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Skin Conditionsi

Guidelines for Patient Assessment

For the purposes of this guide, assessing for skin conditions is a means to identify which conditions may be considered minor, and therefore fall within the scope of practice for pharmacists’ assessment versus those conditions that require a referral.

Minor Skin Conditions are those that are included in Table 1. The Differential Assessment section outlines the conditions that may present with similar signs and symptoms that must be ruled out.

Table 1: Minor Skin Conditions

Condition Location Description of Lesions

A. Allergic Dermatitis and Mild-Moderate Atopic DermatitisAllergic contact dermatitis

Usually confined to area exposed to allergen

Acute onset of itchy vesicles

Eczema Trunk, face, scalp, limbs Patches of dry skin, may be red, itchy; may show signs of scratching, skin thickening

B. Mild Urticaria Can occur anywhere on body

Red patches and wheals (hives), often itchy

C. Impetigo (excluding bullous impetigo)

Usually face and extremities 1 to 2 mm fragile pustules and/or honey-coloured, crusted erosions

D. Fungal Skin Infections: Dermatophyte infectionsTinea corporis (ringworm)

Exposed areas – trunk, limbs, face

Round, red spot that gradually expands with a raised, scaly erythematous border and a clear central area; lesions are 1-10 cm in circumference; itchiness and burning sensation are common

Tinea cruris (jock itch) Symmetrical, involving the upper inner thigh and groin. Can spread down inner thigh or upwards to stomach and buttock. Does not usually involve penis and scrotum, vulva or anus.

Large round, red well defined patches with bumpy or scaling edges. Burning and itching are common.

Skin ConditionsPatient Assessment Guidelines_March 2015 Page | 1

Condition Location Description of Lesions

Tinea manuum Palmar surface of the hand more often than the back of the hand; only one hand may be involved if it occurs in conjunction with tinea pedis

Typically dry, mild diffuse scales on an erythematous base

Tinea pedis(athlete’s foot)

Most commonly between the toes; may spread to instep or sole

Inflamed, blistered and feel itchy, burning, or painful

Fungal Skin Infections: Yeast infectionsPityriasis versicolor/ tinea versicolor

Back, chest, upper arms Multiple white-pink to brown macules with an overlying fine scale

Cutaneous candidiasis Moist areas, skin folds, particularly the groin

A “beefy red” edematous area with irregular edges and many small papules outside the borders (satellite lesions)

Differential Assessment

These conditions are assessed based on signs, symptoms and history. Rule out the following conditions that may present with similar signs/symptoms:

Acne rosacea- pustules, dilated/broken blood vessels; facial flushing including cheeks. Acne vulagris- pustules and blackheads, often in other areas of the face as well. Alopecia areata- small nonscaly patches of sudden hair loss. Bullous impetigo – large, fragile, flaccid bullae that rupture and ooze yellow fluid. Formed

in response to the exfoliative toxins produced by Staphylococcus aureus. Typically found on the trunk, axilla, and extremities, and in intertriginous (diaper) areas.

Burns Ecthyma - an ulcerative, deeper infection usually found in the lower leg area following a

trauma to the skin such as a cut or scratch. Erythrasma- a bacterial infection causing slowly enlarging areas of pink or brown scaling

skin in folds in the groin, armpits, or between the toes. Often asymptomatic. Folliculitis/boils – infected hair follicles; present as red, often itchy papules and/or

pustules at the base of the hair shaft. Subcutaneous folliculitis forms furuncles (boils) – tender red swellings often with a central pustule.

Ichthyosis vulgaris – severe dry skin with characteristic fish-like scales. Lichen simplex chronicus – itchy patches of skin, thickened as a result of chronic

scratching or rubbing, maybe covered in small bumps.


Lupus erythematous- may present as itchy or painful rash – most commonly on face but may occur on chest and back

Lyme disease- a rash expanding over the course of a few days and resembling a bulls-eye around the site of the tick bite. May be accompanied by flu-like symptoms. If not treated, may progress to severe joint pain and swelling, cardiac arrhythmias and neurological symptoms. Refer for evaluation; antibiotics may be required.

Perioral dermatitis- papules and pustules around moth and chin; often includes a history of topical steroid use.

Photosensitivity rash- ask about recent sun exposure; consider medication history and drugs associated with photosensitivity.

Pityriasis rosea- appears as small, scaly lesions on the trunk in an evergreen tree pattern. It starts as a single patch which may be mistaken for tinea corporis.

