Case Studies

CASE 1

A mother comes into the pharmacy with her 6-year-old daughter, KP. The mother reports that KP has been complaining of itchiness and has been scratching her head repeatedly. Today, KP was sent home by the school nurse after lice was discovered in KP’s hair, which is longer than shoulder length. The mother was told she could treat KP with an OTC product. The mother hands you the product Nix (permethrin lotion, 1%; INSIGHT Pharmaceuticals, LLC) and asks, “Is this okay to use?”

As the pharmacist, how do you respond?

CASE 2

JD, a 16-year-old male, presents to your pharmacy consultation booth with concerns regarding his right eye. He states, “My eye has been red for 2 days, and I wonder if Visine-A (McNEIL-PPC, Inc) will help.” You ask to take a closer look at his eye, and you notice that while his conjunctiva is not red, he has purulent discharge, swelling, and crusting around his eyelid. Upon questioning, JD denies having pain, blurred vision, or itchiness, and he has no medical history of allergies.

Based on these findings, what do you think JD has, and how would you treat it?

ANSWERS

Case 1: Nix (permethrin lotion, 1%) is an appropriate product for KP. According to the Centers for Disease Control and Prevention, Nix and RID (pyrethrum extract [equivalent to 0.33% pyrethrins]/piperonyl butoxide 4%; Bayer HealthCare LLC) are both appropriate first-line OTC agents for lice eradication. Nix is approved for children 2 months and older, while RID is approved for children 2 years and older. Although both products kill live lice, neither kills unhatched eggs; therefore, it is not uncommon for a second application to be required about 10 days later (to kill newly hatched lice). The pharmacist should inform the mother that KP’s long hair will likely require 2 bottles per treatment. Additionally, KP’s mother should be told that conditioner should not be used prior to Nix and that KP’s hair should not be washed for 1 or 2 days after application (permethrin has a residual effect after application, and conditioner may disrupt adherence of permethrin to the hair shaft). Treatment should stop after 2 applications and when no eggs or lice are found after combing.

Case 2: JD is likely suffering from conjunctivitis, which can be due to bacterial, viral, or allergic causes. The signs and symptoms can help to determine the root cause. In JD’s case, his physical presentation of purulent discharge, crusting around the eyelid, and swelling are suggestive of acute bacterial conjunctivitis (viral conjunctivitis is typically associated with prominent blood vessels in the eye, watery discharge, and abnormal lymph nodes; allergic conjunctivitis is typically associated with itchy red eyes, lid edema, string-like discharge, and comorbid allergenic rhinitis).

Because JD is likely suffering from acute bacterial conjunctivitis, Visine-A (naphazoline hydrochloride 0.025% as a redness reducer; pheniramine maleate 0.3% as an antihistamine) is not an appropriate treatment option. Referral to his physician is necessary to obtain a broad-spectrum ophthalmic antibiotic such as levofloxacin 0.5% solution to treat the most likely pathogens (Staphylococcus aureus, Haemophilus influenzae, Staphylococcus pneumoniae, or gram-negative bacteria).

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Ms. Sihabout is a student at the University of Connecticut School of Pharmacy, and Dr. Coleman is professor of pharmacy practice, as well as codirector and methods chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.