Paul Rutter BPharm MRPharmS PHD Community Pharmacy Symptoms, Diagnosis and Treatment, 3e
Paul Rutter BPharm MRPharmS PHD Community Pharmacy Symptoms, Diagnosis and Treatment, 3e
Paul Rutter BPharm MRPharmS PHD Community Pharmacy Symptoms, Diagnosis and Treatment, 3e
THIRD EDITION
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2013
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
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Contents
1 Respiratory system 1
2 Ophthalmology 43
3 Ear conditions 67
4 Central nervous system 79
5 Women’s health 107
6 Gastroenterology 133
7 Dermatology 195
8 Musculoskeletal conditions 259
9 Paediatrics 283
10 Specific product requests 313
Abbreviations 339
Glossary of terms 341
Index 343
Useful web sites
Evidence-based Medicine Guild of Healthcare Pharmacists
National Institute for Health and Clinical Excellence http://www.ghp.org.uk/
http://www.nice.org.uk/ UK Clinical Pharmacists Association
Bandolier – evidence-based medicine journal http://www.ukcpa.org/
http://www.medicine.ox.ac.uk/bandolier/ Association of the British Pharmaceutical Industry
Centre for Reviews and Dissemination http://www.abpi.org.uk/
http://www.york.ac.uk/inst/crd/ The Proprietary Association of Great Britain
Medicines and Prescribing support from NICE http://www.pagb.co.uk/
http://www.nice.org.uk/mpc/ British Pharmaceutical Students Association
Midlands Therapeutics Review and Advisory Committee http://www.bpsa.com
http://www.keele.ac.uk/schools/pharm/MTRAC/ International Pharmaceutical Federation (FIP)
Newcastle Regional Drug and Therapeutics Centre http://www.fip.org/
http://www.nyrdtc.nhs.uk/ World Health Organization
King’s Fund http://www.who.ch/
http://www.kingsfund.org.uk/ Medicines and Healthcare products Regulatory Agency
http://www.mhra.gov.uk/index.htm#page=DynamicListMe
Medicines Information dicines
National Electronic Library for Medicines
http://www.nelm.nhs.uk/en/ Journals
UK Medicines Information British Journal of General Practice
http://www.ukmi.nhs.uk/ http://www.rcgp.org.uk/brjgenpract.aspx
Electronic Medicines Compendium British Medical Journal
http://www.emc.medicines.org.uk/ http://www.bmj.com/
UK Medicines Information Central Health Services Research
http://www.ukmicentral.nhs.uk/ http://www.hsr.org/
Prodigy (formerly Clinical Knowledge Summaries) Nursing Standard
http://prodigy.clarity.co.uk/home http://www.nursing-standard.co.uk
PAGB Medicines chest Pharmaceutical Journal
http://www.medicinechestonline.com/ http://www.pharmj.com
Chemist and Druggist
Organisations & Associations http://www.chemistanddruggist.co.uk/1
Royal Pharmaceutical Society
The Lancet
http://www.rpharms.com/home/home.asp
http://www.thelancet.com/
The British Medical Association
International Journal of Clinical Pharmacy
http://www.bma.org
http://www.springer.com/medicine/internal/journal/11096
The Nursing and Midwifery Council
http://www.nmc-uk.org/
General Health Sites for Patients
National Pharmacy Association http://www.patient.co.uk
http://www.npa.co.uk/ http://www.healthfinder.gov/
Pharmaceutical Services Negotiating Committee http://www.mayoclinic.com/index.cfm?
http://www.psnc.org.uk/ http://www.bbc.co.uk/health/
Preface
Demand on healthcare professionals to deliver high- alpha-blockers) allowing community pharmacists to manage
quality patient care has never been greater. A multitude of and treat a wider range of conditions.
factors impinge on healthcare delivery today, including an Further deregulation of medicines to treat acute illness
ageing population, more sophisticated medicines, high from different therapeutic areas seems likely, especially as
patient expectation, health service infrastructure, as well as healthcare professional opinion to acute medicine deregu-
adequate and appropriate staffing levels. In primary care lation is broadly positive and the impact on general prac-
the medical practitioner role is pivotal in providing this tice workload associated with dealing with minor ailments
care and they remain the central member of the healthcare is high (and represents 100 to 150 million GP consultations
team, but demands on their time mean other models of per annum). Government policy now seems also to embrace
service delivery are being adopted in the UK and in other chronic disease management as a self-care activity, and
developed countries that utilise other types of healthcare might well be the largest area for future growth of reclas-
professionals. sification of medicines. The UK, in 2004, was the first
This is leading to a breaking down of the traditional country in the world to deregulate simvastatin; subse-
boundaries of care between doctors, nurses, and pharma- quently, orlistat for the treatment of obesity (2008) and
cists. In particular, certain medical practitioner responsi- tamsulosin (2010) for benign prostatic hyperplasia, have
bilities, which were once seen as their sole domain, are become available.
now being performed by nurses and pharmacists, for Pharmacists, now more than ever before, need to dem-
example, specialist practice nurses; and, more recently, onstrate that they are competent practitioners to be trusted
independent prescribing status allows nurses and pharma- with this additional responsibility. Therefore pharmacists
cists to prescribe medicines. This change in responsibilities require greater levels of knowledge and understanding
is now firmly established in UK government healthcare about commonly occurring medical conditions. They will
policy. Probably of greatest impact to community phar- need to be able to recognise their signs and symptoms, and
macy practice is the prominence placed on self-care by use an evidence-based approach to treatment.
Western governments. In the UK, the government self-care This was, and still is, the catalyst for this book. Although
agenda is clear, with numerous published policy papers other books targeted for pharmacists on diagnosis are
detailing how maximising self-care can be achieved. In published, this book aims to give a more in-depth view of
May 2011, the self-care forum (http://www.selfcareforum. minor conditions and how to differentiate them from more
org/) was established, the purpose of which is to promote sinister pathology that may present in a similar way. The
self-care and embed it in everyday life. book is intended for all non-medical prescribers but espe-
This drive for patients to manage their own health cially for pharmacists, from undergraduate students to
has been facilitated by the Government making more experienced practitioners.
medicines available over the counter. In the UK, between It is hoped that the information contained within the
1983 and 2011, over 80 prescription-only medicines have book is both informative and useful.
been reclassified as pharmacy medicines (sold under
the supervision of the pharmacist). More recent switches Paul Rutter
have included products from new therapeutic classes Wolverhampton
(e.g. anti-emetics, proton pump inhibitors, triptans and
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Introduction
Community pharmacists are the most accessible healthcare Whilst pharmacists could (and some argue should)
professional. No appointment is needed to consult a phar- perform simple physical examinations, most do not, due
macist and patients can receive free, unbiased advice to the lack of training they receive; diagnostic testing is
almost anywhere. A community pharmacist is often the never employed because of the cost (which would have to
first health professional the patient seeks advice from and, be passed on to the patient), the invasive nature of most
as such, provides a filtering mechanism whereby minor tests (e.g. blood taking for analysis) and the lack of imme-
self-limiting conditions can be appropriately treated with diacy in gaining test results.
the correct medication and patients with more sinister Having said this, a number of studies have shown that
pathology referred on to the GP for further investigation. patient history taking is by far the most important element
On a typical day a pharmacist practising in an ‘average’ of arriving at a correct diagnosis, although performing
community pharmacy can realistically expect to help physical examinations and conducting laboratory investi-
between 5 and 15 patients a day who present with various gations do improve the odds of getting the diagnosis right.
symptoms for which they are seeking advice, reassurance, It is vital, therefore, that pharmacists possess excellent
treatment or a combination of all three. communication skills to ensure the correct information is
Current UK health policy, and that of other Western obtained from the patient. This will be drawn from a com-
countries, of making more medicines available has pro- bination of good questioning technique, listening actively
moted patient self-care, and with it a greater role for to the patient and picking up on non-verbal cues.
community pharmacists. The UK over-the-counter (OTC)
medicines market has seen considerable growth over the
last few years, and in 2010 was worth over £2.3 billion. Approaches to differential diagnosis
The upward sales trend for OTC medicines, the UK govern-
ment’s continued promotion of self-care and ever increas- Try to avoid using acronyms
ing demands on primary healthcare services means that
OTC medicines have, and will continue to play, an impor- Traditionally, the use of acronyms has been advocated to
tant part in disease management. help pharmacists remember what questions to ask a patient.
However, it is important that pharmacists do not solely
rely on acronyms in trying to differentially diagnose a
person’s presenting complaint; acronyms are rigid, inflex-
Communication skills ible and often inappropriate. Every patient is different and
therefore it is unlikely that an acronym can be fully
The ability of the community pharmacist to diagnose the
applied, and more importantly, using acronyms can mean
patient’s presenting signs and symptoms is a significant
that vital information is missed, which could shape your
challenge given that, unlike most other healthcare profes-
course of action. Some of the more commonly used acro-
sionals, community pharmacists do not normally have
nyms are discussed briefly below.
access to the patient’s medical record and thus have no
idea about what the person’s problem is until a conversa-
WWHAM
tion is initiated.
For the most part, pharmacists will be totally dependent This is the simplest acronym to remember but it is also the
on their ability to question patients in order to arrive at a worst one to use. It gives the pharmacist very limited
differential diagnosis. This is in stark contrast to the GP information from which to work and it is unlikely that a
and to a lesser extent the nurse, who can draw on physical correct differential diagnosis will be made. It should be
examination and diagnostic tests to help them arrive at a used with caution and it is probably only helpful for
diagnosis. counter assistants to use when a patient first presents, so
x Introduction
Meaning of Attributes of the acronym
the letter
that a general picture of the person’s presenting complaint
Meaning of Attributes of the acronym
can be established.
the letter
In addition, clinical experience (pattern recognition) A 31-year old female asks for advice about a head-
also plays a part in the process. Certain conditions have ache she has.
very characteristic presentations and, once seen, it is a What are your initial thoughts? (Formulating a diagno-
relatively straightforward task to diagnose the next case sis based on the patient and the initial presenting
by recalling the appearance of the rash. Therefore, much complaint.):
of daily practice will consist of seeing new cases that
strongly resemble previous encounters and comparing new • The patient is present
cases to old. • The patient is female and in her early 30s
• The patient looks and sounds OK
• Epidemiology states tension-type headacheis most
Key steps in the process likely but women are more prone to migraine than
men.
1. Formulating a diagnosis based on the patient
and the initial presenting complaint What line of questioning do you take?
Your main aim is to differentiate between tension-type
Before any questions are asked of the patient you should
and migraine headache.
consider who the patient is and how this may influence
your thinking.
Nature of the pain
• What is the general appearance of the patient? Does the Tension headache usually produces a dull ache, as opposed
person look well or poorly? Is the person you are about
to the throbbing nature of migraine pain:
to talk to the patient or someone acting on the patient’s
behalf? This will shape your thinking as to the severity • Patient’s response: dull ache
of the problem. • Pharmacist’s thoughts: suggestive of tension-type
• How old is the patient? This is very useful information. headache.
Epidemiological studies for a wide range of conditions
and disease states has shown that certain age groups Location of pain
will suffer from certain problems. For example, it is
very unlikely that a child who presents with cough will Tension headache is generally bilateral; migraine is nor-
have chronic bronchitis but the probability of an elderly mally unilateral
person having chronic bronchitis is much higher.
• Patient’s response: all over
• What sex is the patient? As with age, sex can dramati- • Pharmacist’s thoughts: suggestive of tension-type
cally alter the chances of suffering from certain condi- headache.
tions. Migraines are five times more common in women
than men, yet cluster headache is nine times more Severity of pain
common in men than women.
• What is the presenting complaint? Some conditions are
Tension headache is not usually severe and disabling;
much more common than others. Therefore you could migraine can be disabling
form an idea of what condition the patient is likely to
be suffering from based on the laws of probability
• Patient’s response: bothersome more than stopping her
doing things
(epidemiology). For example, if a person presents with
a headache then you should already know that the
• Pharmacist’s thoughts: suggestive of tension
headache.
most common cause of headache is tension-type head-
ache, followed by migraine and then sinusitis. Other The answers so far are indicative of tension-type head-
causes of headache are rare but obviously need to be ache. However, further specific questions relating to life-
eliminated. Your line of questioning should try to style and previous and family history should be asked. It
confirm or refute the most likely causes of headache. would be expected that there was no family history of
migraine and there is probably some trigger factor causing
the headache, for example, increased stress due to work or
2. Asking questions
personal pressures. The patient might therefore have had
The questions you ask the patient will be specific to that similar headaches in the past.
patient. After establishing who the person is, how poorly Finally, even though at this stage you are confident of
he or she is and what the presenting complaint is, a your differential diagnosis you should still ask a couple of
number of targeted questions specific to that patient should questions to rule out any sinister pathology. Obviously
be asked. The following scenario will illustrate this point. you are expecting the answers from these questions to be
xii Introduction
negative to support your differential diagnosis. Any ques- information at this stage will not only help you formulate
tions that invoke the opposite to that expected will require your final diagnosis but will also allow the patient to add
further investigation. further information or correct you on facts that you have
failed to remember correctly.
The way in which one goes about establishing what
is wrong with the patient will vary from practitioner
3. Confirm facts
to practitioner. However, it is important that whatever
Before making a recommendation to the patient it is method is adopted it must be sufficiently robust enough
always helpful to try and re-cap on the information elic- to be of benefit to the patient. Using a clinical reasoning
ited. This is especially important when you have had to approach to differential diagnosis allows you to build a
ask a lot of questions. It is well known that short-term fuller picture of the patient’s presenting complaint. It is
working memory is relatively small and that remembering both flexible and specific to each individual, unlike the
all the pertinent facts is difficult. Summarising the use of acronyms.
How to use the book
The book is divided into 10 chapters. The first nine chapters diagnosis from the position of clinical decision-making. To
are systems based and structured in the format shown in help summarise the information, tables and algorithms are
Fig. 1. The final chapter is product based and has a slightly included for many of the conditions.
different format. A list of abbreviations and a glossary are
included at the end of the book.
Arriving at a differential diagnosis
Key features of each chapter A table summarising the key questions that should be
asked for each condition is included. The relevance (i.e.
At the beginning of each chapter there is a short section the rationale for asking the question) is given for each
addressing basic anatomy and history taking specific to question. This will allow pharmacists to determine what
that body system. A basic understanding of the anatomical questions to ask of every patient to enable a differential
location of major structures is useful when attempting to diagnosis.
diagnose/exclude conditions from a patient’s presenting
complaint. It would be almost impossible to know whether
to treat or refer a patient who presented with symptoms
Primer for differential diagnosis
suggestive of renal colic if one doesn’t know where the
A ‘primer for differential diagnosis’ is available for a
kidneys are. However, this book is not intended to replace
number of conditions covered. This algorithmic approach
an anatomy text and the reader is referred to the list of
to differential diagnosis is geared toward nearly or recently
further reading for anatomy texts.
qualified pharmacists. They are not intended to be solely
relied upon in making a differential diagnosis but to act
as an aide memoire. It is anticipated that the primers will
Self-assessment questions be used in conjunction with the text, thus allowing a
broader understanding of the differential diagnosis of the
Twenty multiple choice questions and at least two case- condition to be considered.
studies are presented at the end of each chapter. These are
designed to test factual recall and applied knowledge. The
multiple choice questions are constructed to mimic those Triggers points indicative of referral
set in the pre-registration examination. They start with
simple traditional multiple choice questions in which the A summary box of trigger factors when it would be prudent
right answer has to be picked from a series of five possible to refer the patient to a medical practitioner is presented
answers, and work up to more complex questions which for each condition. These trigger factors are not absolute
are inter-related. and the pharmacist will have to use their professional
The case studies challenge you with ‘real-life’ situations. judgement on a case-by-case basis. For example, a person
All are drawn from practice and have been encountered with a cough of 3 days’ duration might need referral if
by practising pharmacists, but have been modified for they are visibly poorly.
inclusion in the book.
1. Respiratory system
2. Ophthalmology
3. Ear conditions
4. The central nervous system
5. Women's health
6. Gastroenterology
7. Dermatology
8. Musculoskeletal conditions
9. Paediatrics
10. Specific product requests Background
General overview of eye anatomy
History taking and the eye exam
Red eye
Eyelid disorders
Dry eye
Self-assessment
Red eye
Background
Prevalence and epidemiology
Aetiology
Arriving at a differential diagnosis
Clinical features of conjunctivitis
Conditions to eliminate
Evidence base for over-the-counter
medication
Practical prescribing and product selection
Further reading and web sites
(OTC) medicine works, and, second with a quick reference not fall readily into any of the other sections but is none
to the dose of the medicine and when and when it cannot the less useful. For example, some of the hints and tips
be prescribed. This does not replace standard textbooks boxes give advice on how to administer eye drops, sup-
such as Martindale or Stockley’s Drug Interactions, but it positories and other forms of medicines that are not taken
does allow the user to find basic data in one text without via the oral route.
having to reach for three or four other texts to answer
simple questions.
The pregnancy and breastfeeding recommendations in
References, further reading
this book are based largely on those from standard texts and web sites
such as: Briggs’ Drugs in Pregnancy and Lactation and,
Schaefers’ Drugs in Pregnancy and Lactation. In addition, To supplement the text, at the end of each condition a list
the UKMi web site has been used (http://www.ukmi.nhs. of selected references and reading is provided for those
uk/). Many manufacturers of OTC medicines advise against that wish to seek further information on the subject. Web
their products being used in these groups, but where pos- sites are also provided, and all sites have been checked
sible, in the summary tables reference is made to the and were active and relevant at the time of writing
recommendations made from these sources. This hopefully (Winter 2012).
will provide extra information for pharmacists if faced Finally, all information presented in the book is accu-
with queries from pregnant and lactating women. rate and factual as far as the author is aware. It is acknowl-
edged that guidelines change, products become discontinued
and new information becomes available over the lifetime
Hints and tips boxes of a book. Therefore, if any information in the book is not
current or valid, the author would be grateful of any feed-
A summary box of useful information is provided near the back; positive or negative to ensure that the next edition
end of each condition. This contains information that does is as up-to-date as possible.
Chapter 1
Respiratory system
In this chapter
Background 1 The common cold 12
General overview of the anatomy of Sore throats 19
the respiratory tract 1 Rhinitis 25
History taking and physical exam 2 Self-assessment questions 35
Cough 2
Trachea and bronchi chest’. In these cases the cough is probably productive in
nature and should be treated as such.
The trachea connects the larynx with the bronchi. The Coughs are either classed as acute or chronic in nature.
bronchi divide and subdivide into bronchioles and these The British Thoracic Society Guidelines (2006) recommend
in turn divide to form terminal bronchioles, which give that:
rise to alveoli where gaseous exchange takes place. The
epithelial lining of the bronchial tree acts as a defence • an acute cough lasts less than 3 weeks
mechanism known as the mucociliary escalator. Cilia on • chronic cough lasts more than 8 weeks.
the surface of cells beat upwards in organised waves of The guidelines acknowledge that a ‘grey area’ exists for
contraction thus expelling foreign bodies. those coughs lasting between 3 and 8 weeks as it is dif-
ficult to define their aetiological basis because all chronic
Lungs coughs will have started as an acute cough. For community
The lungs are cone shaped and lie in the thoracic cavity. pharmacy practice this ‘grey area’ is rather academic, as
Enclosing and protecting the lungs are the pleural mem- any cough lasting longer than the accepted definition of
branes; the inner membrane covers the lungs and the outer acute should be referred to a medical practitioner for
membrane is attached to the thoracic cavity. Between further investigation.
the membranes is the pleural cavity, which contains fluid
and prevents friction between the membranes during Prevalence and epidemiology
breathing.
Statistics from general medical practice show that respira-
tory illness accounts for more patient visits than any other
History taking and physical exam disease category. Acute cough is usually caused by a viral
upper respiratory tract infection (URTI) and constitutes
Cough, cold, sore throat and rhinitis often coexist and an 20% of consultations. This translates to 12 million GP
accurate history is therefore essential to differentially diag- visits per year and represents the largest single cause of
nose a patient who presents with symptoms of respiratory primary care consultation. In community pharmacy the
disease. A number of similar questions must be asked for figures are even higher with at least 24 million visits per
each symptom, although symptom-specific questions are year (or 2000 visits per pharmacy per year).
also needed (these are discussed under each heading, Schoolchildren experience the greatest number of
below). Currently, examination of the respiratory tract is coughs, with an estimated 7–10 episodes per year (as com-
outside the remit of the community pharmacist, unless they pared to adults with 2–5 episodes per year). Acute viral
have additional qualifications (e.g. independent prescriber URTIs exhibit seasonality, with higher incidence seen in
status). the winter months.
Aetiology
Cough A five-part cough reflex is responsible for cough produc-
tion. Receptors located mainly in the pharynx, larynx,
Background trachea and bifurcations of the large bronchi are stimu-
lated via mechanical, irritant or thermal mechanisms.
The main function of coughing is airway clearance. Excess Neural impulses are then carried along afferent pathways
secretions and foreign bodies are cleared from the lungs of the vagal and superior laryngeal nerves, which termi-
by a combination of coughing and the mucociliary esca nate at the cough centre in the medulla. Efferent fibres of
lator. (the upward beating of the finger-like cilia in the
the vagus and spinal nerves carry neural activity to the
bronchi that move mucus and entrapped foreign bodies to
muscles of the diaphragm, chest wall and abdomen. These
be expectorated or swallowed). Cough is the most common
muscles contract, followed by the sudden opening of the
respiratory symptom and one of the few ways by which
glottis that creates the cough.
abnormalities of the respiratory tract manifest themselves.
Cough can be very debilitating to the patients’ well-being
Arriving at a differential diagnosis
and be disruptive to family, friends and work colleagues.
Coughs can be described as either productive (chesty) The most likely cause of acute cough in primary care for
or non-productive (dry, tight, tickly). However, many all ages is viral URTI. Recurrent viral bronchitis is most
patients will say that they are not producing sputum, prevalent in preschool and young school-aged children
although they go on to say that they ‘can feel it on their and is the most common cause of persistent cough in
Cough 3
children of all ages. Table 1.1 highlights those conditions Table 1.1
1
that can be encountered by community pharmacists and Causes of cough and their relative incidence in
their relative incidence. community pharmacy
As viral infection is the most likely cause of cough
Incidence Cause
encountered by pharmacists it is logical to ask questions
that help to confirm or refute this assumption. However, Most Likely Viral infection
it is important to differentiate other causes of cough from
Likely Upper airways cough syndrome (formerly
viral causes and also refer those cases of cough that might
known as postnasal drip and includes
have more serious pathology. Asking symptom-specific
allergies), acute bronchitis
questions will help the pharmacist to determine if referral
is needed (Table 1.2). Unlikely Croup, chronic bronchitis, asthma,
pneumonia, ACE inhibitor induced
Clinical features of acute viral cough Very unlikely Heart failure, bronchiectasis, tuberculosis,
cancer, pneumothorax, lung abscess,
Viral coughs typically present with sudden onset and asso- nocardiasis, GORD
ciated fever. Sputum production is minimal and symptoms
? Table 1.2
Specific questions to ask the patient: Cough
Question Relevance
Sputum colour Mucoid (clear and white) is normally of little consequence and suggests that no infection is present
Yellow, green or brown sputum normally indicates infection. Mucopurulent sputum is generally
caused by a viral infection and does not require automatic referral
Haemoptysis can either be rust coloured (pneumonia), pink tinged (left ventricular failure) or dark red
(carcinoma). Occasionally, patients can produce sputum with bright red blood as one-off events.
This is due to the force of coughing causing a blood vessel to rupture. This is non-serious and does
not require automatic referral
Nature of sputum Thin and frothy suggests left ventricular failure
Thick, mucoid to yellow can suggest asthma
Offensive foul-smelling sputum suggests either bronchiectasis or lung abscess
Onset of cough A cough that is worse in the morning may suggest upper airways cough syndrome, bronchiectasis or
chronic bronchitis
Duration of cough URTI cough can linger for more than 3 weeks and is termed ‘postviral cough’. However, coughs lasting
longer than 3 weeks should be viewed with caution as the longer the cough is present the more
likely serious pathology is responsible; for example, the most likely diagnoses of cough are as
follows:
at 3 days duration will be a URTI;
at 3 weeks duration will be acute or chronic bronchitis;
and at 3 months duration conditions such as chronic bronchitis, tuberculosis and carcinoma
become more likely
Periodicity Adult patients with recurrent cough might have chronic bronchitis, especially if they smoke
Care should be exercised in children who present with recurrent cough and have a family history of
eczema, asthma or hay fever. This might suggest asthma and referral would be required for further
investigation
Age of the patient Children will most likely be suffering from a URTI but asthma and croup should be considered
With increasing age conditions such as bronchitis, pneumonia and carcinoma become more prevalent
Smoking history Patients who smoke are more prone to chronic and recurrent cough. Over time this might develop in
to chronic bronchitis and COPD
4 Respiratory system
are often worse in the evening. Associated cold symptoms The cough can be severe and violent and described as
are also often present; these usually last between 7 and 10 having a barking (seal-like) quality. In between coughing
days. Duration of longer than 14 days might suggest ‘post episodes the child may be breathless and struggle to
viral cough’ or possibly indicate a bacterial secondary breathe properly. Typically, symptoms improve during the
infection but this is clinically difficult to establish without day and often recur again the following night, with the
sputum samples being analysed. majority of children seeing symptoms resolve in 48 hours.
Warm moist air as a treatment for croup has been used
since the 19th century. This is either done by moving the
Conditions to eliminate
child to a bathroom and running a hot bath or shower or
Likely causes by boiling a kettle in the room. However, UK guidelines
(Prodigy, 2011) do not advocate humidification as there is
Upper airways cough syndrome no evidence to support its use.
(previously referred to as postnasal drip) Croup management is based on an assessment of sever-
Postnasal drip has recently (2006) been broadened to
ity. Advice by pharmacists should be that if symptoms
include a number of rhinosinus conditions related to
persist beyond 48 hours or the child exhibits any symp-
cough. The umbrella term of upper airways cough syn-
toms of stridor then medical intervention is required.
drome (UACS) is being adopted.
Standard treatment for those children with stridor would
UACS is characterised by a sinus or nasal discharge that
be oral or intra-muscular dexamethasone or nebulised
flows behind the nose and into the throat. Patients should
budesonide.
be asked if they are swallowing mucus or notice that they
are clearing their throat more than usual, as these features Chronic bronchitis
are commonly seen in patients with UACS. Allergies are Chronic bronchitis (CB), along with emphysema, is char-
one cause of UACS. Coughs caused by allergies are often acterised by the destruction of lung tissue and collectively
non-productive and worse at night. However, there are known as chronic obstructive pulmonary disease (COPD)
usually other associated symptoms, such as sneezing, nasal The prevalence of COPD in the UK is uncertain. However,
discharge/blockage, conjunctivitis and itching oral cavity. figures from the Health and Safety Executive (2010)
Cough of allergic origin might show seasonal variation, estimate that over a million individuals currently have
for example hay fever. Other causes include vasomotor a diagnosis of COPD, and accounts for 25 000 deaths
rhinitis (caused by odours and changes in temperature/ each year.
humidity) and post-infectious UACS after an URTI. If UACS Patients with CB often present with a long-standing
is present, it is better to direct treatment at the cause of history of recurrent acute bronchitis in which episodes
UACS (e.g. antihistamines or decongestants) rather than become increasingly severe and persist for increasing
just treat the cough. duration until the cough becomes continual. CB has been
defined as coughing up sputum on most days for three or
Acute bronchitis
more consecutive months over the previous 2 years. CB is
Most cases are seen in autumn or winter and symptoms
caused by chronic irritation of the airways by inhaled
are similar to viral URTI but patients also tend to exhibit
substances, especially tobacco smoke. A history of smoking
dyspnoea and wheeze. The cough usually lasts for 7–10
is the single most important factor in the aetiology of CB.
days but can persist for three weeks. The cause is normally
In non-smokers the likely cause of CB is UACS, asthma or
viral, but sometimes bacterial. Symptoms will resolve
gastro-oesophageal reflux. One study has shown that 99%
without antibiotic treatment, regardless of the cause.
of non-smokers with CB and a normal chest X-ray suffered
from one of these three conditions.
Unlikely causes
CB starts with a non-productive cough that later
Laryngotracheobronchitis (croup) becomes a mucopurulent productive cough. The patient
Symptoms are triggered by a recent viral infection, with should be questioned about smoking habit. If the patient
parainfluenza virus accounting for 75% of cases, although is a smoker the cough will usually be worse in the morning.
other viral pathogens implicated include the rhinovirus Secondary infections contribute to acute exacerbations
and respiratory syncytial virus. It affects infants aged seen in CB. It typically occurs in patients over the age of
between 3 months and 6 years old and affects 2 to 6% of 40 and is more common in men. Pharmacists have an
children. The incidence is highest between 1 and 2 years important role to play in identifying smokers with CB as
of age and occurs in boys more than girls; it is more this provides an excellent opportunity for health promo-
common in autumn and winter months. It often follows tion advice and assessing the patient’s willingness to stop
on from an URTI and occurs in the late evening and night. smoking.
Cough 5
1
The exact prevalence of asthma is unknown due to differ- pected then the pharmacist should discuss alternative
ing terminologies and definitions plus difficulties in correct medication with the prescriber, for example the incidence
diagnosis, especially in children, and co-morbidity with of cough with angiotension II receptor blockers is half that
COPD in the elderly. Best estimate of asthma prevalence in of ACE Inhibitors.
adults is approximately 4%, but it may be up to 10%. In
children the figures are higher (10–15%) because a propor- Very unlikely causes
tion of children will ‘grow out’ of it and be symptom free
by adulthood. Cough is a symptom of many other conditions, although
Asthma is a chronic inflammatory condition of the the majority will be rarely encountered in community
airways characterised by coughing, wheeze, chest tightness pharmacy. However, it is important to be aware of these
and shortness of breath. Classically these symptoms tend rare causes of cough to ensure that appropriate referrals
to be variable, intermittent, worse at night and provoked are made.
by triggers. In addition, possible associated features are
family or personal history of atopy and worsening symp- Heart failure
toms after taking non-steroidal anti-inflammatory drugs Heart failure is a condition of the elderly. The prevalence
(NSAIDs) or beta-blockers. of heart failure rises with increasing age; 3 to 5% of people
In the context of presentations to a community phar- aged over 65 are affected and this increases to approxi-
macist, asthma can present as a non-productive cough, mately 10% of patients aged 80 and over. Heart failure is
especially in young children where the cough is often characterised by insidious progression and diagnosing
worst at night. In these cases pay particular attention to early mild heart failure is extremely difficult because
other possible symptoms such as chest tightness, wheeze symptoms are not pronounced. Often, the first symptoms
and difficulty in breathing, which may be frequent and patients experience are shortness of breath, orthopnoea
recurrent and occur even when the child does not have and dyspnoea at night. As the condition progresses from
a cold. mild/moderate to severe heart failure patients might
complain of a productive, frothy cough, which may have
pink-tinged sputum.
Pneumonia (community acquired)
Bacterial infection is usually responsible for pneumonia
Bronchiectasis
and most commonly caused by Streptococcus pneumoniae
Bronchiectasis is caused by irreversible dilation of the
(80% of cases), although other pathogens are also respon-
bronchi. Characteristically, the patient has a chronic cough
sible, e.g. Chlamydia and Mycoplasma. Initially, the cough
of very long duration, which produces copious amounts of
is non-productive and painful (first 24 to 48 hours), but
mucopurulent sputum (green-yellow in colour) that is
rapidly becomes productive, with sputum being stained
usually foul smelling. The cough tends to be worse in the
red. The intensity of the redness varies depending on the
morning and evening. In long-standing cases the sputum
causative organism. The cough tends to be worst at night.
is said to display characteristic layering with the top being
The patient will be unwell, with a high fever, malaise,
frothy, the middle clear and the bottom dense with puru-
headache, breathlessness, and experience pleuritic pain
lent particles.
(inflammation of pleural membranes, manifested as pain
to the sides) that worsens on inspiration. Urgent referral
Tuberculosis
to the doctor is required as antibiotics should be started as
Tuberculosis (TB) is a bacterial infection caused by Myco-
soon as possible.
bacterium tuberculosis and is transmitted primarily by
inhalation. After many decades of decline, the number of
Medicine-induced cough or wheeze new TB cases occurring in industrialised countries is now
A number of medicines may cause bronchoconstriction, starting to increase. In 2009, UK figures showed that over
which presents as cough or wheeze. Angiotensin-converting 9000 cases were notified – an increase of 4% on the previ-
enzyme (ACE) inhibitors are most commonly associated ous year and the highest number for nearly 30 years.
with cough. Incidence might be as high as 16%; it is not The incidence is higher in inner city areas (especially
dose related and time to onset is variable, ranging from a London and the West Midlands), among the elderly and
few hours to more than 1 year after the start of treatment. immigrants from developing countries. TB is characterised
Cough invariably ceases after withdrawal of the ACE by its slow onset and initial mild symptoms. The cough
inhibitor but takes 3 to 4 weeks to resolve. Other medicines is chronic in nature and sputum production can vary
that are associated with cough or wheeze are NSAIDs and from mild to severe with associated haemoptysis. Other
6 Respiratory system
symptoms of the condition are malaise, fever, night sweats inhalation. It is very unlikely a pharmacist will ever
and weight loss. However, not all patients will experience encounter this condition and is included in this text for
all symptoms. A patient with a productive cough for more the sake of completeness. It has a higher incidence in the
than 3 weeks and exhibiting one or more of the associated elderly population, especially men. The sputum is purulent,
symptoms should be referred for further investigation, thick and possibly blood tinged. Fever is prominent and
especially if they fall into one of the groups listed above. night sweats, pleurisy, weight loss and fatigue might also
Chest X-rays and sputum smear tests can be performed to be present.
confirm the diagnosis. Figure 1.1 will aid the differentiation between serious
and non-serious conditions of cough in adults.
Carcinoma of the lung
A number of studies have shown that between 20 and 90%
of patients will develop a cough at some point during the
progression of carcinoma of the lung. The possibility of
carcinoma increases in long-term cigarette smokers who
! TRIGGER POINTS indicative of referral: Cough
have had a cough for a number of months or who develop Symptoms/signs Possible danger/reason for
a marked change in the character of their cough. The cough referral
produces small amounts of sputum that might be blood Chest pain All are symptoms outside
streaked. Other symptoms that can be associated with the Haemoptysis remit of community
cough are dyspnoea, weight loss and fatigue. Pain on inspiration pharmacist
Wheeze and/or
Lung abscess shortness of breath
A typical presentation is of a non-productive cough with Duration longer than 3 Suggests non-acute cause of
pleuritic pain and dyspnoea. It is more common in the weeks cough and requires
elderly. Signs of infection such as malaise and fever can Cough that recurs on a further investigation
also be present. Later the cough produces large amounts regular basis
of purulent and often foul-smelling sputum. Debilitating symptoms This patient group at greater
in the elderly risk of complications
Spontaneous pneumothorax (collapsed lung) Persistent nocturnal Suggests possible asthma
Rupture of the bullae (the small air or fluid filled sacs in cough in children
the lung) can cause spontaneous pneumothorax but nor-
mally there is no underlying cause. It affects approxi-
mately 1 in 10 000 people, usually tall, thin men between
20 and 40 years old. Cigarette smoking and a family Evidence base for over-the-counter medication
history of pneumothorax are contributing risk factors. This
can be a life-threatening disorder causing a non-productive Cough is often trivialised by practitioners but coughing
cough and severe respiratory distress. The patient experi- can impair quality of life and cause anxiety to parents of
ences sudden sharp unilateral chest pain that worsens on children with cough. Patients who exercise self-care will
inspiration. The symptoms often begin suddenly, and can be confronted with a plethora of over-the-counter (OTC)
occur during rest or sleep. medication and many will find the choice overwhelming.
The pharmacist must ensure that the most appropriate
Gastro-oesophageal reflux disease medication is selected for the patient, but this must be done
Gastro-oesophageal reflux disease (GORD) does not usually on an evidence based approach.
present with cough but patients with this condition might All the active ingredients to treat cough were brought
cough when recumbent (lying down). The patient might to the market many years ago when clinical trials suf-
show symptoms of reflux or heartburn. Patients with fered from flaws in study design compared to today’s
GORD have increased cough reflex sensitivity and respond standards, thus clinical efficacy is therefore difficult to
well to proton pump inhibitors. It should always be con- establish.
sidered in all cases of unexplained cough.
Expectorants
Nocardiasis
Nocardiasis is an extremely rare bacterial infection caused A number of active ingredients have been formulated
by Nocardia asteroides; it is transmitted primarily by to help expectoration, including guaifenesin, ammonium
Cough 7
1
Duration Referral symptoms present Refer
Productive Non-productive
Sputum ❸ Sudden onset
colour
Yes No
Mucoid and/or Symptoms associated with ❹ Periodic in nature
mucopurulent
Haemoptysis ➎ infection
Yes No No Yes
Symptoms ❹
Throat Throat Allergy
associated with Refer Viral-Treat
clearing clearing symptoms
infection
Yes No No Yes No
Symptoms
Treat
Trigger ➏ Postnasal drip Refer
debilitating factors
Yes No
Family history
Refer Treat Treat
of asthma
Yes No No No Yes
Avoid triggers,
Treat, but refer if persists Refer
no treatment needed
salts, ipecacuanha, creosote and squill. The majority of an effective antitussive in animal models, and cough-
products marketed in the UK for productive cough induced studies in humans have also shown codeine to
contain guaifenesin, although products containing squill be effective. However, these findings appear to be less
(e.g. Buttercup Syrup) are available. The clinical evidence reproducible in acute and pathological chronic cough.
available for any active ingredient is limited. Older More recent studies have failed to demonstrate a signifi-
ingredients such as ammonium salts, ipecacuanha and cant clinical effect of codeine compared with placebo in
squill were traditionally used to induce vomiting as it patients suffering with acute cough. Greater voluntary
was believed that at subemetic doses they would cause control of the cough reflex by patients has been sug-
gastric irritation, triggering reflex expectoration. This gested for the apparent lack of effect codeine has on
has never been proven and belongs in the annals of acute cough.
folklore. Guaifenesin is thought to stimulate secretion of
respiratory tract fluid, increasing sputum volume and Pholcodine
decreasing viscosity so assisting in removal of sputum.
Guaifenesin is the only active ingredient that has any Pholcodine, like codeine, has been subject to limited
evidence of effectiveness. Two studies identified by clinical trials, with the majority being either animal
Smith, Schroeder & Fahey (Cochrane Review 2008) found models or citric-acid-induced cough studies in man.
conflicting results for guaifenesin as an expectorant. In These studies have shown pholcodine to have antitussive
the largest study (n = 239) participants stated guaifenesin activity. A review by Findlay (1988) concluded that, on
significantly reduced cough frequency and intensity balance, pholcodine appears to possess antitussive activ-
compared to placebo. In the smaller trial (n = 65) guaife- ity but advocates the need for better, well-controlled
nesin was stated to have an antitussive not expectorant studies.
effect.
Dextromethorphan
Summary Trial data for dextromethorphan, like that for codeine and
pholcodine, are limited. It has been shown to be effective
Based on studies, guaifenesin is the only expectorant with
in citric-acid-induced cough and chronic cough but studies
any evidence of effectiveness. However, trial results are
assessing the efficacy of dextromethorphan in acute cough
not convincing and guaifenesin is probably little or no
have shown it to be no better than placebo. It appears to
better than placebo. Given its proven safety record, absence
have limited abuse potential and fewer side effects than
of drug interactions, placebo properties and the public’s
codeine.
desire to treat productive coughs with a home remedy it
would seem reasonable to supply OTC cough medicines
containing guaifenesin.