Psoriasis – well-defined, red papules coalescing into plaques (patches of slightly thickened skin); typically appears as silvery scales on red plaques.

Scabies – generalized, severe itching, burrows in finger webs and sides of fingers. Scalded Skin Syndrome - starts with a localized infection caused by toxins produced by

certain strains of S.aureus. When the blisters break, the top layer of skin peels and becomes inflamed, resembling a burn. This most often affects infants and children under 5 years old.

Seborrheic dermatitis – minimal itch; patches of red, greasy, scaling rash with indistinct margins on scalp, eyebrows, around ears, nose folds, on forehead, chest, or upper back.

Stevens-Johnson syndrome - involves fever, severe rash and skin-peeling in reaction to a drug.

Venomous spider bites - may cause increased body temperature and blood pressure, profuse sweating, dizziness, blurred vision, nausea, pain and swelling around the bite within 1 to 8 hours.

Viral skin diseases such as cold sores, shingles or chickenpox, which may blister, but have a clear exudate. Herpes simplex or herpes zoster may resemble impetigo; however, the lesions are not honey-coloured.

o Cold sores usually occur singly around the border of the lip.o Chickenpox lesions usually develop over the trunk and extremities as well as the

face. Vitiligo- nonscaly, chalk-white lesions


When to Refer

Patients with minor skin conditions often do not require further investigation; however, consider further assessment in the following situations:

Symptoms are severe or large areas of the skin are involved. Secondary infection is present, e.g., fever, excessive swelling, redness, tenderness,

discharge, and folliculitis. Symptoms are not relieved after a course of treatment of an appropriate duration. Anaphylactic reactions

o May appear as: Trouble breathing or swallowing Swelling of the lips or throat Fainting or dizziness Confusion Rapid heart rate Nausea and cramps

o Patients presenting with severe or systemic reactions should receive emergency treatment (911; hospital emergency department). Epinephrine injection may be indicated.

o Refer to physician for testing, assessment and epinephrine injection device. Systemic symptoms are present, e.g., fever, swollen lymph glands, fatigue, painful joints or

nausea. Allergy testing is desired. Suspected adverse reaction to a prescription drug – treat and refer because alternate drug

may be required. Patients with underlying diseases or drug regimens that may cause them to be

immunocompromised. Area of inflammation around lesion expands rapidly over a few hours with or without

systemic symptoms (fever, chills) – may be cellulitis or erysipelas. Suspected MRSA (methicillin-resistant S. aureus):

o It is not possible to distinguish MRSA from methicillin-sensitive S. aureus except by culture. However, risk factors should be examined, such as: recurrent boils or abscesses, previous MRSA infection and underlying medical conditions, close contact with others with the infection and also skin trauma such as scrapes, tattoos, injection drug use, shaving and/or sharing equipment that is not sterilized. Many people who get MRSA have no risk factors.

o MRSA infections usually involve the skin, but can cause more serious bone infections or rarely pneumonia. This is more common in children who also have influenza.

Previous infection that did not fully resolve despite appropriate treatment, or frequent recurrences

Onychomycosis (fungal nail infection)Skin ConditionsPatient Assessment Guidelines_March 2015 Page | 4

Unable to confirm patient assessment or a more serious condition is suspected (see differential assessment above).

A. Contact Allergic Dermatitis and Mild to Moderate Eczema (Atopic Dermatitis)

Description

Contact Allergic Dermatitis

Typically first appears in early childhood (i.e. in the first year of life) and subsides with advancing age. In general, the skin of people over 65 years of age is less reactive to allergens.

It is a delayed or T cell-driven hypersensitivity reaction. Predisposition to develop allergic contact dermatitis is genetic. Allergens of note include:

o Rhus (poison ivy) and Toxicodendron plantso Natural rubber latexo Metalso Bacitracin

Mild to Moderate Eczema (Atopic Dermatitis)

Chronic, recurring, inflammatory disorder of the skin also referred to as atopic dermatitis. Often accompanied by a diagnosis of asthma.

Personal or family history of atopic dermatitis is a common finding. Once thought to be an allergic disorder, but there is now little support for this theory of

pathogenesis (“the rash that itches”). Typically first appears in early childhood (i.e. in the first year of life) and subsides with

advancing age.

Signs and Symptoms

Allergic Contact Dermatitis

The involved area usually reflects the pattern of the contacting substance- margins may be sharp and linear, or unusual shapes.

