OTC Case Studies: Skin and Eye Health

Case 1: Allergies During Pregnancy

RM, a 31-year-old woman, is looking for something for her seasonal allergies. She complains of congestion, a dry cough, and itchy eyes. RM says that this occurs every year during the spring season, and she usually treats of it with fexofenadine. She takes fexofenadine the entire spring and summer. RM has never formally been diagnosed with allergies. but since the medication helps her, she continues to use it. She recently found out she was 12 weeks pregnant and is concerned for the baby. RM wants to make sure that fexofenadine is safe for the baby and if is not wants something else that will relieve her symptoms. She wants OTC medication, because she has no prescription insurance. RM is healthy and has no other medical conditions. What recommendations do you have?

A: Because RM is pregnant, she should be referred to her physician to be formally diagnosed with allergic rhinitis. Intranasal cromolyn can be considered in patients who are pregnant and can be considered safe as a first-line option.¹ In addition, studies show no significant risk of fetal malformations with first-generation antihistamines, such as chlorpheniramine and diphenhydramine. The second-generation antihistamines are primarily pregnancy category B and include cetirizine, fexofenadine, levocetirizine, and loratadine. They also do not appear to increase overall fetal risk.² It is also important to tell RM about allergen avoidance. Because she complaints of pollen, she should try to avoid it if possible. RM should try to stay indoors to limit her exposure. In addition, she can keep her windows closed and use air-conditioning when needed. RM can also try washing her face when she gets in from outdoors to wipe off any allergens that may be on her. She can discuss which medication is the best option with her physician. However, any OTC antihistamine would be considered safe.

Case 2: Contact Solution

GG is a 17-year-old who comes in with his mom looking for something for eye irritation. He recently started wearing soft contact lenses. GG is very excited about not wearing his glasses to school. However, today his eyes are a little irritated. Upon questioning, GG says that he replaces his contact lenses every 2 weeks. His eye doctor recommended that he use a multipurpose solution to store them each night. However, GG’s mother says that she found a bottle that looked like the multipurpose solution called saline. She found it to be significantly cheaper, so she purchased that instead. GG denies any discharge from his eye. He has no medical conditions and takes no medications. What recommendations do you have?

A: Contact lenses come in rigid gas-permeable, or rigid non-gas-permeable material, or soft material. The cleaning and education depend on the type of material. Because GG is using soft lenses, the goals of cleaning would be to disinfect the lens and remove debris. When soft lenses first came out, manufacturers recommended 3 products to clean and disinfect contacts. However, in recent years, multipurpose solutions have replaced the 3-solution method. Saline is commonly confused with multipurpose solution. Saline can lack disinfecting properties and therefore is not recommended, unless a different disinfection solution is being used. GG and his mother should be educated to use multipurpose solution like the doctor recommended. Because his eyes are already a little irritated, he should immediately switch to the multipurpose solution. GG should clean the lenses with the multipurpose solution and rub the contact lenses. If his eyes are still irritated in 1 to 2 days, he should follow up with a physician to confirm that he does not have an infection. Advise GG to avoid reusing or topping off the contact lens solution and to make sure that he rubs the contact lenses every night even if he uses a “no-rub” solution.³

Case 3: Insect Repellant and Sunblock

BF is a 24-year-old woman who will be traveling to the Bahamas for spring break. She wants to know what recommendations you have for sunblock. BF is also concerned about the Zika virus, after hearing that cases have been confirmed in the Bahamas. Upon questioning, she says that she has no intention of getting pregnant in the next few years but still does not want the Zika infection. BF wants to know if there is anything over the counter that she could use to prevent mosquito bites. She is healthy and does not have any allergies to medications or medical problems. What recommendations do you have?

A: Advise BF that the most effective way to prevent a Zika infection is avoiding the Bahamas or any region that would have Zika. But because she has booked her trip, she should wear long pants and sleeves when she is there, especially outdoor..⁴ If BF would like to use an insect repellent, it should contain N,N-Diethyl-M-Toluamide, also known as DEET. Because she is also using sunblock, she should apply the insect repellent over her sunblock.⁵ Remind BF that the sun is most dangerous between 10 a.m. and 4 p.m. During that time, she should wear protective clothing that would also help her avoid mosquito bites. For sunblock, BF should use anything with a sun protection factor of 15 or higher. She can also consider buying products such as octocrylene, meradimate, titanium dioxide, benzophenones, or avobenzone with combination with padimate O that protect against ultraviolet A and B rays. If BF plans on being in the water a lot, she can purchase a water-resistant product. However, she should keep in mind that water-resistant sunblock should be applied every 40 to 80 minutes, and non-water-resistant products can be applied every 2 hours. Let BF know that she should not rub in the insect repellant.

Case 4: Allergic Conjunctivitis

DM is a 48-year-old woman who is looking something to treat her allergies. She takes loratadine 10 mg daily but wants to also try eye drops. DM says that she has had allergies for years, and it has gotten worst over the past few weeks. A few years ago, her physician tested her for allergies and found that she is allergic to pollen. DM loves being outdoors and hikes often. Normally, when she takes Loratadine she feels good. However, when she has been outdoors recently, her eyes have gotten very itchy and red. DM spoke to her doctor, who said she could get some allergy drops over the counter. DM has no other medical conditions and does not take any other medications. What recommendations do you have?

A: As mentioned in the earlier case, trigger avoidance is very key. Although she enjoys the outdoors, DM could try turning on the air conditioning when she is driving or indoors to avoid pollen additional exposure. She can also try to avoid pollen from getting into her eyes but using protective equipment or sunglasses. Advise DM to continue to take Loratadine. In addition, she can use eyes drops for symptom relief. Although ophthalmic antihistamines are available, the first-line treatment for allergic conjunctivitis is artificial tears. Artificial tears can wash out the pollen from DM’s eyes. Depending on the product she purchases, the manufacturer typically recommends 1 to 2 drops as needed.⁶ If artificial tears do not work or symptoms persist, then she can switch to an ophthalmic antihistamine. Ketotifen fumarate 0.025% is now available over the counter to treat allergic conjunctivitis. Brand names available include Alaway or Zaditor. They are recommended for use twice daily and are safe for those 3 years and older. If DM tries an ophthalmic antihistamine, she should see a physician if her symptoms do not resolve after 72 hours of appropriate treatment.⁷

Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

References

• Briggs GG, Freeman RK. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 10th ed. Philadelphia, PA: Wolters Kluwer Health; 2015:132—3, 162–4, 188, 238–9, 252, 385–7, 414–6, 543–4, 576–7, 643, 818–9, 1041–2, 1110, 1168–70, 1398–1400.
• Servey J, Chang J. Over the Counter Medications in Pregnancy. Am Fam Physician. 2014;90(8):548-555.
• Gromacki SJ, Ward MA. Understanding contemporary contact lens care products. Contact Lens Spectrum. June 1, 201 clspectrum.com/articleviewer.aspx?articleID=108437. Accessed April 13, 2019.
• CDC. Protect yourself and others. cdc.gov/zika/prevention/protect-yourself-and-others.html. Updated March 14, 2019. Accessed April 12, 2019.
• Crosby KM, O’Neal KS. Prevention of Sun-Induced Skin Disorders. In: Krinsky DL, Ferreri SP, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 19th ed. Washington, DC: American Pharmacists Association, 2017.
• Systane Ultra Eye Drops Ingredients and Usage. systane.com/product-ingredients/systane-ultra-lubricating-eye-drops/. Accessed April 13, 2019.
• Zaditor. zaditor.com/antihistamine-eye-drops.shtml. Accessed April 13, 2019.