Antihistamines
Antihistamines have been included in cough remedies for
decades. Their mechanism of action is thought to be
Cough suppressants (antitussives) through the anticholinergic-like drying action on the
Cough suppressants act directly on the cough centre to mucous membranes and not via histamine. There are
depress the cough reflex. Their effectiveness has been numerous clinical trials involving antihistamines for the
investigated in patients with acute and chronic cough as relief of cough and cold symptoms, most notably with
well as citric-acid-induced cough. Although trials on diphenhydramine.
healthy volunteers – in whom coughing was induced by Citric-acid-induced cough studies have demonstrated
citric acid – allowed reproducible conditions to assess the significant antitussive activity compared to placebo and
activity of antitussives, they are of little value because they results from chronic cough trials support an antitussive
do not represent physiological cough. Of greatest interest activity for diphenhydramine. However, trials that showed
to OTC medication are trials investigating acute cough, a significant reduction in cough frequency suffered from
because patients suffering from chronic cough should be having small patient numbers, thus limiting their useful-
referred to the GP. ness. Additionally, poor methodological design of trials
investigating the antitussive activity of diphenhydramine
in acute cough makes assessment of its effectiveness dif-
Codeine
ficult. A recent review concluded ‘Presumptions about
Codeine is generally accepted as a standard or bench- efficacy of diphenhydramine against cough in humans are
mark antitussive against which all others are judged. A not unequivocally substantiated in literature’ (Bjornsdottir
review by Eddy et al (1970) showed codeine to be et al 2007). Less-sedating antihistamines, have also not
Cough 9
been shown to have any benefit in treating coughs com- Bulletin (Anonymous 1999) identified just five trials of
1
pared to placebo (Smith et al 2008). sound methodological design. However, of these five
trials, one study used illogical drug combinations (expec-
Demulcents torant combined with suppressant) and a further three
studies used combination products not available on the UK
Demulcents, such as simple linctus, are pharmacologically market.
inert and are used on the theoretical basis that they reduce In 2008 a Cochrane review examining the treatment of
irritation by coating the pharynx and so prevent coughing. acute cough in both adults and children concluded there
There is no evidence for their efficacy and they are used was no good evidence to support the effectiveness of
mainly for their placebo effect. cough medicines in acute cough (Smith et al 2008). In
addition, there has been growing evidence of the potential
Combination cough mixtures harm that these agents can pose to young children, either
due to adverse effects, or from accidental inappropriate
Many of the over-the-counter cough preparations are dosing (Isbister et al 2010; Vassilev et al 2010). Based on
combinations of agents. Some of these include ingredients the lack of efficacy and potential harm, the MHRA/CHM
targeting other aspects of a common cold such as de (in 2008 and 2009 respectively) recommended that cough
congestants. It should be noted that some combination and cold mixtures should not be used in children under 6
products contain sub-therapeutic doses of the active years of age, and should only be used in children aged 6
ingredients, while a few contain illogical combinations to 12 on the advice of a pharmacist or doctor and treat-
such as cough suppressants with an expectorant, or an ment limited to 5 days or less.
antihistamine with an expectorant. If possible, these Furthermore, in October 2010, the MHRA announced
should be avoided. that the risks associated with OTC oral liquid cough medi-
cines containing codeine outweigh the benefits in children
Summary and young people under 18 years and therefore should no
Antitussives have been traditionally evaluated for efficacy longer be used.
in animal studies or cough-induced models on healthy
volunteers. This presents serious problems in assessing
Practical prescribing and product selection
their effectiveness because support for their antitussive
activity does not come from patients with acute cough Prescribing information relating to the cough medicines
associated with URTI. Furthermore, there appear to be no reviewed in the section ‘Evidence base for over-the-counter
comparative studies of sound study design to allow judge- medication’ is discussed and summarised in Table 1.3;
ments to be made on their comparable efficacy. Com- useful tips relating to patients presenting with cough are
pounding these problems is the self-limiting nature of given in Hints and Tips Box 1.1.
acute cough, which further hinders differentiation between
clinical efficacy and normal symptom resolution.
Antitussives therefore have a limited role in the treat- Cough expectorants
ment of acute non-productive cough. Patients should Guaifenesin
be encouraged to drink more fluid and told that their
symptoms will resolve in time on their own. If medication Almost all manufacturers include guaifenesin in their
is recommended then any active ingredient could be cough product ranges, including Benylin, Robitussin and
selected; side effect profile and abuse tendency rather than Vicks. Children aged between 6 and 12 years should take
clinical efficacy will drive choice. On this basis, pholcodine 100 mg four times a day and the dose for adults – if it is
and dextromethorphan would be first-line therapy and going to work – must be 200 mg four times a day. Some
codeine, because of its greater side effect profile and products deliver suboptimal doses or the quantity taken
tendency to be abused, should be reserved for second-line in a single dose would be so large that the product only
treatment. Antihistamines should not be used routinely, lasts 1 or 2 days. It is therefore advisable to always check
unless night-time sedation is perceived as beneficial to the label of any branded guaifenesin product before
aid sleep. recommendation to ensure the patient is receiving appro-
priate treatment. Guaifenesin-based products have no cau-
Cough medication for children tions in their use and no side effects; they are also free
from clinically significant drug interactions so can be
Very few well-designed studies have been conducted in given safely with prescribed medication. Sugar-free ver-
children. A review published in the Drug and Therapeutics sions (e.g. Robitussin range) are available.
10 Respiratory system
Table 1.3
Practical prescribing: Summary of cough medicines
Name of medicine Use in Likely side Drug interactions Patients in Pregnancy &
children effects of note which care breastfeeding
exercised
Cough expectorants
Guaifenesin >6 years None None None OK
Cough suppressants
Codeine >18 years Sedation, Increased sedation Asthmatics Pregnancy – best
constipation with alcohol, avoided in 3rd
opioid trimester
Pholcodine >6 years Possible sedation analgesics, Short periods OK in
Dextromethorphan >6 years anxiolytics, breastfeeding.
hypnotics and Reports of
antidepressants dextromethorphan
causing drowsiness
and poor feeding in
the baby
Antihistamines
Diphenhydramine* >6 years Dry mouth, Increased sedation Glaucoma, Pregnancy – Standard
sedation and with alcohol, prostate references state OK,
constipation opioid enlargement although some
analgesics, manufacturers
anxiolytics, advise avoidance
hypnotics and Breastfeeding – OK as
antidepressants amount secreted
into breast milk
small. It may
however reduce
milk supply. Reports
of poor feeding in
the baby
Demulcents
Simple linctus >1 month None None None OK
*Included in some cough preparations (e.g. Benylin Children’s Night Cough & Benylin 4 Flu).
Treatment for Parents should be advised to make the child drink more fluid and potentially try a
children under 6 non-pharmacological cough mixture such as a demulcent.
Insulin-dependent People with insulin-dependent diabetes should be asked to monitor their blood glucose more
diabetics frequently because insulin requirements increase during acute infections
Avoid theophylline Theophylline is available as an OTC product (e.g. DoDo Chesteze), but it is best avoided because
patients requiring medication to help with shortness of breath or wheeze are best referred
Avoid illogical Very few cough remedies now have illogical medicine combinations. However, there are still a
combinations few on the market and these are best avoided. For example, combinations of expectorants
and suppressants (e.g. Pulmo Bailey)
Cough 11
Cough suppressants (codeine, pholcodine, in potentiation of the sedative properties of the interacting
1
dextromethorphan) medicines. They also possess antimuscarinic side effects,
which commonly result in dry mouth and possibly
Codeine, pholcodine and dextromethorphan are all opiate constipation. It is these antimuscarinic properties that
derivatives and therefore – broadly – have the same inter- mean patients with glaucoma and prostate enlargement
actions, cautions in use and side effect profile. They do should ideally avoid their use, because it could lead
interact with prescription-only medications (POMs) and to increased intraocular pressure and precipitation of
also with OTC medications, especially those that cross the urinary retention.
blood-brain barrier. Their combined effect is to potentiate
sedation and it is important to warn the patient of this,
although short-term use of cough suppressants with the
Demulcents
interacting medication is unlikely to warrant dosage modi- Demulcents, for example simple linctus, provide a safe
fication. Care should be exercised when giving cough alternative for at-risk patient groups such as the elderly,
suppressants to asthmatics because, in theory, cough sup- pregnant women, young children and those taking multi-
pressants can cause respiratory depression. However, in ple medication. They can act as useful placebos when the
practice this is very rarely observed and does not preclude patient insists on a cough mixture and will not take no for
the use of cough suppressants in asthmatic patients. an answer. If recommended they should be given three or
However, other side effects can occur (e.g. constipation), four times a day.
especially with codeine. If a cough suppressant is unsuit-
able, for example in late pregnancy and children, then a
demulcent can be offered.
Codeine
References
The dose for adults and children over 18 is 5 mL three or Bjornsdottir I, Einarson TR, Guomundsson LS, et al. Efficacy of
four times a day. diphenhydramine against cough in humans: a review.
Pharm World Sci 2007;29(6):577–83.
Pholcodine Eddy NB, Friebel H, Hahn KJ, et al. Codeine and its alternatives
for pain and cough relief. Geneva: World Health Organ
The adult dose is 5 to 10 mL (5 to 10 mg) three or four 1970;1–253.
times a day. For children aged 6 to 12 years the dose is Findlay JWA. Review Articles: Pholcodine. J Clin Pharm Ther
half the adult dose, 2.5 to 5 mL (2.5 to 5 mg). Sugar-free 1988;13:5–17.
versions (e.g. Pavacol-D) are available. Isbister GK, Prior F, Kilham HA. Restricting cough and cold
medicines in children. Journal of Paediatrics and Child
Health 2012;48:91–8.
Dextromethorphan Smith SM, Schroeder K, Fahey T. Over-the-counter (OTC)
Dextromethorphan can also be given in children over the medications for acute cough in children and adults in
ambulatory settings. Cochrane Database of Systematic
age of 6. One product is commercially available (Vicks
Reviews 2008, Issue 1. Art. No.: CD001831. DOI:
Cough Syrup with honey for dry coughs) – the dose being
10.1002/14651858.CD001831.pub3.
5 mL every six hours. For adults and children aged over Vassilev ZP, Kabadi S, Villa R. Safety and efficacy of over-the-
12, there are a number of products available. (e.g. Benylin counter cough and cold medicines for use in children.
dry cough original and non-drowsy; Covonia original Expert Opinion Drug Safety 2010;9(2):233–42.
Bronchial Balsam and Robitussin for Dry coughs). The
dosing is standard – 10 mL four times a day. Further Reading
Dicpinigaitis PV, Colice GL, Goolsby MJ, et al. Acute cough:
a diagnostic and therapeutic challenge. Cough 2009;
Antihistamines 5:11.
Knutson D, Aring A. Viral croup. Am Fam Physician
Routine use of antihistamines is unjustified in treating 2004;69:535–40, 541–2.
non-productive cough. However, the sedative side effects MeReC Bulletin. The management of common infections in
from antihistamines can, on occasion, be useful to allow primary care Volume 17 Number 3 December 2006.
the patient an uninterrupted night’s sleep. Morice AH, McGarvey L, Pavord I. Recommendations for
All antihistamines included in cough remedies are first- the management of cough in adults. Thorax 2006;61:
generation antihistamines and associated with sedation. S1–24.
They interact with other sedating medication, resulting
12 Respiratory system
1
Specific questions to ask the patient: but up to a quarter of people will have symptoms lasting
The common cold 14 days or more.
Question Relevance
Onset of Peak incidence of flu is in the winter Conditions to eliminate
symptoms months; the common cold occurs any
Likely causes
time throughout the year
Flu symptoms tend to have a more abrupt Rhinitis
onset than the common cold – a matter A blocked or stuffy nose, whether acute or chronic in
of hours rather than 1 or 2 days nature, is a common complaint. Rhinitis is covered in
Summer colds are common but they must more detail on page 25 and the reader is referred to this
be differentiated from seasonal allergic section for differential diagnosis of rhinitis from the
rhinitis (hay fever) common cold.
Nature of Marked myalgia, chills and malaise are
symptoms more prominent in flu than the Acute rhinosinusitis
common cold. Loss of appetite is also Rhinosinusitis (formerly sinusitis) is inflammation of one
common with flu or more of the paranasal sinuses. Up to 2% of patients will
develop acute rhinosinusitis as a complication of the
Aggravating Headache/pain that is worsened by common cold. Anatomically the sinuses are described in
factors sneezing, coughing and bending over four pairs; frontal, ethmoid, maxillary and sphenoid.
suggests sinus complications
(Fig. 1.2) All are air-filled spaces that drain into the nasal
If ear pain is present, especially in
cavity. Following a cold, sinus air spaces can become filled
children, middle ear involvement is
with nasal secretions, which stagnate because of a reduc-
likely
tion in ciliary function of the cells lining the sinuses.
Bacteria – commonly Streptococcus and Haemophilus –
can then secondarily infect these stagnant secretions.
It is clinically defined by at least two of the following
existing medical conditions might need greater support symptoms:
and care. In the first instance, the pharmacist should
make an overall assessment of the person’s general state • blockage or congestion
of health. Anyone with debilitating symptoms that effec- • discharge or UACS
tively prevents them from doing their normal day-to-day • facial pain or pressure
routine should be managed more carefully. Whilst it is • reduction or loss of smell.
likely that a patient will have a common cold, severe colds The pain in the early stages tends to be relatively mild
can mimic the symptoms of flu, which is the only condi- and localised, usually unilateral and dull but becomes
tion of any real significance that has to be eliminated bilateral and more severe the longer the condition persists.
before treatment can be given, although secondary com- Bending forwards often exacerbates the pain (moving the
plications can occur. Asking symptom specific questions eyes from side to side, coughing or sneezing can also
will help the pharmacist to determine if referral is needed increase the pain) and sinuses will be tender when gently
(Table 1.5). palpated. If the ethmoid sinuses are involved, retro-orbital
pain (behind the eye) is often experienced. Analgesics for
Clinical features of the common cold pain relief and oral or nasal sympathomimetics can be
tried, to remove the nasal secretions. Antibiotics are now
Symptoms of the common cold are well known. However, not routinely recommended (2011) unless the person is
the nature and severity of symptoms will be influenced by systemically unwell or at risk of complications due to
factors such as the causative agent, patient age and under- underlying medical conditions. If antibiotics are to be
lying medical conditions. Following an incubation period prescribed then amoxicillin is first line (or doxycycline if
of between 1 and 3 days (although this can be as short as the patient has a penicillin allergy).
10–12 hours), the patient develops a sore throat and sneez-
ing, followed by profuse nasal discharge and congestion. Acute otitis media
Cough and UACS commonly follow. In addition, headache, This is commonly seen in children following a common
mild to moderate fever (<38.9°C; 102°F) and general cold and results from the virus spreading to the middle ear
14 Respiratory system
Ethmoid
air cells
Lacrimal sac
Maxillary
sinus
Middle
turbinate ! TRIGGER POINTS indicative of referral:
The common cold
Alternative therapies
Echinacea
Many products are advocated to help treat cold symptoms.
Three products in particular have received much attention The herbal remedy echinacea is marketed as a treatment
and are widely used. for URTIs, including the common cold. Several reviews
16 Respiratory system
Table 1.6
1
Practical prescribing: Summary of cold medicines
Name of Use in Likely side Drug interactions Patients in which Pregnancy &
medicine children effects of note care exercised breastfeeding
Antihistamines
Diphenhydramine >6 years Dry mouth, Increased sedation Glaucoma, prostate Pregnancy – Standard
sedation with alcohol, enlargement references state OK,
and opioid although some
constipation analgesics, manufacturers
anxiolytics, advise avoidance
hypnotics and Breastfeeding – OK as
antidepressants amount secreted
into breast milk
small. It may
however reduce milk
supply
Systemic sympathomimetics
Phenylephrine >12 years At OTC doses Avoid concomitant Control of Best avoided in
insomnia use with hypertension pregnancy as mild
Pseudoephedrine >6 years most likely. MAOIs and and diabetes fetal malformations
Possibly moclobemide may be affected, have been reported
may cause due to risk of but a short Breastfeeding – OK as
tachycardia hypertensive treatment amount secreted
crisis. Avoid in course is into breast milk
patients taking unlikely to be small. It may,
Beta-blockers and clinically however, reduce
TCAs important milk supply
Topical sympathomimetics
Oxymetazoline >12 years Possible local Avoid concomitant None Pregnancy
irritation in use with Not adequately
Xylometazoline >6 years ~5% of MAOIs and studied, avoid
(Otrivine Child patients moclobemide Breastfeeding – OK
Nasal Drops) due to risk of
hypertensive
crisis
useful tips relating to patients presenting with a cold are breathing. Sympathomimetics interact with monoamine
given in Hints and Tips Box 1.2. oxidase inhibitors (MAOIs) (e.g. phenelzine, isocarboxazid,
tranylcypromine and moclobemide), which can result in a
Antihistamines fatal hypertensive crisis. The danger of the interaction per-
sists for up to 2 weeks after treatment with MAOIs is discon-
First-generation antihistamines are now included in rela-
tinued. In addition, systemic sympathomimetics can also
tively few cough and cold remedies. Further information
increase blood pressure, which might, although unlikely
on antihistamines can be found on page 8.
with short courses of treatment, alter control of blood pres-
sure in hypertensive patients and disturb blood glucose
Sympathomimetics
control in diabetics. However, coadministration of medi-
Sympathomimetics serve to constrict dilated blood vessels cines such as beta-blockers is probably clinically unimpor-
and swollen nasal mucosa, easing congestion and helping tant and does not preclude patients on beta-blockers from
18 Respiratory system
taking a sympathomimetic. A topical sympathomimetic or three times a day. They are made by a number of manu-
could be given to such patients to negate this potential facturers (e.g. Otrivine range, Sudafed Blocked Nose Spray
interaction. The most likely side effects of sympathomimet- and Vicks range) who all recommend use from 12 years
ics are insomnia, restlessness and tachycardia. Patients upwards, except Otrivine Child Nasal Drops, which can be
should be advised not to take a dose just before bed-time given to children over the age of six (1 or 2 drops into
because their mild stimulant action can disturb sleep. each nostril once or twice daily).
As with cough remedies, the MHRA/CHM has stated
that sympathomimetics (oral or nasally administered)
should not be given to children under 6 years of age and
for those aged between 6 and 12 duration of treatment
should be limited to a maximum of 5 days. Additionally, References
maximum pack sizes are limited to 720 mg (the equivalent De Sutter AIM, Lemiengre M, Campbell H. Antihistamines for
of 12 tablets or capsules of 60 mg or 24 tablets or capsules the common cold. Cochrane Database of Systematic
Reviews 2003, Issue 3.
of 30 mg) and sales restricted to one pack per person
Hemilä H, Chalker E, Douglas B. Vitamin C for preventing and
owing to concerns over illicit manufacture of methylam- treating the common cold. Cochrane Database of
phetamine (crystal meth) from OTC sympathomimetics. Systematic Reviews 2010, Issue 3. Art. No.: CD000980. DOI:
10.1002/14651858.CD000980.pub3.
Systemic sympathomimetics Kassel JC, King D, Spurling GKP. Saline nasal irrigation for
Phenylephrine acute upper respiratory tract infections. Cochrane Database
Phenylephrine is available in a number of proprietary cold of Systematic Reviews 2010, Issue 3. Art. No.: CD006821.
remedies, for example Lemsip and Beechams, in doses DOI: 10.1002/14651858.CD006821.pub2.
ranging between 5 and 12 mg three or four times a day Linde K, Barrett B, Bauer R, et al. Echinacea for preventing and
treating the common cold. Cochrane Database of
for adults and children over the age of 12.
Systematic Reviews 2006, Issue 1. Art. No.: CD000530.
DOI: 10.1002/14651858.CD000530.pub2.
Pseudoephedrine Shah S, Sander S, White CM, et al. Evaluation of echinacea for
Pseudoephedrine is widely available as either a single the prevention and treatment of the common cold: a
ingredient (e.g. Sudafed Decongestant Tablets) or in multi- meta-analysis. Lancet Infect Dis 2007;7:473–80.
ingredient products in cold and cough remedies (e.g. Singh M, Das RR. Zinc for the common cold. Cochrane
Benylin Four Flu Tablets). The standard adult dose is 60 mg Database of Systematic Reviews 2011, Issue 2. Art. No.:
four times a day and half the adult dose is suitable for CD001364. DOI: 10.1002/14651858.CD001364.pub3.
children between 6 and 12 years of age. Singh M, Singh M. Heated, humidified air for the common
cold. Cochrane Database of Systematic Reviews 2011, Issue
Nasal sympathomimetics 5. Art. No.: CD001728. DOI: 10.1002/14651858.CD001728.
pub4.
Nasal administration of sympathomimetics represents the
Taverner D, Latte GJ. Nasal decongestants for the common
safest route of administration. They can be given to most
cold. Cochrane Database of Systematic Reviews 2009, Issue
patient groups, including pregnant women after the first 2. Art. No.: CD001953. DOI: 10.1002/14651858.CD001953.
trimester and patients with pre-existing heart disease, pub4.
diabetes, hypertension and hyperthyroidism. However, a
degree of systemic absorption is possible, especially when Further reading
using drops, as a small quantity might be swallowed, and Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al.
therefore they should be avoided in patients taking MAOIs. Antibiotics for acute maxillary sinusitis. Cochrane Database
All topical decongestants should not be used for longer of Systematic Reviews 2008, Issue 2. Art. No.: CD000243.
than 5 to 7 days (September 2012, BNF 64 states maximum DOI: 10.1002/14651858.CD000243.pub2.
of 7 days) otherwise rhinitis medicamentosa (rebound con- Aljazaf K, Hale TW, Ilett KF, et al. Pseudoephedrine: effects on
milk production in women and estimation of infant
gestion) can occur.
exposure via breastmilk. Br J Clin Pharmacol
2003;56:18–24.
Ephedrine and phenylephrine Chadha NK, Chadha R. 10-minute consultation: sinusitis. BMJ
Both are short acting and need to be administered three or 2007;334:1165 (2 June), doi:10.1136/bmj.39161.557211.47.
four times a day. Sanders S, Glasziou PP, Del Mar CB, et al. Antibiotics for acute
otitis media in children. Cochrane Database of Systematic
Oxymetazoline and xylometazoline Reviews 2004, Issue 1. Art. No.: CD000219. DOI:
These agents are longer acting than ephedrine and phe- 10.1002/14651858.CD000219.pub2.
nylephrine and require less frequent dosing, typically two
Sore throats 19
Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines Table 1.7
1
for the management of rhinosinusitis and nasal polyposis. Causes of sore throat and their relative incidence in
Clinical and Experimental Allergy 2007;38(2):260–75. community pharmacy
Incidence Cause
Web sites
Common Cold Centre: http://www.cf.ac.uk/biosi/associates/ Most likely Viral infection
cold/
SIGN Guidelines on Diagnosis and management of childhood Likely Streptococcal infection
otitis media in primary care: http://www.sign.ac.uk/ Unlikely Glandular fever,
guidelines/fulltext/66/index.html
trauma
Commoncold Inc: http://www.commoncold.org
Very unlikely Carcinoma, medicines
Sore throats
clusters are suggestive for sore throat of bacterial origin
(see conditions to eliminate) but these are by no means
Background fool proof. Other causes of sore throat also need to be
Any part of the respiratory mucosa of the throat can give considered and Table 1.7 highlights those conditions that
rise to symptoms of throat pain. This includes the pharynx can be encountered by community pharmacists and their
(pharyngitis) and tonsils (tonsillitis), yet clinical distinction relative incidence. Asking symptom-specific questions will
between pharyngitis and tonsillitis is unclear and the term help the pharmacist to determine the cause and whether
sore throat is commonly used. Pain can range from referral is needed (Table 1.8).
scratchiness to severe pain. Sore throats are often associ-
ated with the common cold. However in this section, Physical examination
people who present with sore throat as the principal
symptom are considered. After questioning, the pharmacist should inspect the mouth
and cervical glands (located just below the angle of the
Prevalence and epidemiology jaw) to substantiate the differential diagnosis. (Fig. 1.3)
Using a good light source (e.g. pen torch) ask the patient
Sore throats are extremely common. UK figures show that to say ‘ah’; this should allow you to see the pharynx well.
a GP with a list size of 2000 patients will see about 120 When examining the mouth pay particular attention to the
people each year with a throat infection. However, four to fauces and tonsils. Are they red and swollen? Is there any
six times as many people will visit the pharmacy and self- exudate present? Is there any sign of ulceration?
treat. Figures from other countries such as New Zealand
and Australia broadly support UK findings. On average an
Clinical features of sore throat
adult will experience two to three sore throats each year.
Many studies have now shown that it is exceedingly dif-
Aetiology ficult to differentiate viral and bacterial infection on
patient history and clinical findings. Patients will present
Viral infection accounts for between 70 and 90% of all with a sore throat as an isolated symptom or as part of
sore throat cases. Remaining cases are nearly all bacterial; a cluster of symptoms that include rhinorrhoea, cough,
the most common cause being Group A beta-haemolytic malaise, fever, headache and hoarseness (laryngitis).
Streptococcus (also known as Streptococcus pyogenes). Symptoms are relatively short-lived with 40% of people
A fuller account of the aetiology of viral and bacterial being symptom free after 3 days and 85% of people
pathogens that affect the upper respiratory tract appears symptom free after 1 week.
on page 12.
Conditions to eliminate
Arriving at a differential diagnosis
Likely cause
The overwhelming majority of cases will be acute and
self-limiting URTI, whether viral or bacterial in origin. Streptococcal sore throat
Clinically, differentiation between viral and bacterial infec- Patients who present with pharyngeal or tonsillar exudates,
tion is extremely difficult, although specific symptom swollen anterior cervical glands, high grade fever (over
20 Respiratory system
? Table 1.8
Specific questions to ask the patient:
Sore throat
Question Relevance
Age of the Although viruses are the commonest cause Hard palate
Posterior Soft palate
patient of sore throat there are epidemiological pillar
variance with age: Uvula
Anterior
Under 3 years old Streptococcus is pillar
uncommon Pharynx
Streptococcal infections are more Right
tonsil
prevalent in people under the age of 30,
particularly those of school age (5 to 10
years) and young adults (15–25 years Tongue
old)
Viral causes are the commonest cause of
sore throat in adults
Glandular fever is most prevalent in
adolescents
Tender On examination, patients suffering from
cervical glandular fever and streptococcal sore
glands throat often have markedly swollen Fig. 1.3 Major structures of the mouth
glands. This is less so in viral sore throat
Tonsillar Marked tonsillar exudate is more
exudate suggestive of a bacterial cause than a patient has a history of rheumatic fever, increased risk
present viral cause from acute infection, unilateral peritonsillitis and marked
systemic upset.
Ulceration Herpetiform and herpes simplex ulcers can
also cause soreness in the mouth Glandular fever (infectious mononucleosis)
especially in the posterior part of the Glandular fever is caused by the Epstein–Barr virus and
mouth. is often called the kissing disease because transmission
primarily occurs from saliva. It has a peak incidence in
adolescents and young adults. The signs and symptoms
of glandular fever can be difficult to distinguish from
sore throat because it is characterised by pharyngitis
39.4°C; 101°F) and absence of cough are more likely to (occasionally with exudates), fever, cervical lymphaden-
have a bacterial infection. However, even if the patient opathy and fatigue. The person can also suffer from
exhibits all these four ‘classic’ symptoms up to 40% will general malaise prior to the start of the other symptoms.
not have bacterial infection. To further compound the dif- A macular rash can also occur in a small proportion of
ficulty of diagnosis the routine use of throat swabs per- patients.
formed by GPs are not recommended as asymptomatic
carriage of Streptococcus affects up to 40% of people Trauma-related sore throat
making it impossible to differentiate between infection and Occasionally patients develop a sore throat from direct
carriage. Table 1.9 summarises the potential distinguishing irritation of the pharynx. This can be due to substances
features of viral and bacterial infection. such as cigarette smoke, a lodged foreign body or from
If bacterial infection is suspected then referral to acid reflux.
the GP is appropriate. The use of antibiotics in such situ-
ations is debatable as a Cochrane review (Spinks et al Medicine induced sore throat
2006) found that the absolute benefit of antibiotics was A rare complication associated with certain medication is
modest, with an average reduction in illness time of 1 agranulocytosis, which can manifest as a sore throat. The
day. The National Institute of Health and Clinical Excel- patient will also probably present with signs of infection
lence recommend a 10 day course of penicillin or including fever and chills. Medicines known to cause this
erythromycin (where an allergy to penicillin exists) if the adverse event are listed in Table 1.10.
Sore throats 21
Table 1.9
1
Features of viral and bacterial sore throat
Age Tonsillar/pharyngeal Duration Cervical Cough Other symptoms
exudate glands present
Viral Infection Any age Possible but 3–7 days Normal Common Low grade fever,
generally limited headache
Bacterial Infection School children Often present and 3–7 days Swollen Rare High grade fever,
can be substantial possible rash
Table 1.10
Examples of medication known to cause
agranulocytosis
! TRIGGER POINTS indicative of referral:
Sore Throat
>14 days
Duration Refer ❶
<14 days
Yes
Dysphagia Refer ❷
No No Mouth
Yes
ulcers? ❹
Mouth ulceration, blistering Medicine-induced
or petechial haemorrhage ❸ agranulocytosis?
Refer
Yes
No
Avoid trigger
Stimulation of saliva
production
Sucking a lozenge or pastille promotes saliva production, which will lubricate the throat
and thus exert a soothing action
1
Gargles or lozenges? Gargles have very short contact time with inflamed mucosa and therefore any effect will
be short lived. A lozenge or a pastille is preferable, as contact time will be longer
do have antibacterial activity, and some inhibit Candida on their effectiveness and until such time that evidence
albicans growth. In vivo tests have also shown antibacte- becomes available they should not be recommended.
rial effects.
The use of antibacterial and antifungal agents should
not be routinely recommended since the vast majority of Practical prescribing and product selection
sore throats are caused by viral infections for which they Prescribing information relating to the sore throat medi-
have no action against. As adverse effects are rare and cines reviewed under ‘Evidence base for over-the-counter
stimulation of saliva from sucking the lozenge may confer medication’ is discussed and summarised in Table 1.11 and
symptomatic relief, the use of such products may be useful tips relating to patients presenting with a sore throat
justified. are given in Hints and Tips Box 1.3.
Table 1.11
Practical prescribing: Summary of sore throat medicines
Name of medicine Use in children Likely side Drug Patients in Pregnancy &
effects interactions which care breastfeeding
of note exercised
Local anaesthetics
Lidocaine >12 years Can cause None None OK
sensitisation
Benzocaine Lozenge >3 years reactions
Spray >6 years
Anti-inflammatories
Benzydamine Rinse >12 years Oral rinse may None None OK, but in
Spray >6 years cause pregnancy limit
stinging use after 30 wks
Flurbiprofen >12 years None reported None Avoid in Avoid if possible
patients
with peptic
ulcers
Watson N, Nimmo WS, Christian J, et al. Relief of sore throat Table 1.12
1
with the anti-inflammatory throat lozenge flurbiprofen Allergens responsible for rhinitis
8.75mg: a randomised, double-blind, placebo-controlled
When Causative
study of efficacy and safety. Int J Clin Pract
allergen
2000;54:490–6.
Intermittent February to Tree pollens (hazel
Web sites allergic April and alder
Sinus Care Center: http://www.sinuscarecenter.com/ rhinitis associated with
early symptoms
and silver birch
in March/April)
May to August Grass pollen
Rhinitis (peak in June
and July)
Background
September to Fungal spores
Rhinitis is simply inflammation of the nasal lining. It is October
characterised by rhinorrhoea, nasal congestion, sneezing Persistent allergic Year round House dust mite,
and itching. The majority of cases that present in a com- rhinitis (e.g. animal dander,
munity pharmacy will be viral infection, colds or allergic perennial especially cats
rhinitis (AR). Currently there are different classifications of rhinitis)
AR. ARIA (Allergic Rhinitis and its Impact on Asthma)
guidelines reclassify AR into intermittent and persistent
categories, with subdivision into mild or moderate-severe
disease. In 2007, the British Society for Allergy and Clinical Allergic rhinitis is a recognised risk factor for the develop-
Immunology published guidelines that differed from ARIA ment of asthma and usually precedes it.
where classification of AR was based on seasonal or peren-
nial types of rhinitis. This text adopts the ARIA criteria. Aetiology
The ARIA classification is based on the timing of the
symptoms and is divided into intermittent (occurring on AR is a mucosal reaction in response to allergen exposure.
less than 4 days per week and less than 4 weeks at a time) Initially, the patient must come into contact with an aller-
or persistent (occurring on more than 4 days per week and gen; for intermittent AR this is usually pollen or fungal
more than 4 weeks at a time). Rhinitis has a significant spores. The allergen lodges within the mucous blanket
impact on quality of life, impairing performance at work lining the nasal membranes, and activates IgE antibodies
and school, and disrupting sleep. (formed from previous allergen exposure) on the surface
of mast cells. Potent chemical mediators are released, pri-
marily histamine, but also leukotrienes, kinins and pros-
Prevalence and epidemiology
taglandins, which exert their action via neural and vascular
AR is a global health problem and has dramatically mechanisms. This immediate response to an allergen is
increased over the last 20 years with studies suggesting known as the early-phase allergic reaction and gives rise
the prevalence has at least doubled in that time. The UK to nasal itch, rhinorrhoea sneezing and nasal congestion.
has one of the highest levels of allergic rhinitis in the A late-phase reaction then occurs 4 to 12 hours after
world, with estimates ranging from 10 to 25% of adults allergen exposure with nasal congestion as the main
and as many as 40% of children affected. These figures symptom.
might, however, represent an underestimate as many Also of importance is the phenomenon of nasal priming.
people do not consult their doctor and choose to self- Patients, after a period of continuous allergen exposure,
medicate. Seasonal intermittent allergic rhinitis (hay fever) can find that they experience the same level of severity in
commonly affects school-aged children with 10 to 30% of symptoms with lower levels of allergen exposure. Simi-
the adolescent population suffering from the condition. larly, symptoms will be worse than previously experienced
The mean age of onset is 10 years and the incidence peaks when levels of the allergen are the same. This may explain
between the ages of 13 and 19 years. It is believed that why patients complain of worsening hay fever symptoms
improved living standards and reduced risk of childhood the longer the season goes on. Table 1.12 highlights the
infections might increase susceptibility to hay fever. main allergens responsible for AR.
26 Respiratory system
!
hypoactive sympathetic nervous system response to irri-
TRIGGER POINTS indicative of referral: Rhinitis
1
tants such as dry air, pollutants, or strong odours. The
symptoms can be similar to AR yet an allergy test will be
negative. Itching and sneezing are less common and Symptoms/signs Possible danger/reason
patients might experience worsening nasal symptoms in for referral
response to climatic factors, such as a sudden change in Failed medication Requires involvement
temperature. Medicine induced rhinitis of doctor for further
medicine treatment
Rhinitis of pregnancy Nasal obstruction which fails Suggests polyp
It is thought that this occurs because of hormonal changes; to clear
however, evidence is lacking (Wallace et al 2008). It usually
Unilateral discharge Possible trapped
starts after the second month of the pregnancy, and
especially in children foreign body
resolves spontaneously after childbirth. Nasal congestion
is the prominent feature.
Nasal obstruction
❶ Yes Refer
Polyps or
septum deviation?
No
Unilateral ❷ Yes Refer
discharge Foreign body?
No
Nasal itch, sneeze No Cough, sore throat
prominent ❸ prominent
Yes Yes
Infective rhinitis
Allergic rhinitis
(common cold)
No
Rhinorrhoea > Consider
nasal congestion vasomotor rhinitis
Ocular symptoms
present
No Yes
Perennial Seasonal ❹
Seasonal
occurrence only
Treat with Treat with
steroid spray antihistamine
Sneezing
common
Controlled Controlled
No
No
1
of AR falls broadly into two categories; systemic and Azelastine is currently the only nasally administered
topical. antihistamine marketed for OTC sale. Clinical trials have
proven its efficacy and a meta analysis concluded that
Systemic therapy: antihistamines azelastine was more effective than placebo and equivalent
to oral antihistamines (Lee & Pickard 2007).
Both sedating and non-sedating antihistamines are clini-
cally effective in reducing the symptoms associated with Mast cell stabilisers
AR (Sheikh et al 2006). However, given the sedative Like corticosteroids, sodium cromoglicate is a prophylactic
effects of first generation antihistamines they should not agent. However, the effect of sodium cromoglicate is only
be routinely recommended compared to second generation, partial – it is less effective than corticosteroids, although
non-sedating antihistamines. it is not clear why. A further drawback with nasal cromo-
Of the second generation antihistamines the community glicate is the frequency of administration; between four
pharmacist has a choice between acrivastine, cetirizine, or and six times a day. Although no data is available for the
loratadine. All are equally effective and are considered to compliance with such a regimen it is likely to be poor and
be non-sedating, although they are not truly non-sedating result in inadequate symptom control. Their place in aller-
and do cause different levels of sedation. Loratadine has gic rhinitis is therefore limited.
been shown to have the lowest affinity for histamine
receptors in the brain and a paper published by Mann et al Decongestants
in 2000 reviewing reported sedation with second genera- Topical decongestants are effective in the treatment of
tion antihistamines showed loratadine to be least sedating nasal congestion but are of limited value in treating AR
of the non-sedating antihistamines. In comparison ceti- as prolonged use is associated with rebound congestion.
rizine was 3.5 times more likely to cause sedation and Their place in therapy is probably best reserved for when
acrivastine 2.5 times more likely to cause sedation than nasal congestion needs to be treated quickly and can
loratadine. On this basis, loratadine would be the antihis- provide symptom relief whilst corticosteroid therapy is
tamine of choice. initiated and has time to begin to exert its action.
Intraocular medication
Topical therapy
Mast cell stabilisers
To combat nasal congestion and ocular symptoms a range Sodium cromoglicate has proven efficacy and is signifi-
of topically administered medication is available, including cantly better than placebo (Lindsay-Miller 1979). It does
antihistamines, corticosteroids, mast cell stabilisers and require four times a day dosing and compliance might be
decongestants. All can be administered intranasally but a problem. Further, cromoglicate takes 4 to 6 weeks to
corticosteroids cannot be administered intraocularly. reach maximal response, thus, mast cell stabilisers alone
only have a role when patients can predict well in advance
Intranasal medication the onset of the symptoms.
Corticosteroids
Intranasal corticosteroids have been recommended by the Antihistamines
World Health Organization (WHO) as first-line therapy for The only ocular antihistamine available OTC is antazoline.
allergic rhinitis because a number of clinical trials have It is available in combination with xylometazoline. There
confirmed their efficacy. Additionally, they have demon- appears to be little trial data in the public domain regard-
strated superiority to antihistamines in the treatment of ing decongestant/antihistamine combinations, although
allergic rhinitis for all nasal symptoms, and equivalence one small trial involving 25 patients concluded that a
for ocular symptoms (Wallace et al 2008). There is little combination of the two drugs was superior to either alone.
difference in efficacy between the intranasal corticoster- At best it should be used short-term to avoid possible
oids and clinical evidence does not support the use of one rebound conjunctivitis caused by xylometazoline, which is
intranasal corticosteroid over another. They have a slow well documented.
onset of action and patients should be advised that it will
take 2 weeks before maximum clinical efficacy is observed. Sympathomimetics
Patients who regularly suffer from nasal congestion associ- OTC ocular sympathomimetics are commonly used to
ated with allergic rhinitis should be advised to commence control ocular redness and discomfort. There appears to be
therapy before exposure to the allergen to ensure symptom no significant differences between ocular decongestants
control. on the basis of their vasoconstrictive effectiveness. Like
30 Respiratory system
nasal sympathomimetics they should be restricted to short- antihistamines and more than one type may have to
term (less than 5 days) use to avoid rebound effects. be tried to provide symptom control. They possess very
few side effects and can be given safely with other
Summary prescribed medication. They can also be prescribed to
all patient groups, although manufacturers advise against
Loratadine should be recommended as first-line therapy if
prescribing to the elderly. First generation, sedating anti-
the patient suffers from mild intermittent general symp-
histamines are the preferred antihistamines in pregnancy
toms such as nasal itching, sneezing, rhinorrhoea and
as the risk of foetal toxicity appears low, with chlorphen-
associated ocular symptoms. If this fails to control all
amine being medicine of choice. Of the non-sedating
symptoms then sodium cromoglicate eye drops or a corti-
antihistamines loratadine is the most widely studied and
costeroid nasal spray should be added to the regimen. If a
data available does not indicate an increased risk of
patient has moderate to severe intermittent symptoms, or
teratogenicity yet manufacturers advise avoidance (pre-
persistent AR then regular topical nasal corticosteroids are
sumably on the basis of being outside their product
recommended as first-line treatment, with antihistamines
licences). For breastfeeding mothers non-sedating antihis-
added if there is a poor response. If nasal congestion pre-
tamines should be avoided as infant drowsiness has been
dominates then regular topical nasal corticosteroids are
associated with their use. Expert opinion states cetirizine
recommended as first-line treatment. The Allergic Rhinitis
and loratadine are antihistamines of choice despite manu-
and its Impact on Asthma (ARIA) group, working in
facturers advising that they should not be used in this
collaboration with WHO, has produced a guideline for
patient group.
pharmacists on the management of allergic rhinitis (see
Web sites).