It may spread through lymphocytes, or contact substances may be transferred from the primary site through touch (e.g. to the eyelids or neck).

The distribution of lesions may help identify the likely allergen trigger. Acute reactions are often red, edematous papules which later become oozing vesicles and

bullae if the reaction is severe enough. In chronic reactions, primary lesions are minimal and symptoms such as dryness, skin

thickening, pigment changes, itching and excoriation, and fissuring predominate.

Mild to Moderate EczemaSkin ConditionsPatient Assessment Guidelines_March 2015 Page | 5

Pruritus- can be intense. Dermal lesions

o Distribution Infants: trunk, face, and extensor surfaces (the skin on the opposite site of the

joint when body part is straightened). Children: the flexor surface (the skin that touches the joint when the body part

is bent) of the elbow and knee. Adults: scalp, face, neck, hands, upper chest, and genital areas.

o Morphology of lesions: Infants: redness and papules (solid skin elevations not containing pus); may

develop oozing, crusting vesicles. Children and adults: chronic eczema may lead to skin lichenification

(thickening) and scaling. Nummular discoid eczema- small round plaques of small papules and

blisters, usually on trunk or extremities Classification of Severity

o Mild: patches of dry skin, may or may not be reddened, infrequent itching.o Moderate: patches of dry red skin, redness, frequent itching- may show signs of

scratching and skin thickening.o Severe: widespread patches of dry, red skin; persistent itching – may show signs of

scratching and extensive skin thickening, cracking, bleeding, and oozing.

Treatment1

Goals of Treatment

Eliminate individual trigger factors or contact with allergens Improve symptoms and skin lesions

Nonpharmacologic treatment

Avoid agents that may cause irritation:o Environmental allergens: harsh soaps, detergents, shampoos, alcohol based

products, astringents, poor home ventilation, dry grass and leaves.o Diet: Food allergens are possible; common allergy triggers are milk, egg, wheat, soy,

peanut, tree nuts, fish and shellfish. Consider allergy testing if concerned.o Irritants: disinfectants, solvents, cleansers, fabric softeners, wool, perfumes.

Advise patient that sweating and overheating can increase itching. Avoid scratching if possible. Fingernails should be kept short. Mittens may be helpful for

infants. Advise patient of proper bathing to reduce irritation – brief duration, lukewarm water, pat

dry, apply emollients to damp skin.

1 Refer to standard clinical references for a full discussion of treatment.Skin ConditionsPatient Assessment Guidelines_March 2015 Page | 6

Nonprescription Drug Options

Emollients and hydrating agents Barrier repair products Potent sedating antihistamines (non-sedating antihistamines not generally useful as the itch

is not histamine-related) Topical corticosteroids Tar preparations (eczema)

Prescription Drug Options2

Topical corticosteroidso A large number of corticosteroids of varying potency are available. The lowest

potency steroid that is effective should be used. o Hydrocortisone is the drug of choice for use on the face and intertriginous areas to

reduce the risk of steroid side effects.o A variety of vehicles are available – ointments provide better delivery of the steroid

and help prevent water loss; creams are cosmetically acceptable and better tolerated in heat and humidity; lotions are good for large or hairy areas but the alcohol may be irritating to open areas.

o Different formulations (e.g. cream vs. ointment) of the same strength of the same drug may have different potencies.

o Dose of topical can be described in fingertip units (FTU). One FTU is amount squeezed out from a standard tube among an adult finger from the very tip to the first joint. One FTU will cover twice the area of the flat of an adult hand with the fingers closed. One gram of a topical will cover approximately 2 FTUs. See http://www.dermnetnz.org/treatments/fingertip-units.html .

2 Refer to individual drug monographs for detailed information on contraindications, cautions, adverse effects, interactions and dosing.Skin ConditionsPatient Assessment Guidelines_March 2015 Page | 7

http://www.dermnetnz.org/treatments/fingertip-units.html

Advice and Monitoring

Expect improvement of symptoms within 7 days of corticosteroid therapy; if no improvement, discontinue the product and refer for further assessment.

Emollients applied immediately before or after a topical steroid may reduce its effectiveness.

If symptoms have resolved for 48 hours, discontinue the topical corticosteroid (step-down to low potency product first if applicable) and continue with regular emollient use.

If stinging and burning on application is very bothersome, recommend/prescribe an alternate product.

