two to three times daily for no more than 7 days. ⁽⁴⁾Once the condition is controlled, patients may reduce the use of medicated shampoos to once or twice weekly.

ContactAnother form of dermatitis commonly encountered by community pharmacists is contact dermatitis, which manifests itself as a rash that results from skin contact with an allergen or irritant. ⁽¹⁾ The primary symptom is profuse itching. When contact dermatitis occurs, the patient should wash the area well to remove the offending agent. If the area is oozing, the patient can apply compresses of cool tap water and aluminum acetate for 20 minutes four to six times daily. Between compresses the patient can use calamine, colloidal oatmeal, or hydrocortisone to relieve itching. ⁽¹⁾ Hydrocortisone will also decrease erythema. If itching becomes so bothersome that the patient has trouble sleeping at night, oral diphenhydramine at bedtime may be helpful. Contact dermatitis should resolve within a few days of initial treatment. In addition, patients should be educated to avoid contact with known allergens, avoid occlusion of the skin, and use hypoallergenic cosmetics and soap-free cleansers on the