Non-sedating antihistamines
Practical prescribing and product selection Acrivastine (Benadryl Allergy Relief)
Acrivastine is recommended for adults and children
Prescribing information relating to the rhinitis medicines
over 12 years of age. The dose is one capsule (8 mg) as
reviewed in the section ‘Evidence base for over-the-counter
necessary, up to three times a day. Acrivastine can also be
medication’ is discussed and summarised in Table 1.15 and
purchased as a combination product (Benadryl Plus), which
useful tips relating to patients presenting with rhinitis are
contains a sympathomimetic (pseudoephedrine). However,
given in Hints and Tips Box 1.4.
if nasal congestion is a problem, corticosteroids should be
considered in preference to a decongestant.
Systemic antihistamines
Systemic antihistamines selectively inhibit histamine H1 Cetirizine (e.g. Zirtek Allergy, Benadryl One-a-Day
receptors and suppress many of the vascular effects of and Benadryl Allergy Oral Syrup, Pollenshield)
histamine. They have rapid onset of action (approximately Cetirizine is available as either tablets or solution. The dose
30 min to 1 hour) and relieve ocular symptoms, rhinor- for adults and children 6 years and over is one tablet
rhoea and nasal irritation, but have little effect on nasal (10 mg) daily. The dose for the oral solution can either be
congestion. For maximum effect they are best taken 10 mL (10 mg) once daily, or 5 mL (5 mg) twice daily. For
on a regular basis but will have an effect if taken when children aged between 2 and 5 years of age the dose is
required. Patient response is variable between the differing 2.5 mL (2.5 mg) twice daily.
Table 1.15
1
Practical prescribing: Summary of rhinitis medicines
Name of medicine Use in Likely Drug Patients in Pregnancy &
children side effects interactions of which care breastfeeding
note exercised
Systemic antihistamines
Acrivastine >12 years Sedation, but rare None None Manufacturers
and least likely advise
Cetirizine >2 years with loratadine avoidance, but
Loratadine >2 years safety data has
shown them to
be safe
Chlorphenamine >1 year Dry mouth, Increased Glaucoma, Standard
sedation and sedation with prostate references state
constipation alcohol, opioid enlargement OK, although
analgesics, some
anxiolytics, manufacturers
hypnotics and advise avoidance
antidepressants
Ocular antihistamines
Antazoline* >12 years Local irritation, Avoid Avoid in Safety not
bitter taste concomitant glaucoma established, but
use with probably OK
MAOIs and
moclobemide
due to risk of
hypertensive
crisis
Nasal antihistamines
Azelastine >5 years Nasal irritation None None Safety not
(5%), bitter established, but
taste (3%) probably OK
Nasal corticosteroids
Beclometasone >18 years Nasal irritation, None Avoid in Manufacturers
bitter taste, glaucoma advise
Fluticasone headache avoidance, but
(fluticasone) safety data has
nosebleeds shown them to
be safe
Triamcinolone Headache,
nosebleeds,
dyspepsia,
bronchitis,
flu-like
symptoms and
cough
32 Respiratory system
Table 1.15
Practical prescribing: Summary of rhinitis medicines (Continued)
Name of medicine Use in Likely Drug Patients in Pregnancy &
children side effects interactions of which care breastfeeding
note exercised
Ocular and nasal mast cell stabilisers
Sodium cromoglicate >12 years Local irritation, None None OK
ocular blurred vision
Sodium cromoglicate >5 years Nasal irritation. OK
nasal Rare
-wheezing and
shortness of
breath
Ocular sympathomimetics
Naphazoline >12 years Local irritation Avoid None Not adequately
concomitant studied but not
use with yet shown to be
MAOIs and a risk – probably
moclobemide OK
due to risk of
hypertensive
crisis
1
symptoms are controlled the patient should use the lowest Ocular products either contain a combination of sympa
effective dose. thomimetic and antihistamine (antazoline/xylometazoline,
Otrivine Antistin) or sympathomimetic alone (e.g. Nap-
Triamcinolone (Nasacort Allergy Nasal Spray) hazoline 0.01%). They are useful in reducing redness in
The standard adult dose is two sprays into each nostril the eye but will not treat the underlying pathology that
(220 µg/day) once daily, which can be reduced to just one is causing the eye to be red. They should be limited
spray per nostril daily. to short-term use to avoid rebound effects. Like all
sympathomimetics they can interact with monoamine
Nasal antihistamines oxidase inhibitors and should not be used by patients
Intranasal antihistamines are useful in treating mild or receiving such treatment or within 14 days of ceasing
intermittent nasal symptoms and work more quickly therapy.
than systemic antihistamines (15 minutes). They appear
to have no drug interactions and there is no evidence Otrivine Antistin
to show they are unsafe in pregnancy, although manu- Used in adults and children over 12 years, the dose is one
facturers advise caution. There is a lack of data for use or two drops two or three times a day. Patients with glau-
in breastfeeding but it is assumed that if oral anti coma should avoid this product due to the potential of the
histamines can be used then intranasal antihistamines, antihistamine component to increase intraocular pressure.
which result in lower blood concentrations, would be Local transient irritation and a bitter taste after application
safe to use. have been reported.
Azelastine (Rhinolast Allergy) Naphazoline (E.g. Murine, Optrex Bloodshot Eyes Eye
Azelastine can be given to adults and children over 5 years Drops & Optrex Eye Brightening Drops)
of age. The dose is one application (0.14 mL) in each The use of products containing naphazoline is restricted to
nostril twice daily (0.56 mg of azelastine hydrochloride). adults and children over the age of 12 years old. One to
two drops should be administered into the eye three or
Mast cell stabilisers (sodium cromoglicate) four times a day.
Sodium cromoglicate eye drops and nasal spray are
Complementary therapies
poorly absorbed at therapeutic doses and the amount
reaching the systemic circulation is very low. It has no Butterbur is promoted as having anti-allergic properties.
drug interactions and can be given to all patient groups. Two clinical trials have reported favourable outcomes of
Clinical experience has shown it to be safe in preg- butterbur in controlling symptoms. Both trials found but-
nancy and expert opinion considers sodium cromogli- terbur to be as effective as its comparator drug (cetirizine
cate to be safe in breastfeeding. It is a prophylactic and fexofenadine respectively) although another trial
agent and has to be given continuously whilst exposed found it to be no better than placebo. Until further larger
to the allergen. studies are conducted to assess butterbur’s effect it should
not be routinely recommended.
Ocular cromoglicate (e.g. Opticrom Allergy,
Optrex Allergy)
One or two drops should be administered in each eye four
times a day. Instillation of the drops can cause a transient
References
blurring of vision. Lee TA, Pickard AS. Meta-analysis of azelastine nasal spray for
the treatment of allergic rhinitis. Pharmacotherapy
Nasal cromoglicate (Rynacrom 4% Nasal Spray) 2007;27(6):852–9.
The dose for adults and children is one spray into each Lindsay-Miller ACM. Group comparative trial of 2% sodium
nostril two to four times daily. Nasal irritation is possible, cromoglycate (Opticrom) with placebo in treatment of
especially during the first few days of use. seasonal allergic conjunctivitis. Clin Allergy 1979;
9:271–5.
Sympathomimetics Mann RD, Pearce GL, Dunn N, et al. Sedation with ‘non-
sedating’ antihistamines: four prescription-event
For general information about sympathomimetics and monitoring studies in general practice. BMJ
product information on nasally administered products see 2000;320:1184–6.
page 17.
34 Respiratory system
Sheikh A, Hurwitz B, Nurmatov U, et al. House dust mite Price D, Bond C, Bouchard J, et al. International Primary
avoidance measures for perennial allergic rhinitis. Cochrane Care Respiratory Group (IPCRG) Guidelines:
Database of Systematic Reviews 2010, Issue 7. Art. No.: Management of Allergic Rhinitis. Prim Care Respir J
CD001563. DOI: 10.1002/14651858.CD001563.pub3. 2006;15:58–70.
Saleh HA, Durham SR. Perennial rhinitis. BMJ 2007;335:502–7,
Further Reading doi:10.1136/bmj.39304.678194.AE
Asher MI, Montefort S, Björkstén B, et al. ISAAC Phase Three Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines
Study Group. Worldwide time trends in the prevalence of for the management of rhinosinusitis and nasal polyposis.
symptoms of asthma, allergic rhinoconjunctivitis, and eczema Clin Exp Allergy 2008;38:260–75.
in childhood: ISAAC phases one and three repeat multicountry Skoner DP. Allergic rhinitis: definition, epidemiology,
cross-sectional surveys. Lancet 2006;368:733–43. pathophysiology, detection, and diagnosis. J Allergy Clin
Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Immunol 2001;108(supplement 1):2–8.
Impact on Asthma (ARIA) 2008 update (in collaboration Slater JW, Zechnich AD, Haxby DG. Second-generation
with the World Health Organization, GA2LEN and antihistamines: a comparative review. Drugs
AllerGen). Allergy 2008;63(Suppl 86):S8–160. 1999;57:31–47.
Farooque S. Diagnosis, allergen avoidance and treatment of Wallace DV, Dykewicz MS, Bernstein DI, et al. The
allergic rhinitis. The Prescriber 2009;19th May:38–48. diagnosis and management of rhinitis: an updated
Hans de Groot, Brand PLP, Fokkens WF, et al. Allergic practice parameter. J Allergy Clin Immunol
rhinoconjunctivitis in children BMJ 2007;335:985–8, 2008;122(2S):1–84.
doi:10.1136/bmj.39365.617905.BE.
Jones NS, Carney AS, Davis A. The prevalence of allergic
rhinosinusitis: a review. J Laryngol Otol 1998;112:1019–30. Web sites
Marshall S. An update on hay fever treatments. Pharm J Action Against Allergy: www.actionagainstallergy.co.uk
2009;282:489–92. Allergy UK: http://www.allergyuk.org/
Passalacqua G, Bousquet PJ, Kai-Hakon C, et al. ARIA Update: Allergic Rhinitis and its Impact on Asthma (ARIA) resources for
1-Systematic review of complimentary and alternative pharmacists: http://www.whiar.org/Pharmacy.php
medicine for rhinitis and asthma. J Allergy Clin Immunol The British Society for Allergy and Clinical Immunology:
2006;117:1054–62. www.bsaci.org
Self-assessment questions 35
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
1
knowledge to be applied to a practice setting.
1.1 Which respiratory condition is characterised by 1.6. Which patient group is most likely to suffer from
shortness of breath and bronchoconstriction? infectious mononucleosis?
a. Acute bronchitis a. Infants
b. Heart failure b. Children
c. Asthma c. Adolescents
d. Chronic bronchitis d. Adults
e. Pneumonia e. The elderly
1.2 What course of action would be most appropriate if a 1.7. What symptoms are commonly associated with acute
baby was suffering with croup-like symptoms? sinusitis?
a. Take the infant to casualty a. Dull, localised unilateral pain that is often worse on
b. Put the infant into a steamy room bending down
c. Seek medical help if symptoms persist for more b. Dull, localised unilateral pain that often eases on
than 48 hours bending down
d. Give the infant a cough suppressant c. Dull, diffuse bilateral pain that is often worse on
e. Give the infant an antihistamine bending down
d. Dull, diffuse bilateral pain that often eases on
1.3. Which patient group is most at risk of pneumothorax? bending down
e. Sharp, localised bilateral pain that often eases on
a. Elderly women
bending down
b. Young men
c. Young women
1.8. The most likely cause of acute cough in children is:
d. Elderly men
e. None of the above a. Bacterial infection
b. Viral infection
1.4. Which one of the following medicines can cause c. Postnasal drip
rebound congestion with over use? d. Croup
e. Asthma
a. Pseudoephedrine tablets
b. Guaifenesin cough mixture
Questions 1.9 to 1.11 concern the following conditions:
c. Oxymetazoline nasal spray
d. Chlorphenamine tablets A. Tuberculosis
e. Codeine linctus B. Left ventricular failure
C. Chronic bronchitis
1.5. Which medicine is drug of choice for nasal congestion D. Pneumonia
caused by allergic rhinitis? E. Acute bronchitis
a. Loratadine
b. Nasal sodium cromoglicate
c. Azelastine
d. Nasal beclometasone
e. Chlorphenamine
36 Respiratory system
Select in which of the above conditions (A to E): 1.17. Which of the following precautions should a patient
take if he or she suffers from perennial rhinitis:
1.9. Shortness of breath is often the main presenting
a. Avoid contact with animals, especially household
symptom
pets
b. Reduce house dust mite by regular cleaning of
1.10. Cigarette smoking is the main cause of the condition
carpets
c. Close the windows when in the house
1.11. A higher prevalence is seen in ethnic groups
Questions 1.18 to 1.20: these questions consist of a
Questions 1.12 to 1.14 concern the following medicines:
statement in the left-hand column followed by a
A. Codeine statement in the right-hand column. You need to:
B. Pseudoephedrine
• decide whether the first statement is true or false
C. Pholcodine
• decide whether the second statement is true or false
D. Beclometasone
E. Benzydamine
Then choose:
Select, from A to E, which of the above medicines: A. If both statements are true and the second statement
is a correct explanation of the first statement
1.12. Should be avoided by patients taking beta-blockers B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
1.13. Is associated with illicit drug manufacture C. If the first statement is true but the second statement
is false
1.14. Can reduce breast milk production D. If the first statement is false but the second statement
is true
Questions 1.15 to 1.17: for each of these questions one or E. If both statements are false
more of the responses is (are) correct. Decide which of the
responses is (are) correct. Then choose: Directions summarised
A. If 1, 2 and 3 are correct 1st 2nd
B. If 1 and 2 only are correct statement statement
C. If 2 and 3 only are correct A True True 2nd explanation is a
D. If 1 only is correct correct explanation of
E. If 3 only is correct the first
Case study
1
CASE STUDY 1.1
Questions should fall broadly into two groups: A few weeks later Mr RT returns to the pharmacy
and complaining that he is still having trouble
Those that relate to the presenting complaint, for clearing his blocked nose. A friend at work
example: nature, duration, onset, periodicity, sputum recommended Otrivine Nasal Spray.
colour (if applicable), associated symptoms,
aggravating/alleviating symptoms. c. The use of local decongestants is associated
with this phenomenon known as rhinitis
Those which look at the medical, family and social medicamentosa. Explain what this is and what
history of the patient: current medication regimen advice you would give to Mr RT?
(recent changes to medication or dosage
adjustment), self-medication, general well-being of Rhinitis medicamentosa relates to the problem of
the patient, smoking status. overly long use of topical sympathomimetics.
Prolonged use (normally more than 7 days
Discussion with Mr RT indicates he has a continuous use) results in vascular engorgement of
productive cough that appeared a few days ago and the nose on withdrawal of the medication. Patients
the sputum is white. His nose is ‘a bit blocked’. He often believe mistakenly that symptoms have
has a headache and he does not have any chest pain. returned and begin to use the medication again and
Before you can make a recommendation for the thus perpetuate the problem. This cycle of overuse
symptoms you identify he is taking the following has to be broken and explained to patients so that
medication they understand why they have continued nasal
congestion. Strategies to relieve the problem are, if
• Manerix 150 mg bd – he has taken this for over 6 appropriate, a switch to systemically administered
months. decongestants or if this is not appropriate then on
• Trusopt tds – he has used this for 2 years withdrawal of the medication the patient counselled
• Paracetamol 2 qds prn – for lower back pain that the symptoms will initially worsen but that
symptoms will gradually resolve. In Mr RT’s case he
b. Compare and contrast the different products should be advised not to take the nasal spray
available to treat Mr RT’s symptoms and indicate because of the risk of a drug interaction between the
which you consider would be the most beneficial spray and Manerix.
to him and those that are contraindicated.
A female patient (about 30 years old) presents to Using the information gained from questioning and
the pharmacist complaining of a bothersome sore linking this with known epidemiology on sore throat
throat. The following information is gained from (see Table 1.7) it should be possible to make a
the patient. differential diagnosis.
When this information is applied to the information is the cause of her symptoms. Trauma appears less
gained from our patient we see that her symptoms likely due to having no systemic symptoms – a
most closely match viral infection or trauma. As supplementary question about precipitating factors
epidemiology states viral infection is the most should exclude trauma as a cause.
prevalent cause of sore throat it seems likely that this
Glandular fever X ✓ X X ✓ ✓ X
Trauma ✓ ✓ ✓? ✓ ✓ ✓ X
Carcinoma X ✓ X ✓ ✓ X X
Mr JL, an Asian man in his early sixties (slightly Epidemiology of cough suggests that viral sore
overweight) wants something for his persistent throat is the most likely cause of cough in primary
cough. He has tried some stuff from the care for all ages. However, other conditions are
supermarket but it did not work. The following possible and are noted below:
information is gained from the patient. Using the information gained from questioning and
linking this with known epidemiology on cough (see
Table 1.1) it should be possible to make a differential
Information Data generated
diagnosis.
gathering
Presenting complaint Diagnostic pointers with respect to
Describe symptoms Cough with a little bit of symptom presentation
phlegm
Below summarises the expected findings for questions
How long had the Weeks. Just been there in the when related to the different conditions that can be
symptoms background. Not really seen by community pharmacists.
bothered by it but just doesn’t
seem to want to go. Saw the
GP about 6 weeks ago and
was given antibiotics. Seemed
to help but the cough came
back again
Nature of sputum Not a lot there really. Seems
green/brown
Onset/timing Not noticed it being better or
worse at any time
Other symptoms/ Generally feel off colour and
provokes has done for a while
Additional questions No blood in sputum that
noticed; No weight loss
Previous history of Gets coughs and colds from
presenting complaint time-to-time but not
constantly
Past medical history GORD, hypothyroidism
Drugs (OTC, Rx, and Pantoprazole 1 od
compliance) Thyroxine 100 µg 1od
Allergies KNA
Social history Drink most nights down the
Smoking club plus smokes 20–40 a day.
Alcohol Unemployed currently
Drugs
Employment
Relationships
Family history Lives on own
On examination N/A
Case study 41
Acute or
chronic
Sputum Sputum colour Age Systemic
symptoms
Worse
1
Viral Acute Sometimes White to green or yellowy Any Yes PM
PND Acute No N/A Adults No None
Allergy Either No N/A Any No PM
AB Acute Sometimes White to green or yellowy Adults Yes None
Croup Acute No N/A Young children No PM
CB Chronic Yes Mucopurulent > 40 No AM
Asthma Chronic Sometimes Yellow Any No PM
Pneumonia Acute Yes Rust tinged > 50 Yes PM
Medication Either No N/A Adults No None
HF Chronic Yes Pink tinged Elderly No PM
Bronchiectasis Chronic Yes Mucopurulent Adults No AM & PM
TB Chronic Yes Blood present Any Yes None
Ca Chronic Yes Dark red > 50 No None
Pneumothorax Acute No N/A Young adults No None
Lung abscess Chronic No N/A Elderly Yes None
Nocardiasis Chronic Yes Mucopurulent Adults Yes None
When this information is applied to the information he says that he has not a repeated history of cough.
gained from our patient we see that the conditions The patient has felt unwell for ‘a while’ and this
that most closely fit with the man’s symptoms are suggests systemic involvement. Although rare,
chronic bronchitis, tuberculosis or nocardiasis. Based tuberculosis appears to be a possibility and it would
on epidemiology, nocardiasis seems highly unlikely so is seem sensible to refer him to his GP because of the
it chronic bronchitis or tuberculosis? The man does long-standing nature of the symptoms, general malaise
smoke heavily and this fits with chronic bronchitis but and being of an ethnic background.
42 Respiratory system
Allergy X? X N/A ✓ X
Acute bronchitis X ✓ X? ✓ ✓
Croup X X N/A X X
Chronic ✓ ✓ ✓ ✓ X
bronchitis
Asthma ✓ ✓? ✓? ✓ X
Pneumonia X ✓ ✓? ✓ ✓
Medication X? X N/A n/a N/A
Heart failure ✓ ✓ X X X
Bronchiectasis ✓ ✓ ✓? ✓ X
Tuberculosis ✓ ✓ ✓? ✓ ✓
Carcinoma ✓ ✓ ✓? ✓ X
Pneumothorax X X N/A X X
Lung abscess ✓ X N/A ✓ ✓
Nocardiasis ✓ ✓ ✓? ✓ ✓
Answers
1 = c 2 = c 3 = b 4 = c 5 = d 6 = c 7 = a 8 = b 9 = b 10 = c
11 = a 12 = b 13 = b 14 = b 15 = b 16 = e 17 = b 18 = c 19 = b 20 = a
Chapter 2
Ophthalmology
In this chapter
Background 43 Red eye 44
General overview of eye anatomy 43 Eyelid disorders 53
History taking and the eye exam 44 Dry eye (keratoconjunctivitis sicca) 56
The eye examination 44 Self-assessment questions 60
Orbital bone
The eye examination
Obliquus inferior muscle Sclera
(under conjunctiva) The eye can only be examined in good light. This might
mean asking the patient to move to an area within the
pharmacy where this can be performed. Before performing
an eye exam it is important to explain to the patient fully
Limbal area what you are about to do, and gain their consent.
Conjunctiva
and episclera • First, wash your hands.
• Next, ask the patient to look straight ahead. This allows
Lacrimal you to view the pupil, cornea and sclera.
puncta • Then, gently pull down the lower lid and ask the patient
to look upwards and to both the left and the right.
• Next, gently lift the upper lid and ask the patient to
Iris Sclera look downwards and to both the left and right.
(under conjunctiva) • These two steps enable you to examine the
Pupil conjunctiva.
Fig. 2.1 Anatomy of the eye. Above: side view; below: • Now ask the patient to look directly into a near light
front view. and then to look back at you. This is best performed
using a pen-torch. This enables you to examine the
reaction of the pupils to light. Any abnormal pupil
reaction in the presence of ocular symptoms should
The retina always be treated seriously.
The retina is the light-sensitive layer of the eye; it is the • You should finally assess the visual acuity of the patient
reason for the presence of all the other eye structures. The by asking the patient to read small print with the
functioning of the retina can be compromised by many affected eye. If the patient shows any difficulty in
factors, such as underlying disease states, and foreign reading small print this should be viewed with caution.
bodies causing retinal damage and detachment. (Snellen charts – standard charts used to assess visual
acuity – are not usually available in a community
pharmacy).
History taking and the eye exam
A detailed history should be sought from the patient when Red eye
attempting to decide on the presenting complaint. Pay
attention to vision, the severity and nature of discomfort Background
and the presence of discharge. Do not forget to ask about
any family history of eye disease (e.g. glaucoma), the Conjunctivitis simply means inflammation of the conjunc-
person’s previous eye and medication history. Answers to tiva and is characterised by varying degrees of ocular
Red eye 45
2
eye and inflammation of the conjunctiva has been reported Causes of red eye and their relative incidence in
as being the most common ophthalmic problem encoun- community pharmacy
tered in the Western world.
Incidence Cause
As conjunctivitis (bacterial, viral and allergic forms) is
the most common ocular condition encountered by com- Most likely Bacterial or allergic conjunctivitis
munity pharmacists, this section concentrates on recognis-
Likely Viral conjunctivitis, subconjunctival
ing the different types of conjunctivitis and differentially
haemorrhage
diagnosing these from more serious ocular disorders.
Unlikely Episcleritis, scleritis, keratitis, uveitis
Prevalence and epidemiology Very Unlikely Acute closed angle glaucoma
The exact prevalence of conjunctivitis is not known,
although statistics for GPs show that eye problems account
for 2–5% of their workload and one small UK community
pharmacy-based study found that on average pharmacies
saw two cases of red eye per week. Infective (bacterial and
viral) account for 1/3 of eye cases seen by GPs. Conjunc-
tivitis seems to affect sexes equally and may present in
any age of patient although it is more common in children
and the elderly. All three types of conjunctivitis are essen-
tially self-limiting, although viral conjunctivitis can be
recurrent and persist for many weeks.
Aetiology
The various pathogens that cause bacterial conjunctivitis
vary between adults and children. In adults Staphylococcus
species are most common (over 50% of cases), followed
by Streptococcus pnuemoniae (20%), Moraxella species
(5%) and Haemophilus influenzae (5%). In children, Strep- Fig. 2.2 Bacterial conjunctivitis. Reproduced from David A.
tococcus, Moraxella and Haemophilus are most common. Palay and Jay H. Krachmer, 2005, Primary Care Ophthalmology,
The adenovirus is most commonly implicated in viral 2nd edition, Elsevier Mosby, with permission.
conjunctivitis and pollen usually causes seasonal allergic
conjunctivitis.
conjunctivitis. Each of the three common types of conjunc-
Arriving at a differential diagnosis tivitis has similar but varying symptoms. Each presents
with the main symptoms of redness, discharge and discom-
Red eye is a presenting complaint of both serious and fort. Table 2.3 and Figures 2.2, 2.3 and 2.4 highlight the
non-serious causes of eye pathology. Community pharma- similarities and differences in the classical presentations of
cists must be able to differentiate between those conditions the three conditions.
that can be managed and those that need referral. Table
2.1 depicts those conditions which the pharmacist may see.
Redness of the eye can occur alone or present with Conditions to eliminate
accompanying symptoms of pain, discomfort, discharge
Likely causes
and loss of visual acuity. Along with an examination of
the eye a number of eye specific questions should always Subconjunctival haemorrhage
be asked of the patient to aid in diagnosis (Table 2.2). The rupture of a blood vessel under the conjunctiva causes
subconjunctival haemorrhage. A segment of, or even the
whole eye will appear bright red (Fig. 2.5). It occurs spon-
Clinical features of conjunctivitis
taneously but can be precipitated by coughing, straining
The overwhelming majority of patients presenting to or lifting. The suddenness of symptoms and the brightness
the pharmacy with red eye will have some form of of the blood invariably means patients present very soon
46 Ophthalmology
? Table 2.2
Specific questions to ask the patient: Red eye
Question Relevance
Discharge present Most commonly seen in conjunctivitis. Can vary from watery through to mucopurulent, dependent
on the type
Mucopurulent discharge is more suggestive of bacterial conjunctivitis especially if the eyes are glued
together in the absence of itching
Visual changes Any loss of vision or haloes around objects should be viewed with extreme caution, especially if
scleral redness is also present
Pain/discomfort/itch True pain is generally associated with conditions requiring referral, e.g. scleritis, keratitis and acute
glaucoma. Pain associated with conjunctivitis is often described as a gritty/foreign-body-type pain
Location of redness Redness concentrated near or around the coloured part of the eye can indicate sinister pathology,
for example uveitis. Generalised redness and redness toward the fornices (corner of the eyes) is
more indicative of conjunctivitis. Localised scleral redness can indicate scleritis or episcleritis
Duration Minor eye problems are usually self-limiting and resolve within a few days. Any ocular redness,
apart from subconjunctival haemorrhage, and allergic conjunctivitis that lasts more than 1 week
requires referral
Photophobia Photophobia is usually associated with sinister eye pathology, for example keratitis and uveitis
Other symptoms Signs and symptoms of an upper respiratory tract infection point toward a viral cause of
conjunctivitis
Vomiting suggests glaucoma
Unlikely causes
after they have noticed the problem. There is no pain and
the patient should be reassured that symptoms will resolve Episcleritis
in 10 to 14 days without treatment. However, a patient The episclera lies just beneath the conjunctiva and adjacent
with a history of trauma should be referred to exclude to the sclera. If this becomes inflamed the eye appears red,
ocular injury. which is segmental affecting only part of the eye (Fig. 2.6).
Red eye 47
Table 2.3
2
Symptoms that help to distinguish between the different types of conjunctivitis
Bacterial Viral Allergic
Scleritis
Inflammation of the sclera is much less common than
episcleritis. It is often associated with autoimmune dis-
eases, for example in 20% of cases the patient has rheu-
matoid arthritis. It presents similarly to episcleritis but pain
Fig. 2.5 Subconjunctival haemorrhage. Reproduced from is a predominant feature as is blurred vision. Eye move-
Jack J Kanski, 2007, Clinical Ophthalmology: A Systematic
ment can worsen pain. Scleritis also tends to affect older
Approach, 6th edition, Butterworth Heinemann, with
people (mean presentation age in the early 50s).
permission.
Discharge is rare or absent in both episcleritis and
scleritis.
Fig. 2.6 Episcleritis. Reproduced from Jack J Kanski, 2007, Uveitis (iritis)
Clinical Ophthalmology: A Systematic Approach, 6th edition, Uveitis describes inflammation involving the uveal tract
Butterworth Heinemann, with permission. (iris, ciliary body and choroids). The likely cause is an
48 Ophthalmology
Yes
2
Is the redness No Is redness away Yes Eye pain
generalised? ❶ from the pupil? present?
Yes No
Assess the level of No Consider
None
pain in the eye episcleritis
Seasonal Bacterial
variation conjunctivitis
Yes No
Yes No
organisms, including those responsible for bacterial con- washing hands frequently), which will help to control the
junctivitis. However, clinical trials are lacking to substanti- spread of the virus.
ate their effectiveness and a further possible limitation is
their licensed dosage regimen (four times a day for drops) Allergic conjunctivitis
has been reported to be too infrequent to achieve sufficient
Avoidance of the allergen will, in theory, result in control
concentrations to kill or stop the growth of the infecting
of symptoms. However, total avoidance is almost impos-
pathogen.
sible and the use of prophylactic medication is usually
In 2005, chloramphenicol eye drops and in 2007 chlo-
advocated. The evidence base for mast cell stabilisers,
ramphenicol ointment were deregulated. Deregulation was
antihistamines and sympathomimetics is discussed in
probably hindered by case reports linking topical use to
Chapter 1 (page 27).
cases of aplastic anaemia. However, fears of an association
between topical use of chloramphenicol and aplastic
anaemia have proven so far to be unfounded. Chloram- Practical prescribing and product selection
phenicol has proven efficacy but its routine use has been
called in to question. Prescribing information relating to medication for red eye
Rose et al (The Lancet 2005) questioned whether anti- reviewed in the section ‘Evidence base for over-the-
biotics were needed in children as no significant difference counter medication’ is discussed and summarised in Table
was seen in the cure rate after 7 days; 86% of the children 2.4 and useful tips relating to treatment are given in Hints
were clinically cured in the antibiotic group compared and Tips Box 2.1.
with 83% in the placebo group. The authors concluded
that antibiotics were not needed in children. The most Products for bacterial conjunctivitis
recent Cochrane review (Sheikh & Hurwitz 2006) con-
cluded that: Chloramphenicol (e.g. Golden Eye Antibiotic
Drops/Ointment, Optrex Infected Eye Drops/
although the use of antibiotics is associated with signifi- Ointment, Brochlor Eye Ointment)
cantly improved rates of clinical and microbiological
remission, the benefits are marginal as in most cases the Chloramphenicol drops and ointment are licensed for use
infection is self-limiting. Therefore, when people with in children over the age of 2 years old. The recommended
clinically diagnosed infective conjunctivitis are treated, the dosage for the drops is one drop every two hours for the
chances that an individual will benefit from treatment is first 48 hours then reducing to four times a day for a
very small. maximum of 5 days treatment. The ointment, if used in
conjunction with the drops, should be only applied at night
Summary of advice for patients – approximately 1 cm of ointment should be applied to
the inside of the eyelid, after which blinking several times
Anti-infectives should not be routinely recommended and will spread the ointment. If used alone, then the ointment
patients told that the condition is self-limiting but if symp- should be used three or four times a day. They can be used
toms persist for more than 7 days then they should be in most patient groups, although they should be avoided
re-assessed. Self-help measures should be recommended in patients with a family history of blood dyscrasias. In
and include: pregnancy and breastfeeding there is a lack of manufac-
turer data for them to recommend their use. Practically,
• bathe the eyelids with lukewarm water to remove any
during pregnancy hygiene measures should be adopted
discharge
and if absolutely necessary they can be used in breast
• tissues should be used to wipe the eyes and thrown feeding women.
away immediately
• avoid wearing contact lenses until symptoms have
resolved Propamidine isethionate 0.1% (Brolene and
• regular hand washing and avoid sharing pillows and Golden Eye Drops) and Dibromopropamidine
towels. isethionate 0.15% (Golden Eye Ointment)
Propamidine and dibromopropamidine isethionate are only
Viral conjunctivitis
licensed for adults and children over the age of 12. The
Currently, there are no specific OTC preparations available dose for eye drops is one or two drops up to four times
to treat viral conjunctivitis. Viral causes are highly conta- daily, whereas the ointment should be applied once or
gious and the pharmacist should instruct the patient to twice daily. If there has been no significant improvement
follow strict hygiene measures (e.g. not sharing towels and after 2 days the person should be referred to the
Red eye 51
Table 2.4
2
Practical prescribing: Summary of medicines for red eye
Name of medicine Use in Likely side Drug Interactions Patients in which Pregnancy &
children effects of note care exercised breastfeeding
Allergic conjunctivitis
Mast cell stabilisers >6 years Local irritation, None None OK
sodium cromoglicate blurred vision
Antihistamines >12 years Local irritation, Avoid concomitant Avoid in glaucoma
Antazoline* bitter taste use with MAOI’s
and moclobemide
due to risk of
hypertensive crisis
Sympathomimetics >12 years Local irritation Avoid concomitant None Not adequately
Naphazoline use with MAOIs studied but
and moclobemide not yet shown
due to risk of to be a risk –
hypertensive crisis probably OK
Bacterial conjunctivitis
Chloramphenicol >2 years Local burning None Avoid if family In pregnancy
and stinging history of blood ideally avoid
and bone marrow
problems
Propamidine and >12 years Blurred vision None None OK
dibromopropamidine
isethionate
GP. Blurring of vision on instillation may occur but is and expert opinion considers sodium cromoglicate to be
transient. The manufacturers state that use in pregnancy safe in breastfeeding. It has no drug interactions and can
has not been established but there appears to be no reports be given to all patient groups. Instillation of the drops may
of teratogenic effects and therefore could be used in preg- cause a transient blurring of vision.
nancy if deemed appropriate. They are free from drug
interactions and can be given to all patient groups.
Sympathomimetics
These agents can be used to reduce redness of the eye.
Products for allergic conjunctivitis
Products either contain a combination of sympatho-
Mast cell stabilisers (sodium cromoglicate) mimetic and antihistamine (antazoline/xylometazoline,
Intraocular sodium cromoglicate (e.g. Opticrom Allergy, Otrivine Antistin) or sympathomimetic alone (e.g. Nap-
Optrex Allergy) is a prophylactic agent and therefore has hazoline 0.01%). They are useful in reducing redness in
to be given continuously whilst exposed to the allergen. the eye but will not treat the underlying pathology that
One or two drops should be administered in each eye four is causing the eye to be red. They should be limited to
times a day. Although no minimum age is stated for their short-term use to avoid rebound effects. Like all sym-
use, data on file from Sanofi Aventis (Opticrom Allergy) pathomimetics they can interact with monoamine oxidase
show it can be used from children over the age of six. inhibitors and should not be used by patients receiving
Clinical experience has shown it to be safe in pregnancy such treatment or within 14 days of ceasing therapy.
52 Ophthalmology
Children and school The Health Protection Agency recommends (2010) that children with conjunctivitis do not
need to be kept away from schools
Contact Lens wearers Patients who wear soft contact lenses should be advised to stop wearing them while
treatment continues and for 48 hours afterwards. This is because preservatives in the eye
drops can damage the lenses
Brolene and Golden If the patient is instructed to use the drops every 2 hours rather than four times a day then
Eye drops the drops will probably be more efficacious. However this is outside the current product
license
Choramphenicol drops These must be stored in the fridge. If they are put into the eye cold it will be uncomfortable
so patients should be told to remove them from the fridge prior to use to allow them to
warm up to room temperature
Administration of eye 1. Wash your hands
drops 2. Tilt your head backwards, until you can see the ceiling
3. Pull down the lower eyelid by pinching outwards to form a small pocket, and look upwards
4. Holding the dropper in the other hand, hold it as near as possible to the eyelid without
touching it
5. Place one drop inside the lower eyelid then close your eye
6. Wipe away any excess drops from the eyelid and lashes with the clean tissue
7. Repeat steps 2 to 6 if more than one drop needs to be administered
Administration of eye 1. Repeat eye drop steps 1 and 2
ointment 2. Pull down the lower eyelid
3. Place a thin line of ointment along the inside of the lower eyelid
4. Close your eye, and move the eyeball from side to side
5. Wipe away any excess ointment from the eyelids and lashes using the clean tissue
6. After using ointment, your vision may be blurred, but will soon be cleared by blinking
2
International Glaucoma Association: http://www.glaucoma- Causes of eyelid disorders and their relative
association.com/ incidence in community pharmacy
Uveitis Information Group: http://www.uveitis.net/ Incidence Cause
Eyecare Trust: http://www.eyecaretrust.org.uk/
The Royal College of Ophthalmologists: www.rcophth.ac.uk Most likely Blepharitis, hordeola
Likely Contact or irritant dermatitis
Unlikely Chalazion, ectropion, entropion
Eyelid disorders
Very unlikely Orbital cellulitis, carcinoma
Background
A number of disorders can afflict the eyelids, ranging from ? Table 2.6
mild dermatitis to malignant tumours. In the context of Specific questions to ask the patient:
community pharmacy consultations, the most common The eye lid
presenting conditions will be blepharitis, hordeola (styes)
Question Relevance
and chalazion.
Duration A long standing history of sore eyes
is indicative of blepharitis, a
Prevalence and epidemiology chronic, persistent condition,
Data on the incidence or prevalence of eyelid disorders is although it can be intermittent
limited yet clinical practice suggests that the above three with periods of remission
conditions are frequently encountered. For example, Lid involvement If the majority of the lid margin
blepharitis has been reported to account for 5% of primary is inflamed and red then this
care ophthalmic consultations. suggests blepharitis. Hordeola tend
to show localised lid involvement
Aetiology Eye involvement Conjunctivitis is a common
Blepharitis is classified into three categories that reflect the complication in blepharitis
aetiology of the condition; staphylococcal, seborrhoeic and Other co-existing Patients who suffer from blepharitis
meibomian gland dysfunction. Further classification of conditions often have a co-existing skin
blepharitis is sometimes used based on anatomical loca- condition such as seborrhoeic
tion. For example, anterior blepharitis refers to staphylo- dermatitis or rosacea
coccal and seborrhoeic causes as they primarily affect the
bases of the eyelashes. Posterior blepharitis refers to mei-
bomian gland dysfunction as these are situated on the Arriving at a differential diagnosis
posterior lid. Patients with blepharitis do though show
overlapping signs and symptoms that suggest mixed aeti- Blepharitis and hordeola are the most likely presentations
ology. Furthermore, it appears that many blepharitis suf- (Table 2.5) and should be relatively straightforward to
ferers also have dry eye syndrome but the exact relationship recognise, so long as a careful history, eye exam and
between the two conditions is unclear. appropriate questioning are undertaken (Table 2.6).
Styes are caused by bacterial infection (staphylococcal
in 90–95% of cases) and can either be internal or external. Clinical features of blepharitis
External styes occur on the outside surface of the eyelid
and are due to an infected gland (either the Zeis gland – a Typically, blepharitis is bilateral with symptoms ranging
type of sebaceous gland) or the gland of Moll (a type of from irritation, itching and burning of the lid margins. Lid
sweat gland), both of which are located near the base of margins may appear red and raw accompanied with exces-
the eyelashes. An internal hordeolum is a secondary sive tearing and crusty debris or skin flakes around the
infection of the meibomian gland in the tarsal plate. eyelashes. Symptoms also tend to be worse in the mornings
Occasionally, internal styes can evolve into a chalazion, a and patients might complain of eyelids being stuck together
granulomatous inflammation that develops into a painless (Fig. 2.10). In chronic cases, madarosis (missing lashes) and
lump. trichiasis (inturned lash) can occur. This latter symptom
54 Ophthalmology
Conditions to eliminate
Likely causes
Contact or irritant dermatitis
Many products – especially cosmetics – can be sensitising
and result in itching and flaking skin that mimics blephari-
tis. The patient should be questioned about recent use of
such products to allow dermatitis to be eliminated. For
further information on dermatitis see page 239.