Discontinue product and refer if local side effects such as easy bruising, telangiectasia, striae, or skin atrophy (thinning, wrinkling, depression) are reported.

B. Mild Urticaria (Including Insect Bites and Stings)

Description

Urticaria is a group of disorders in adults and children that involves the development of red patches and wheals (hives) on the skin as a result of histamine and other chemical release from mast cells and basophils in the skin.

Surface wheals may be accompanied by deeper swelling (angioedema); angioedema may also occur without wheals.

Generalized ordinary urticaria may involve wheals anywhere on the body. Classification:o Acute urticaria – recent onset (hours, days, or a few weeks)o Episodic urticaria – intermittent attacks which may last for a few days to a few weekso Chronic urticaria- persists for several months or longer.

Causes of acute urticaria may be:o Allergic – such as a drug eruption, food allergy, insect bite or bee or wasp stingo Non-allergic – such as infection, serum sickness, non-allergic food or drug reactions.

Chronic urticaria may be associated with autoimmune conditions, e.g. thyroid disease, celiac disease.

Physical urticaria is caused by external physical factors; wheals develop in about 5 minutes and last for 15 to 30 minutes.

o Dermographism – stroking the skin causes it to wheal in the line of the strokeo Cholinergic urticaria – results from sweatingo Cold urticaria– affects skin that is warming after being in colder temperatures,

especially in winter. Wheals may be widespread and may cause fainting.o Contact urticaria – from absorption of an eliciting substance; may be confined to the

site of contact or widespread; may be allergic or nonallergic. Insect bites which cause local inflammatory reactions are puncture wounds from insects

whose saliva contains concentrated irritant substances such as anticoagulants and enzymes. Symptoms vary depending on the type of insect and the sensitivity of the person bitten.


o In Canada, the most common bites are from mosquitoes, flies, fleas and ticks.o The chance of being bitten by an insect increases with the amount of skin exposed.o Some diseases are spread by insect bites. Mosquitoes of the Culex tarsalis species,

which are active from late June to August, are responsible for human infections of West Nile virus in Canada. Bites from deer ticks can cause Lyme disease. Although these are the only significant diseases spread by insects in Canada, other less common diseases can also be tick-borne.

All North American spiders are poisonous, but most are too small, don’t have biting apparatuses strong enough to penetrate human skin, or have too little poison to be a threat to humans.

o There may be a mild reaction at the site of the bite, but any severe reaction from a spider bite is usually delayed from 1 to 8 hours.

o The two most common species of spiders that are considered health threats are the brown recluse (not found in Canada) and the black widow (may be imported on produce).

o Eighty percent of suspected spider bites have been found to be due to ants, fleas, bedbugs, ticks, mites, mosquitoes and biting flies.

Bee and wasp stings are not the same as insect bites. o The body’s reaction to a sting may differ by species. o Honey bee stingers remain in the skin. o Bumble bees and wasps do not leave their stingers behind and can sting more than

once.o Bee stings are more likely to cause anaphylactic reactions; 0.5 to 5% of the

population is affected.

Signs and Symptoms

Urticarial wheals may be a few millimetres or several centimetres in diameter, white or red in colour and often surrounded by a red flare, and are often itchy. Each wheal may last minutes to hours and may change in shape – round, form rings, a map-like pattern or large patches.

Some people find urticaria more noticeable at certain times of day, or when they are warm or upset.

Allergic reactions may cause skin symptoms such as hives. Question the patient about exposure to new detergents, soaps or shampoos, or whether they have eaten something which might cause a reaction.

Adverse drug reactions may present as rash or hives. Question patient on current or recent drug treatment, especially antibiotics.

Insect bites usually start as small, itchy red bumps or blisters. Bee and wasp stings usually start as a sharp burning pain which may progress to a red,

swollen welt.


Bites may progress to larger reactions with inflammation, pain, severe itching and swelling, and in some cases, fever, hives, and joint pain.

Severe reactions (anaphylaxis) may cause facial swelling and trouble breathing. Bites from ants may cause a painful, itchy raised pustule. Location of the bite may give some clue as to the type of insect that caused it:

o Flying insects tend to bite or sting exposed skin areaso Flea bites are likely to be on the lower legs and around the waist, often occurring in

clusterso Bedbugs may bite in clusters, usually around the head and necko Ticks attach themselves as a person brushes past leaves and grasses the ticks are

in. Once in contact, they may move to a warm and moist location such as the armpit, groin, back of the knee, or hairline, where they burrow into the host’s skin and feed off their blood

o Black fly bites are often along the hairline and around the earso Sand fly bites are usually in clusters around the ankles.