Entropion
Entropion is defined as inversion of the eyelid margin. It
Fig. 2.11 External stye. Reproduced from Jack J Kanski, 2007, can occur unilaterally or bilaterally, with the lower eyelid
Clinical Ophthalmology: A Systematic Approach, 6th edition, more frequently affected. The in-turning of the eyelid
Butterworth Heinemann, with permission. causes the eyelashes to be pushed against the cornea,
resulting in ocular irritation and conjunctival redness
(Fig. 2.12). Referral is needed for surgical repair to correct
can lead to further local irritation and result in conjunc- the problem. Taping down the lower lid to draw the eyelid
tivitis. Seborrhoeic aetiology is likely if greasy crusting of margin away from the eye is sometimes employed as a
the lashes and oily scale predominates compared to eyelash temporary solution.
loss or misdirection, which suggests staphylococcal cause.
Ectropion
Ectropion is the converse to entropion. The eyelid turns
Clinical features of styes outward exposing the conjunctiva and cornea to the
atmosphere (Fig. 2.13). Patients will often present com-
Patients with external styes present with a swollen upper
plaining of a continually watering eye. Paradoxically, this
or lower lid, which will be painful and sensitive to touch.
can lead to dryness of the eye, as the eye is not receiving
Over time the swelling develops into a pus-filled lesion.
adequate lubrication.
The lesion will then either spontaneously shrink and
resolve or burst over the next few days (Fig. 2.11). The
Very unlikely causes
primary symptoms of an internal stye are as external styes;
pain, redness and swelling, although pain is often more Orbital cellulitis
severe and pus filled lesions are not obvious due to inward Inflammation of the skin surrounding the orbit of the eye
growth. is usually a complication from a sinus infection, although
Eyelid disorders 55
compress, applied for 5–10 minutes, every three or four Table 2.7
times a day might bring to a head an external stye and Causes of dry eye and their relative incidence in
once burst, the pain will subside and the symptoms resolve. community pharmacy
The use of dibromopropamidine has been advocated in the
Incidence Cause
treatment of styes but is of unproven benefit.
Most likely KCS
Likely Blepharitis, Sjögren’s syndrome,
Further reading medicine-induced dry eye
Miller K, Odufuwa B, Liew G, Anderson KL. Interventions for
blepharitis. Cochrane Database of Systematic Reviews Unlikely Ectropion, rosacea
2005, Issue 4. Art. No.: CD005556. DOI: 10.1002/14651858.
CD005556. Very unlikely Bell’s palsy
Shields SR. Managing eye disease in primary care. Postgrad
Med 2000;108:83–6, 91–6.
? Table 2.8
2
Specific questions to ask the patient: Dry eye
Question Relevance
Clarifying questions Have you had daily, persistent, troublesome dry eyes for more than 3 months?
Do you have a recurrent sensation of sand or gravel in the eyes?
A positive response to at least one of these questions would indicate dry eye syndrome
Aggravating factors Dry eye is worsened by dry air, wind, dust and smoke
Associated symptoms Normally no other symptoms are present in dry eye. If the patient complains of a dry
mouth, check for medication that can cause dry mouth. If medication is not implicated
then symptoms could be due to an autoimmune disease
Amount of tears produced If the patient complains of watery eyes but states that the eyes are dry and sore, check
for ectropion
!
commonly in women. The patient will have a history of
dry eyes but experiences periods of exacerbation and TRIGGER POINTS indicative of referral: Dry eye
remission. It is also associated with dryness of other
• Associated dryness of mouth and other mucous
mucous membranes, especially the mouth. Criteria for
membranes
diagnosing and classifying of Sjögren’s syndrome have • Outward turning lower eyelid
been proposed (Viteli 2002).
Table 2.10
Practical prescribing: Summary of medicines for dry eye
Name of Use in children Likely side effects Drug Patients in Pregnancy &
medicine Interactions which care breastfeeding
of note exercised
Hypromellose & Dry eye in children Transient stinging and/or None None OK
carmellose rare & therefore burning reported.
should be Blurred vision after
Carbomer 940 referred instillation of carbomer
and polyvinyl alcohol
Polyvinyl alcohol None reported
Wool fats
Hyaluronate
Preservatives in eye drops Many eye drops contain benzalkonium chloride which itself can cause eye
irritation. If symptoms persists or are worsened by the eye drops it may be
worth trying a preservative-free formulation or single dose unit preparations
This disadvantage of frequent installation has led to the useful alternatives to hypromellose because they can be
development of other products. Polyvinyl alcohol in a administered less frequently; these products are more
concentration of 1.4% acts as a viscosity enhancer. At this expensive.
concentration the products have the same surface tension
as normal tears, lending them optimal wetting character- Practical prescribing and product selection
istics and hence less frequent dosing, typically four times
a day. Similarly to hypromellose there is a lack of pub- Prescribing information relating to medication for dry eye
lished data confirming their efficacy. that is reviewed in the section ‘Evidence base for over-the-
Carbomer has been shown to be more efficacious than counter medication’ is discussed and summarised in Table
placebo and as safe as, but better tolerated, than polyvinyl 2.10 and useful tips on medication are given in Hints and
alcohol. In a comparison study between two proprietary Tips Box 2.2.
brands, Viscotears and GelTears, both were found to be The dosage of all products marketed for dry eye is
equally effective although neither was significantly better largely dependent on the patient’s need for lubrication, and
than the other. Sodium hyaluronate has been subject to a is therefore given on a when-required basis. None of these
number of trials that have shown a reduction in symptom products is known to interact with any medicine, they
severity. They have also been compared with carbomer cause minimal and transient side effects and are suitable
products and carboxymethylcellulose, and found to be for all patient groups.
equally effective.
Hypromellose and carmellose
Summary
Hypromellose is widely available as a non-proprietary
Despite hypromellose lacking trial evidence, its place in medicine in a strength of 0.3%; it is also available at 0.5%
the management of dry eye is well established. In addition, (Isopto Plain) and 1% (Isopto Alkaline); carmellose is avail-
it is very cheap and should therefore be recommended as able as 0.5%. Both might require hourly or even half-
a first-line treatment. However, other newer products, hourly dosing initially, which should reduce as symptoms
which possess better wetting characteristics, provide improve. They are pharmacologically inert and all patient
Dry eye (keratoconjunctivitis sicca) 59
groups should be able to use it safely, including pregnant Sodium hyaluronate (e.g. Hayabak, Oxyal)
2
and breastfeeding women. However, because of a lack of The dose for all products containing sodium hyaluronate
data, some manufacturers err on the side of caution and is on a when-needed basis.
recommend that it should be avoided.
Reference
Polyvinyl alcohol Vitali C, Bombardieri S, Jonsson R, et al. Classification criteria
Two proprietary products are available; Liquifilm Tears and for Sjogren’s syndrome: a revised version of the European
Sno Tears. The standard dose is four times day. Liquifilm criteria proposed by the American-European Consensus
is also available as a preservative-free formulation. It can Group. Ann Rheum Dis 2002;61:554–8.
be given to all patient groups.
Further reading
Brodwall J, Alme G, Gedde-Dahl S, et al. A comparative study
Carbomer (E.g. Clinitas Gel, GelTears, Liposic, of polyacrylic acid [Viscotears] liquid gel versus
Liquivisc, Viscotears) polyvinylalcohol in the treatment of dry eyes. Acta
Ophthalmol Scand 1997;75:457–61.
Manufacturers recommend that adults and the elderly use Bron AJ, Daubas P, Siou-Mermet R, et al. Comparison of the
one drop three or four times a day or as required, depend- efficacy and safety of two eye gels in the treatment of dry
ing upon patient need. Due to the products viscosity, car- eyes: Lacrinorm and Viscotears. Eye 1998;12:839–47.
bomer should be used last if other eye drops need to be Johnson ME, Murphy PJ, Boulton M. Carbomer and sodium
instilled. Manufacturers advise avoidance in pregnancy hyaluronate eyedrops for moderate dry eye treatment.
and lactation due to insufficient data. Clinical experience, Optometry Vision Sci 2008;85(8):750–7.
however, has shown carbomer can be used safely in these Lee JH, Ahn HS, Kim EK, Kim TI. Efficacy of sodium
patient groups. hyaluronate and carboxymethylcellulose in treating mild to
moderate dry eye disease. Cornea 2011;30(2):175–9.
Moss SE, Klein R, Klein BEK. Incidence of dry eye in an older
Lubricants population. Arch Ophthalmol 2004;122:369–73.
Sullivan LJ, McCurrach F, Lee S, et al. Efficacy and safety of
Wool fats (e.g. Lacri-Lube and Simple eye ointment) 0.3% carbomer gel compared to placebo in patients with
These products contain a mixture of white soft paraffin, moderate to severe dry eye syndrome. Ophthalmology
liquid paraffin and wool fat. They are useful at bedtime 1997;104:1402–8.
when prolonged lubrication is needed but because they
blur vision are unsuitable during the day. They are phar- Web sites
macologically inert and can be used in pregnancy and Sjögren’s Syndrome Foundation: http://www.sjogrens.org/home
breastfeeding.
60 Ophthalmology
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
knowledge to be applied to a practice setting.
2.1 Which of the following would be the most appropriate 2.6 In which of the following conditions is severe eye pain
course of action for a patient with a chalazion? experienced?
a. Instillation of Brolene eye drops four times a day a. Subconjunctival haemorrhage
b. Bathing with salt water three times a day b. Episcleritis
c. Application of Golden Eye ointment twice a day c. Keratitis
d. No treatment d. Ectropion
e. Referral to the GP e. Viral conjunctivitis
2.2 Basal cell carcinoma usually affects? 2.7 What viral pathogen is responsible for the majority of
viral conjunctivitis cases?
a. The upper eye lid
b. The lower lid margin a. The rhinovirus
c. Upper and lower eyelids equally b. The Epstein–Barr virus
d. The lower lid margin and eye itself c. The adenovirus
e. The eye only d. The Norwalk-like virus
e. The rotavirus
2.3 How can visual acuity be assessed in the community
pharmacy? 2.8 Subconjunctival haemorrhage is associated with?
a. By checking the reaction of the pupils to light a. A segment or whole eye appearing bright red and
b. Getting the patient to walk in a straight line no pain
c. Getting the patient to read print from a book b. A segment or whole eye appearing bright red and
d. Getting the patient to read distant print with pain
e. None of the above c. A segment of the eye only that appears pale red
and no pain
2.4 Which one of the following medicines can cause d. A segment of the eye only that appears bright red
dry eyes? and with pain
e. Ciliary flush
a. Pseudoephedrine
b. Atenolol
Questions 2.9 to 2.11 concern the following conditions:
c. Codeine
d. Isotretinoin A. A clear, watery discharge
e. Pantoprazole B. Haloes seen around bright lights
C. Soreness of the surface of the eye
2.5 Symptoms of blurred vision and eye pain that is D. A small, hard lump under the skin of the upper lid
associated with onset in the evening suggests: E. Grittiness and burning of the eyes in an elderly patient
a. Episcleritis
b. Keratitis
c. Uveitis
d. Glaucoma
e. Viral conjunctivitis
Self-assessment questions 61
Select from A to E, which of the above statements relate 2.17 Patients with dry eye syndrome can present with:
2
to the following conditions:
a. Itchy/sore eyes
2.9 Acute closed-angle glaucoma b. Associated red eye
c. A long-standing history of dry eye
2.10 Chalazion
Questions 2.18 to 2.20: these questions consist of a
2.11 Allergic conjunctivitis statement in the left-hand column followed by a
statement in the right-hand column. You need to:
Questions 2.12 to 2.14 concern the following OTC • decide whether the first statement is true or false
medications: • decide whether the second statement is true or false.
A. Hypromellose
Then choose:
B. Naphazoline
C. Carbomer 940 A. If both statements are true and the second statement
D. Dibromopropamide isethionate is a correct explanation of the first statement
E. Sodium cromoglicate B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
Select, from A to E, which of the above medicines: C. If the first statement is true but the second statement
2.12 Is used to treat allergic conjunctivitis is false
D. If the first statement is false but the second statement
2.13 Can cause rebound conjunctivitis is true
E. If both statements are false
2.14 May require hourly administration
Directions summarised
1st 2nd
Questions 2.15 to 2.17: for each of these questions one or
statement statement
more of the responses is (are) correct. Decide which of the
responses is (are) correct. Then choose: A True True 2nd explanation is a
correct explanation
A. If a, b and c are correct
of the first
B. If a and b only are correct
C. If b and c only are correct B True True 2nd statement is not
D. If a only is correct a correct explanation
E. If c only is correct of the first
C True False
Directions summarised
A B C D E D False True
2.16 Subconjunctival haemorrhage is characterised by: 2.20 Blepharitis can cause Skin flaking results in direct
red eye conjunctival irritation
a. Eye that is red and bloodshot
b. No pain
c. Onset is sudden
62 Ophthalmology
Case study
• General questions: duration, onset, medication, family You decide that Mrs JR appears to be suffering from
history. allergic conjunctivitis.
• More specific questions: degree of discomfort, whether
there is any discharge, if there have been any changes c. What OTC preparations are available to treat
to vision, if the patient has experienced previous allergic conjunctivitis?
episodes.
Based on evidence and side-effect profiles it would be
You perform a physical examination. normal to recommend:
b. What signs or symptoms would cause you to refer • First line: Topical-mast cell stabilisers
Mrs JR, rather than recommend OTC treatment? • Second line: Systemic antihistamines
When this information is applied to that gained from most likely. (Episcleritis is more common in women
our patient (below) we see that his symptoms most and not seen as an ‘injection’ of bright red blood in
closely match subconjunctival haemorrhage or the eye.) Subconjunctival haemorrhage also has
episcleritis. Looking at the presenting history and a very sudden onset and fits with the patient’s
who it is then subconjunctival haemorrhage is symptoms.
Associated vomiting ✗
Clouding of the cornea ✗
Distortion of vision ✗
Irregular shaped pupil or abnormal pupil reaction ✗
to light
Photophobia ✗
Redness caused by a foreign body ✗
Redness localised around the pupil ✗
True eye pain ✗
A mother asks for your advice for her 14-year-old Using the information in case study 2.2, what do
daughter. Emma has a sore and red eye. Questioning you think is wrong with her?
reveals that:
Differential diagnosis of bacterial or viral
• Emma has had the symptoms for 2 to 3 days. conjunctivitis
• The redness is located away from the coloured part What action are you going to take?
of the eye.
• There is a slight discharge, although Emma has not Give advice about hygiene measures and if these fail
noticed much colour in the discharge. to control symptoms or symptoms not improved after
• Her eye feels slightly gritty. 7 days then ask the patient to return for re-assessment.
• Her other eye is a little red but not as red as the Antibiotic eye drops may then be needed.
problem eye.
• She is complaining of slight headaches around her
eyes.
• She has taken nothing for the problem and only takes
erythromycin for acne from the GP.
• She has not had these types of symptoms before.
Answers
1 = d 2 = b 3 = c 4 = d 5 = d 6 = c 7 = c 8 = a 9 = b 10 = d
11 = a 12 = e 13 = b 14 = a 15 = d 16 = a 17 = a 18 = d 19 = b 20 = a
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Chapter 3
Ear conditions
In this chapter
Background 67 Ear wax impaction 67
General overview of ear anatomy 67 Otitis externa 71
History taking and physical exam 67 Self-assessment questions 75
Table 3.2
Possible causes of the presenting complaint
Patient presents with Possible causes
Helix
Redness and swelling Perichondritis, haematoma
Triangular Discharge Otitis externa or media. If
fossa
discharge mucinous,
originates from middle
Antihelix External ear as EAM has no
auditory mucous glands
meatus
Concha Pain in mastoid area Otitis media, mastoiditis
Tragus
Pain when pressing tragus or Otitis externa
Antitrogus moving pinna
Lobule
? Table 3.3
3
Specific questions to ask the patient:
Tympanic membrane Ear wax
Question Relevance
Auricle
Course of The patient usually has a history of
External ear canal
symptoms gradual hearing loss with ear wax
impaction
Associated Dizziness and tinnitus indicates an inner
symptoms ear problem and should be referred. Ear
1.3 cm wax impaction rarely causes tinnitus,
vertigo or true pain
History of Check if the person has recently tried to
trauma clean the ears. This often leads to wax
impaction
Use of If a patient has used an appropriate OTC
medicines medication correctly this would
necessitate referral for further
investigation and possibly ear-syringing
Tympanic
membrane
Clinical features of ear wax impaction
The key features of ear wax impaction are a history of
gradual hearing loss, ear discomfort (to variable degrees)
and recent attempts to clean ears. Itching, tinnitus and
dizziness occur infrequently. Otoscopical examination
External should reveal excessive wax.
ear canal
2.5 cm
Conditions to eliminate
Trauma of the ear canal
It is common practice for people to use all manner of
implements to try and clean the ear canal of wax (e.g.
cotton buds, hairgrips, and pens). Inspection of the ear
Fig. 3.2 Inspection of the external auditory meatus. Above: canal might reveal laceration of the ear canal and the
in children; below: in adults. patient may experience greater conductive deafness
because of the wax becoming further impacted. Trauma
might also lead to discharge from the ear canal; these cases
are probably best referred.
Table 3.4
Practical prescribing: Summary of medicines for ear wax
Name of medicine Use in children Likely side Drug interactions Patients in which Pregnancy &
effects of note care exercised breastfeeding
Oil-based products No lower age None None None OK
limit stated
Peroxide-based products Irritation
Docusate Irritation
Sodium bicarbonate None
Glycerin >1 year
(Earex Plus)
Peanut allergy Peanut allergy affects approximately 1 in 200 people and patients should be
warned about preparations that contain arachis or almond oil
3
Hypersensitivity reactions to ear Local reactions to the active ingredient or constituents have been reported. If a
drops person has had a previous reaction using ear drops then care must be exercised
Administration of ear drops Hold the bottle in your hands for a few minutes prior to administration to warm
the solution. This makes insertion more comfortable
Lie on a bed with the affected ear pointing toward the ceiling or alternatively tilt
your head to one side with the affected ear pointing toward the ceiling
With one hand straighten the ear canal. Adults pull the pinna up and back and in
children, pull down and back
Holding the dropper in the other hand, hold it as near as possible to the ear canal
without touching it and place the correct number of drops into the ear canal
The head should be kept in the same position for several minutes
Once the head is returned to the normal position, any excess solution should be
wiped away with a clean tissue
cotton wool plug should be gently placed in the ear to is that it should be used twice daily for 4 days and can be
retain the liquid. given to children over 1 year of age.
more common in hot and humid climates and in western Table 3.5
society the number of episodes increases in the summer Causes of ear symptoms and their relative incidence
months. People who swim are five times more likely in community pharmacy
than non-swimmers to contract it and it is commoner in
Incidence Cause
adults and reported to be slightly more common in women
than men. Most likely Otitis externa caused by infection
or trauma
Aetiology Likely Otitis Media
Primary infection, contact sensitivity or a combination of Unlikely Dermatitis (contact, allergic,
both causes otitis externa. Pathogens implicated with acute seborrhoeic or atopic)
otitis externa include Pseudomonas aeruginosa, Staphylo-
coccus spp. and Streptococcus pyogenes. Fungal over- Very unlikely Perichondritis, malignancy
growth with Aspergillus niger is also seen especially after
prolonged antibiotic treatment.
Certain local or general factors can precipitate otitis
externa. Local causes include trauma or discharge from the ? Table 3.6
middle ear and general causes include seborrhoeic derma- Specific questions to ask the patient:
titis, psoriasis and skin infections. otitis externa
Question Relevance
Arriving at a differential diagnosis
Symptom Principal symptom of acute otitis
In common with ear wax impaction, otitis externa is easily presentation externa is itch/irritation and pain
recognised providing a careful history and ear examination
has been conducted. However, other otological conditions Discharge Otitis media is the commonest cause
of ear discharge and is usually
can present with similar symptoms of pain and discharge
mucopurulent. If discharge is
(Table 3.5).
present with otitis externa, then
It is therefore important to differentiate between otitis
discharge is not mucopurulent
externa and conditions that require referral. Table 3.6
highlights some of the questions that should be asked of Systemic Otitis externa should not present with
the patient. symptoms any systemic symptoms
Fever and cold symptoms usually
Clinical features of otitis externa present in otitis media
In all forms of dermatitis, systemic
Otitis externa is characterised by itching and irritation, symptoms should not be present
which, depending on the severity, can become intense. This
provokes the patient to scratch the skin of the EAM, result-
ing in trauma and pain. Patients might not present until
pain becomes a prominent feature. However, there should
old. In older children, ear pain/earache is the predominant
be a period when irritation is the only symptom apparent.
feature and tends to be throbbing. In young children this
Chewing and manipulation of the tragus and pinna can
is often manifested as irritability or crying with character-
exacerbate pain. Otorrhoea (ear discharge) follows and
istic ear tugging/rubbing. Systemic symptoms can also be
the skin of the EAM can become oedematous, leading to
present such as fever and loss of appetite. An examination
conductive hearing loss. On examination, the ear canal or
of the ear should reveal a red/yellow and bulging tympanic
external ear, or both, appear red, swollen, or eczematous
membrane. Pain resolves on rupture of the tympanic
(Fig. 3.3).
membrane, which releases a mucopurulent discharge. Over
three-quarters of episodes resolve within 3 days without
Conditions to eliminate treatment and current UK guidelines do not advocate the
routine use of antibiotics. Patients should be managed with
Likely causes
analgesia (paracetamol or ibuprofen) unless they are sys-
Acute otitis media temically unwell or are under 2 years of age and have
A rapidly accumulating effusion in the middle ear (acute discharge. These cases should be referred for GP considera-
otitis media) is most common in children aged 3 to 6 years tion of antibiotics.
Otitis externa 73
Table 3.7
Practical prescribing: Summary of medicines for otitis externa
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Choline >1 year None reported None None OK
salicylate
Acetic acid >12 years Transient stinging or
burning sensation
Evidence base for over-the-counter medication Choline salicylate (Earex Plus – choline
salicylate 21.6%, glycerol 12.62%)
OTC treatment of otitis externa is currently very limited.
Inflammation of the EAM would respond to corticoster- Choline salicylate can be given to adults and children over
oids; however, all ear drops/sprays that contain steroids the age of 1 year. The EAM should be completely filled
are currently POM. This limits OTC options to either oral with drops and then plugged with cotton wool soaked with
antihistamines – to try and combat itching and irritation the ear drops. This should be repeated every 3 to 4 hours.
or analgesia to control pain.
Choline salicylate is found in two proprietary products Acetic acid (Earcalm Spray)
(Earex Plus, Audax). Two small trials comparing the anal- This can be given to adults and children aged 12 and over.
gesic effect of choline salicylate against aspirin and para- The dose is one spray (60 mg) into the affected ear at least
cetamol have been conducted. Both trials concluded that three times a day. The maximum dosage frequency is one
choline salicylate reduced pain more quickly than oral spray every 2 to 3 hours. Treatment should be continued
analgesia. until 2 days after symptoms have disappeared but if symp-
In addition, acetic acid is available OTC (Earcalm Spray, toms do not improve or worsen within 48 hours the patient
2% acetic acid) and is indicated for the treatment of should be referred to a medical practitioner. The spray
superficial infections of the EAM. The British National should not be used for more than 7 days.
Formulary 64 states ‘that it may be used to treat mild
otitis externa but more severe cases an anti-inflammatory
preparation with or without an anti-infective drug is References
Hajioff D, Mackeith S. Otitis Media. BMJ Clinical Evidence
required.’ This advice appears to be taken from a 2003
2008;06:510.
BMJ article (van Balen et al) who found acetic acid to
van Balen FA, Smit WM, Zuithoff NP, et al. Clinical efficacy
be far less effective than acetic acid combined with a of three common treatments in acute otitis externa in
steroid or a steroid/anti-infective combination. A further primary care: randomised controlled trial. Br Med J
review article published in 2008 also found insufficient 2003;327:1201–5.
evidence to demonstrate the effectiveness of acetic acid
in treating otitis externa (Hajioff & Mackeith 2008). Further reading
However, current Prodigy guidance (2012) states acetic Hewitt HR. Clinical evaluation of choline salicylate ear drops.
acid alone can be used first-line to treat bacterial and/ The Practitioner 1970;204:438–40.
or fungal disease. Lawrence N. A comparison of analgesic therapies for the relief
of acute otalgia. Brit J Clin Pract 1970;24:478–9.
Milford C, Rowlands A. Shared Care for ENT. Oxford: Isis
Practical prescribing and product selection Medical Media Ltd; 1999.
Rosenfeld RM, Brown L, Cannon CR, et al. Otolaryngol Head
Prescribing information relating to otitis externa medicines Neck Surg 2006;134:S4–S23.
reviewed in the section ‘Evidence base for over-the- SIGN (2003) Diagnosis and management of childhood otitis
counter medication’ is discussed below and summarised media in primary care. Report No. 66. Scottish
in Table 3.7. Pain associated with otitis media can be Intercollegiate Guidelines Network. www.sign.ac.uk
managed with simple analgesics such as paracetamol and (accessed: 6 June 2012).
ibuprofen.
Self-assessment questions 75
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
3
knowledge to be applied to a practice setting.
3.1 Which of the following OTC treatments would you 3.6 The best way to view the EAM of an adult is to?
recommend for otitis media?
a. Pull the pinna up and back to straighten the EAM
a. Hydrocortisone b. Pull the pinna down and back to straighten
b. An astringent the EAM
c. Local analgesia c. Pull the pinna up and forward to straighten the EAM
d. Emollient d. Pull the pinna down and forward to straighten
e. None of the above the EAM
e. Pull the pinna back to straighten the EAM
3.2 Otitis media is more prevalent in which age group?
3.7 Elderly people are more prone to ear wax because?
a. 0 to 3 years
b. 3 to 6 years a. Of an increase in cerumen production
c. 6 to 9 years b. The skin migrates at a slower rate
d. 9 to 12 years c. Decreased oestrogen concentrations cause less wax
e. Over 12 years to be produced
d. The number of cerumen glands decreases with age
3.3 If a patient complains of tinnitus and deafness, what is e. Greater immobility
the most likely part of the ear which is affected?
3.8 Which of the following contains peanut oil?
a. Outer ear
b. Middle ear a. Otex
c. Inner ear b. Earcalm
d. Either middle or outer ear c. Earex
e. Either inner or middle d. Molcer
e. Exterol
3.4 Which patient group is predisposed to otitis externa?
Questions 3.9 to 3.11 concern the following anatomical
a. Patients with seborrhoeic dermatitis
locations:
b. Patients with acne vulgaris
c. Patients with tinea corporis A. Mastoid area
d. Patients with discoid eczema B. The pinna
e. Patients with lichen planus C. Tympanic membrane
D. External auditory maetus
3.5 Symptoms suggestive of a middle ear problem are? E. Helix
a. Itch, pain and discharge Select from A to E, which of the above relate to the
b. Pain, discharge and deafness following statements:
c. Deafness, dizziness and tinnitus
d. Pain only 3.9 When painful on manipulation suggests external ear
e. Itch only involvement
Questions 3.12 to 3.14 concern the following OTC Questions 3.18 to 3.20: these questions consist of a
medications: statement in the left-hand column followed by a
statement in the right-hand column. You need to:
A. Hydrogen peroxide ear drops
B. Almond oil • decide whether the first statement is true or false
C. Hydrocortisone 1% cream • decide whether the second statement is true or false.
D. Choline salicylate ear drops
E. Sodium bicarbonate ear drops Then choose:
A. If both statements are true and the second statement
Select, from A to E, which of the above medicines:
is a correct explanation of the first statement
3.12 Should not be given to children B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
C. If the first statement is true but the second statement
3.13 Can reduce pain
is false
D. If the first statement is false but the second statement
3.14 Avoided in peanut allergy is true
E. If both statements are false
Questions 3.15 to 3.17: for each of these questions one or
more of the responses is (are) correct. Decide which of the Directions summarised
responses is (are) correct. Then choose: 1st 2nd
A. If a, b and c are correct statement statement
B. If a and b only are correct A True True 2nd explanation is a
C. If b and c only are correct correct explanation
D. If a only is correct of the first
E. If c only is correct
B True True 2nd statement is not
a correct explanation
Directions summarised of the first
A B C D E C True False
a, b and c a and b b and c a only c only
D False True
only only
E False False
3.15 Which statements are associated with the EAM:
a. The outer third consists mainly of cartilage First statement Second statement
b. To inspect the EAM of a child the pinna should be 3.18 Swimmers often get otitis Prolonged exposure to
pulled down and back externa water predisposes people
c. To inspect the EAM of an adult the pinna should be to EAM infections
pulled down and back 3.19 Perichondritis is a Topical antibiotics are
precursor to otitis externa ineffective
3.16 Conductive deafness can be caused by:
3.20 All children with ear pain Systemic antibiotics are
a. Insertion of a foreign body into the EAM must be referred needed
b. Blockage of the eustachian tube
c. Poor ear-cleaning technique
Case study
CASE STUDY 3.1 3
Mr SW has asked to speak to the pharmacist as his c. Compare and contrast the different products
ear is bothering him. available to treat Mr SW’s symptoms?
a. Discuss the appropriately worded questions you Cerumenolytics remain the mainstay of treatment in
will need to ask Mr SW to determine the the UK. However, the evidence base for efficacy is
diagnosis of his complaint. poor. The British National Formulary advocates the
Questions to ask include: duration; medication tried; use of simple agents such as olive and almond oil
whether the symptoms are getting better, worse or and Prodigy also recommends tap water, sodium
staying about the same; degree of discomfort; whether chloride 0.9% or sodium bicarbonate ear drops.
there is any discharge. You should also check the order Dosing for all products is similar and therefore
in which the symptoms presented, any precipitating treatment choice will be driven by patient
factors, and if there is a previous history of symptoms. acceptability.
Mrs PR asks to speak to the pharmacist about her • Is there any loss of hearing?
4-year-old son Luke. She wants some Calpol to • Is the earache associated with any trauma?
treat his earache?
You find out that the earache has been present for a
day or so and Luke is more irritable than normal. Mrs
a. How do you respond?
PR says he has a temperature but she hasn’t actually
taken it. Apart from this Luke has no other symptoms.
The pharmacist needs to establish the severity of the However, he has had this problem about a year ago
earache and try to determine the cause of the pain. and was given Calpol then and it seemed to help.
b. What questions will you need to ask?
c. What course of action are you going to take?
• When was the onset of the earache? It appears Luke has a middle ear infection.
• Description of the pain Examination of the tympanic membrane would
• If any discharge is present confirm this and if possible should be carried out in
• Are there any associated symptoms (e.g. cough and the pharmacy. Instigation of Calpol seems reasonable
cold)? and Mrs PR could buy some for Luke. If symptoms did
• How is Luke’s general condition compared to normal? not subside in the next 24 h then referral to the GP
• If this is the first episode or is a recurrent problem? would be appropriate.
Answers
1 = e 2 = b 3 = c 4 = a 5 = b 6 = a 7 = d 8 = c 9 = b 10 = b
11 = c 12 = c 13 = d 14 = b 15 = b 16 = d 17 = e 18 = a 19 = d 20 = e
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Chapter 4
Central nervous system
In this chapter
Background 79 Insomnia 89
General overview of CNS anatomy 79 Nausea and vomiting 94
History taking 79 Self-assessment questions 98
Headache 79
Background Headache
The number of patient requests for advice and or products
Background
to treat headache, and insomnia make up a smaller propor-
tion of pharmacist’s workload than other conditions such Headache is not a disease state or condition but rather a
as coughs and colds yet sales for analgesics and hypnotics symptom, of which there are many causes. Headache can
are extremely high (nearly £400 million in 2010–2011). The be the major presenting complaint, for example in migraine,
vast majority of patients will present with benign and cluster and tension-type headache, or one of many symp-
non-serious conditions and only in very few cases will toms, for example in an upper respiratory tract infection.
sinister pathology be responsible. Table 4.1 highlights those conditions that may be seen in
a community pharmacy in which headache is one of the
major presenting symptoms.
General overview of CNS anatomy
The central nervous system (CNS) comprises of the brain Headache classification
and spinal cord. Its major function is to process and inte- If the pharmacist is to advise on appropriate treatment
grate information arriving from sensory pathways and and referral then it is essential to make an accurate
communicate an appropriate response back via afferent diagnosis. However, with so many disorders having head-
pathways. CNS anatomy is complex and outside the scope ache as a symptom pharmacists should endeavour to
of this book. The reader is referred to any good anatomical follow an agreed classification system. The third edition
text for a comprehensive description of CNS anatomy. (2010) of the International Headache Society (IHS) clas-
sification is now almost universally accepted (Table 4.2).
The system first distinguishes between primary and sec-
History taking ondary headache disorders. This is useful to the com-
munity pharmacist, as any secondary headache disorder
A differential diagnosis for all CNS conditions will be made is symptomatic of an underlying cause and would nor-
solely from questions asked of the patient. It is especially mally require referral. In the IHS system, primary head-
important that a social and work-related history is sought aches are classified on symptom profiles, relying on careful
alongside questions asking about the patient’s presenting questioning coupled with epidemiological data on the
symptoms because pressure and stress are implicated in the distribution a particular headache disorder has within the
cause of conditions such as headache and insomnia. population.
80 Central nervous system
Table 4.2
The International Headache Society classification of headache
Primary 1. Migraine, including: 3. Cluster headache and other trigeminal
headaches 1.1 Migraine without aura autonomic cephalalgias, including:
1.2 Migraine with aura 3.1 Cluster headache
2. Tension-type headache, including: 4. Other primary headaches
2.1 Infrequent episodic tension-type headache
2.2 Frequent episodic tension-type headache
2.3 Chronic tension-type headache
Secondary 5. Headache attributed to head and/or neck trauma, 8.2 Medication-overuse headache
headaches including: 8.2.1 Ergotamine-overuse headache
5.2 Chronic post-traumatic headache 8.2.2 Triptan-overuse headache
6. Headache attributed to cranial or cervical 8.2.3 Analgesic-overuse headache
vascular disorder, including: 9. Headache attributed to infection, including:
6.2.2 Headache attributed to subarachnoid 9.1 Headache attributed to intracranial
haemorrhage infection
6.4.1 Headache attributed to giant cell arteritis 10. Headache attributed to disorder of
7. Headache attributed to non-vascular intracranial homoeostasis
disorder, including: 11. Headache or facial pain, attributed to
7.1.1 Headache attributed to idiopathic disorder of cranium, neck, eyes, ears, nose,
intracranial hypertension sinuses, teeth, mouth or other facial or
7.4 Headache attributed to intracranial cranial structures including:
neoplasm 11.2.1 Cervicogenic headache
8. Headache attributed to a substance or its 11.3.1 Headache attributed to acute
withdrawal, including: glaucoma
8.1.3 Carbon monoxide-induced headache 12. Headache attributed to psychiatric disorder
8.1.4 Alcohol-induced headache
Neuralgias 13. Cranial neuralgias, central and primary facial pain 14. Other headache, cranial neuralgia, central
and other and other headaches including: or primary facial pain
headaches 13.1 Trigeminal neuralgia
Source: adapted by the British Association of Headache (BASH) from the International Headache Society Classification Subcommittee,
The International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004, Blackwell Publishing, reproduced with permission.
Headache 81
Frontal
Arriving at a differential diagnosis
Given that headache is extremely common, and most
patients will self-medicate, any patient requesting advice
should ideally be questioned by the pharmacist, as it Cluster, glaucoma, sinusitis
is likely that the headache has either not responded to
OTC medication or is troublesome enough for the patient
to seek advice. Arrival at an accurate diagnosis will Orbital
rely exclusively on questioning; therefore a number of
headache-specific questions should be asked (Table 4.3). In
addition to these symptom-specific questions, the pharma-
cist should also enquire about the person’s social history
because social factors – mainly stress – play a significant Subarachnoid haemorrhage,
role in headache. Ask about the person’s work and family tension
status to determine if the person is suffering from greater
levels of stress than normal. Occipital
? Table 4.3
Specific questions to ask the patient: Headache
Question Relevance
Onset of In early childhood or as young adult, primary headache is most likely. After 50 years of age the
headache likelihood of a secondary cause is much greater
Headache that follows head trauma might indicate post-concussive headache or intracranial pathology
Frequency and Headache associated with the menstrual cycle or certain times, e.g. weekend or holidays, suggests
timing migraine
Headaches that occur in clusters at the same time of day/night suggest cluster headache
Headaches that occur on most days with the same pattern suggests tension-type headache
Location of pain Cluster headache is nearly always unilateral in frontal, ocular or temporal areas
(see Fig. 4.1) Migraine headache is unilateral in 70% of patients but can change from side to side from attack to
attack
Tension-type headache is often bilateral, either in frontal or occipital areas, and described as a tight
band
Very localised pain suggests an organic cause
Severity of Pain Pain is a subjective personal experience and there are therefore no objective measures. Using a
numeric pain intensity scale should allow you to assess the level of pain the person is experiencing:
0 represents no pain and 10 the worst pain possible
Dull and band-like suggests tension-type headache
Severe to intense ache or throbbing suggests haemorrhage or aneurysm
Piercing, boring, searing eye pain suggests cluster headache
Moderate to severe throbbing pain that often starts as dull ache suggests migraine
Triggers Pain that worsens on exertion, coughing and bending suggests a tumour
Food (in 10% of sufferers), menstruation and relaxation after stress are indicative of migraine
Lying down makes cluster headache worse
Attack duration Typically migraine attacks last between a few hours and 3 days
Tension-type headaches last between a few hours and several days, e.g. a week or more
Cluster headache will only normally last 2 to 3 hours
Associated Headache and fever at same time imply an infectious cause
symptoms Nausea suggests migraine or more sinister pathology, e.g. subarachnoid haemorrhage and space
occupying lesions
Scalp tenderness is associated with temporal arteritis
Patients who have frequent episodic tension-type head- The peak onset for a person to have their first attack is in
aches suffer more frequent headaches that last longer and adolescence or as a young adult. Migraines are rare over
over time these can develop into chronic tension-type the age of 50 and anyone in this age group presenting for
headache. Headaches occur for more than 15 days per the first time with migraine-like symptoms should be
month, and might be daily which last for at least 3 months. referred to the GP to eliminate secondary causes of head-
These types of headaches can severely affect the patient’s ache. If this is not their first attack they will normally have
quality of life and should not be managed by the com- a history of recurrent and episodic attacks of headache.
munity pharmacist. Attacks last anything between a few hours and up to 3
days. The average length of an attack is 24 hours. The IHS
Migraine classification recognises several subtypes of migraine but
the two major subtypes are migraine with aura (classical
There are an estimated 5 million migraine sufferers in the migraine) and migraine without aura (common migraine).
UK, half of whom have not been diagnosed by their GP. A migraine attack can be divided into three phases:
Headache 83
Table 4.4 pain becomes more generalised and diffuse. Physical activ-
4
Triggers and strategies to reduce migraine attacks ity and movement tends to intensify the pain. Nausea
affects almost all patients but less than a third will vomit.
Trigger Strategy Photophobia and phonophobia often mean patients will
Stress Maintain regular sleep pattern seek out a dark quiet room to relieve their symptoms. The
Take regular exercise patient might also suffer from fatigue, find concentrating
Modify work environment difficult and be irritable.
Relaxation techniques, e.g. yoga
Diet Maintain a food diary. If an Headache without aura (common migraine)
Any food can be a attack occurs within 6 h of
potential trigger but food ingestion and is The remaining 75% of sufferers do not experience an
food implicated reproducible it is likely that aura but do suffer from all other symptoms as described
includes: it is a trigger for migraine above.
Cheese Eat regularly and do not skip
Citrus fruit meals
Chocolate Note: Detecting triggers is Other likely causes of headache
complicated because they Eye strain
appear to be cumulative, People that perform prolonged close work, for example
jointly contributing to a VDU operators, can suffer from frontal aching headache.
‘threshold’ above which
In the first instance, patients should be referred to an opti-
attacks are initiated.
cian for a routine eye check.
Sinusitis
The pain tends to be relatively localised, usually orbital,
unilateral and dull. A course of decongestants could be
• Phase one: premonitory phase (prodrome phase), tried but if treatment failure occurs referral to the GP for
which can occur hours or possibly days before the possible antibiotic therapy would be needed. For further
headache. The patient might complain of a change in information on sinusitis see page 13.
mood or notice a change in behaviour. Feelings of well
being, yawning, poor concentration and food cravings
have been reported. These prodromal features are Unlikely causes
highly individual but are relatively consistent to each
Cluster headache
patient. Identification of ‘triggers’ is sometimes possible
Cluster headache is predominantly a condition that affects
(Table 4.4).
men over the age of 30. Typically the headache occurs
• Phase two: headache with or without aura,
at the same time each day with abrupt onset and lasts
• Phase three: as the headache subsides the patient can between 10 minutes and 3 hours, with 50% of patients
feel lethargic, tired and drained before recovery, which
experiencing night-time symptoms. Patients are woken 2
might take several hours and is termed the resolution
to 3 h after falling asleep with very intense unilateral
phase.
orbital boring pain. Additionally, conjunctival redness,
lacrimation, nasal congestion (which laterally becomes
watery) are observed on the pain side of the head. Patients
Headache with aura (classic migraine)
tend to be restless and irritable and move about to relieve
This accounts for less than 25% of migraine cases. The the pain.
aura, which are fully reversible, develop over 5 to 20 min The condition is characterised by periods of acute
and can last for up to 1 h. It can either be visual or neu- attacks, typically lasting a number of weeks to a few
rological. Visual auras can take many guises, such as months with sufferers experiencing between one to three
scotomas (blind spots), fortification spectra (zig-zag lines) attacks per day. This is then followed by periods of remis-
or flashing and flickering lights. Neurological auras (pins sion, which can last months or years. During acute phases,
and needles) typically start in the hand, migrating up the alcohol can trigger an attack. Nausea is usually absent and
arm before jumping to the face and lips. Within 60 min of a family history uncommon. Referral is required, as
the aura ending the headache usually occurs. Pain is uni- sumatriptan, the drug of choice, does not have an OTC
lateral, throbbing and moderate to severe. Sometimes the licence for cluster headache.
84 Central nervous system
!
For episodic tension-type, a systematic review by
TRIGGER POINTS indicative of referral: Headache
4
Verhagen et al (2006) investigated the comparative
efficacy of simple analgesics. The authors concluded that
Symptoms/signs Possible danger/reason all simple analgesics had similar efficacy (measured as
for referral >50% pain relief).
Headache in children under Meningitis? Combinations of simple analgesics with codeine are
12 who have a stiff neck available (page 263); however, there is doubt whether the
or skin rash amount of codeine in these preparations is sufficient to
provide any additional pain relief. Further, there is growing
Headache occurs after recent Haematoma?
evidence of problems with the over-use of these products
(1 to 3 months) trauma
injury resulting from dependence on the codeine components
(Frei et al 2010). In response to the ongoing concerns about
Nausea and/or vomiting in All can suggest sinister the over-use of codeine-containing products, the MHRA,
the absence of migraine pathology and require in 2009, issued new guidance to restrict codeine-containing
symptoms further investigation products for the short term (3 days) treatment of acute,
Neurological symptoms, if
moderate pain which is not relieved by paracetamol, ibu-
migraine excluded,
profen or aspirin alone.
especially change in
In summary, simple analgesia should be tried as first-line
consciousness
options for the relief of pain in migraine and tension-type
New or severe headache in
patients over 50 headache.
Progressive worsening of Additionally, four UK products are specifically marketed
headache symptoms over to aid relief from pain and/or nausea associated with
time migraine: Migraleve; Midrid; Buccastem; and Imigran
Very sudden and/or severe Recovery. The evidence for these products is reviewed.
onset of headache
Headache unresponsive to Simple analgesia is Migraleve
analgesics effective, therefore if
Migraleve is available as either Migraleve Pink tablets,
they have not worked
the patients’ which contain a paracetamol codeine combination (500/8)
symptoms require plus buclizine 6.25 mg or Migraleve Yellow tablets, which
further investigation contain only the analgesic combination. A number of trials
have investigated Migraleve Pink tablets against placebo,
Headache that has lasted for Most acute (or
buclizine and ergotamine products in an attempt to estab-
more than 2 weeks uncomplicated) cases
lish clinical effectiveness.
will last less than
A review of two trials in which Migraleve was compared
2 weeks. Further
against buclizine (Jorgensen 1974) and placebo (Scopa
investigation required
et al 1974) showed Migraleve was as effective as buclizine
and superior to placebo in reducing severity of migraine
attacks. However, patient numbers were small (n = 21 and
Evidence base for over-the-counter medication 20 respectively) and statistical significance was not
reported. Migraleve has also been compared to ergotamine-
Simple analgesia (paracetamol, aspirin and ibuprofen) have containing products; the standard drug at the time the trial
shown clinical benefit in relieving migraine attacks. A was conducted. Results from a GP research group (Anon
recent Cochrane review (Derry et al 2010) found that a 1973) concluded that Migraleve was equally effective as
single oral dose of paracetamol 1000 mg was effective in Migril in treating migraine. However, results should be
relieving moderate to severe migraine symptoms, com- viewed with caution because the trial suffered from poor
pared with placebo. Approximately 20% of patients will design, lacked randomisation, placebo or proper blinding.
be pain free in 2 hours (reduced from moderate to severe) A further trial by Carasso and Yehuda (1984) also reported
and approximately 60% of patients can expect a reduction beneficial effects of Migraleve. The most recent trial (Adam
in the severity of pain from moderate/severe to mild pain 1987) was well designed, being double-blind, randomised
by 2 hours. (Note that addition of metoclopramide saw and placebo controlled. The author concluded that, com-
efficacy equivalent to 100 mg sumatriptan – such products pared with placebo, Migraleve did reduce the severity of
are available OTC in other countries, e.g. Australia.) attacks significantly but not their total duration.
86 Central nervous system
Patient presents
with headache
No
>50 years Refer
New, severe <12 years
Signs of
Age ❶
headache infection
No
Yes >12 years but <50 years Treat
Yes
Refer ❷ Unilateral No Pain dull and
Sinister pathology? pain band-like
No Yes Yes
Yes Orbital pain No Throbbing Nausea and/or No Worse when
Cluster
and tearing pain vomiting stressed
Yes Yes
No No Nausea and/or Yes Tension
Refer Temples tender
vomiting headache
Yes Yes
Temporal Family history Refer ❸
arteritis of migraine Sinister pathology?
No Yes
Pain worse in
Migraine
morning
Yes No Yes
Refer No Pain lasts
Sinister pathology? <3 days
beneficial than placebo, although it is unclear whether this children aged between 10 and 14 years of age, the
4
was statistically significant. maximum dose is four tablets (one Migraleve Pink and
three Migraleve Yellow) in 24 hours.
Summary The buclizine component of Migraleve Pink tablets can
cause drowsiness and antimuscarinic effects, whereas the
Limited trial data for both products suggests that they
codeine content might result in patients experiencing con-
might be more effective than placebo. They could be rec-
stipation. Buclizine and codeine can interact with POM and
ommended but it is not known which product is most
OTC medication, especially those that cause sedation. The
efficacious. However, with the deregulation of sumatriptan
combined effect is to potentiate sedation and it is impor-
in 2006 their place in therapy is now questionable.
tant to warn the patient of this. It appears that Migraleve
is safe in pregnancy but because of the codeine compo-
Prochlorperazine (Buccastem M)
nent, it is best avoided in the third trimester. It is also
Prochlorperazine has been found to be a potent antiemetic generally safe in breastfeeding, but drowsiness in the baby
in a number of conditions, including migraine. It works by is possible – in such cases discontinue use.
blocking dopamine receptors found in the chemoreceptor
trigger zone. It is administered via the buccal mucosa and Midrid
therefore patients will need to be counselled on correct Midrid is licensed for use only in adults. The dose is two
administration. capsules at the start of an attack followed by one capsule
every hour until relief is obtained. A maximum of five
Sumatriptan (Imigran Recovery) capsules can be taken in a 12-h period. It is a sympatho-
Sumatriptan was the first ‘triptan’ to be marketed in the mimetic agent, therefore, like decongestants, it interacts
UK and subsequently deregulated to OTC status. Triptans with MAOIs, which might lead to fatal hypertensive crisis,
are 5HT1 agonists and stimulate 5HT1B and 5HT1D recep- and it can affect diabetes and hypertension control (see
tors. Triptans cause constriction of the cranial blood page 17). Side effects reported with Midrid include tran-
vessels, stop the release of inflammatory neurotransmitters sient rashes and other allergic reactions. Midrid is best
at the trigeminal nerve synapses and reduce pain signal avoided in both pregnancy and breastfeeding due to lack
transmission. As a class of medicines they have been of data.
extensively researched. Most trials with sumatriptan (and
other triptans) use end point data of 2-hour pain-free Buccastem M
response, headache relief, and functional disability. In all Buccastem M is indicated for previously diagnosed
end points sumatriptan 100 mg was significantly superior migraine sufferers aged 18 years and over who experience
to placebo. At the lower 50 mg OTC dose evidence of nausea and vomiting. The dose is one or two tablets
efficacy is less strong than 100 mg but is still effective twice daily. Side effects include, drowsiness, dizziness, dry
(McCrory & Gray 2011). mouth, insomnia, agitation and mild skin reactions.
Because it crosses the blood-brain barrier it will potentiate
Practical prescribing and product selection the effect of other CNS depressants and interact with
alcohol. Prochlorperazine has been safely used in preg-
Prescribing information relating to specific products used nancy, although the manufacturer advises avoidance
to treat migraine in the section ‘Evidence base for over- unless absolutely necessary. Minimal prochlorperazine
the-counter medication’ is discussed and summarised in passes into the breast milk and could be used.
Table 4.5 and useful tips relating to patients presenting
with migraine are given in Hints and Tips Box 4.1. Imigran Recovery
Patients over the age of 18, but younger than 65, should
Migraleve
take a single tablet (50 mg) as soon as possible after the
Migraleve is recommended for children aged 10 and over. onset of the headache. If the headache clears and then
The dose for adults and children over 14 is two Migraleve recurs a second tablet can be taken, provided there was a
Pink tablets taken when the attack is imminent or begun. response to the first tablet and more than 2 hours have
If further treatment is required, one or two Migraleve elapsed between the first and second tablet. No more
Yellow tablets can be taken every 4 h. The dose for chil- than 100 mg can be taken during any 24 hour period. If
dren aged between 10 and 14 is half that of the adult dose. there is no response to the first tablet, a second tablet
The maximum adult dose is eight tablets (two Migraleve should not be taken for the same attack. Sumatriptan is
Pink and six Migraleve Yellow) in 24 hours and for associated with a well-recognised side-effect profile with
88 Central nervous system
Table 4.5
Practical prescribing: Summary of medicines for migraine
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Migraleve >10 years Dry mouth, sedation Increased sedation Glaucoma, prostate Pregnancy – Avoid
and constipation with alcohol, enlargement in 3rd trimester
opioid analgesics, Breastfeeding – OK
anxiolytics, but infant
hypnotics and drowsiness
antidepressants reported
Midrid >12 years Dizziness, rash Avoid concomitant Control of Avoid
use with MAOIs hypertension and
and moclobemide diabetes may be
due to risk of affected, but a
hypertensive short treatment
crisis. course is unlikely
Avoid in patients to be clinically
taking beta- important
blockers and TCAs
Buccastem M >18 years Drowsiness Increased sedation Patients with Manufacturers
with alcohol, Parkinson’s advise avoidance
opioid analgesics, disease, epilepsy but it has been
anxiolytics, and glaucoma used safely in
hypnotics and both pregnancy
antidepressants and breastfeeding
Imigran >18 years Dizziness, drowsiness, MAOIs, ergotamine Avoid in people with Avoid, but data
Recovery tingling feeling a previous MI, does suggest it
warm, flushed or IHD, TIA, can be used
weak and peripheral vascular safely. Only use if
sensation of disease, cardiac absolutely
heaviness in any arrhythmias, necessary.
part of the body, hypertension;
pressure in the history of seizures;
throat, neck, chest Hepatic and renal
and arms or legs, impairment;
shortness of breath Atypical migraines
MAOI, monoamine oxidase inhibitor; MI, myocardial infarction; TCA, tricyclic antidepressant.
the commonest adverse events (classified as occurring in • A previous myocardial infraction, ischaemic heart
1 to 10% of patients) being dizziness, drowsiness, tingling, disease, peripheral vascular disease, cardiac arrhythmias
feeling warm, flushed or weak, sensation of heaviness in and history of transient ischaemic attack and stroke
any part of the body, shortness of breath, and pressure in • known hypertension
the throat, neck, chest and arms or legs. Triptans are asso- • history of seizures
ciated with rare cases of cardiac disorders and therefore to • hepatic and renal impairment
allow wider availability via OTC sales the warnings associ- • atypical migraines
ated with prescription use have become contraindications. • concomitant administration of MAOIs and ergotamine,
Therefore those patients ineligible for OTC use are: or other 5-HT1 receptor agonists.
Insomnia 89
although 10% of people can function on less than 5 hours sleep. Therefore insomnia may be caused by any factor,
per night. Sleep requirements also decrease with increasing which increases activity in arousal systems or decreases
age and people over 70 commonly have 6 hours sleep per activity in sleep systems.
day. Insomnia is classified by its duration; transient (a few
days), short-term (up to 3 weeks) or chronic (greater than Arriving at a differential diagnosis
3 weeks).
The key to arriving at a differential diagnosis is to take a
It is likely that everyone at some point will experience
detailed sleep history. Asking symptom-specific questions
insomnia as it can arise from many different causes (Fig.
will help the pharmacist to determine if referral is needed
4.3) but for most people the problem will be of nuisance
(Table 4.6). Two key features of insomnia need to be deter-
value, affecting next day alertness. The pharmacist can
mined: the type of insomnia and how it affects the person.
manage most patients with transient or short-term insom-
Transient insomnia is often caused by a change of routine,
nia, however cases of chronic insomnia are best referred
for example, time zone changes or a change to shift pat-
to the GP, as there is usually an underlying cause.
terns, excessive noise, sleeping in a new environment (e.g.
hotel) or extremes of temperature. Short-term insomnia is
Prevalence and epidemiology
usually related to acute stress such as sitting exams,
Approximately 20 to 40% of adults report occasional sleep bereavement, loss of job, forthcoming marriage or house
difficulty and half of them consider it to be significant. It move. Asking the patient to tell you what they are thinking
is twice as common in women than men. It is reported that about before they fall asleep and when they awake will
only 5 to 10% of patients go on to develop chronic insom- give you a clue to the cause of the insomnia. Often it can
nia, although chronic insomnia is more common in the be difficult to determine the cause of insomnia and getting
elderly, affecting approximately 20% of people over 65 the patient to keep a sleep diary (retiring and waking times,
years of age. time taken to fall asleep etc) is sometimes beneficial as it
allows an objective measure of the persons habits com-
Aetiology pared to their subjective perceptions.
Sleep is essential to allow the body to repair and restore Clinical features of insomnia
brain and body tissues. The mechanisms controlling sleep
are complex and not yet fully understood but reflect dis- Insomnia is a subjective complaint of poor sleep in terms
turbances of arousal and/or sleep promoting systems in the of its quality and duration. Patients will complain of
brain. Their relative activities determine the degree of difficulty in falling asleep, staying asleep or lack refresh-
alertness during wakefulness and depth and quality of ment by sleep. Sometimes patients will experience daytime
Insomnia 91
? Table 4.6
4
Specific questions to ask the patient: Insomnia
Question Relevance
Pattern of sleep An emotional disturbance (predominantly anxiety) is commonly associated in patients who find
it difficult to fall asleep; patients who fall asleep but wake early and cannot fall asleep again,
or who are then restless, is sometimes associated with depression
Daily routine Has there been any change to the work routine – changes to shift patterns, additional workload
resulting in longer working hours and greater daytime fatigue
Too much exercise or intellectual arousal prior to going to bed can make sleep more difficult
Underlying medical Medical conditions likely to cause insomnia are GORD, pregnancy, pruritic skin conditions,
conditions asthma, Parkinson’s disease, painful conditions (osteoarthritis), hyperthyroidism (night sweats),
menopausal symptoms (hot flushes) and depression.
Recent travel Time zone changes will affect the person’s normal sleep pattern and it can take a number of
days to re-establish normality
Daytime sleeping Elderly people might ‘nap’ through the day, which results in less sleep needed in the evening,
making patients believe they have insomnia
fatigue but not generally sleepiness. This tiredness can lead Table 4.7
to poor performance at work. Medication that may cause insomnia
Stimulants Caffeine, theophylline, sympathomimetics
Conditions to eliminate
amines (e.g. pseudoephedrine), MAOIs –
Insomnia in children especially in early treatment
Bedwetting is the most common sleep arousal disorder in Antiepileptics Carbamazepine, phenytoin
children. If this is not the cause, then insomnia invariably Alcohol Low to moderate amounts can promote
stems from a behavioural problem such as fear of the dark, sleep but when taken in excess or over
insecurity or nightmares. Children should not be given a long period it can disturb sleep
sleep aids but referred to their GP for further evaluation,
as the underlying cause needs to be addressed. Beta-blockers Can cause nightmares, especially
propranolol. Limit by swapping to a
Medicine-induced insomnia beta-blocker that does not readily
cross the blood–brain barrier
Medication can cause all three types of insomnia (Table
4.7). The stimulant effects of caffeine (contained in choco- SSRIs Especially fluoxetine
late, tea, coffee and cola drinks) should not be underesti-
Diuretics Ensure doses not taken after midday to
mated. Drinking four or more cups of coffee can cause
stop the need to urinate at night
insomnia in the average healthy adult. It is therefore advis-
able to instruct patients to avoid caffeine containing prod- Griseofulvin
ucts 6 hours before bedtime. Abruptly stopping some
medications can also lead to insomnia. This is particularly
seen with the long-term use of sedative drugs such as regime is appropriate. If improvements to prescribing could
benzodiazepines and tricyclic antidepressants. be made then the prescriber should be contacted to discuss
possible changes to the patient’s medication.
Underlying medical conditions
Depression
Many medical conditions may precipitate insomnia (Table
4.6). It is therefore necessary to establish a medical history It is well known that between one-third and two-thirds of
from the patient. A key role for the pharmacist in these patients suffering from chronic insomnia will have a
situations is to ensure that the underlying condition is recognisable psychiatric illness; most commonly depres-
being treated optimally and check that the medication sion. Many of these patients do not seek medical help and
92 Central nervous system
Patient presents
with insomnia
❶
❷ Yes Environmental <3 weeks >3 weeks Signs of anxiety or Yes
Treat Duration Refer
factors depression
No No
No
Refer Drug induced Yes
❶ No cases of insomnia lasting longer than 3 weeks should be ❷ Patients should not take antihistamines for more than 7 to
treated with OTC medication. If a previously undiagnosed 10 continuous days as tolerance to their effect can develop.
medical condition is suspected, most often anxiety or depres-
sion or if insomnia has been possibly caused by the patient’s ❸ In the first instance, strategies to manage the patient’s
pre-existing condition/medicines, then the GP should be con- insomnia should be suggested rather than issuing medication.
sulted and treatment options discussed/suggested.
will self-medicate. The patient will complain of having Evidence base for over-the-counter medication
difficulty in staying asleep and suffer from early morning
waking. The pharmacist should look for other symptoms Many cases of transient and short-term insomnia should
of depression such as fatigue, loss of interest and appetite, be managed initially by non-pharmacological measures. If
feelings of guilt, low self-esteem, difficulty in concentrat- these fail to rectify the problem then short-term use of
ing and constipation. NICE (CG90, October 2009) recom- sedating antihistamines may be tried.
mends using the DSM-IV criteria for diagnosing and
assessing the severity of depression and could be applied
to those patients the pharmacists suspects might have Sleep hygiene
depression. Once a diagnosis of insomnia has been reached, underlying
Figure 4.4 will help in the differential diagnosis of the causes ruled out and any misconceptions about normal
different types of insomnia. sleep addressed then educating patients about behaviour
and practice which affects sleep should be tackled
! TRIGGER POINTS indicative of referral: Insomnia (Table 4.8).
Children under 12
Duration of more than 3 weeks Medication
Insomnia for which no cause can be ascertained
Previously undiagnosed medical conditions The sedating antihistamines diphenhydramine (DPH) and
Symptoms suggestive of anxiety or depression promethazine are the mainstay of OTC pharmacological
treatment.
Insomnia 93
4
Key steps to good sleep hygiene
These products are used by a substantial number of patients
Maintain a routine, with a regular bedtime and wakening as a self-care measure (Byrne 2006; Pearson et al, 2006).
time Herbal remedies containing hops, German chamomile,
Food snacks, alcoholic and caffeine containing drinks skullcap, wild lettuce, lavender, passiflora and valerian are
should be avoided available. However, there is little evidence to support their
Avoid sleeping in very warm rooms use. The majority of information available in the literature
Avoid stimulants and alcohol relates to hypothesised action of chemical constituents or
Take daytime and not evening exercise studies in animals. Valerian appears to be the only product
No daytime naps in which more than one trial has been conducted on
No sleeping in to catch up on sleep
humans. One systematic review (Stevinson & Ernst, 2000)
No strenuous mental activity at bed time (e.g. doing a
found some evidence of efficacy in long-term studies
crossword in bed)
(14–28 nights of therapy) but inconclusive evidence in
Solve problems before retiring
the short-term (1–4 nights’ therapy). In addition, the
Associate bed with sleep – try not to watch TV or listen
to music trials were often of short duration, used volunteers or
If unable to get to sleep, get up and do something and patients with different criteria, and were usually methodo-
return to bed when sleepy logically poor. A number of branded products, containing
combinations of herbal ingredients, are available OTC
(e.g. Kalms range, Nytol herbal tablets, Potters Nodoff,
Niteherb).
Diphenhydramine Melatonin
A substantial body of evidence exists to support the Melatonin is advocated for sleep disturbance, particularly
clinical effectiveness of DPH as a sleep aid. At doses of associated with jet lag. A Cochrane review (Herxheimer
50 mg DPH has been shown to be consistently superior to et al 2002) found melatonin to be effective in reducing jet
placebo in inducing sleep, and as effective as 60 mg of lag. The timing of the dose is critical. It has to be taken at
sodium pentobarbital. Doses higher than 50 mg DPH bedtime after darkness has fallen on the first day of travel
do not produce statistically superior clinical effect and then again in the same way on the second, and any sub-
night-time doses should therefore not exceed this sequent day, of travel. Once at the final destination
amount. It appears to be most effective at shortening sleep- it should be taken for the following few days at the
onset time. same time.
Table 4.9
Practical prescribing: Summary of medicines for insomnia
Name of Use in Likely side Drug interactions Patients in which Pregnancy &
medicine children effects of note care exercised breastfeeding
Diphenhydramine >16 years Dry mouth, Increased sedation Glaucoma, prostate Some Manufacturers
sedation, and with alcohol, enlargement advise avoidance
Promethazine grogginess opioid analgesics, In breastfeeding
next day anxiolytics, occasional use OK
hypnotics and but discontinue if
antidepressants baby becomes drowsy
? Table 4.10
4
Specific questions to ask the patient: Nausea and vomiting
Question Relevance
Presence of abdominal Certain abdominal conditions, e.g. appendicitis, cholecystitis and cholelithiasis, can also cause
pain nausea and vomiting. However, for all three conditions abdominal pain would be the presenting
symptom and not nausea and vomiting. The severity of the pain alone would trigger referral
Timing of nausea and Early morning vomiting is often associated with pregnancy and excess alcohol intake
vomiting If vomiting occurs immediately after food this suggests gastritis and if vomiting begins after 1 or
more hours after eating food then peptic ulcers are possible
Signs of infection Acute cases of gastroenteritis will normally have other associated symptoms such as diarrhoea,
fever and abdominal discomfort
If infection is due to food contamination then other people are often affected at the same time
They are common symptoms of many disorders, especially a differential diagnosis to be made. Most cases will have
gastrointestinal conditions. However, infection, acute a gastrointestinal origin, with gastroenteritis being the
alcohol ingestion, anxiety, severe pain, labyrinth and car- commonest acute cause in all age groups. However, ques-
diovascular causes can also produce nausea and vomiting. tioning the patient about associated symptoms should be
Deregulation of domperidone and prochlorperazine made as other causes of nausea and vomiting need to be
has meant that community pharmacists can now more eliminated (Table 4.10).
effectively manage nausea and vomiting. Until their
deregulation, treatment choices were limited to anticholin- Clinical features associated with gastroenteritis
ergics and first-generation antihistamines, used as prophy-
lactic agents for the prevention of motion sickness (see Gastroenteritis is characterised by acute onset, vomiting
page 313). and/or diarrhoea and systemic illness (e.g. fever). Most
cases, regardless of infecting pathogen, resolve in a few
Prevalence and epidemiology days and rarely last more than 10 days. In children under
5 years old over 60% of cases are viral in origin with the
Nausea and vomiting are symptoms of other conditions rotavirus and small round structured virus most commonly
and therefore their prevalence and epidemiology within the identified. Vomiting usually precedes diarrhoea by several
population are determined by that condition. Needless to hours. Bacterial gastroenteritis presents with similar symp-
say nausea and vomiting is common and most people at toms although fever is usually a more prominent feature.
some point in time will experience these symptoms.
Conditions to eliminate
Aetiology
Nausea occurs because activity in the vomiting centre Gastritis
(located in the medulla oblongata) increases. Information Gastritis is often alcohol or medicine induced and can
received from the receptor cells in the walls of the gas- present as acute or chronic nausea and vomiting. Epigas-
trointestinal tract and parts of the nervous system reach a tric pain is usually present. For further information on
‘threshold value’ that induces the vomiting reflex. Addi- gastritis see page 146.
tionally, further input is received at the vomiting centre
from an area known as the chemoreceptor trigger zone. Nausea and vomiting associated
This is highly sensitive to certain circulating chemicals, for with headaches
example substances released by damaged tissues as a result
of bacterial infection. Vomiting, and especially nausea, are common symptoms
in patients who suffer from migraines. However, other
causes of headache such as raised intracranial pressure can
Arriving at a differential diagnosis
also cause nausea and vomiting. For further information
Nausea and/or vomiting rarely occur in isolation. Other on nausea and vomiting associated with headaches see
symptoms are usually present and should therefore allow page 82.
96 Central nervous system
Table 4.11
4
Practical prescribing: summary of medicines for nausea and vomiting
Name of Use in Likely side Drug interactions of Patients in which Pregnancy &
medicine children effects note care exercised breastfeeding
Domperidone >16 years None None None Insufficient evidence in
pregnancy – avoid
Breastfeeding OK. May
increase breast milk
supply as it increases
prolactin levels
Prochlorperazine >18 years Drowsiness Increased sedation with Patients with Manufacturers advise
alcohol, opioid Parkinson’s avoidance but it has
analgesics, anxiolytics, disease, epilepsy been used safely in
hypnotics and and glaucoma both pregnancy and
antidepressants breastfeeding
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
knowledge to be applied to a practice setting.
4.1 The most common cause of nausea and vomiting is: 4.6 Which trigger sign or symptom warrants referral?
a. Migraine a. Headache lasting 7 to 10 days
b. Gastroenteritis b. Headache described as vice-like
c. Gastritis c. Headache associated with the workplace
d. Medicine induced environment
e. Excess alcohol consumption d. Headache in children under 12 with no sign of
infection
4.2 Which product can increase breast milk production? e. Headache associated with fever
a. Prochlorperazine
4.7 The amount of sleep needed with increasing age:
b. Midrid
c. Domperidone a. Increases
d. Migraleve b. Decreases
e. Sumatriptan c. Stays the same
4.3 Cluster headache could be best described as: 4.8 Which of these statements is true when giving advice
on sleep hygiene?
a. Bilateral piercing pain that lasts for a matter of
only minutes a. Drinking coffee and tea is OK before bedtime
b. Unilateral piercing pain that lasts for a matter of b. Try to vary the time when you go to bed
only minutes c. Sleep in a warm room
c. Unilateral orbital piercing pain with associated d. Try not to nap through the day
unilateral nasal congestion e. Take light exercise before going to bed
d. Bilateral orbital piercing pain with associated nasal
congestion Questions 4.9 to 4.11 concern the following anatomical
e. Bilateral orbital piercing pain only locations of the brain:
A. Orbital
4.4 Nausea and vomiting is associated with:
B. Temporal
a. Tension headache C. Occipital
b. Trigeminal neuralgia D. Generalised
c. Cluster headache E. Unilateral and frontal
d. Subarachnoid haemorrhage
e. Sinusitis Select, from A to E, which of the above locations:
4.9 Is associated with cluster headache
4.5 What herbal remedy is used to help treat insomnia?
a. Golden Rod
4.10 Is associated with subarachnoid haemorrhage
b. Tolu Balsam
c. Burdock
d. Mugwort 4.11 Is associated with tension-type headache
e. Passion Flower
Self-assessment questions 99
Questions 4.12 to 4.14 concern the following medicines: Questions 4.18 to 4.20: these questions consist of a
4
statement in the left-hand column followed by a
A. Motilium 10
statement in the right-hand column. You need to:
B. Midrid
C. Maxolon • decide whether the first statement is true or false
D. Marvelon • decide whether the second statement is true or false
E. Migraleve
Then choose:
Select, from A to E, which of the above medicines:
A. If both statements are true and the second statement
4.12 Should be avoided by patients taking paracetamol is a correct explanation of the first statement
B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
4.13 Is licensed for nausea associated with migraine
C. If the first statement is true but the second statement
is false
4.14 Has been linked to causing migraine D. If the first statement is false but the second statement
is true
E. If both statements are false
Questions 4.15 to 4.17: for each of these questions one or
more of the responses is (are) correct. Decide which of the
responses is (are) correct. Then choose: Directions summarised
Case study
CASE STUDY 4.1
Mr AM, a male (early 30s) patient presents in the Epidemiology dictates that tension-type
pharmacy at lunchtime complaining of headaches. headache is the most likely cause in primary care
The following questions are asked, and responses (see Table 4.1).
received.
Diagnostic pointers with regard to
symptom presentation
Information gathering Data generated
Below summarises the expected findings for questions
Presenting complaint
when related to the different conditions that can be
What symptoms/ General aching feeling all
describe the symptoms over the head
seen by community pharmacists.
When this information is applied to that gained from Depression is also a possibility, although less likely.
our patient (below) we see that his symptoms most It might be worth checking symptoms relating to the
closely match tension-type headache, which may DSM-IV classification to eliminate depression.
(or may not) be triggered by extra pressure at work.
102 Central nervous system
Mr FD, A 67-year-old man, asks you for a strong It appears that tension-type headache and migraine
painkiller for his headache. He has had the can be ruled out. Cluster headache is a possibility but
headache for a few days but it doesn’t seem to be the type of pain and location is not right. This suggests
going away. After talking with the man you find the headache might be a secondary type of headache
out the following: requiring referral. Sinusitis is a secondary cause of
headache but the patient shows no recent symptoms
of URTI. From the remaining secondary causes of
• The headache is located in the frontal area and is
unilateral. headache it appears the symptoms most closely match
temporal arteritis.
• He describes the pain as throbbing.
• He has never had a headache like this before.
• He has not suffered from migraines in the past. b. What extra questions could you have asked to
• There are no associated symptoms of upper support this conclusion?
respiratory tract infection.
• He is retired and has a non-stressful lifestyle. Enquire about tenderness in the temple region or if
• There are no symptoms of nausea or vomiting. the scalp was tender to touch.
• He has tried paracetamol but without much success.
• He takes atenolol for hypertension.
Answers
1 = b 2 = c 3 = c 4 = d 5 = e 6 = d 7 = b 8 = d 9 = a 10 = c
11 = d 12 = e 13 = a 14 = d 15 = b 16 = a 17 = d 18 = b 19 = c 20 = c
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Chapter 5
Women’s health
In this chapter
Background 107 Primary dysmenorrhoea (period pain) 117
History taking 107 Premenstrual syndrome 120
Cystitis 107 Heavy menstrual bleeding (menorrhagia) 122
Vaginal discharge 111 Self-assessment questions 125
and perianal areas. Bacteria are thus transferred to the result of cystitis. Asking symptom-specific questions will
bladder where they proliferate. The most common bacterial help the pharmacist to determine if referral is needed
organisms implicated in cystitis are Escherichia coli (>80% (Table 5.2).
of cases), Staphylococcus (up to 10%) and Proteus. However,
several studies have shown that up to 50% of women do Clinical features of acute
not have positive urine cultures according to traditional uncomplicated cystitis
criteria (>105 bacteria per mL of urine), although they do
have signs and symptoms of infection. These patients with Cystitis is characterised by pain when passing urine and
‘low count bacteriuria’ are classed as having a urinary tract causes frequency, urgency, nocturia and haematuria. The
infection. diagnostic probability of cystitis is over 90% if patients
exhibit dysuria and frequency without vaginal discharge
or irritation. In addition, the patient might report only
Arriving at a differential diagnosis
passing small amounts of urine, with pain worsening at
The majority of patients who present in the community the end of voiding urine. Symptoms usually start suddenly.
pharmacy will have acute uncomplicated cystitis (Table Suprapubic discomfort not associated with passing urine
5.1). and accurately made a self-diagnosis. The pharma- might also be present but is not common. Haematuria,
cist’s aims are therefore to confirm a patient self-diagnosis, although common, should be viewed with caution because
rule out upper urinary tract infection (pyelonephritis) and it might indicate stones or a tumour. Such cases are best
identify patients who are at risk of complications as a referred.
Conditions to eliminate
Table 5.1
Causes of cystitis symptoms and their relative Likely conditions
incidence in community pharmacy
Pyelonephritis
Incidence Cause The most frequent complication of cystitis is when the
invading pathogen involves the ureter or kidney by
Most likely Acute uncomplicated cystitis
ascending from the bladder to these higher anatomical
Likely Pyelonephritis structures. The patient will show signs of systemic infec-
tion such as fever, chills, flank or loin pain and possibly
Unlikely Sexually transmitted disease,
nausea and vomiting. Referral is needed to confirm the
oestrogen deficiency
diagnosis, exclude pelvic inflammatory disease and issue
Very unlikely Medicine induced cystitis, vaginitis appropriate treatment (7-day course of ciprofloxacin
500 mg twice daily).
? Table 5.2
Specific questions to ask the patient: Cystitis
Question Relevance
Duration Symptoms that have lasted longer than 5 to 7 days should be referred because of the risk that the
person might have developed pyelonephritis
Age of the patient Cystitis is unusual in children and should be viewed with caution. This might be a sign of a
structural urinary tract abnormality. Referral is needed
Elderly female patients (>70 years) have a higher rate of complications associated with cystitis and
are therefore best referred
Presence of fever Referral is needed if the person presents with fever associated with dysuria, frequency and
urgency, as fever is a sensitive indicator of an upper urinary tract infection
Vaginal discharge If a patient reports vaginal discharge then the likely diagnosis is not cystitis but a vaginal infection
Location of pain Pain experienced in the loin area suggests an upper urinary tract infection
Cystitis 109
! TRIGGER POINTS indicative of referral: Cystitis Studies involving cranberry juice were not associated
with any serious adverse events but widespread use of
• Children under 16 cranberry juice has resulted in the identification of a pos-
• Diabetics sible interaction with warfarin, although evidence is cur-
• Duration longer than 7 days rently (2012) conflicting. Until evidence is conclusive it
• Haematuria would seem prudent that patients on warfarin should be
• Immunocompromised advised not to take products containing cranberry.
• (Men)
• Patients with associated fever and flank pain Practical prescribing and product selection
• Pregnancy
• Vaginal discharge Prescribing information relating to cystitis medicines
• Women older than 70 reviewed in the section ‘Evidence base for over-the-
counter medication’ is discussed and summarised in
110 Women’s health
Sex of patient
Male Female
Yes
Refer Sign of upper UTI ❶ Refer
No
Yes
Vaginal discharge Refer
No
Yes
Onset gradual ❷ Refer
No
No
Less than 50
years old
Yes No
Treat with OTC Treat and/or consider
medication vaginal lubricant ❹
Persists Persists
Refer Refer
❶ Involvement of the higher urinary tract structures elderly and those patients in whom symptoms have been
Symptoms such as fever, flank pain, nausea and vomiting present for more than 5 to 7 days.
suggest conditions such as pyelonephritis.
❹ Patients over 50 years old
❷ Gradual onset Oestrogen deficiency might account for the patient’s symptoms
STDs should be considered in patients whose symptoms are not resulting in local atrophy of the vagina.
sudden.
❸ At-risk patients
Patients at risk of developing upper UTI include those with
diabetes, pregnant women, the immunocompromised, the
Table 5.3 and useful tips relating to patients presenting taken three times a day, although potassium citrate can
with cystitis are given in Hints and Tips Box 5.1. be bought as a ready-made solution (the dose is 10 mL
three times a day diluted well with water) They possess
very few side effects and can be given safely with other
Alkalinising agents
prescribed medication, although in theory products con-
All marketed products are presented as a 2-day treatment taining potassium should be avoided in patients taking
course. The majority are presented as sachets (Effercitrate angiotensin-converting enzyme inhibitors, potassium-
are dissolvable tablets) and the dose is one sachet to be sparing diuretics and spironolactone. However, in practice
Vaginal discharge 111
Table 5.3
5
Practical prescribing: Summary of medicines for cystitis
Name of Use in children Likely side Drug interactions Patients in which Pregnancy &
medicine effects of note care exercised breastfeeding
Potassium citrate
Effercitrate >1 year* Gastric irritation None Patients taking ACE OK
inhibitors, potassium
Cystopurin >6 years* None sparing diuretics and
spironolactone
Sodium citrate
Cymalon Not recommended None reported None Patients with heart OK
disease, hypertension
Cystemme or renal impairment
Canesten Oasis
*Children should not be treated for UTI by pharmacists as unusual in this age group.
ACE, angiotensin converting enzyme.
Fluid intake Patients should be advised to drink about 5 L of fluid during every 24-h period. This will help promote
bladder voiding, which is thought to help ‘flush’ bacteria out of the bladder
Product taste The taste of potassium citrate mixture is unpleasant. Patients should be advised to dilute the mixture
with water to make the taste more acceptable
References
Jepson RG, Williams G, Craig JC. Cranberries for preventing
urinary tract infections. Cochrane Database of Systematic Vaginal discharge
Reviews 2012, Issue 10. Art. No.: CD001321. DOI:
10.1002/14651858.CD001321.pub5. Background
Jepson RG, Mihaljevic L, Craig JC. Cranberries for treating
urinary tract infections. Cochrane Database of Systematic Patients of any age can experience vaginal discharge. The
Reviews 1998, Issue 4. Art. No.: CD001322. DOI: three most common causes of vaginal discharge are
10.1002/14651858.CD001322. bacterial vaginosis, vulvovaginal candidiasis (thrush) and
Le J, Briggs GG, McKeown A, et al. Urinary tract infections trichomoniasis (Table 5.4). As thrush is the only condition
during pregnancy. An Pharmacother 2004;38(10):1692–701. that can be treated OTC, the text concentrates on differ-
entiating this from other conditions.