Treatment3

Goal of Treatment

Improve symptoms

Nonpharmacologic Treatment

Cold compresses to minimize swelling Oatmeal or baking soda baths to soothe itch. Application of a paste of baking soda and water, left on for 15 to 20 minutes. For stings, recommend lying down and lowering stung arm or leg. Removal of honey bee stingers as quickly as possible to stop further venom release.

Scratch out the stinger with fingernail or something flat; do not pull it to avoid forcing more venom into the skin.

Prompt and careful removal of ticks – use tweezers to grasp the tick near the head or mouth and gently pull to remove the whole tick without crushing it. If possible, seal the tick in a jar in to take to the doctor should signs of illness develop after a bite. Wash hands and bite area with soap and water. Seek medical attention if the entire tick cannot be removed.


Nonprescription drug options

Oral antihistamines Oral analgesics and/or non-steroidal anti-inflammatory drugs Topical corticosteroids Topical counterirritants Any patient who has had a systemic reaction to an allergen, bite or sting should carry an

epinephrine injector device.

Prescription drug options4

Topical corticosteroids


Relief expected from symptoms within 24 hours; further assessment required if no improvement or symptoms worsen, or if symptoms do not resolve in 7 days.

Adverse effects are rare. Provide patients with advice on avoiding allergen, and/or future insect bites or stings:

o Wear light-coloured clothing and long sleeves and pants when outside, especially in wooded areas and tall grasses.

o Be aware that mosquitoes are most active at dawn and dusk.o Stay away from wasp nests and keep food inside or well-covered.o Wear appropriate insect repellent /protective clothing when outdoors, especially

during West Nile Virus season (June-September).o Check yourself and pets regularly when returning from potential tick habitats.

Remind patients with systemic reactions, or who have had a large local reaction, to carry an epinephrine injector device.

Bites from mites or fleas on pets may require veterinary treatment of the animal.

C. Impetigo

Description

Impetigo is a skin infection common in children and highly contagious through direct contact with lesions or infected exudate.

The most common causative agents are Staphylococcus aureus alone or in combination with Streptococcus pyogenes (also known as group A streptococcus)

There are two types: non-bullous (most common) and bullous impetigo (see Differential Diagnosis).

Generally a self-limiting condition, but rare complications can include cellulitis, septicemia, osteomyelitis, septic arthritis, lymphangitis, lymphadentitis and acute poststreptococcal glomerulonephritis.

4 Refer to individual drug monographs for detailed information on contraindications, cautions, adverse effects, interactions and dosing.


Signs and Symptoms

Non-bullous impetigoo Begins as small maculopapular lesions that change into thin-walled vesicles that

rupture leaving superficial erosions covered by honey-coloured crusts.o Lesions are generally 1 – 3 cm, may be itchy and tender and heal without scarring o Most commonly affects the exposed skin of the face and the extremities o Regional lymph nodes may be swollen and tender, but systemic symptoms,

including fever, are unlikelyo Most commonly caused by Staphylococcus aureus, but Streptococcus pyogenes

may be involved, especially in warm, humid climates.

Treatment5

Goals of Treatment

Relieve symptoms and heal lesions Prevent spread of infection

Nonpharmacologic Treatment

Patient education to prevent spread of infectiono Avoid scratching or picking soreso Keep fingernails short.o Wash hands often and void touching other parts of the body, and other people, after

touching lesions.o Keep infected person’s clothing and towels separate from other members of the

family. Launder frequently. Prior to application of a topical antibiotic, remove crusts with warm water or saline

compresses (applied for 10-15 minutes, using a clean compress each time) or soap and water washes – 3 to 4 times per day.


Topical polymyxin B plus bacitracin and/or gramicidin



Topical antibacterials mupirocin and fusidic acid have similar efficacy, and are as or more effective than oral therapy when impetigo is not extensive.

Ointments are more occlusive than creams; if necessary, the area can be covered with gauze.

Mupirocin 2% cream or ointment has minimal systemic absorption. The ointment contains propylene glycol – avoid intranasal application or if hypersensitive

Fusidic acid 2% cream or sodium fusidate 2% ointment: up to 2% of fusidic acid is absorbed systemically. The ointment contains lanolin; avoid if hypersensitive.

Topical fusidic acid/hydrocortisone combination products have no evidence of improved outcomes vs. fusidic acid monotherapy.


Refer the patient for further assessment if there is no improvement after 48 hours of treatment, if condition spreads or worsens at any time, or if the patient develops a fever.

All vesicles and crusts should clear by 7-10 days with treatment; normal skin appearance is expected after 2-3 weeks.

If red marks persist on the skin after the lesions heal, reassure the patient that these post-inflammatory pigment skin changes can take several months to resolve. If no improvement after several months, refer for further assessment.

If patient experiences recurrent infections (within a few months), refer for further assessment to rule out MRSA.

Adverse effects are uncommon. Persistent irritation, redness, swelling, rash or itching may indicate hypersensitivity.

D. Fungal Infections of the Skin

Description

Fungal infections of the skin are common. Three dermatophytes (Trichophyton, Epidermophyton and Microsporum) which use the

keratin layer of the epidermis for nutrition, and the yeast-like fungi, Candida or Malassezia furfur, are responsible for most superficial fungal infections of the skin.



Dermatophyte infections

Description

Tinea infections are classified by location on the body, not by the causative organism. Tinea infections are contagious. They may be spread by skin to skin contact (tinea pedis is

often the cause of tinea corporis or cruris through self-inoculation), through contaminated towels, clothing or surfaces, and occasionally, through infected soil or animals.

Tinea dermatophytes proliferate in warm, humid places such as showers, swimming pools, and changing rooms.

Tinea corporis and tinea cruris affects 10-20% of the general population at some point in their lifetime and up to 44% of wrestlers (tinea corporis gladiatorum).

Tinea corporis affects men more than women; tinea cruris is most common in men and athletes. People with diabetes or who are overweight are also more susceptible to tinea cruris.

Tinea pedis has an incidence of up to 50% of the general population.o More common in men and teenagers; rare in children under 12 years of age.o Classified as:

Interdigital infection, the most common form White, cracked, macerated areas between the toes Untreated, it may progress to moccasin-type tinea pedis

Moccasin-type infection Usually present on the soles of both feet and may progress to sides and

top of foot Diffuse inflammation and scaling Often affects the toenails

Vesiculobullous type infection Blistering on the instep and middle of the bottom of the arch More often seen in summer

Treatment:7

Goals of therapy

Eradicate causative organism Resolve the lesion and symptoms Prevent spread of infection Prevent secondary complications



Patient educationo Keep site dry to prevent spread of infection.o Use a hair dryer on cool setting to dry the affected area.o Wear loose fitting, cotton clothing or moisture absorbing synthetics.o Although a person should no longer be contagious 24 hours following initiation of

treatment, the patient should be instructed to avoid direct skin contact with others and sharing clothing or personal items, and restrict activities such as wrestling and swimming. Launder items used by the infected person separately and often.

o Avoid rubbing or scratching lesions.o Have pets examined by a veterinarian to make sure they are not carrying a fungal

infection; have the animal treated if it is a carrier.o Clean and dry affected area before applying topical treatments. Apply topical

treatments to visible lesions as well as 2-5 cm outside the visible infection to help treat fungus in the process of spreading.

Cornstarch-free nonmedicated powders to help absorb moisture.


Nonprescription topical antifungals:o Effective in treating tinea skin infections but may require longer duration of treatment

versus prescription agents.o Generally, creams and solutions are most effective because they can be massaged

into the affected area so more product comes in contact with the fungus. Solutions are easier to apply to hairy areas; sprays and powders can be useful adjunctive treatment, especially for oozing lesions and as preventive agents.

o Clotrimazole and miconazole are the agents of choice in pregnancy.o Clotrimazole is the agent of choice in breastfeeding patients, but miconazole is

acceptable.o Tolnaftate has not been thoroughly studied in pregnancy and lactation.

Prescription Drug Options8

Prescription topical antifungals o Topical nystatin is ineffective for tinea infections.

Steroid or combination steroid- antifungal products o Topical treatment may be tried for tinea manuum, but systemic therapy may be

required.



o The itch caused by tinea infections subsides fairly soon after topical antifungal treatment begins. Extended treatment with steroid or steroids/antifungal products may unnecessarily expose patients to steroid side effects.

Topical antifungals in pediatrics:o Ciclopirox safety and effectiveness in children under 10 has not been established.o Ketoconazole can be used in infants and childreno Terbinafine has not been studied in children under 12 and should not be

recommended.