112 Women’s health
Prevalence and epidemiology production; therefore any changes in oestrogen levels will
result in either increased or decreased glycogen concentra-
It has been reported that sexually active women have a tions. If oestrogen levels decrease glycogen concentration
75% chance of experiencing at least one episode of thrush also decreases, giving rise to an increased vaginal pH and
during their childbearing years, and half of these will have making the vagina more susceptible to opportunistic infec-
more than one episode. Most cases are acute attacks but tion such as Candida albicans; 95% of thrush cases are
some women will develop recurrent thrush defined as 4 or caused by C. albicans. The remaining cases are caused by
more attacks each year. The condition is uncommon in C. glabrata although symptoms are indistinguishable.
prepubertal girls unless they have been receiving antibiot-
ics. In adolescents it is the second most common cause of
vaginal discharge after bacterial vaginosis. Arriving at a differential diagnosis
Many patients will present with a self-diagnosis and the
Aetiology of thrush pharmacists’ role will often be to confirm a self-diagnosis
of thrush. This is very important as studies have shown that
The vagina naturally produces a watery discharge (physi-
misdiagnosis by patients is common (Ferris et al 2002) and
ological discharge), the amount and character of which
can have important consequences because other conditions
varies depending on many factors, such as ovulation,
can lead to greater health concerns. For example, bacterial
pregnancy and concurrent medication. At the time of
vaginosis has been linked with pelvic inflammatory disease
ovulation the discharge is greater in quantity and of
(PID) and the preterm delivery of low-birth-weight infants
higher viscosity. Normal secretions have no odour. The
and C. trachomatis can cause infertility. Symptoms of
epithelium of the vagina contains glycogen, which is
pruritus, burning and discharge are possible in all three
broken down by enzymes and bacteria (most notably lacto-
common causes of vaginal discharge. Therefore no one
bacilli) into acids. This maintains the low vaginal pH,
symptom can be relied upon with 100% certainty to dif-
creating an environment inhospitable to pathogens.
ferentiate between thrush, bacterial vaginosis and tricho-
The glycogen concentration is controlled by oestrogen
moniasis. However, certain symptom clusters are strongly
suggestive of a particular diagnosis. Asking symptom spe-
Table 5.4 cific questions will help the pharmacist to determine if
Causes of vaginal discharge and their relative
incidence in community pharmacy referral is needed (Table 5.5).
Incidence Cause
Clinical features of thrush
Most likely Bacterial vaginosis
The dominant feature of thrush is vulval itching. This is
Likely Thrush, (medicine-induced thrush)
often accompanied with discharge (in up to 20% of
Unlikely Trichomoniasis, atrophic vaginitis, cystitis patients). The discharge has little or no odour and is curd-
like. Symptoms are generally acute in onset.
? Table 5.5
Specific questions to ask the patient: Vaginal discharge
Question Relevance
Discharge Any discharge with a strong odour should be referred. Bacterial vaginosis is associated with a white
discharge that has a strong fishy odour and trichomoniasis is malodorous with a green-yellow
discharge. By contrast, discharge associated with thrush is often described as ‘curd-like’ or
‘cottage cheese-like’ with little or no odour
Age Thrush can occur in any age group, unlike bacterial vaginosis and trichomoniasis, which are rare in
premenarchal girls. In addition, trichomoniasis is also rare in women aged over 60
Pruritus Vaginal itching tends to be most prominent in thrush compared with bacterial vaginosis and
trichomoniasis where itch is slight
Onset In thrush, the onset of symptoms is sudden, whereas bacterial vaginosis and trichomoniasis onset
tends to be less sudden
Vaginal discharge 113
Yes
❶ If the person is pregnant or has diabetes then referral is ❷ Discharge that has a strong odour and is not white and
the most appropriate option. If the person is suffering from curd-like should be referred, as trichomoniasis or bacterial
medicine-induced candidiasis the prescriber should be con- vaginosis are more likely causes.
tacted to discuss suitable treatment options and, if appropri-
ate, alternative therapy.
Evidence base for over-the-counter medication over-the-counter medication’ is discussed below and sum-
marised in Table 5.6; useful tips relating to patients pre-
Topical imidazoles and one systemic triazole (fluconazole) senting with thrush are given in Hints and Tips Box 5.2.
are available OTC to treat vaginal thrush. They are potent
and selective inhibitors of fungal enzymes necessary for Topical imidazoles (clotrimazole,
the synthesis of ergosterol, which is needed to maintain econazole, miconazole)
the integrity of cell membranes.
A number of formulations are available for local applica-
Imidazoles and triazoles have proven and comparable
tion including creams, vaginal tablets and pessaries. Phar-
efficacy with clinical cure rates between 85 and 90%.
macists and the public are probably most familiar with the
Additionally, cure rates between single or multiple dose
Canesten range of products. All internal preparations
therapy and multiple day therapy show no differences
should be administered at night. This gives the medicine
(Nurbhai et al 2007, updated in 2009). Treatment choice
time to be absorbed and eliminates the possibility of acci-
will therefore be driven by patient acceptability and cost.
dental loss, which is more likely to occur if the person is
mobile. Slight irritation on application is infrequently
Practical prescribing and product selection
reported (about 5% of users) and has been linked to the
Prescribing information relating to medicines for vehicle and not the active ingredient. Systemic absorption
thrush reviewed in the section ‘Evidence base for is minimal and therefore there are no interactions of note,
Vaginal discharge 115
Table 5.6
5
Practical prescribing: Summary of medicines for thrush
Name of Use in Likely side Drug interactions Patients in which Pregnancy &
medicine children effects of note care exercised breastfeeding
Imidazoles Not applicable Vaginal None None OK but pregnant women
irritation should be referred
OK in breastfeeding
Fluconazole GI disturbances Anticoagulants, Avoid
ciclosporin, rifampicin,
phenytoin, tacrolimus
GI, gastrointestinal.
Administration of As the dosage is at night, patients should be advised to use the pessary when in bed
pessaries • Remove the pessary from the packaging and place firmly into applicator (the end of the
applicator needs to be gently squeezed to allow the pessary to fit)
• Lying on your back, with knees drawn toward the chest, insert the applicator as deeply as
is comfortable into the vagina
• Slowly press the plunger of the applicator until it stops. Remove and dispose of the
applicator
• Remain in the supine position
Use of yoghurt Some people recommended live yoghurt as a ‘natural’ treatment. This is based on sound
rationale as lactobacilli contained in the yoghurt produce lactic acid, which inhibits the
growth of Candida. However, to date, there is a lack of evidence to prove or disprove this
theory
General advice to help Avoid tight clothing, e.g. underwear, jeans etc.
prevent infection Use simple non-perfumed soaps when washing
Symptom resolution The symptoms of thrush (burning, soreness or itching of the vagina) should disappear within
3 days of treatment. If no improvement is seen after 7 days the patient should see their GP
Vaginal douching This should not be encouraged, has no evidence of efficacy, and is associated with serious
complications such as pelvic inflammatory disease
although they may damage latex condoms and diaphragms. topical clotrimazole.) Fluconazole is generally well toler-
Consequently the effectiveness of such contraceptives may ated but can cause gastrointestinal disturbances, such as
be reduced. Topical imidazoles do have a number of nausea, abdominal discomfort, diarrhoea and flatulence in
product licence restrictions which should be observed up to 10% of patients. There are a number of established
when recommending these products and are listed in clinically important drug interactions with fluconazole.
Table 5.7. These include anticoagulants, ciclosporin, rifampicin,
phenytoin and tacrolimus. However, these drug interac-
tions relate to the use of multiple-dose fluconazole and the
Fluconazole (e.g. Diflucan One, Canesten oral)
relevance to single-dose fluconazole has not yet been
Fluconazole is a single oral dose treatment that can be established. It would be prudent to avoid these combina-
taken at any time of the day. (Note: there are also combi- tions until further evidence is available with single-dose
nation packs containing oral fluconazole and a tube of fluconazole.
116 Women’s health
Table 5.7
Product licence restrictions – topical imidazoles
Product licence restriction Rationale
Is under 16, or over 60, years of age Thrush less common in these age groups
Has systemic symptoms Suggests infection from a cause other than thrush
Has symptoms that are not entirely consistent with a previous Suspect bacterial vaginitis or trichomoniasis
episode (e.g. discharge is coloured or malodorous, there are ulcers
or blisters)
Has had two episodes in 6 months, and has not consulted her GP Good practice as repeat infection may be due to
about the condition for more than a year misdiagnosis or predisposing risk factors
May be pregnant or is breastfeeding Safe in both pregnancy and breastfeeding, although
thrush is more common during pregnancy and it
is also important to rule out gestational diabetes.
Has had a previous sexually transmitted infection (or her partner Rule out STD
has)
Has had abnormal menstrual bleeding or lower abdominal pain Symptoms not suggestive of thrush
Does not experience complete resolution of symptoms after 7 days Imidazoles are highly effective and continuing
of treatment symptoms point to misdiagnosis
5
Causes of period pain and their relative incidence in
Background community pharmacy
Incidence Cause
Menstruation spans the years between menarche to meno-
pause. Typically this will last 30 to 40 years, starting Most likely Primary dysmenorrhoea
around the age of 12 and ceasing around the age of 50.
Likely Secondary dysmenorrhoea
The menstrual cycle usually lasts 28 days but this varies
and it can last anything between 21 and 45 days. Men- Unlikely Pelvic inflammatory disease, dysfunctional
struation itself lasts between 3 and 7 days. Individuals can uterine bleeding
also exhibit differences in menstrual cycle length and
blood flow. Dysmenorrhoea is usually categorised as
primary or secondary; primary dysmenorrhoea (PD) is
? Table 5.9
defined as menstrual pain without organic pathology Specific questions to ask the patient:
whereas in secondary dysmenorrhoea an identifiable path- Primary dysmenorrhoea
ologic condition can be identified.
Question Relevance
Age PD is most common in adolescents and
Prevalence and epidemiology women in their early twenties. Secondary
dysmenorrhoea usually affects women
PD is very common in adolescents but exact prevalence
many years after the menarche, typically
rates vary due to differing definitions of dysmenorrhoea
after the age of thirty
used in studies. However, it is likely to affect over
50% of women, and 7 to 15% of these women report Nature of A great deal of overlap exists between PD
symptoms severe enough to cause school and work pain and secondary dysmenorrhoea but
absence. generally PD results in cramping whereas
secondary causes are usually described as
dull, continuous diffuse pain
Aetiology
Severity Pain is rarely severe in PD; the severity
Overproduction of uterine prostaglandins E2 and F2-alpha are of pain decreases with the onset of menses. Any
major contributory factors in causing painful cramps. patient presenting with severe lower
Prostaglandin production is controlled by progesterone abdominal pain should be referred
and before menstruation starts progesterone levels decrease
Onset of PD starts very shortly before or within 24
allowing prostaglandin production to increase, and if over-
pain hours of the onset of menses and rarely
produced cramps occur. Ovulation inhibition can also lasts for more than 3 days. Pain associated
improve symptoms (by using the oral contraceptive pill) with secondary dysmenorrhoea typically
as it lessens the endometrial lining of the uterus reducing starts a few days before the onset of menses
menstrual fluid volume and reducing prostaglandin
production.
Clinical features of PD
Arriving at a differential diagnosis
A typical presentation of PD is of lower abdominal cramp-
The main consideration of the community pharmacist is ing pains shortly before (6 hours) and for 2 or possibly 3
to exclude conditions that have a pathologic cause (sec- days after the onset of bleeding. Commonly associated
ondary dysmenorrhoea). Fortunately, by far and away symptoms include fatigue, back pain, nausea and/or vom-
the most likely problem seen in primary care is PD iting and diarrhoea. It is classically associated with young
(Table 5.8). women who have recently (6–12 months) started having
It is essential to take a detailed history of the patient’s regular periods. However, there may be a gap of months
menstrual history as PD is a diagnosis based on exclusion. or years between menarche and onset of symptoms. This
The frequency, severity and relationship of symptoms to is due to as many as 50% of women being anovulatory in
the menstrual cycle need to be established. Asking the first year (and still 10% of women 8 years after the
symptom-specific questions will help the pharmacist to menarche). This is important to know, as anovulatory
determine if referral is needed (Table 5.9). cycles are usually pain free.
118 Women’s health
Table 5.10
5
Practical prescribing: Summary of medicines for primary dysmenorrhoea
Name of Use in children Likely side Drug interactions Patients in which Pregnancy &
medicine effects of note care exercised breastfeeding
Ibuprofen Not GI discomfort, Lithium, Elderly (increased Not applicable in pregnancy
recommended nausea and anticoagulants, risk of side as patients do not
Naproxen diarrhoea methotrexate effects) menstruate when
Diclofenac pregnant.
NSAIDs OK in breastfeeding
Hyoscine Dry mouth, Other Glaucoma but avoid hyoscine if
sedation and anticholinergics, possible due to lack of
constipation e.g. TCAs data
? Table 5.11
5
Specific questions to ask the patient: Premenstrual syndrome
Question Relevance
Onset of symptoms Symptoms that are experienced 7 to 14 days before, and that disappear a few hours after the
onset of menses, are suggestive of PMS
Age of patient PMS is most common in women aged in their 30s and 40s
Presenting symptoms Patients with PMS will normally have symptoms suggestive of mental health disorders such as low
mood, insomnia and irritability. This can make excluding mental health disorders such as
depression difficult. However, the cyclical nature of the symptoms in conjunction with symptoms
such as breast tenderness, bloatedness and fluid retention point to PMS
Calcium
Table 5.13
Practical prescribing: Summary of medicines used in premenstrual syndrome
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Pyridoxine Not applicable Very high doses can Levodopa when None Not applicable in
cause toxicity administered pregnancy as patients
(>500 mg daily) alone do not menstruate
when pregnant.
Calcium Nausea and None Renally impaired OK in breastfeeding
flatulence patients
? Table 5.14
5
Specific questions to ask the patient: HMB
Question Relevance
Timing of bleeding Symptoms that might suggest structural or pathological abnormality include bleeding at
times other than menses
Effect on quality of life An assessment should be made to determine what effect menstrual bleeding is having on
the patient
Symptoms in relation to normal Patients will show cycle-to-cycle variation in the amount of blood loss. It is important to
cycles discuss with the patient this normal variation and to determine from the patient if she
feels blood loss is within the normal range
uterine and pelvic pathology (e.g. fibroids, polyps and Table 5.15
carcinoma), systemic disorders (e.g. hypothyroidism) and Medication that can alter menstrual
iatrogenic factors (e.g. medication and intrauterine devices). bleeding
Anticoagulants
Arriving at a differential diagnosis Cimetidine
Monoamine oxidase inhibitors
The main consideration of the community pharmacist is Phenothiazines
to exclude sinister pathology. A detailed history of the Steroids
patient’s menstrual cycle is essential. Asking symptom- Thyroid hormones
specific questions will help the pharmacist to determine if
referral is needed (Table 5.14).
Which treatment? if menorrhagia/heavy menstrual bleeding coexists with dysmenorrhoea, the use of NSAIDs should
be preferred to tranexamic acid
Treatment failure if there is no improvement in symptoms within 3 menstrual cycles then use of NSAIDs and/or
(NICE guidance) tranexamic acid should be stopped
has produced guidance for pharmacy staff and placed of thrombosis has been identified with those taking
certain restrictions on its sale over the counter (see http:// tranexamic acid. Nevertheless, women at high risk of
www.femstrual.co.uk/pharmacy/femstrual-protocol.html). thrombosis have been excluded from pharmacy supply.
As an OTC product it is restricted to women with a history Tranexamic acid should not be taken in patients on anti-
of heavy bleeding who have regular (21–35 day) cycles coagulants, taking the combined oral contraceptive, unop-
that show no more than 3 days individual variability in posed oestrogen or tamoxifen. In breastfeeding, one small
cycle duration. unpublished study suggests that only low levels of tran-
examic acid pass into breast milk and that waiting 3–4
Tranexamic acid (e.g. Femstrual) hours before breastfeeding will minimise any risk.
Tranexamic acid should be taken once bleeding starts. The
dose is two tablets 3 times a day for a maximum of 4 days.
The dose can be increased to two tablets 4 times a day in
References
very heavy menstrual bleeding. The maximum dose is
NICE guidelines. Heavy menstrual bleeding (Jan 2007).
eight tablets (4 g) daily. Side effects are unusual. Those Available from http://www.nice.org.uk/guidance/
reported include mild nausea, vomiting and diarrhoea index.jsp?action=byID&o=11002 (accessed 7 November
(affecting between 1 and 10% of patients). 2012).
Visual disturbances and thromboembolic events have Vessey MP, Villard-Mackintosh L, McPherson K, et al. The
been reported but are very rare. The causal relationship of epidemiology of hysterectomy: findings in a large cohort
thromboembolic events and tranexamic acid is unclear and study. Br J Obstet Gynaecol 1992;99(5):402–7.
NICE guidance states that no increase in the overall rate
Self-assessment questions 125
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
5
knowledge to be applied to a practice setting.
5.1 Primary dysmenorrhoea affects? 5.6 Dysuria accompanied with fever and flank pain is
indicative of?
a. 10 to 20% of women
b. 20 to 30% of women a. Cystitis
c. 30 to 40% of women b. Trichomoniasis
d. 40 to 50% of women c. Pyelonephritis
e. Over 50% of women d. Vaginitis
e. Endometriosis
5.2 When do PMS symptoms usually begin?
5.7 What symptoms are commonly associated with primary
a. Before ovulation
dysmenorrhoea?
b. At the start of ovulation
c. Before menstruation a. Lower abdominal cramping pain that starts 7 to 10
d. At the start of menstruation days before onset of the period
e. Following menstruation b. Lower abdominal cramping pain that starts 2 to 3
days before onset of period
5.3 What percentage of women of childbearing age will c. Lower abdominal cramping pain that starts 6 to 12
experience an episode of thrush? hours before onset of period
d. Lower abdominal griping pain that starts 2 to 3
a. 50%
days before onset of period
b. 55%
e. Lower abdominal griping pain that starts 6 to 12
c. 60%
hours before onset of period
d. 70%
e. 75%
5.8 Which of the following medicines can interact with
phenytoin?
5.4 What medication can precipitate thrush?
a. Fluconazole
a. Aspirin
b. Hyoscine
b. Propranolol
c. Potassium citrate
c. Ampicillin
d. Paracetamol
d. Ramipril
e. Codeine
e. Levothyroxine
Questions 5.9 to 5.11 concern the following patient
5.5 Which condition predisposes patients to pyelonephritis?
groups:
a. Hypertension
A. Children under 12 years old
b. Rheumatoid arthritis
B. Women over 30 years old
c. Diabetes mellitus
C. Women between the ages of 12 and 50
d. Hyperlipidaemia
D. Women aged over 60 years old
e. Asthma
E. Women between the ages of 40 and 60
126 Women’s health
Select, from A to E, which of the patient groups: 5.17 Which of the following medicines can cause menstrual
bleeding?
5.9 Are most likely to suffer from endometriosis
a. Levothyroxine
5.10 Are unlikely to suffer from cystitis
b. Sertraline
5.11 Should be referred automatically if they have vaginal c. Amoxicillin
discharge
Questions 5.18 to 5.20: these questions consist of a
Questions 5.12 to 5.14 concern the following conditions: statement in the left-hand column followed by a
statement in the right-hand column. You need to:
A. Vaginal thrush
B. Bacterial vaginosis • decide whether the first statement is true or false
C. Trichomoniasis • decide whether the second statement is true or false
D. Atrophic vaginitis
E. Cystitis Then choose:
A. If both statements are true and the second statement
Select from A to E, which of the conditions:
is a correct explanation of the first statement
5.12 Has a fishy-smelling discharge B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
5.13 Is rare in patients aged over 60 years old
C. If the first statement is true but the second statement
5.14 Has a cottage-cheese-like discharge is false
D. If the first statement is false but the second statement
Questions 5.15 to 5.17: for each of these questions one or is true
more of the responses is (are) correct. Decide which of the E. If both statements are false
responses is (are) correct. Then choose:
A. If a, b and c are correct Directions summarised
B. If a and b only are correct 1st 2nd
C. If b and c only are correct statement statement
D. If a only is correct
E. If c only is correct A True True 2nd explanation is a
correct explanation
of the first
Directions summarised
B True True 2nd statement is not
A B C D E a correct explanation
a, b and c a and b b and c a only c only of the first
only only
C True False
D False True
5.15 A pharmacist should refer patients with vaginal
candidiasis when: E False False
a. They have had more than two attacks in the last six
months First statement Second statement
b. Women are under 16 years old 5.18 Cystitis is uncommon in They have a shorter
c. Women are taking antibiotics men urethra than women
5.19 Vaginal discharge is Antibiotic therapy may
5.16 Which of the following symptoms are associated with uncommon in children precipitate attacks in this
premenstrual syndrome? under 12 age group
a. Fatigue 5.20 Imidazoles have similar Symptoms tend to resolve
b. Irritability cure rates in about 3 days
c. Breast tenderness
Case study 127
Case study
CASE STUDY 5.1
5
Mrs PR, a 26-year-old women, presents to the these symptoms previously about 2 years ago but they
pharmacy one Saturday afternoon asking for went on their own after a day or two. She takes no
something for cystitis. The counter assistant finds medicine from her GP.
out that the patient has had the symptoms about
three days and has tried no medication to relieve b. What course of action are you going to take?
the symptoms. At this point the patient is referred
to the pharmacist. Symptoms suggest an uncomplicated acute urinary
tract infection and empirical treatment could be
a. What other questions do you need to ask? instigated but the patient should be told that if
treatment fails then she should visit the GP. Advice
about adequate fluid intake should also be given.
• Location of the pain
• Nature of the pain
• Severity of the pain Mrs PR returns to the pharmacy on Monday
• Associated symptoms evening with a prescription for Erythromycin
• Previous history 250 mg qds × 20.
• Any factors that might have precipitated the attack
• Medical history, including any regular medication c. Is this an appropriate antibiotic for a urinary tract
currently taking infection?
• Presence of any vaginal discharge
Trimethoprim (or nitrofurantoin) is first-line
You find out that Mrs PR is suffering from pain on treatment. This is because Escherichia coli and
urination, discomfort and she is going to the toilet Staphylococcus usually cause cystitis for which
frequently but has no other symptoms. She has had trimethoprim has activity.
128 Women’s health
When this information is applied to that gained from previous episodes and simple analgesia seems to be
our patient we see that her symptoms strongly suggest ineffective. Treat her symptoms this time but review
primary dysmenorrhoea. A degree of caution needs to over the next few cycles.
be exercised because her symptoms seem worse than
When this information is applied to that gained from a consequence of her diabetes. Treatment could be given
our patient we see that her symptoms support a but the patient should be advised to see her doctor to
differential diagnosis of thrush. Discharge is least often check her diabetic control.
reported with thrush compared to bacterial vaginosis
and trichomoniasis and lends further weight of the
diagnosis being thrush. It is worth remembering that Timing Discharge Odour Itch
certain disease states and actions can precipitate thrush Thrush ✓ ✗? ✓ ✓
and should be excluded. Symptoms do not appear to be
brought on by any changes in toiletries but the patient Bacterial ✗? ✗? ✗ ✗
is diabetic. The patient has had symptoms previously vaginosis
(although questioning did not reveal when the last
Trichomoniasis ✗? ✗? ✗ ✗
episode was) and it is possible that the symptoms are as
Answers
1 = e 2 = b 3 = e 4 = c 5 = c 6 = c 7 = c 8 = a 9 = b 10 = a
11= a 12 = b 13 = c 14 = a 15 = b 16 = a 17 = d 18 = c 19 = b 20 = b
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Chapter 6
Gastroenterology
In this chapter
Background 133 Dyspepsia 146
General overview of the anatomy of Diarrhoea 154
the GI tract 133 Constipation 160
History taking and physical exam 134 Irritable bowel syndrome 168
Conditions affecting the oral cavity 134 Haemorrhoids 172
Mouth ulcers 134 Abdominal pain 177
Oral thrush 139 Self-assessment questions 187
Gingivitis 143
Background Stomach
The stomach is roughly ‘J’ shaped and receives food and
The main function of the gastrointestinal (GI) tract is to fluid from the oesophagus. It empties into the duodenum.
break food down in to a suitable energy source to allow It is located slightly left of midline and anterior (below) to
normal physiological function of cells. Needless to say, the the rib cage. The lesser curvature of the stomach sits adja-
process is complex and involves many different organs. cent to the liver.
Consequently, there are many conditions that affect the GI
tract, some of which are acute and self-limiting and
respond well to OTC medication and others that are serious Liver
and require referral.
The liver is located below the diaphragm and located
mostly right of midline in the upper right quadrant of the
abdomen. The liver performs many functions, including
General overview of the anatomy of carbohydrate, lipid and protein metabolism and the
the GI tract processing of many medicines.
via the pancreatic duct and secretion of hormones such as usually present with some form of oral lesion and/or pain
insulin. in a particular part of the mouth. The pharmacist should
examine this area carefully, but the rest of the oral cavity
should also be inspected. Checks for periodontal disease
History taking and physical exam (bleeding gums) and other sites of mouth soreness should
be performed.
A thorough patient history is essential as physical exami- The floor of the mouth and underside of the tongue can
nation of the GI tract in a community pharmacy is limited be viewed by asking the patient to curl the tongue toward
to inspection of the mouth. This should allow confirmation the roof of the mouth; the buccal mucosa is best observed
of the diagnoses for conditions such as mouth ulcers and when the patient half opens the mouth.
oral thrush. A description of how to examine the oral
cavity appears in the following section.
Mouth ulcers
Conditions affecting the oral cavity Background
Background Aphthous ulcers, more commonly known as mouth ulcers,
is a collective term used to describe various different clini-
The process of digestion starts in the oral cavity. The
cal presentations of superficial painful oral lesions that
tongue and cheeks position large pieces of food so that the
occur in recurrent bouts at intervals between a few days
teeth can tear and crush food into smaller particles. Saliva
to a few months. The majority of patients (80%) who
moistens, lubricates and begins the process of digesting
present in a community pharmacy will have minor aph-
carbohydrates (by secreting amylase enzymes) prior to
thous ulcers (MAU). It is the community pharmacists’ role
swallowing.
to exclude more serious pathology, for example, systemic
causes and carcinoma.
The physical exam
The oral cavity can easily be observed in the pharmacy
Prevalence and epidemiology
provided the mouth can be viewed with a good light The prevalence and epidemiology of MAU is poorly under-
source, preferably a pen torch (Fig 6.1). The patient will stood. They occur in all ages but it has been reported that
they are more common in patients aged between 20 and
40, and up to 66% of young adults give a history consist-
ent with MAU. Lifetime prevalence is estimated to affect
one in five of the general population.
Aetiology
Hard palate The cause of MAU is unknown. A number of theories have
Posterior Soft palate
pillar been put forward to explain why people get MAU, includ-
Uvula ing a genetic link, stress, trauma, food sensitivities, nutri-
Anterior
pillar tional deficiencies (iron, zinc and vitamin B12) and infection,
Pharynx but none have so far been proven.
Right
tonsil
Arriving at a differential diagnosis
Tongue
There are three main clinical presentations of ulcers:
minor, major or herpetiform. Although it is most likely the
patient will be suffering from MAU (Table 6.1) it is essen-
tial that these and other causes are recognised and referred
to the GP for further evaluation.
A number of ulcer-specific questions should always be
asked of the patient (Table 6.2) and an inspection of the
oral cavity should also be performed to help aid the
Fig. 6.1 The oral cavity. diagnosis.
Mouth ulcers 135
Table 6.1
Causes of ulcers and their relative incidence in
community pharmacy
Incidence Cause
Most likely Minor aphthous ulcers (MAU)
Likely Major aphthous ulcers, Trauma
Unlikely Herpetiform ulcers, herpes simplex, oral
thrush medicine-induced
Very unlikely Oral carcinoma, erythema multiforme
(Steven’s Johnson syndrome), Behçet’s Fig. 6.2 Minor aphthous ulcer. Reproduced from R Cawson
syndrome et al, 2002, Essentials of oral pathology and oral medicine,
7th edition, Churchill Livingstone, with permission.
? Table 6.2
Specific questions to ask the patient: Mouth ulcers
Question Relevance
Number of ulcers MAU occur singly or in small crops. A single large ulcerated area is more indicative of pathology
outside the remit of the community pharmacist
Patients with numerous ulcers are more likely to be suffering from major or herpetiform ulcers
rather than MAU
Location of ulcers Ulcers on the side of the cheeks, tongue and inside of the lips are likely to be MAU
Ulcers located toward the back of the mouth are more consistent with major or herpetiform
ulcers
Size and shape Irregular-shaped ulcers tend to be caused by trauma. If trauma is not the cause then referral is
necessary to exclude sinister pathology
If ulcers are large or very small they are unlikely to be caused by MAU
Painless ulcers Any patient presenting with a painless ulcer in the oral cavity must be referred. This can indicate
sinister pathology such as leukoplakia or carcinoma
Age MAU in young children (<10 years old) is not common and other causes such as primary infection
with herpes simplex should be considered
If ulcers appear for the first time after adolescence then the diagnostic probability is increased for
them to be caused by things other than MAU
136 Gastroenterology
Oral thrush
Oral thrush usually presents as creamy-white soft elevated
patches. It is covered in more detail in the next section
and the reader is referred to page 139 for differential
diagnosis of thrush from other oral lesions.
Herpes simplex
Herpes simplex virus is a common cause of oral ulceration
Fig. 6.4 Ulcer caused by trauma. Reproduced from D Wray in children. Primary infection results in ulceration of any
et al, 1999, Textbook of general and oral medicine, by Churchill part of the oral mucosa, especially the gums, tongue and
Livingstone, with permission. cheeks. The ulcers tend to be small and discrete and
many in number. Prior to the eruption of ulcers the person
might show signs of systemic infection such as fever
and pharyngitis.
Trauma
Medicine-induced ulcers
Trauma to the oral mucosa will result in damage and
ulceration. Trauma may be mechanical (e.g. tongue biting) A number of case reports have been received of medication
or thermal resulting in ulcers with an irregular border. causing ulcers. These include cytotoxic agents, nicoran-
Patients should be able to recall the traumatic event and dil, alendronate, non-steroidal anti-inflammatory drugs
have no history of similar ulceration or signs of systemic (NSAIDs) and beta-blockers. Ulcers are often seen at the
infection (Fig. 6.4). start of therapy or when the dose is increased.
Mouth ulcers 137
6
Carcinoma Duration Refer ❶
In 2009, over 6000 cases of oral cancer were confirmed. <14 days
It is twice as common in men than women. Incidence rates
increase sharply beyond 45 years of age. In men the No
highest incidence is seen in those aged 60–69, and in
Painful or sore Refer ❷
women it peaks in the over 80s. Smoking and excess Yes
alcohol consumption are two major risk factors.
The majority of cancers are noted on the side of the Yes Symptomatic relief
Trauma related
tongue, mouth and lower lip. Initial presentation ranges if pain bothersome
from painless spots, lumps or ulcers in the mouth or lip No
area that fail to resolve. Over time these become painful,
change colour crust over or bleed. The painless nature of More than 10 Yes
early symptoms leads people to seek help only when other ulcers present
Refer ❸
symptoms become apparent. Symptoms therefore can be No
present for a number of weeks before the patient presents
to a health care practitioner. Urgent referral is needed as Lesion size >1 cm Yes Major ulcer or
survival rates increase dramatically if the disease is diag- in diameter Candidiasis ❹
nosed in its early stages.
No
Erythema multiforme
Infection or drug therapy can cause erythema multiforme, MAU: symptomatic relief
if pain bothersome
although in about 50% of cases no cause can be found.
Symptoms are sudden in onset causing widespread ulcera-
Fig. 6.6 Primer for differential diagnosis of mouth ulcers.
tion of the oral cavity. In addition the patient can have
annular and symmetric erythematous skin lesions located
❶ Duration
toward the extremities. Conjunctivitis and eye pain is also
MAU normally resolve in 7 to 14 days. Ulcers that fail to heal
common.
within this time need referral to exclude other causes.
Behcet’s syndrome
Most patients will suffer from recurrent, painful major ❷ Painless ulcers
aphthous ulcers that are slow to heal. Lesions are also These can indicate sinister pathology, especially if the patient
observed in the genital region and eye involvement (irido- is over 50 years old. In addition, it is likely that the ulcer will
cyclitis) is common. have been present for some time before the patient presented
to the pharmacy.
Figure 6.6 will aid the differentiation between serious and
non-serious conditions that cause mouth ulcers. ❸ Numerous ulcers
Crops of 5 to 10 or more ulcers are rare in MAU. Referral is
necessary to determine the cause.
! TRIGGER POINTS indicative of referral:
Mouth ulcers ❹ Major ulcer or candidiasis
See Figure 6.9 for primer for differential diagnosis of oral
Symptoms/signs Possible Danger/reason thrush.
for referral
Children under 10 Minor ulcers rare
Evidence base for over-the-counter medication
Ulcers greater than 1 cm in Suggests other causes
diameter of ulceration outside A wide range of products are used for the temporary relief
Ulcers in crops of five to ten, scope of community and treatment of mouth ulcers. These products contain
or more pharmacist corticosteroids, local anaesthetics, antibacterials, astrin-
Duration longer than 14 days gents and antiseptics. Until, recently, corticosteroids were
Painless ulcer Possible sinister available OTC (triamcinolone acetonide 0.1% in Orabase
Eye involvement pathology and hydrocortisone sodium succinate pellets) but these
have been discontinued by the manufacturers. This is
138 Gastroenterology
Table 6.3
Practical prescribing: Summary of medicines for ulcers
Name of Use in children Likely side Drug interactions Patients in which Pregnancy &
medicine effects of note care exercised breastfeeding
Choline salicylate >16 years None None None OK
Lidocaine Can cause None None OK
sensitisation
Benzocaine >12 years reactions
Chlorhexidine >12 years None None None OK
Carmellose No age limit stated* None None None OK
*Children should not be routinely given products as ulcers are rare in this age group.
Antibacterial agents (e.g. chlorhexidine) surfaces. There is a paucity of data to support its efficacy.
However, it has no known side effects, and can be used in
A number of random controlled trials have investigated
any patient population.
antibacterial mouthwashes containing chlorhexidine glu-
conate. Data from some, but not all studies, have found
that they reduced the pain and severity of each episode of
Practical prescribing and product selection
ulceration. Prescribing information relating to the medicines used for
ulcers reviewed in the section ‘Evidence base for over-the-
Products containing anaesthetic or analgesics counter medication’ is discussed and summarised in Table
There is very little trial data to support the pain-relieving 6.3; useful tips relating to patients presenting with ulcers
effect of anaesthetics or analgesics in MAU, apart from are given in Hints and Tips Box 6.1.
choline salicylate. However, these preparations are clini- Antibacterial agents (e.g. chlorhexidine)
cally effective in other painful oral conditions. It is there-
fore not unreasonable to expect some relief of symptoms Chlorhexidine (e.g. Corsodyl) mouthwash is indicated as
to be shown when using these products to treat MAU. an aid in the treatment and prevention of gingivitis and
in the maintenance of oral hygiene, which includes the
Choline salicylate management of aphthous ulceration. Ten mL of the mouth-
wash should be rinsed around the mouth for about 1
Choline salicylate has been shown to exert an analgesic minute twice a day. It can be used by all patient groups,
effect in a number of small studies. However, only one including those who are pregnant and breastfeeding. Side
study by Reedy (1970) involving 27 patients evaluated effects associated with its use include reversible tongue
choline salicylate in the treatment of oral aphthous ulcera- and tooth discolouration, burning of the tongue and taste
tion. No significant differences were found between choline disturbance.
salicylate and placebo in ulcer resolution but choline sali-
cylate was found to be significantly superior to placebo in Choline salicylate (Bonjela Cool)
relieving pain.
Adults and children over 16 years old should apply the gel,
using a clean finger, over the ulcer when needed, but limit
Protectants
this to every 3 hours. It is a safe medicine and can be given
Orabase is a paste of gelatin, pectin and carmellose sodium, to all patient groups. It is not known to interact with any
which sticks when it comes in contact with wet mucosal medicines or cause any side effects.
Oral thrush 139
6
gel, Medijel) and benzocaine (e.g. Oralgel & Oralgel Extra
Strength).
Background
All local anaesthetics have a short duration of action;
frequent dosing is therefore required to maintain the Oropharyngeal candidiasis (oral thrush) is an opportunistic
anaesthetic effect. They are thus best used on a when mucosal infection and is unusual in healthy adults. If oral
needed basis although the upper limit on the number of thrush is suspected in this population community pharma-
applications allowed does vary depending on the concen- cists should determine if any identifiable risk factors. A
tration of anaesthetic included in each product. They healthy adult with no risk factors generally requires refer-
appear to be free from any drug interactions, have minimal ral to the GP.
side effects and can be given to most patients. A small
percentage of patients might experience a hypersensitivity
Prevalence and epidemiology
reaction with lidocaine or benzocaine; this appears to be
more common with benzocaine. The very young (neonates) and the very old are most likely
to suffer from oral thrush. It has been reported that 5% of
Carmellose sodium (Orabase Protective Paste) newborn infants and 10% of debilitated elderly patients
suffer from oral thrush. Most other cases will be associated
Orabase can be applied as frequently as requred. It is
with underlying pathology such as diabetes, xerostomia
important that it is dabbed on, and not rubbed on, for it
(dry mouth), patients who are immunocompromised or
to stick correctly. Also, patients should be discouraged
be attributable to identifiable risk factors such as recent
from putting too much on as the excess can peel off
antibiotic therapy, inhaled corticosteroids, and ill-fitting
leaving the lesion exposed. There are no apparent interac-
dentures.
tions, and Orabase can be used in all patient groups.
Aetiology
Reference
Reedy BL. A topical salicylate gel in the treatment of oral It is reported that Candida albicans is found in the oral
aphthous ulceration. Practitioner 1970;204:846–50. cavity of 30–60% of healthy people in developed countries
(Gonsalves et al 2007). Prevalence in denture wearers is
Further reading even higher. It is transmitted directly between infected
Browne RM, Fox EC, Anderson RJ. Topical triamcinolone people or via objects that can hold the organism. Changes
acetonide in recurrent aphthous stomatitis. A clinical trial. to the normal environment in the oral cavity will allow
Lancet 1968;1:565–7. C. albicans to proliferate.
MacPhee IT, Sircus W, Farmer ED, et al. Use of steroids in
treatment of aphthous ulceration. Br Med J 1968;2(598):
147–9. Arriving at a differential diagnosis
Scully C. Aphthous ulceration. N Engl J Med 2006;355:
165–72. Oral thrush is not difficult to diagnose provided a careful
Truelove SC, Morris-Owen RM. Treatment of aphthous history is taken and an oral examination performed. It is
ulceration of the mouth. Br Med J 1958;1:603–7. the role of the pharmacist to eliminate underlying pathol-
Zakrzewska JM. Fortnightly review: oral cancer. Br Med J ogy and exclude risk factors. A number of other conditions
1999;318:1051–4. need to be considered (Table 6.4) and specific questions
asked of the patient (Table 6.5). After questioning the
Web sites pharmacist should inspect the oral cavity to confirm the
British Association of Dermatologists (2009) Multi-professional diagnosis.
Guidelines for the Management of the Patient with Primary
Cutaneous Squamous Cell Carcinoma: http://
www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20 Clinical features of oral thrush
Guidelines/SCC%20Guidelines%20Final%20Aug%2009.pdf
General site on oral health: http://www.nlm.nih.gov/
The classical presentation of oral thrush is of creamy-white
medlineplus/mouthandteeth.html soft elevated patches that can be wiped off revealing
The Behçet’s Syndrome Society: http://www.behcets.org.uk/ underlying erythematous mucosa (Fig. 6.7). Pain, soreness,
menus/main.asp altered taste and a burning tongue can be present. Lesions
The British Dental Health Foundation: http:// can occur anywhere in the oral cavity but usually affect
www.dentalhealth.org.uk/ the tongue, palate, lips and cheeks. Patients sometimes
complain of malaise and loss of appetite. In neonates,
140 Gastroenterology
Table 6.4
Causes of oral lesions and their relative incidence in
community pharmacy
Incidence Cause
Most likely Thrush
Likely Minor aphthous ulcers, medicine induced,
ill-fitting dentures
Unlikely Lichen planus, underlying medical
disorders, e.g. diabetes, xerostomia (dry
mouth) and immunosuppression, major
& herpetiform ulcers, herpes simplex
Very Unlikely Leukoplakia, squamous cell carcinoma
? Table 6.5
Specific questions to ask the patient:
Oral thrush
Question Relevance
Fig. 6.7 Oral candidiasis. Reproduced from CD Forbes and WF
Size and shape Typically, patients with oral thrush Jackson, 2004, Illustrated pocket guide to clinical medicine,
of lesion present with ‘patches’. They tend to 2nd edition, Mosby, with permission.
be irregularly shaped and vary in
size from small to large
Associated pain Thrush usually causes some degree of
discomfort or pain. Painless patches, dryness of the mouth can also predispose people to thrush.
especially in people aged over 50, Always take a drug history to determine if medicines could
should be referred to exclude sinister be a cause of the symptoms.
pathology such as leukoplakia
Denture wearers
Location of Oral thrush often affects the tongue
Wearing dentures, especially if they are not taken out at
lesions and cheeks, although if precipitated
night, not kept clean, or do not fit well can predispose
by inhaled steroids the lesions
appear on the pharynx people to thrush.