Improvement of symptoms such as itching and burning occurs within a few days, and the infection should not spread once treatment begins.

Follow up in 7 days to assess initial effect of topical treatment. If symptoms are improving, advise patient to continue treatment for 1 week after symptoms

disappear (except terbinafine). Refer for further assessment if there is no improvement, or if symptoms worsen. Minor redness, itching or stinging does not usually require discontinuation. Persistent or severe symptoms may indicate a contact dermatitis reaction to a component

of the anti-fungal cream. Advise patient to stop therapy and refer for further assessment.

Yeast Infections: Pityriasis Versicolor (Tinea Versicolor)

Description

Commonly presents as multiple white to reddish- brown macules that may coalesce to form large patches that range in colour from white to tan. A fine scale is noticeable when scratched.

Neither contagious nor related to poor hygiene.

Treatment9

Goals of Therapy

Reduce or eliminate yeast elements Reduce or heal skin lesions and symptoms Prevent recurrences


Environmental measures – control excess heat and humidity Avoid application of oil to the skin – Malassezia can overgrow in such conditions.


Topical agents:


o Selenium sulfide 2.5% shampooo Azole creams - clotrimazole 1%, miconazole 2%o Ketoconazole 2% shampooo Sulfur 2%o Salicylic acido Zinc pyrithione 1% or 2% shampooo Benzoyl peroxideo Compounded propylene glycol 50%


Topical antifungal creams


Follow up in 7 days to assess initial effect of topical treatment. Refer for further assessment if there is no improvement or if the condition worsens.. While scaling improves promptly, pigmentary changes may take weeks to months to

resolve. Minor redness, itching or stinging from topical therapy does not usually require

discontinuation. Persistent or severe symptoms may indicate a contact dermatitis reaction to a component of the cream. Advise patient to stop therapy and refer for further assessment.

Yeast Infections: Cutaneous Candidiasis

Description

Candida yeasts are part of the normal flora. Intertrigo is the most common form of C. albicans infection.

Any skin fold area can be affected: gluteal fold, axillae, interdigital spaces, under breasts or abdominal folds

Candidal diaper dermatitis - secondary infection; typically a 3+ day history of irritant contact dermatitis rash on buttocks and pubic skin. Can be painful, with severe crying during diaper changes or when urinating/defecating.



Treatment11


Strategies to keep skin dry and promote healing in adults:o Avoid tight fitting clotheso Cool water or astringent soaks (aluminum acetate) followed by air dryingo Cornstarch-free, nonmedicated powders.

Strategies for candida diaper dermatitis:o Frequent diaper changeso Wash skin with warm water, alone or with mild soap, patting to dryo Expose diaper area to air as much as possibleo Avoid use of perfumed or lanolin-containing wipes and products, and powderso Try to avoid irritants (caffeine, citrus, or spicy foods) in mother's diet in breastfed

infants.o Avoid feeding infant food that can cause diarrheao Avoid applying barrier products to diaper area until candida infection clears.


Topical antifungal creams for infection Topical hydrocortisone 0.5% cream for inflammation Tolnaftate and undecylenic acid are ineffective.


Topical antifungal creamso Ciclopirox 1% (individuals 10 years of age and older)o Ketoconazole 2% (indicated for all ages)o Terbinafine 1% (individuals 12 years and older).

Low-potency steroid creams- e.g. hydrocortisone 1% If both antifungal and steroid creams are being used, advise patient to apply separately (by

a few minutes) to avoid diluting concentrations of active ingredients.


Symptoms should improve within 7 days. If not, refer for further assessment. Local effects- if symptoms worsen with application of topical treatment, discontinue and

seek further assessment. Advise patient on nonpharmacologic strategies after resolution to prevent recurrences.

11 Refer to standard clinical references for a full discussion of treatment.12 Refer to individual drug monographs for detailed information on contraindications, cautions, adverse effects, interactions and dosing.


i References:DermNet NZ http://dermnetnz.org/eTherapeutics: Minor AilmentsMedSask Guidelines for Minor Ailment Prescribing http://medsask.usask.ca/professional/guidelines/index.phpHartman-Adams, H., Banvard, C., Juckett, G. (2014) Impetigo: Diagnosis and Treatment. American Family Physician, 90(4), 229-235.

http://medsask.usask.ca/professional/guidelines/index.php

http://dermnetnz.org/

pans.ns.ca · web viewacne rosacea - pustules, dilated/broken blood vessels; facial flushing...

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