Unlikely causes
Other forms of ulceration (e.g. major and herpetiform Figure 6.9 will aid the differentiation of thrush from other
6
ulcers, herpes simplex) oral lesions.
These are covered in more detail on page 135 and the
!
reader is referred to this section for differential diagnosis
of these from oral thrush. TRIGGER POINTS indicative of referral: Oral thrush
Table 6.6
Practical prescribing: Summary of medicines for oral thrush
Name of Use in children Likely side effects Drug interactions Patients in which Pregnancy &
medicine of note care exercised breastfeeding
Daktarin >4 months Nausea and vomiting Warfarin None OK
(approx. 5% of patients)
142 Gastroenterology
>3 weeks
Duration Refer ❶
<3 weeks
Lesion >1 cm No
in diameter
Possibly MAU ❷
Good
Refer to dentist
Dentures
Check sterilisation
procedure
Treat with imidazole
Poor
No
Steroid use ❹
Refer to dentist
No
Yes
Treat with imidazole
No
Refer ❶
❶ Duration ❸ Antibiotics
Any lesion lasting more than 3 weeks must be referred to Broad-spectrum antibiotics, e.g. amoxicillin and macrolides,
exclude sinister pathology. can precipitate oral thrush by altering normal flora of the oral
cavity.
❷ MAU
See Figure 6.6 for primer for differential diagnosis of mouth ❹ Inhaled corticosteroids
ulcers. High-dose inhaled corticosteroids can cause oral thrush.
Patients should be encouraged to use a spacer and wash their
mouth out after inhaler use to minimise this problem.
a published report (De Vries et al 2006) documenting a and anticoagulants. However, there is a lack of published
17-day-old baby who choked when exposed to miconazole data to determine how clinically significant these interac-
oral gel. tions are except with warfarin. Co-administration of war-
It can occasionally cause nausea and vomiting. The farin with miconazole increases warfarin levels markedly
manufacturers state that it can interact with a number of and the patient’s (internationalised normalised ratio) INR
medicines, namely mizolastine, cisapride, triazolam, mida- should be monitored closely. The manufacturers advise
zolam, quinidine, pimozide, HMG-CoA reductase inhibitors that Daktarin should be avoided in pregnancy but
Gingivitis 143
Application of Daktarin Patients should be advised to hold the gel in the mouth for as long as possible to
increase contact time between the medicine and the infection
6
Duration of treatment Treatment should be continued for up to 2 days after the symptoms have cleared to
prevent relapse and reinfection
Patient acceptability Gel is flavoured orange to make retention in the mouth more acceptable to patients
published data does not support an association between will experience gingival disease. Men more than women
miconazole and congenital defects. It appears to be safe to tend to suffer from severe gingivitis.
use whilst breastfeeding.
Aetiology
References
de Vries TW, Wewerinke ME, de Langen JJ. Near asphyxiation Following tooth brushing, the teeth soon become coated
of a neonate due to miconazole oral gel. Ned Tidschr in a mixture of saliva and gingival fluid, known as pel-
Geenskd 2004;148:1598–600. licle. Oral bacteria and food particles adhere to this coating
Gonsalves WC, Chi A, Neville BW. Common oral lesions:
and begin to proliferate forming plaque; subsequent brush-
Part I. Superficial mucosal lesions. Am Fam Physician
2007;75:501–7.
ing of the teeth removes this plaque build up. However,
if plaque is allowed to build up for 3 or 4 days, bacteria
Further reading begin to undergo internal calcification producing calcium
Hoppe JE, Hahn H. Randomized comparison of two nystatin phosphate better known as tartar (or calculus). This adheres
oral gels with miconazole oral gel for treatment of oral tightly to the surface of the tooth and retains bacteria
thrush in infants. Antimycotics Study Group. Infection in situ. The bacteria release enzymes and toxins that
1996;24:136–9. invade the gingival mucosa, causing inflammation of the
Hoppe JE. Treatment of oropharyngeal candidiasis in gingiva (gingivitis). If the plaque is not removed the
immunocompetent infants: a randomized multicenter study inflammation travels downwards, involving the periodon-
of miconazole gel vs. nystatin suspension. The Antifungals
tal ligament and associated tooth structures (periodontitis).
Study Group. Pediatr Infect Dis J 1997;16:288–93.
A pocket forms between the tooth and gum and, over a
Parvinen T, Kokko J, Yli-Urpo A. Miconazole lacquer compared
with gel in treatment of denture stomatitis. Scand J Dent period of years, the root of the tooth and bone are eroded
Res 1994;102:361–6. until such time that the tooth becomes loose and lost.
This is the main cause of tooth loss in people over 40
Web sites years of age.
General information: http://www.netdoctor.co.uk/diseases/ A number of risk factors are associated with gingivitis
facts/oralthrush.htm and periodontitis; these include diabetes mellitus, cigarette
smoking, poor nutritional status and poor oral hygiene.
? Table 6.7
Specific questions to ask the patient:
Gingivitis
! TRIGGER POINTS indicative of referral: Gingivitis
Table 6.8
6
Practical prescribing: Summary of medicines for gingivitis
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Chlorhexidine >12 years Staining of teeth and None None OK
tongue. Mild irritation
Hexetidine >6 years Mild irritation or None OK
numbness of tongue
Hydrogen peroxide Mucosal irritation, but rare
Dental Correct technique is important otherwise gums can be traumatised. A piece of floss about eight
flossing inches long should be wrapped around the ends of the middle fingers of each hand leaving two to
three inches between the first finger and thumb. The floss should be placed between two teeth and
curved in to a ‘C’ shape around one tooth and slid up between the gum and tooth until resistance
is felt then moved vertically up and down several times to remove plaque
Using fluoride Fluoride does reduce dental caries. Drinking water in some parts of the UK contains measurable
concentrations of fluoride. Therefore fluoride toothpastes or fluoride supplementation is not needed.
However, most people in Britain require fluoride supplementation which is normally through
toothpaste. Most packs of toothpaste state how many parts per million of fluoride the toothpaste
contains; 500 ppm is a low level, 1000-1500 ppm is a high level. A low-dose toothpaste should be
used for children under 7 to avoid dental fluorosis which causes tooth discoloration
Oral fluoride supplements can also be given where fluoride in water is less than 0.7 parts per million.
(see BNF for dosing)
the mouth between 30 seconds and 1 minute then spat Hydrogen peroxide (e.g. Peroxyl)
out.
Adults and children over 6 years of age should use 10 mL
rinsed around the mouth up to four times a day.
Chlorhexidine gluconate (e.g. Corsodyl 0.2%,
Eludril 0.1%)
References
The standard dose for adults and children over 12 years Ernst CP, Prockl K, Willershausen B. The effectiveness and side
old is 10 mL twice a day. Although it is free from side- effects of 0.1% and 0.2% chlorhexidine mouthrinses: a
effects, patients should be warned that prolonged use may clinical study. Quintessence Int 1998;29:443–8.
stain the tongue and teeth brown. This can be reduced or Robinson P, Deacon SA, Deery C, et al. Manual versus powered
toothbrushing for oral health. Cochrane Database of
removed by brushing teeth before use. If this fails to
Systematic Reviews 2005, Issue 2. Art. No.: CD002281. DOI:
remove the staining then it can be removed by a dentist.
10.1002/14651858.CD002281.pub2.
Corsodyl is also available as a spray (0.2%) and gel (1%)
and used twice a day. Further reading
Brecx M, Brownstone E, MacDonald L, et al. Efficacy of
Listerine, Meridol and chlorhexidine mouthrinses as
Hexetidine (Oraldene)
supplements to regular tooth cleaning measures. J Clin
Adults and children over 6 years of age should use a 15 mL Periodontol 1992;19:202–7.
dose two or three times a day.
146 Gastroenterology
Hase JC, Ainamo J, Etemadzadeh H, et al. Plaque formation Prevalence and epidemiology
and gingivitis after mouthrinsing with 0.2% delmopinol
The exact prevalence of dyspepsia is unknown. This is
hydrochloride, 0.2% chlorhexidine digluconate and placebo
for 4 weeks, following an initial professional tooth
largely because of the number of people who self-medicate
cleaning. J Clin Periodontol 1995;22:533–9. or do not report mild symptoms to their GP. However, it
Jones CM, Blinkhorn AS, White E. Hydrogen peroxide, the is clear that dyspepsia is extremely common. Between 25
effect on plaque and gingivitis when used in an oral and 40% of the general population in Western society are
irrigator. Clin Prev Dent 1990;12:15–8. reported to suffer from dyspepsia and virtually everyone
Kelly M. Adult Dental Health Survey: Oral Health in the United at some point in their lives will experience an episode.
Kingdom 1998. London: TSO; 2000. Estimates suggest that 10% of people suffer on a weekly
Lang NP, Hase JC, Grassi M, et al. Plaque formation and basis and that 5% of all GP consultations are for dyspepsia.
gingivitis after supervised mouthrinsing with 0.2% The prevalence of dyspepsia is modestly higher in women
delmopinol hydrochloride, 0.2% chlorhexidine digluconate
than men.
and placebo for 6 months. Oral Dis 1998;4:105–13.
Maruniak J, Clark WB, Walker CB, et al. The effect of 3
mouthrinses on plaque and gingivitis development. J Clin Aetiology
Periodontol 1992;19:19–23.
The aetiology of dyspepsia differs depending on its cause.
Web sites Decreased muscle tone leads to lower oesophageal sphinc-
The British Dental Association: http://www.bda.org/ ter incompetence (often as a result of medicines or overeat-
The British Fluoridation Society: http://www.bfsweb.org/ ing) and is the principal cause of GORD. Increased acid
The British Dental Health Foundation: http:// production results in inflammation of the stomach (gastri-
www.dentalhealth.org.uk/ tis) and is usually attributable to Helicobacter pylori infec-
The American Academy of Periodontology: http://
tion, or acute alcohol indigestion. The presence of H. pylori
www.perio.org/
is central to duodenal and gastric ulceration – H. pylori is
present in 95% of duodenal ulcers and 80% of gastric
ulcers. The exact mechanism by which it causes ulceration
is still unclear but the bacteria does produce toxins that
stimulate the inflammatory cascade. Increasingly common
Dyspepsia are medicine induced ulcers, most notably NSAIDs and
low-dose aspirin.
Finally, when no specific cause can be found for a
Background
patient’s symptoms the complaint is said to be non-ulcer
Confusion surrounds the terminology associated with dyspepsia. (Some authorities do not advocate the use of
upper abdominal symptoms and the term dyspepsia is used this term, preferring the term ‘functional dyspepsia’.)
by different authors to mean different things. It is therefore
an umbrella term generally used by healthcare profession-
Arriving at a differential diagnosis
als to refer to a group of upper abdominal symptoms that
arise from five main conditions: Overwhelmingly, patients who present with dyspepsia are
likely to be suffering from GORD, gastritis or non-ulcer
• non-ulcer dyspepsia/functional dyspepsia (indigestion) dyspepsia (Table 6.9). Research has shown that even those
• gastro-oesophageal reflux disease (GORD, heartburn) patients who meet NICE guidelines for endoscopical inves-
• gastritis tigation are found to have either gastritis/hiatus hernia
• duodenal ulcers (30%), oesophagitis (10–17%) or no abnormal findings
• gastric ulcers. (30%). It has also been reported that a medical practitioner
These five conditions represent 90% of dyspepsia cases with an average list size will only see one new case of
presented to the GP. oesophageal cancer and one new case of stomach cancer
In August 2004, The National Institute for Health and every four years. Despite these statistics, a thorough
Clinical Excellence (NICE) issued clinical guidance on the medical and drug history should be taken to enable the
management of dyspepsia in adults in primary care (see community pharmacist to rule out serious pathology.
web sites at end of section). This guidance has specific ALARM symptoms (see Trigger points for referral), which
information on pharmacist management of dyspepsia. This would warrant further investigation are surprisingly
is still current (July 2012) and specific reference is made common and it is important that patients exhibiting these
to this guidance. symptoms are referred. A number of dyspepsia specific
Dyspepsia 147
questions should always be asked of the patient to aid in • vague abdominal discomfort (aching) above the umbili-
6
diagnosis (Table 6.10). cus associated with belching
• bloating
Clinical features of dyspepsia • flatulence
• a feeling of fullness
Patients with dyspepsia present with a range of symptoms • nausea and/or vomiting
commonly involving: • heartburn.
Although, dyspeptic symptoms are a poor predictor of
disease severity or underlying pathology, retrosternal
Table 6.9 heartburn is the classic symptom of GORD.
Causes of upper GI symptoms and their relative
incidence in community pharmacy
Conditions to eliminate
Incidence Cause
Unlikely causes
Most likely Non-ulcer dyspepsia
Peptic ulceration
Unlikely Medicine induced, peptic ulcers, irritable
Ruling out peptic ulceration is probably the main consid-
bowel syndrome
eration for community pharmacists when assessing patients
Very unlikely Gastric and oesophageal cancers, with symptoms of dyspepsia. Ulcers are classed as either
atypical angina gastric or duodenal. They occur most commonly in patients
aged between 30 and 50, although patients over the age
? Table 6.10
Specific questions to ask the patient: Dyspepsia
Question Relevance
Age The incidence of dyspepsia decreases with advancing age and therefore young adults are likely to
suffer from dyspepsia with no specific pathologic condition, unlike patients over 50 years of age, in
which a specific pathologic condition becomes more common
Location Dyspepsia is experienced as pain above the umbilicus and centrally located (epigastric area). Pain
below the umbilicus will not be due to dyspepsia
Pain experienced behind the sternum (breastbone) is likely to be heartburn
If the patient can point to a specific area of the abdomen then it is unlikely to be dyspepsia
Nature of pain Pain associated with dyspepsia is described as aching or discomfort. Pain described as gnawing, sharp
or stabbing is unlikely to be dyspepsia
Radiation Pain that radiates to other areas of the body is indicative of more serious pathology and the patient
must be referred. The pain might be cardiovascular in origin, especially if the pain is felt down the
inside aspect of the left arm
Severity Pain described as debilitating or severe must be referred to exclude more serious conditions
Associated Persistent vomiting with or without blood is suggestive of ulceration or even cancer and must be referred
symptoms Black and tarry stools indicate a bleed in the GI tract and must be referred
Aggravating or Pain shortly after eating (1 to 3 hours) and relieved by food or antacids are classic symptoms of ulcers
relieving factors Symptoms of dyspepsia are often brought on by certain types of food, for example caffeine containing
products and spicy food
Social history Bouts of excessive drinking are commonly implicated in dyspepsia. Likewise, eating food on the move
or too quickly is often the cause of the symptoms. A person’s job is often a good clue to whether
these are contributing to their symptoms
148 Gastroenterology
of 60 account for 80% of deaths even though they only prominent despite the patient maintaining a good
account for 15% of cases. Typically the patient will have appetite.
well localised mid-epigastric pain described as ‘constant’,
‘annoying’ or ‘gnawing/boring’. In gastric ulcers the pain
Atypical angina
Not all cases of angina have classical textbook presenta-
comes on whenever the stomach is empty, usually 30
tion of pain in the retrosternal area with radiation to the
minutes after eating and is generally relieved by antacids
neck, back or left shoulder that is precipitated by tem
or food and aggravated by alcohol and caffeine. Gastric
perature changes or exercise. Patients can complain of
ulcers are also more commonly associated with weight loss
dyspepsia-like symptoms and feel generally unwell. These
and GI bleeds than duodenal ulcers. Patients can experi-
symptoms might be brought on by a heavy meal. In such
ence weight loss of 5 to 10 kg and although this could
cases antacids will fail to relieve symptoms and referral is
indicate carcinoma, especially in people aged over 40, on
needed.
investigation a benign gastric ulcer is found most of the
time. NSAID use is associated with a three- to fourfold
Figure 6.10 will aid differentiation of the causes of
increase in gastric ulcers.
dyspepsia.
Duodenal ulcers tend to be more consistent in symptom
presentation. Pain occurs 2 to 3 hours after eating and pain
that wakes a person at night is highly suggestive of duo-
denal ulcer. If ulcers are suspected referral to the GP is
necessary as peptic ulcers can only be conclusively diag-
nosed by endoscopy. ! TRIGGER POINTS indicative of referral: Dyspepsia
Table 6.11 varies dependent on the metal salt used. In addition, the
6
Medicines that commonly cause dyspepsia solubility of each metal salt differs, which affects their
onset and duration of action. Sodium and potassium salts
Antibiotics, e.g. macrolides and tetracyclines are the most highly soluble, which makes them quick but
Anticoagulants short acting. Magnesium and aluminium salts are less
soluble so have a slower onset but greater duration of
ACE inhibitors action. Calcium salts have the advantage of being quick
Alcohol (in excess) acting yet have a prolonged action.
It is therefore commonplace for manufacturers to
Bisphosphonates combine two or more antacid ingredients together to
Calcium antagonists ensure a quick onset (generally sodium salts e.g. sodium
bicarbonate) and prolonged action (aluminium, magne-
Iron sium or calcium salts).
Metformin
Metronidazole
Alginates
For patients suffering from GORD an alginate product
Nitrates
should be first-line treatment. When in contact with gastric
Oestrogens acid the alginate precipitates out, forming a sponge-like
matrix that floats on top of the stomach contents. Alginate
Potassium supplements
preparations are also commonly combined with antacids
SSRIs to help neutralise stomach acid. In clinical trials alginate-
containing products have demonstrated superior symptom
Sibutramine
control compared to placebo and antacids. However,
Steroids PPIs and H2 antagonists do have superior efficacy to
alginates.
Theophylline
H2 antagonists
ACE, angiotensin-converting enzyme; SSRI, selective serotonin
reuptake inhibitor. Two H2 antagonists are currently available OTC in the UK;
ranitidine and famotidine. Cimetidine was also available
OTC but withdrawn by the manufacturer and nizatidine
has exemption from POM control but currently there is no
marketed product.
benefits. The patient should be assessed in terms of diet
H2 antagonists are effective at POM doses but OTC
and physical activity:
licensed indications use lower doses. The question is, at
1. Move to a lower fat diet these lower doses are they still effective? There is a paucity
2. Alcohol intake to recommended levels (14 and 21 units/ of publicly available trial data supporting their use at non-
week for women and men respectively) prescription doses. Famotidine appears to have the greatest
3. Smoking cessation body of accessible trial data. A number of trials have been
4. Decrease weight conducted in patients suffering from heartburn and who
5. Reduce caffeine intake regularly self-medicate with antacids. Famotidine was
shown to be more effective than placebo and equally effec-
It might also be possible to identify factors that precipi-
tive to antacids. No trials involving ranitidine could be
tate or worsen symptoms. Commonly implicated foods that
found on public databases that involved patients taking
precipitate dyspepsia are spicy or fatty food, caffeine,
OTC doses.
chocolate and alcohol. Bending is also said to worsen
However, the inhibitory effects of OTC doses of raniti-
symptoms.
dine on gastric acid have been investigated in healthy
volunteers. Trials showed conclusively that ranitidine, and
Antacids
its comparator drug famotidine, did significantly raise
Antacids have been used for many decades to treat dys- intragastric pH compared to placebo, although antacids
pepsia and have proven efficacy in neutralising stomach (calcium carbonates) had a significantly quicker onset of
acid. However, the neutralising capacity of each antacid action but with shorter duration.
150 Gastroenterology
❶ Alarm symptoms
These include, anaemia (signs can include tiredness and pale complexion), loss of weight, anorexia, dark stools, difficulty in swal-
lowing, vomiting blood.
Summary
Antacids will work for the majority of people presenting Practical prescribing and product selection
at the pharmacy with mild dyspeptic symptoms. They can
be used as first-line therapy unless heartburn predominates Prescribing information relating to the medicines used for
then an alginate or alginate/antacid combination can be dyspepsia reviewed in the section ‘Evidence base for
Dyspepsia 151
Table 6.12
6
Practical prescribing: Summary of medicines for dyspepsia
Name of Use in Likely side effects Drug interactions of Patients in Pregnancy &
medicine children note which care breastfeeding
exercised
Antacids
Sodium only >12 years None None Patients with OK
heart disease
Calcium only Constipation Tetracyclines, None OK
quinolones,
Magnesium Diarrhoea imidazoles, phenytoin,
only penicillamine and
Aluminium Constipation bisphosphonates
only
Alginates >12 years* None None Patients with OK
heart disease
H2 antagonists >16 years Abdominal pain, None None Experience has
diarrhoea, shown them to
constipation and be OK. Reported
headache reported diarrhoea with
but uncommon famotidine during
breastfeeding
PPIs-
Omeprazole >18 years Headache, diarrhoea, Azole antifungals, None Avoid
constipation, clopidogrel, diazepam,
nausea and fluvoxamine,
vomiting, abdominal cilostazol
pain, flatulence
Rabeprazole As above plus Azole antifungals,
insomnia atazanavir
*Certain products can be given to children but dyspepsia unusual in children and it might be prudent to refer such patients to their GP.
over-the-counter medication is discussed and summarised however, if both are combined in the same product then
in Table 6.12. neither side effect is noticed. Useful tips relating to antac-
ids are given in Hints and Tips Box 6.4.
Antacids can affect the absorption of a number of
Antacids
medications via chelation and adsorption. Commonly
The majority of marketed antacids are combination prod- affected medicines include tetracyclines, quinolones, imi-
ucts containing two, three or even four constituents. The dazoles, phenytoin, penicillamine and bisphosphonates. In
rationale for combining different salts together appears to addition, the absorption of enteric-coated preparations can
be twofold. First, to ensure the product has quick onset be affected due to antacids increasing the stomach pH. The
(containing sodium or calcium) and a long duration of majority of these interactions are easily overcome by
action (containing magnesium, aluminium or calcium). leaving a minimum gap of 1 hour between the respective
Second, to minimise any side effects that might be expe- doses of each medicine.
rienced from the product. For example, magnesium salts Most patient groups can take antacids, although patients
tend to cause diarrhoea and aluminium salts constipation, on salt-restricted diets (e.g. patients with coronary heart
152 Gastroenterology
Type of formulation? Ideally, antacids should be given in the liquid form because the acid-neutralising capacity
and speed of onset is greater than that of tablet formulations
Over use of antacids Misuse and chronic use of antacids will result in significant systemic absorption leading
to various unwanted medical conditions. Milk-alkali syndrome has been reported with
chronic abuse of calcium containing antacids, as has osteomalacia with aluminium
containing products
Antacid therapy should ideally not be longer than 2 weeks. If symptoms have not resolved in
this time then other treatments and/or evaluation from the GP should be recommended
When is the best time Antacids should be taken after food because gastric emptying is delayed in the presence of
to take antacids? food. This allows antacids to exert their effect for up to 3 hours
Salt (sodium) content Be aware that some antacid preparations do contain significant amounts of sodium – for
example Gaviscon Advance contains 4.6 mmol of sodium per 10 mL. UKMi have produced
a document detailing medicines with high sodium content http://www.nelm.nhs.uk/en/
NeLM-Area/Evidence/Medicines-Q--A/What-is-the-sodium-content-of-medicines/
(accessed February 18, 2013)
The elderly Avoid constipating products, as the elderly are prone to constipation
Possible solutions to Simple suggestions such as eating less but more often or eating smaller meals might help
minimise symptoms control symptoms. Avoid eating late at night and lying flat at night – use a pillow to prop
the person up
disease) should ideally avoid sodium-containing antacids. appear to have been unfounded as follow-up studies and
In addition, antacids should not be recommended in chil- post marketing surveillance has not shown any increase in
dren because dyspepsia is unusual in children under 12. risk associated with greater availability. Indeed, H2 antago-
Indeed, most products are licensed for use only for children nists are now available as general sales list medicines. They
aged 12 and over. However, there are a few exceptions (e.g. have been used in pregnancy and breastfeeding, with rani-
Acidex, Topal), which have product licences for use in tidine having been used most. Data suggests that there are
children. no significant increases in any major malformations in
pregnancy and can be used whilst breastfeeding and man-
Alginates (e.g. the Gaviscon range) ufacturers of OTC products advise patients to speak to the
doctor or pharmacist before taking.
Products containing alginates are combination prepara-
tions that contain an alginate with antacids. They are best
Famotidine (PepcidTwo)
given after each main meal and before bedtime, although
The dose for famotidine is 10 mg (one tablet) at the onset
they can be taken on a when-needed basis. They can be
of symptoms; however, if symptoms persist an additional
given during pregnancy and breastfeeding and to most
dose can be repeated after 1 hour. The maximum dose is
patient groups but, as with antacids, patients on salt-
20 mg (two tablets) in 24 hours. A dose can be taken 1
restricted diets should ideally avoid sodium-containing
hour prior to consuming food or drink that are known to
alginate preparations. They are reported not to have any
bring on symptoms. PepcidTwo is a combination of famo-
side effects or interactions with other medicines.
tidine, calcium carbonate and magnesium hydroxide. The
antacid component of the product provides quick onset of
H2 antagonists
action helping to relieve symptoms before famotidine
Sales of H2 antagonists are restricted to adults and children exerts its action, which can take 2 hours.
over the age of 16. They possess no clinically important
drug interactions and side effects are rare. Safety concerns Ranitidine (e.g. Zantac range, Gavilast
were raised on deregulation of H2 antagonists about the and Gavilast P, Ranzac)
potential to mask serious underlying conditions and the Dosing for ranitidine (Zantac 75) is similar to famotidine
possibility of increased adverse reactions. These fears in that one tablet should be taken straight away but if
Dyspepsia 153
6
1 hour later. The maximum dose is 300 mg (four tablets)
Moayyedi P, Soo S, Deeks J, et al. Pharmacological
in 24 hours. The General Sales List versions of ranitidine interventions for non-ulcer dyspepsia. Cochrane Database
(Zantac 75 Relief and Ranzac), have slightly different of Systematic Reviews 2006, Issue 4. Art. No.: CD001960.
license in that they cannot be used for prevention of DOI: 10.1002/14651858.CD001960.pub3.
heartburn and the maximum dose is only two tablets Talley NJ, Moore MG, Sprogis A, et al. Randomised controlled
in 24 hours. trial of pantoprazole versus ranitidine for the treatment of
uninvestigated heartburn in primary care. Med J Aust
2002;177(8):423–7.
Omeprazole (Zanprol) van Pinxteren B, Sigterman KE, Bonis P, Lau J, et al. Short-
Zanprol is licensed for the relief of reflux-like symptoms term treatment with proton pump inhibitors, H2-receptor
(e.g. heartburn) associated with acid-related dyspepsia in antagonists and prokinetics for gastro-oesophageal reflux
patients aged over 18 years of age. The initial dose is disease-like symptoms and endoscopy negative reflux
two 10 mg tablets once daily. Once symptoms improve disease. Cochrane Database of Systematic Reviews, 2006,
the dose can be reduced to one tablet (10 mg). If symp- Issue 3. Art. No.: CD002095. DOI: 10.1002/14651858.
toms return then the dose can be stepped back up to CD002095.pub3.
20 mg. Patients should be referred to their GP if symptoms
Further reading
do not resolve in 2 weeks or they need to use omeprazole Castell DO, Dalton CB, Becker D, et al. Alginic acid
for more than 4 weeks continuously. Omeprazole can decreases postprandial upright gastroesophageal reflux.
cause a number of common side effects (>1 in 100), which Comparison with equal-strength antacid. Dig Dis Sci
include headache, diarrhoea, constipation, abdominal pain, 1992;37:589–93.
nausea and vomiting and flatulence. Drug interactions Dowswell T, Neilson JP. Interventions for heartburn in
with omeprazole are possible because it is metabolised in pregnancy. Cochrane Database of Systematic Reviews
the liver by cytochrome P450 isoenzymes. These include 2008, Issue 4. Art. No.: CD007065. DOI: 10.1002/14651858.
‘azole’ antifungals (decrease in azole bioavailability), CD007065.pub2.
diazepam (enhanced diazepam side effects), fluvoxamine Drake D, Hollander D. Neutralizing capacity and cost
effectiveness of antacids. Ann Intern Med 1981;
(increased omeprazole levels), cilostazol (increased cilo
94:215–7.
stazol levels – and UK manufacturers advise against
Feldman M. Comparison of the effects of over-the-counter
co-administration) and clopidogrel (reduced clopidogrel famotidine and calcium carbonate antacid on postprandial
levels). Other interactions listed in the manufacturer’s gastric acid. A randomized controlled trial. JAMA
literature include phenytoin and warfarin but their clinical 1996;275:1428–31.
significance appears low. Halter F. Determination of neutralization capacity of
It appears to be safe in pregnancy and excreted in only antacids in gastric juice. Z Gastroenterol 1983;21:
small amounts of breast milk and is not contraindicated S33–40.
when used as a POM medicine, however for pharmacy use Netzer P, Brabetz-Hofliger A, Brundler R, et al. Comparison of
it is not recommended. the effect of the antacid Rennie versus low dose H2
receptor antagonists (ranitidine, famotidine) on intragastric
acidity. Ailment Pharmacol Ther 1998;12:337–42.
Rabeprazole (Pariet Pharmacy) Reilly TG, Singh S, Cottrell J, et al. Low dose famotidine and
The MHRA have recently approved the deregulation of rantidine as single post-prandial doses: a three-period
rabeprazole from POM to P. Its product license is very placebo-controlled comparative trial. Ailment Pharmacol
similar to that of omeprazole: it has a license for the Ther 1996;10:749–55.
short-term symptomatic treatment of GORD-like symptoms Smart HL, Atkinson M. Comparison of a dimethicone/antacid
(e.g. heartburn) in adults aged 18 and over; if symptoms (Asilone gel) with an alginate/antacid (Gaviscon liquid) in
the management of reflux oesophagitis. J R Soc Med
have not been controlled within 2 weeks or if continuous
1990;83:554–6.
treatment for more than 4 weeks is required, then the
patient should be referred to their doctor; and it should
Web sites
be avoided in pregnant and breastfeeding women. The
NICE Guidance on management of dyspepsia in primary care:
dose is one 10 mg tablet each day. Side effects commonly http://publications.nice.org.uk/dyspepsia-cg17
seen include insomnia, headaches, dizziness, cough, British Society of Gastroenterology: http://www.bsg.org.uk/
diarrhea, vomiting, nausea, abdominal pain and consti CORE – research charity: http://www.corecharity.org.uk/
pation. It interacts with oral ‘azole’ medicines and on American Gastroenterological Association: http://
theoretical grounds should not be co-administered with www.gastro.org/
atazanavir.
154 Gastroenterology
? Table 6.14
6
Specific questions to ask the patient: Diarrhoea
Question Relevance
Frequency and nature Patients with acute self-limiting diarrhoea will be passing watery stools more frequently than
of the stools normal
Diarrhoea associated with blood and mucus (dysentery) requires referral to eliminate invasive
infection such as Shigella, Campylobacter, Salmonella or E. coli O157
Bloody stools is also associated with conditions such as inflammatory bowel disease
Periodicity A history of recurrent diarrhoea of no known cause should be referred for further investigation
Duration A person who presents with a history of chronic diarrhoea should be referred. The most frequent
causes of chronic diarrhoea are IBS, inflammatory disease and colon cancer
Onset of symptoms Ingestion of bacterial pathogens can give rise to symptoms in a matter of a few hours (toxin
producing bacteria) after eating contaminated food or up to 3 days later. It is therefore
important to ask about food consumption over the last few days, establish if anyone else ate
the same food and to check the status of his or her health
Timing of diarrhoea Patients who experience diarrhoea first thing in the morning might well have underlying pathology
such as IBS
Nocturnal diarrhoea is often associated with inflammatory bowel disease
Recent change of Changes in diet can cause changes to bowel function, for example when away on holiday. If the
diet person has recently been to a non-Western country then giardiasis is a possibility
Signs of dehydration Mild (<5%) dehydration can be vague but include tiredness, anorexia, nausea and light-headedness
Moderate (5 to 10%) dehydration is characterised by dry mouth, sunken eyes, decreased urine
output, moderate thirst and decreased skin turgor (pinch test of 1 to 2 seconds or longer)
Table 6.15
Examples of medicines known to cause diarrhoea (defined as very common [>10%] or
common [1–10%])
α-blocker Prazosin
ACE inhibitor Lisinopril, perindopril
Angiotensin receptor blocker Telmisartan
Acetylcholinesterase inhibitor Donepezil, galantamine, rivastigmine
Antacid Magnesium salts
Antibacterial All
Antidiabetic Metformin, acarbose
Antidepressant SSRIs, clomipramine, venlafaxine
Anti-emetic Aprepitant, dolasetron
Anti-epileptic Carbamazepine, oxcarbamazepine, tiagabine, zonisamide, pregabalin, levetiracetam
Antifungal Caspofungin, fluconazole, flucytosine, nystatin (in large doses), terbinafine, voriconazole
Antimalarial Mefloquine
Antiprotozoal Metronidazole, sodium stibogluconate
Antipsychotic Aripiprazole
Antiviral Abacavir, emtricitabine, stavudine, tenofovir, zalcitabine, zidovudine, amprenavir,
atazanavir, indinavir, lopinavir, nelfinavir, saquinavir, efavirenz, ganciclovir,
valganciclovir, adefovir, oseltamivir, ribavirin, fosamprenavir
Beta-blocker Bisoprolol, carvedilol, nebivolol
Bisphosphonate Alendronic acid, disodium etidronate, ibandronic acid, risedronate, sodium clodronate,
disodium pamidronate, tiludronic acid
Cytokine inhibitor Adalimumab, infliximab
Cytotoxic All classes of cytotoxics
Dopaminergic Levodopa, entacapone
Growth hormone antagonist Pegvisomant
Immunosuppressant Ciclosporin, mycophenolate, leflunomide
NSAID All
Ulcer healing Proton pump inhibitors
Vaccines Pediacel (5 vaccines in 1), haemophilus, meningococcal
Miscellaneous Calcitonin, strontium ranelate, colchicines, dantrolene, olsalazine, anagrelide, nicotinic
acid, pancreatin, eplerenone, acamprosate
Reproduced with permission from R Walker and C Whittlesea, Clinical pharmacy and therapeutics, 5th edition, 2011, Churchill Livingstone.
Dyspepsia 157
Malabsorption syndromes
! TRIGGER POINTS indicative of referral: Diarrhoea
6
Lactose intolerance is often diagnosed in infants under 1
year old. In addition to more frequent loose bowel move-
ments symptoms such as fever, vomiting, perianal excoria- Symptoms/signs Possible danger/reason
tion and a failure to gain weight might occur. for referral
Coeliac disease has a bimodal incidence: first, in early Change in bowel (long term) Sinister pathology?
infancy when cereals become a major constituent of the habit in patients over 50
diet, and second, during the fourth and fifth decades. Diarrhoea following recent Giardiasis?
Steatorrhoea (fatty stools) is common and might be travel to tropical or
observed by the patient as frothy or floating stools in the subtropical climate
toilet pan. Bloating and weight loss in the presence of a
normal appetite might also be observed. Duration longer than 2 to 3 At risk of dehydration
days in children and elderly and associated
Patients unable to drink fluids complications
Colorectal cancer (Signs of dehydration)
Any middle-aged patient presenting with a longstanding Presence of blood or mucus in Outside scope of
change of bowel habit must be viewed with suspicion. the stool community
Suspected faecal impaction in pharmacist
Persistent diarrhoea accompanied by a feeling that the
the elderly
bowel has not really been emptied is suggestive of neo-
Severe abdominal pain
plasm. This is especially true if weight loss is also present.
Steatorrhoea Malabsorption
Figure 6.11 will aid differentiation of diarrhoeal cases that syndrome?
require referral.
Age
Infants or young children Adult
and elderly
>4 days or
Yes Signs of recurrent
Refer dehydration Duration Refer
No <4 days
Suggest an Yes
Medicine induced
alternative to GP
No
Vomiting precludes
oral rehydration therapy
No Yes
Evidence base for over-the-counter medication diarrhoea. The majority of well-designed double-blind
placebo-controlled trials have consistently shown it to be
Acute infectious diarrhoea still remains one of the leading significantly better than placebo and comparable to diphe-
causes of death in developing countries, despite advances noxylate. Loperamide is also available compounded with
in its treatment. In developed and Western countries diar- simeticone. However, there is little evidence of better
rhoeal disease is primarily of economic and socially dis- efficacy in terms of diarrhoeal symptoms with the
ruptive significance. Goals of OTC treatment in the UK are combination.
therefore concentrated on relief of symptoms.
Before considering treatment it is important to stress to Bismuth subsalicylate
patients the importance of hand washing. Interventions
that promote hand washing can reduce diarrhoea episodes Bismuth-containing products have been used for many
by about one-third. decades. Its use has declined over time as other products
have become more popular. However, bismuth subsali-
cylate has been shown to be effective in treating traveller’s
Oral rehydration solution (ORS)
diarrhoea. A review paper by Steffen (1990) concluded that
ORS represents one of the major advances in medicine. It bismuth subsalicylate was clinically superior to placebo,
has proved to be a simple highly effective treatment, which decreasing the number of unformed stools and increasing
has decreased mortality and morbidity associated with the number of patients who were symptom free. However,
acute diarrhoea in developing countries. The formula rec- two of the trials reviewed showed bismuth subsalicylate to
ommended by the World Health Organization (WHO) con- be significantly slower in symptom resolution than its
tains glucose (75 mmol/L), sodium (75 mmol/L), potassium comparator drug loperamide.
(20 mmol/L), chloride (65 mmol/L) and citrate (10 mmol/L)
in an almost isotonic fluid. Until recently, the WHO oral Kaolin and morphine
rehydration solution contained 90 mmol/L sodium but a
systematic review (Hahn et al 2002) concluded that ORS The constipating side effect of opioid analgesics can be
with a reduced osmolarity compared to the standard WHO used to treat diarrhoea. However, kaolin and morphine
formula were associated with fewer complications in chil- products have no evidence of efficacy and should not be
dren with mild to moderate diarrhoea. Based on this, and recommended. It remains a popular home remedy, espe-
other findings, the WHO oral rehydration solution now cially with the elderly.
has a reduced osmolarity of 245 mm/L, which contains
75 mmol of sodium. A number of similar preparations are Rotavirus vaccine
available commercially in the form of sachets that require
In 2006, two new oral vaccines (Rotarix, and RotaTeq) were
reconstitution in clean water before use; however, com-
licensed by the European Medicines Agency and the US
mercially available solutions in the UK contain lower
Food and Drug Administration. Clinical trials have shown
sodium concentrations as diarrhoea tends to be isotonic,
them to be effective (Soares-Weiser et al 2012).
and therefore replacement of large quantities of sodium is
From 2013, the rotavirus vaccine will be added to the
less important.
routine UK childhood vaccination schedule.
Table 6.16
6
Practical prescribing: Summary of medicines for diarrhoea
Name of Use in children Likely side effects Drug interactions Patients in which Pregnancy &
medicine of note care exercised breastfeeding
ORS Infant upwards None None None OK
Loperamide >12 years Abdominal cramps, None None OK
nausea, vomiting,
tiredness
Bismuth >16 years Black stools or Quinolone None Avoid if possible
tongue. antibiotics
Morphine salts >12 years None None None OK
Reconstitution of ORS All proprietary sachets require 200 mL of water per sachet to reconstitute
Different brands come in different flavours:
• Dioralyte – blackcurrant and citrus
• Diorolyte Relief – apricot, raspberry or blackcurrant
• Electrolade – banana, blackcurrant, lemon and lime and orange
Once reconstituted ORS must be stored in the fridge and drunk within 24 hours
Note Oralyte is sold as a ready to drink product and requires no reconstitution.
Rough guidelines for <1 year old: refer if duration >1 day
referral for children <3 years old: refer if duration >2 days
>3 years old: refer if duration >3 days
Kaolin and morphine Subject to abuse. Store out of sight
Alternative to ORS Patients can be advised to increase their intake of fluids, particularly fruit juices with their
glucose and potassium content, and soups because of their sodium chloride content
Table 6.16; useful tips relating to patients presenting with quantities less frequently. In infants, 1 to 11 2 times the
diarrhoea are given in Hints and Tips Box 6.5. usual feed volume should be given.
ORS (Dioralyte, Dioralyte Relief (rice-based), Loperamide (e.g. Diocalm Ultra, Diah-Limit,
Electrolade, Oralyte) Imodium range)
ORS can be given to all patient groups, has no side effects The dose is two capsules immediately, followed by one
or drug interactions. The volume of solution given is capsule after each further bout of diarrhoea. It has minimal
dependent on how much fluid is lost. As infants and the CNS side effects, although CNS depressant effects and
elderly are more at risk of developing dehydration they respiratory depression have been reported at high doses.
should be encouraged to drink as much ORS as possible. OTC doses are therefore limited to 16 mg a day and cannot
In adults, 2 L of ORS should be given in the first 24 hours, be used in children under 12. The excellent safety record
followed by unrestricted normal fluids with 200 mL of of loperamide has seen it granted General Sales List status,
rehydration solution per loose stool or vomit. The solution although abdominal cramps, nausea, vomiting, tiredness,
is best sipped every 5–10 min rather than drunk in large drowsiness, dizziness and dry mouth have been reported.
160 Gastroenterology
estimated that 25 to 40% of all people over the age of 65 disease and can be caused by many different conditions.
6
have constipation. The majority of the elderly have normal Constipation does not usually have sinister pathology and
frequency of bowel movements but strain at stool. This is the commonest cause in the vast majority of non-elderly
probably a result of sedentary lifestyle, a decreased fluid adults will be a lack of dietary fibre (Table 6.17). However,
intake, poor nutrition, avoidance of fibrous foods and constipation can be caused by medication and many
chronic illness. Women are two to three times more likely disease states including neurological disorders (e.g. multi-
to suffer from constipation than men and 40% of women ple sclerosis, Parkinson’s disease), metabolic and endocrine
in late pregnancy experience constipation. conditions (diabetes, hypothyroidism) and neoplasm. A
number of constipation-specific questions should always
Aetiology be asked of the patient to aid in diagnosis (Table 6.18).
? Table 6.18
Specific questions to ask the patient: Constipation
Question Relevance
Change of diet or routine Constipation usually has a social or behavioural cause. There will usually be some event that
has precipitated the onset of symptoms
Pain on defecation Associated pain when going to the toilet is usually due to a local anorectal problem.
Constipation is often secondary to the suppression of defecation because it induces pain.
These cases are best referred for physical examination
Presence of blood Bright red specks in the toilet or smears on toilet tissue suggest haemorrhoids or a tear in the
anal canal (fissure). However, if blood is mixed in the stool (melaena) then referral to the
GP is necessary. A stool that appears black and tarry is suggestive of an upper GI bleed
Duration (chronic or Constipation lasting 6 weeks or more is said to be chronic. If a patient suffers from
recent?) longstanding constipation and has been previously seen by the GP then treatment could be
given. However, cases of more than 14 days with no identifiable cause or previous
investigation by the GP should be referred
Lifestyle changes Changes in job or marital status can precipitate depressive illness that can manifest with
physiological symptoms such as constipation
162 Gastroenterology
might also notice the child is more irritable and have a associated with defecation, for example, unwillingness to
decreased appetite. Specks of blood in the toilet pan might defecate due to association of prior pain on defecation.
be present and are usually due to straining at stool. In the
vast majority of cases blood in the stool does not indicate Very unlikely causes
sinister pathology. Those patients presenting with acute
Colorectal cancer
constipation with no other symptoms apart from very
Colorectal carcinomas are rare in patients under the age
small amounts of bright red blood can be managed in the
of 40. However, the incidence of carcinoma increases with
pharmacy, however, if blood loss is substantial (stools
increasing age and any patient over the age of 40 present-
appear tarry, red or black) or the patient has other associ-
ing for the first time with a marked change in bowel habit
ated symptoms such as malaise, abdominal distension and
should be referred. Sexes appear to be equally affected.
is over 40 years old then referral is needed.
The patient might complain of abdominal pain, rectal
bleeding and tenesmus. Weight loss – a classical textbook
Conditions to eliminate sign of colon cancer – is common but observed only in
the latter stages of the disease. Therefore a patient is
Likely causes
unlikely to have noticed marked weight loss when visiting
Medicine-induced constipation a pharmacy early in disease progression.
Many medicines are known to cause constipation. Most
exert their action by decreasing gut motility, although Hypothyroidism
opioids tend to raise sphincter tone and reduce sensitivity The signs and symptoms of hypothyroidism are often
to rectal distension. A detailed medication history should subtle and insidious in onset. Patients might experience
always be sought from the patient and Table 6.19 lists the weight gain, lethargy, cold intolerance, coarse hair and dry
commonly implicated medicines that cause constipation. skin as well as constipation. Hypothyroidism affects ten
times more women than men and peak incidence is in the
Unlikely causes fifth or sixth decade. Constipation is often less pronounced
than lethargy and cold intolerance.
Irritable bowel syndrome
Patients younger than 45 with lower abdominal pain and
Figure 6.12 will aid differentiation between common
a history of alternating diarrhoea and constipation are
causes of constipation and more serious causes.
likely to have IBS. For further details on IBS see page 168.
Pregnancy
Constipation is common in pregnancy, especially in the ! TRIGGER POINTS indicative of referral:
third trimester. A combination of increased circulating
Symptoms/signs Possible danger/reason
progestogen, displacement of the uterus against the colon
for referral
by the fetus, decreased mobility and iron supplementation
all contribute to an increased incidence of constipation Pain on defecation causing Check for anal fissure
whilst pregnant. Most patients complain of hard stools patient to suppress
rather than a decrease in bowel movements. If a laxative defactory reflex
is used a bulk-forming laxative should be recommended. Patients aged over 40 years Danger symptom for
old with sudden change rectal carcinoma
Depression in bowel habits with no
Upwards of 20% of the population will suffer from depres- obvious cause
sion at sometime. Many will present with physical as well Greater than 14 days’ Suspect underlying cause
as emotional symptoms. It has been reported that a third duration with no that requires fuller
of all patients suffering from depression present with gas- identifiable cause investigation by GP
trointestinal complaints in a primary care setting. Core
Tiredness Check for anaemia or
symptoms of persistent low mood and loss of interest in thyroid dysfunction
most activities should trigger referral.
Table 6.19
6
Examples of medicines known to cause constipation (frequency defined as very common [>10%] or
common [1–10%])
α-blocker Prazosin
Antacid Aluminium and calcium salts
Anticholinergic Trihexyphenidyl, hyoscine, oxybutynin, procyclidine, tolterodine
Antidepressant Tricyclics, SSRIs, reboxetine, venlafaxine, duloxetine, mirtazapine
Anti-emetic Palonosetron, dolasetron, aprepitant
Anti-epileptic Carbamazepine, oxcarbazepine
Antipsychotic Phenothiazines, haloperidol, pimozide and atypical antipsychotics such as amisulpride,
aripiprazole, olanzapine, quetiapine, risperidone, zotepine, clozapine
Antiviral Foscarnet
Beta-blocker Oxprenolol, bisoprolol, nebivolol; other βετα-blockers tend to cause constipation more rarely
Bisphosphonate Alendronic acid
CNS stimulant Atomoxetine
Calcium channel blocker Diltiazem, verapamil
Cytotoxic Bortezomib, buserelin, cladribine, docetaxel, doxorubicin, exemestane, gemcitabine,
irinotecan, mitoxantrone, pentostatin, temozolomide, topotecan, vinblastine, vincristine,
vindesine, vinorelbine
Dopaminergic Amantadine, bromocriptine, cabergoline, entacapone, tolcapone, levodopa, pergolide,
pramipexole, quinagolide
Growth hormone antagonist Pegvisomant
Immunosuppressant Basiliximab, mycophenolate, tacrolimus
Lipid-lowering agent Cholestyramine, colestipol, rosuvastatin, atorvastatin (other statins uncommon), gemfibrozil
Iron Ferrous sulphate
Metabolic disorders Miglustat
Muscle relaxant Baclofen
NSAID Meloxicam; other NSAIDs, e.g. aceclofenac, and COX-2 inhibitors reported as uncommon
Smoking cessation Bupropion
Opioid analgesic All opioid analgesics and derivatives
Ulcer healing All proton pump inhibitors, sucralfate
Reproduced with permission from R Walker and C Whittlesea, Clinical pharmacy and therapeutics, 5th edition, 2011, Churchill Livingstone.
simple dietary and lifestyle modifications (increasing exer- approximately 30 g day in the form of fruit, vegetables,
cise) will relieve the majority of acute cases of constipa- cereals, grain foods and wholemeal bread. It is important
tion. Advice includes increasing fluid and fibre intake. to remind patients that adequate fluid intake (2 L per day)
Dietary fibre increases stool bulk, stool water content and is needed when following a high-fibre diet and patients
colonic bacterial load. Fibre intake should be increased to might experience excessive gas production, colicky
164 Gastroenterology
Age
Child Adult
Refer ❸
❶ Patients with unexplained constipation of recent onset ❷ See Fig. 6.13 for primer for differential diagnosis of IBS.
accompanied with rectal bleeding should be referred for
further investigation; most likely a colonoscopy or sig- ❸ If no obvious cause of constipation can be found referral
moidoscopy and stool culture to eliminate carcinoma to the GP is needed for further evaluation.
abdominal pain and bloating. Effects of a high-fibre diet which demonstrated statistically significant increases in
are usually seen in 3 to 5 days. bowel movement. The remaining 16 trials compared dif-
If medication is required, four classes of OTC laxatives ferent types of laxatives with each other. The review con-
are available: bulk-forming agents, stimulants, osmotics cluded that laxatives do increase the number of bowel
and stool softeners. Despite their widespread use surpris- movements and, in 9 of 11 trials studying overall symptom
ingly few well-designed trials have substantiated clinical control, laxatives did perform significantly better than
efficacy. placebo. Unfortunately, because of a lack of comparative
A systematic review in 1997 (Tramonte et al) identified trial data, the review could not conclude which laxative
36 trials involving 1815 participants that met their inclu- was most efficacious. A further review of laxative effect
sion criteria and involved 25 different laxatives represent- in elderly patients suffering with chronic constipation also
ing all four classes of laxative. Twenty of the trials failed to determine superior clinical effect between laxative
compared laxative against placebo or regular diet, 13 of classes. The findings from the Tramonte paper was reviewed
Constipation 165
in 2005 by the centre for reviews and dissemination which have failed to respond to dietary intervention should be
6
supported them. referred to their GP. The text below does however make
reference to dosing in children younger than 6.
Summary
Bulk-forming laxatives (e.g. ispaghula husk,
It appears from the evidence that laxatives do work, but methylcellulose and sterculia)
deciding on which laxative to give a patient cannot be
made on an evidence-based approach. Other factors will Bulk-forming laxatives exert their effect by mimicking
need to be considered such as the patients’ status, side- increased fibre consumption, swelling in the bowel and
effect profile of the medicine and its cost. increasing faecal mass. In addition, they also encourage
the proliferation of colonic bacteria and this helps further
increase faecal bulk and stool softness. Patients should be
Practical prescribing and product selection advised to increase their fluid intake whilst taking bulk-
Prescribing information relating to the medicines used for forming medicines. Their effect is usually seen in 12 to
constipation reviewed in the section ‘Evidence base for 36 hours but can take as long as 72 hours. Side effects
over-the-counter medication’ is discussed and summarised commonly experienced include flatulence and abdominal
in Table 6.20; useful tips relating to these medicines are distension. They are well tolerated in pregnancy and
given in Hints and Tips Box 6.6. breastfeeding and have no teratogenic effects. They appear
Prescribing laxatives in children should ideally be left to have no drug interactions of any note.
to those healthcare professionals experienced in managing
Ispaghula husk
childhood constipation (BNF edition 63). OTC products are
licensed for use in young children but in accordance with Ispaghula husk is widely available as either granules
good practice those children younger than 6 years old who (Fibrelief, Fybogel, Isogel, Ispagel) or powder (Regulan). All
Table 6.20
Practical prescribing: Summary of medicines for constipation
Name of medicine Use in children Likely side Drug interactions Patients in which Pregnancy &
effects of note care exercised breastfeeding
Bulk forming
Ispaghula husk >6 years Flatulence and None None OK
abdominal
Methylcellulose >7 years bloating
Sterculia >6 years
Stimulant
Senna >2 years Abdominal pain None None OK, but use other
laxatives in
Glycerol Infant upwards* preference to
Sodium picosulphate >10 years stimulants in
pregnancy and
Bisacodyl >4 years breastfeeding
Osmotic
Lactulose Infant upwards* Flatulence, None None OK
abdominal
Magnesium Not pain and colic
hydroxide recommended
Stool softeners
Docusate >6 months None reported None None OK
*If prescribing to children less than 6 years of age then the pharmacist must be competent in prescribing laxatives for children.
166 Gastroenterology
have to be reconstituted with water prior to taking. The a day. Each dose should be taken with at least 300 mL of
dose for adults and children over 12 years old can range liquid.
from one to six sachets a day depending on the brand used
and the severity of the condition. Fybogel is probably the Sterculia (Normacol and Normacol Plus
most familiar branded product used OTC in the UK – adults granules or sachets)
should take 1 sachet or 2 level 5 mL spoonfuls twice a day
Both products contain 62% sterculia but Normacol Plus
and for children aged between 6 and 12, 1 2 to one 5 mL
also contains 8% frangula. The dose for both products is
spoonful twice daily.
the same. Adults and children over 12 should take either
one or two sachets or heaped 5 mL spoonfuls, once or
Methylcellulose (Celevac)
twice daily after meals. For children aged between 6 and
Methylcellulose is only available as Celevac tablets. The 12 the dose is half that of the adult dose.
adult dose is three to six tablets twice daily, and for chil- The granules should be placed dry on the tongue and
dren aged between 7 and 12, the dose is two tablets twice swallowed immediately with plenty of water or a cool
Constipation 167
drink. They can also be sprinkled onto, and taken with, Flatulence, abdominal pain and colic are frequently
6
soft food such as yoghurt. reported. They can be taken by all patient groups, have no
drug interactions and safely used in pregnancy and
Stimulant laxatives (e.g. bisacodyl, glycerol, breastfeeding.
senna, sodium picosulfate)
Stimulant laxatives increase GI motility by directly stimu- Lactulose
lating colonic nerves. It is this action that, presumably, Lactulose is given twice daily for all ages. The dose for
causes abdominal pain and is the main side effect associ- adults is initially 15 mL, for children aged between 5 and
ated with stimulant laxatives. Additionally, stimulant laxa- 18 the dose is 5–20 mL, those aged between 1 and 5 the
tives are associated with the possibility of nerve damage dose is 2.5–10 mL and children under 1 year of age 2.5 mL.
in long-term use and are the most commonly abused laxa- It has been reported that up to 20% of patients experience
tives. Their onset in action is quicker than other laxative troublesome flatulence and cramps, although these often
classes, with patients experiencing a bowel movement in settle after a few days. It may take 48 hours or longer for
6 to 12 hours when taken orally. They can be taken by all it to work.
patient groups, have no drug interactions and are safe in
pregnancy and breastfeeding. However, because of their Macrogols (e.g. Movicol, Dulcobalance)
stimulant effect on uterine contractions they are best Macrogols are available as powders that are reconstituted
avoided in pregnancy if possible. with water. They are licensed for chronic constipation and
should therefore not be routinely recommended by phar-
Bisacodyl (Dulcolax) macists because treatment should be only instigated in
Bisacodyl is available as either tablets or suppositories and those presenting with acute constipation. Section 1.6.4 of
can be given to patients aged over 4 years old. The dose the BNF highlights doses for the respective products.
for children aged between 4 and 10 years is 5 mg (one
tablet or one paediatric suppository) and for adults and Magnesium salts
children over 10 years the dose is 5 to 10 mg (one to two Magnesium, when used as a laxative, is usually given as
tablets or one Dulcolax 10 mg suppository). magnesium hydroxide. The adult dose ranges between 30
to 45 mL when needed. It is generally not recommended
Glycerol suppositories for use in children but is commonly prescribed in the
elderly.
Glycerol suppositories are normally used when a bowel
movement is needed quickly. The patient should experi-
ence a bowel movement in 15 to 30 minutes. Varying sizes Stool softeners (liquid paraffin
are made to accommodate use in different ages. The 1-g and docusate sodium)
suppositories are designed for infants, the 2-g for children
Liquid paraffin has been traditionally used to treat consti-
and the 4-g for adults.
pation. However, the adverse side-effect profile of liquid
Senna (e.g. Senokot) paraffin now means it should never be recommended
because other, safer and more effective medications are
Senna is available as syrup, tablets or granules. Dosing of available.
proprietary products differs from those recommended in
the BNF and BNF-C. Proprietary products recommend Docusate sodium
BNF/BNF-C starting doses. These are: adults and children Docusate sodium is a non-ionic surfactant that has stool-
over 12 should take 15 mg each day, preferably at bedtime; softening properties that allows penetration of intestinal
children over 6 the dose is half that of the adult dose fluids into the faecal mass. It also has weak stimulant prop-
(7.5 mg, e.g Senokot syrup). erties. Docusate is available as either capsules (Dioctyl) or
Sodium picosulfate (e.g. Dulcolax Pico) solution (Docusal). It can be given from children aged 6
months and over. Children between the age of 6 months
Adults and children over 10 years old should take 5 to and 2 years should take 12.5 mg (5 mL of Docusal paediat-
10 mg at night. ric solution) three times a day. For children aged between 2
and 12 the dose is 12.5 to 25 mg (5 to 10 mL) three times a
Osmotic laxatives (e.g. lactulose, macrogols and
day. Adults and children over 12 years old should take up
magnesium salts)
to 500 mg daily in divided doses. In contrast to liquid par-
These act by retaining fluid in the bowel by osmosis or by affin, docusate sodium seems to be almost free of any side
changing the pattern of water distribution in the faeces. effects. Docusate sodium can be given to all patient groups.
168 Gastroenterology
Reference Aetiology
Tramonte SM, Brand MB, Mulrow CD, et al. The treatment of No anatomic cause can be found to explain the aetiology
chronic constipation in adults. A systematic review. J Gen
of IBS but it is now clearly understood to be multifactorial.
Intern Med 1997;12:15–24.
Many factors can contribute to disease expression and
Further reading include motility dysfunction, diet and genetics. In a small
Borum ML. Constipation: evaluation and management. Primary proportion of cases symptoms appear after bacterial gas-
Care 2001;28:577–90. troenteritis. Psychological factors also influence symptom
Gattuso JM, Kamm MA. Adverse effects of drugs used in the reporting and consultation and some studies have shown
management of constipation and diarrhoea. Drug Saf patients who suffer from higher levels of stress or depres-
1994;10:47–65. sion experience worse symptoms when compared to other
Gerber PD, Barrett JE, Barrett JA, et al. The relationship of patients. Flare-up of symptoms has also been associated
presenting physical complaints to depressive symptoms in with periods of increased stress. Symptoms of diarrhoea
primary care patients. J Gen Intern Med 1992;170–3.
and constipation appear to be linked with hyperactivity of
Herz MJ, Kahan E, Zalevski S, et al. Constipation: a different
the small intestine and colon in response to food ingestion
entity for patients and doctors. Fam Pract 1996;13:156–9.
Higgins PDR, Johnson JF. Epidemiology of constipation in and parasympathomimetic drugs. Excessive parasym-
North America: a systemic review. Am J Gast pathomimetic activity might account for mucus associated
2004;99:750–9. with the stool.
Jewell D, Young G. Interventions for treating constipation in
pregnancy. Cochrane Database of Systematic Reviews 2001, Arriving at a differential diagnosis
Issue 2. Art. No.: CD001142. DOI: 10.1002/14651858.
IBS is essentially a diagnosis of exclusion and a careful
CD001142.
and thorough history of the patient is essential. Diagnostic
Leng-Peschlow E. Senna and its rational use. Pharmacology
1992;44:S1–52. aids, such as rectal examination and biopsy, which can be
Paraskevaides EC. Fatal lipid pneumonia and liquid paraffin. used by GPs are of limited use. A number of IBS-specific
Br J Clin Pract 1990;44:509–10. questions should always be asked of the patient to aid in
Petticrew M, Watt I, Brand M. What’s the ‘best buy’ for diagnosis (Table 6.21).
treatment of constipation? Results of a systematic review
of the efficacy and comparative efficacy of laxatives in the Clinical features of IBS
elderly. Br J Gen Pract 1999;49:387–93.
Talley NJ, Fleming KC, Evans JM, et al. Constipation in an IBS is characterised by abdominal pain or discomfort,
elderly community: a study of prevalence and potential risk located especially in the left lower quadrant of the
factors. Am J Gastroenterol 1996;9:19–25. abdomen, which is often relieved by defecation or the
passage of wind. Altered defecation, either constipation or
diarrhoea, with associated bloating is also normally
Irritable bowel syndrome present. People with IBS can present with ‘diarrhoea
predominant’, ‘constipation predominant’ or alternating
Background symptom profiles. During bouts of diarrhoea, mucus tends
to be visible on the stools. Patients might also complain
IBS is one of the commonest GI tract conditions seen in of increased stool frequency but pass normal or pellet-like
primary care. It can be defined as a functional bowel dis- stools. Diarrhoea on wakening and shortly after meals is
order (i.e. absence of abnormality) in which abdominal also observed in many patients.
pain and bloating is associated with a change in bowel
habit. The diagnosis is suggested by the presence of long- Conditions to eliminate
standing colonic symptoms without any deterioration in
the patient’s general condition.
Constipation and diarrhoea
Since the major presenting symptom of IBS is an alteration
Prevalence and epidemiology in defecation, it is necessary to differentiate IBS from acute
and chronic causes of constipation and diarrhoea. For
IBS is common. Adult prevalence rates in Western coun-
further information on differentiating these conditions
tries are reported to be between 10 and 20%, with approxi-
from IBS please refer to page 160 (for constipation) and
mately twice as many women than men affected. It most
page 154 (for diarrhoea).
commonly affects people between 20 and 30 years old but
recent trends indicate that there is a significant prevalence Figure 6.13 will aid differentiation of IBS from other
of IBS in older people. abdominal conditions.
Irritable bowel syndrome 169
? Table 6.21
6
Specific questions to ask the patient: IBS
Question Relevance
Duration NICE Guidance (CG61) states that primary care clinicians should consider a diagnosis of IBS if the
patient has had any of the following symptoms for 6 months:
Abdominal pain or discomfort
Bloating
Change in bowel habit
Age IBS usually affects people under the age of 45
Particular care is required in labelling middle-aged (i.e. over 45 years old) and elderly patients with
IBS when presenting with bowel symptoms for the first time. Such patients are best referred for
further evaluation to eliminate organic bowel disease
Periodicity IBS tends to be episodic. The patient might have a history of being well for a number of weeks or
months in between bouts of symptoms. Often patients can trace their symptoms back many years,
even to childhood
Presence of The nature of pain experienced by patients with IBS is very varied, ranging from localised and sharp
abdominal pain to diffuse and aching. It is therefore not very discriminatory; however, the patient will probably
have experienced similar abdominal pain in the past. Any change in the nature and severity of the
pain is best referred for further evaluation
Location of pain Pain from IBS is normally located in the left lower quadrant. For further information on other
conditions that cause pain in the lower abdomen see page 183
Diarrhoea and Patients with IBS do not have textbook definitions of constipation or diarrhoea but bowel function
constipation will be different than normal
Constipation predominant IBS is more common in women
Yes Recent change in >45 years <16 years IBS rare in this
Refer Age
bowel habit age group
Refer
No
No Symptoms
Refer 16–45 years
recurrent
Yes
Suggest Yes
alternative Medication related
No
Flare-ups associated No
with life events
IBS probable
Yes but refer to GP
for evaluation
Associated bloating
or wind No
Yes
IBS
Antispasmodics The only OTC product which the review found evidence of
efficacy was peppermint oil. For peppermint oil a statisti-
The Cochrane review by Ruepert (2011) concluded that cally significant effect for improvement of global assess-
antispasmodics as a class of medicines when compared to ment and effect for improvement of IBS symptom score
placebo provided a statistically significant benefit for was found.
abdominal pain, global assessment and IBS symptom
score. However, as the authors acknowledge, antispasmod-
ics are pharmacologically diverse and in their review it
Alternative treatments
was not possible to include all compounds (due to limited
number of studies) at sub-group analysis. Therefore, in this Herbal remedies for IBS have been subject to a Cochrane
review, it was not possible to determine the individual review (Liu et al 2006). Seventy-five trials were reviewed
effectiveness of certain OTC antispasmodics available in involving 71 different herbal medicines versus placebo or
the UK. No data was reviewed for alverine and only one conventional pharmacological treatment. When compared
trial was included that considered mebeverine. In that trial against placebo, STW 5 and STW5-II, Padma Lax, Tongxie
(Kruis et al 1986) no statistically significant effect for Yaofang, and Ayurvedic preparation showed significant
improvement of global assessment was found for mebev- improvement of global symptoms. Compared with conven-
erine. Similarly, for hyoscine no statistically significant tional therapy (in 65 trials testing 51 different herbal
effect for improvement of global assessment was found. medicines) 22 herbal medicines demonstrated a statistically
Irritable bowel syndrome 171
significant benefit for symptom improvement. Most trials Practical prescribing and product selection
6
were however deemed to be of poor methodological quality
and authors concluded that findings should be interpreted Prescribing information relating to the medicines used for
with caution. IBS reviewed in the section ‘Evidence base for over-the-
Probiotics, such as Lactobacillus and Bifidobacterium counter medication’ is discussed and summarised in Table
have also been promoted for IBS. A systematic review 6.22; useful tips relating to the treatment of patients with
identified 18 studies using probiotics either alone or in IBS are given in Hints and Tips Box 6.7.
combination for the treatment of IBS (Moayyedi et al All marketed products can be given to children (see
2010). The results suggested probiotics significantly individual entries) but anyone aged under 16 suspected of
improved IBS symptoms and there was no apparent differ- having IBS should be referred to a doctor as IBS in this
ence across the probiotics. However, the authors noted that age group is unusual.
there was potential publication bias in the review, with an
over-representation of small, positive studies, and there-
Hyoscine butylbromide (Buscopan IBS Relief)
fore these estimates of efficacy are likely to be overesti-
mates. The authors concluded that probiotics appear to The recommended starting dose for adults is one tablet
be effective in IBS, however the size of the effect and three times a day, although this can be increased to two
the effectiveness of individual probiotics is still to be tablets four a day if necessary. It is not recommended for
established. children under the age of 12. It is a quaternary derivative
Table 6.22
Practical prescribing: Summary of IBS medicines
Name of Use in Likely side Drug interactions of Patients in which Pregnancy &
medicine children effects note care exercised breastfeeding
Hyoscine >12 years Constipation Tricyclic antidepressants, Glaucoma, Avoid if possible
and dry neuroleptics, myasthenia gravis
mouth antihistamines and and prostate
disopyramide enlargement
Mebeverine >10 years None None None OK
Peppermint Oil >15 years Heartburn None None OK in pregnancy; try to
avoid in breastfeeding
Alverine >12 years Rash None None OK
Dietary advice (taken from Have regular meals and avoid missing meals
NICE CG61) Drink at least eight cups of fluid per day, especially non-caffeinated drinks
Reduce intake of alcohol and fizzy drinks
Consider limiting intake of high-fibre food
Reduce intake of ‘resistant starch’ often found in processed or re-cooked foods
Limit fresh fruit to three portions per day
Hypnotherapy This has been subject to a Cochrane review. Current trial data is inconclusive as to its
effectiveness, although some data does show promising findings. A register of IBS
therapists specialising in hypnotherapy can be found at http://www.ibs-register.co.uk
(accessed 8 November 2012)
172 Gastroenterology
one episode at some point during their lives. Haemorrhoids cushions leads to their descent. The prolapsed anal cushion
6
can occur at any age but are rare in children and adults has impaired venous return resulting in venous stasis and
under the age of 20. It affects both sexes equally and is inflammation of the cushion’s epithelium.
more common with increasing age; especially in people Haemorrhoids are classified as either internal or exter-
aged between 45 to 65 years of age. There is a high inci- nal. This distinction is an anatomical one. Superior to the
dence of haemorrhoids in pregnant women. anal sphincter there is an area known as the dentate line.
At this junction epithelial cells change from squamous to
columnar epithelial tissue. Above the dentate line haemor-
Aetiology
rhoids are classed as internal and below, external. Further-
The cause of haemorrhoids is probably multifactorial more internal haemorrhoids are graded according to
with anatomical (degeneration of elastic), physiological severity: grade I, do not prolapse out of the anal canal;
(increased anal canal pressure) and mechanical (straining grade II, prolapse on defecation but reduce spontaneously;
at stool) processes implicated. Haemorrhoids have been grade III, require manual reduction; and grade IV, cannot
traditionally described as engorged veins of the haemor- be reduced.
rhoidal plexus. The analogy of varicose veins of the anal
canal is often used but is misleading. Current thinking Arriving at a differential diagnosis
favours the theory of prolapsed anal cushions. Anal cush-
ions maintain fine continence and are submucosal vascular In the first instance most patients with anorectal symptoms
structures suspended in the canal by a connective tissue will self-diagnose haemorrhoids and often self-treat due
framework derived from the internal anal sphincter and to embarrassment about symptoms. Bleeding tends to
longitudinal muscle. Within each of the three cushions is cause the greatest concern and often instigates the patient
a venous plexus that is fed by arteriovenous blood supply. to seek help. Invariably, rectal bleeding is of little conse-
Veins in these cushions fill with blood when sphincters quence but should be thoroughly investigated to exclude
inside them relax and empty when the sphincters contract. sinister pathology. A number of haemorrhoid-specific
Fragmentation of the connective tissue supporting the questions should always be asked (Table 6.23).
? Table 6.23
Specific questions to ask the patient: Haemorrhoids
Question Relevance
Duration Patients with haemorrhoids tend to have had symptoms for some time before requesting advice. However,
patients with symptoms that have been constantly present for more 3 weeks should be referred
Pain Pain associated with haemorrhoids tends to occur on defecation. It can occur at other times, for
example when sitting. Pain is usually described as a dull ache
Sharp or stabbing pain at the time of defecation can suggest an anal fissure or tear
Rectal Bleeding Slight rectal bleeding is often associated with haemorrhoids. Blood appears bright red and might be
visible in the toilet bowl or on the surface of the stool. The presence of blood is usually a direct
referral sign but if the cause is haemorrhoids this could be treated unless the patient is unduly
anxious in which case referral is appropriate
Blood mixed in the stool has to be referred to eliminate a GI bleed
Large volumes of blood or blood loss not associated with defecation must be referred to eliminate
possible carcinoma
Associated Symptoms associated with haemorrhoids are usually localised, for example anal itching. Other
symptoms symptoms such as nausea, vomiting, loss of appetite and altered bowel habit should be viewed with
caution and underlying pathology suspected. Referral would be needed
Diet A lack of dietary fibre that leads to constipation is a contributory factor to haemorrhoids. The passage
of hard stools and straining during defecation can cause haemorrhoids. Find out about the patient’s
diet and current bowel habits
174 Gastroenterology
6
Threadworm? Age
No Yes
Bleeding, except Yes
Constipation? ❹ specks on paper
Refer ❷
No
Severity: piles need Yes
reducing manually
Refer ❸
No
Medication Yes Suggest an
exacerbating piles alternative to GP
No
Yes
Offer dietary advice
and/or OTC medicine
❶ Duration ❸ Severity
Patients with long-standing symptoms that have not been seen Medication is unlikely to help any patient who has to manually
previously by the GP should be referred to eliminate any under- reduce haemorrhoids. Referral for other treatments is
lying pathology. In the vast majority of cases no sinister find- recommended.
ings will result.
❹ Constipation
❷ Rectal bleeding See Fig. 6.12.
In the majority of cases rectal bleeding is a sign of referral.
However, in cases where sinister pathology has been excluded
and only mild local bleeding has occurred the pharmacist could
instigate treatment.
Evidence base for over-the-counter medication should therefore be asked about their normal diet to deter-
mine fibre intake. Those with diets low in fibre should be
Diet
encouraged to increase their fibre and fluid intake; this
Reviews by Alonso-Coelle et al (2005, 2006a, b) have con- will help produce softer stools and reduce constipation.
cluded that general measures to prevent constipation will Patients should try to eat more fruit, vegetables, bran,
help to decrease straining during defecation, ease the and wholemeal bread. If this is not possible then fibre
symptoms of haemorrhoids and reduce recurrence. Patients supplementation with a bulk-forming laxative could be
176 Gastroenterology
recommended. Bulk-forming laxatives will take 2–3 days also an ethical dimension to using a product with no effi-
to relieve constipation and may take up to 6 weeks to cacy sourced from sharks.
improve symptoms of haemorrhoids.
Other agents
Pharmacological Intervention
Sclerosing agents (lauromacrogol), and wound-healing
Numerous products are marketed for the relief and treat- agents (yeast cell extract) can also be found in some prod-
ment of haemorrhoids. These include a wide range of ucts. There is no evidence supporting their effectiveness.
therapeutic agents and commonly include anaesthetics,
astringents, anti-inflammatories and protectorants. Most Flavonoids
products contain a combination of these agents.
Dietary supplementation with flavonoids is a common
The inclusion of such a diverse range of chemical en
alternative treatment that is popular in continental Europe
tities appears to be based largely on theoretical grounds
and the Far East. As an adjunct, their use has been shown
rather than any evidence base. Extensive literature
to reduce acute symptoms and secondary haemorrhage
searching found only one published trial regarding the
after haemorrhoidectomy.
efficacy of any marketed product (Ledward 1980);
however, this trial suffered from serious methodological Summary
flaws.
With so little data available on their effectiveness it is
Anaesthetics (lidocaine, benzocaine impossible to say whether any product is a credible treat-
and cinchocaine) ment for haemorrhoids, and many medical authorities
regard them as little more than placebos. A Cochrane
No trials appear to have been conducted using local anaes-
review is underway to assess the efficacy of topical prod-
thetics in the treatment and relief of symptoms for haemor-
ucts and may give a more definitive answer (Kopljar et al
rhoids. However, anaesthetics have proven efficacy when
2011). Until such time, it seems prudent to recommend
used on other mucosal surfaces; their use could therefore
products containing a local anaesthetic or hydrocortisone
be justifiably recommended. Their action is short lived and
as they do have proven effectiveness in other similar
will produce temporary relief from perianal itching and
conditions.
pain. They require frequent application and might there-
Treatment should only be recommended to patients
fore cause skin sensitisation.
with mild haemorrhoids. Any person complaining of pro-
lapsing haemorrhoids, which need reducing by the patient
Astringents (allantoin, bismuth,
should be referred, because these patients might require
zinc, Peru balsam)
non-surgical intervention with sclerotherapy or rubber
Astringents are included in haemorrhoid preparations on band ligation. If these fail to cure the problem then a
the theoretical basis that they precipitate surface proteins haemorrhoidectomy might be performed.
thus producing a protective coat over the haemorrhoid.
There appears to be no evidence to support this theory. Practical prescribing and product selection
Certain proprietary products only contain astringents and
at best will provide a placebo effect. Prescribing information relating to the medicines used for
haemorrhoids reviewed in the section ‘Evidence base for
Anti-inflammatories (hydrocortisone) over-the-counter medication’ is discussed and summarised
in Table 6.24.
Steroids have proven effectiveness in reducing inflam
The product licenses of products for haemorrhoids allow
mation and would therefore be useful in reducing haem
all patient groups, except children under 12, to use them.
orrhoidal swelling, however trials with OTC products
(Note-good practice dictates that people under 20 years
containing hydrocortisone appear not to have taken
old with suspected haemorrhoids should be referred.) They
place.
do not interact with any other medicines and can be
used in pregnancy and breastfeeding. The standard dose
Protectorants (e.g. shark liver oil)
for any formulation is twice daily, plus application after
Protectorants are claimed to provide a protective coating each bowel movement. Minimal side effects have been
over the skin and thus produce temporary relief from pain reported and are usually limited to slight irritation. Products
and perianal itch. These claims cannot be substantiated that contain hydrocortisone are subject to several licensing
and as with astringents any benefit conveyed by a protec- restrictions: they are restricted to use in patients over a
torant is probably a placebo effect. In addition, there is certain age (Perinal spray 14 years, Germoloids spray 16
Abdominal pain 177
Table 6.24
6
Practical prescribing: Summary of haemorrhoid products
Form Anaesthetics Astringents Steroids Protectorant
Anacal* Ointment No No No No
Anodesyn Ointment or suppository Yes Yes No No
Anusol Cream, ointment or suppository No Yes No No
Anusol Plus HC Ointment or suppository No Yes Yes No
Germoloids Cream, ointment or suppository Yes Yes No No
Germoloids HC Spray Yes No Yes No
Hemocane Cream Yes No No No
Nupercainal Ointment Yes No No No
Perinal Spray Yes No Yes No
Preparation H** Ointment No No No Yes
Preparation H Gel No Yes No No
References
Alonso-Coello P, Guyatt GH, Heels-Ansdell D, et al. Laxatives
Abdominal pain
for the treatment of hemorrhoids. Cochrane Database of
Systematic Reviews 2005, Issue 4. Art. No.: CD004649. Background
DOI: 10.1002/14651858.CD004649.pub2.
Abdominal pain is a symptom of many different condi-
Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the
treatment of hemorrhoids complications: a systematic tions, ranging from acute self-limiting problems to life
review and meta-analysis. Am J Gastroenterol threatening conditions such as ruptured appendicitis and
2006a;101:181–8. bowel obstruction. However, the overwhelming majority of
Alonso-Coello P, Zhou Q, Martinez-Zapeta MJ, et al. Meta- cases will be of a non-serious nature, self-limiting and not
analysis of flavonoids for the treatment of haemorrhoids. require medical referral. The most common conditions that
Br J Surg 2006b;93(8):909–20. present to community pharmacies are dyspepsia affecting
Ledward RS. The management of puerperal haemorrhoids: A the upper abdomen and IBS affecting the lower abdomen.
double blind clinical trial of Anacal rectal ointment. The These are covered in more detail on pages 146 and 168.
Practitioner 1980;224:660–1. However, other conditions will present with abdominal
Kopljar M, Balduzzi S, Patrlj L, et al. Topical treatment for
pain (Fig. 6.15 and Table 6.25) and these are covered in
hemorrhoids. Cochrane Database of Systematic Reviews
2011, Issue 11. Art. No.: CD009443. DOI:
this chapter.
10.1002/14651858.CD009443. (Protocol).
Prevalence and epidemiology
Further reading
Nisar PJ, Scholefield JH. Managing haemorrhoids. Br Med J The prevalence and epidemiology of abdominal pain
2003: 327; 847–51. within the population is determined by those conditions
that cause it. As so many conditions can give rise to
178 Gastroenterology
Conditions arising from the RUQ Conditions arising from the LUQ
Biliary colic Gastritis
Hepatitis Splenic enlargement or rupture
Peptic ulcer Pancreatitis
Pancreatitis Renal colic
Renal colic Herpes zoster
Herpes zoster Myocardial ischaemia
Myocardial ischaemia
Conditions arising from the RLQ Conditions arising from the LLQ
Appendicitis Diverticulitis
Diverticulitis Intestinal obstruction
Intestinal obstruction Renal colic
Renal colic Irritable bowel syndrome
Ectopic pregnancy Ectopic pregnancy
Ovarian cyst Ovarian cyst
Salpingitis Salpingitis
Endometriosis Endometriosis
Fig. 6.15 Anatomical location of organs and conditions that can cause abdominal pain.
abdominal pain it is likely that the majority of the popula- Aetiology
tion will, at some point, suffer from abdominal pain. For
example, one study found that 40% of the UK population Abdominal pain does not only arise from the GI tract but
had suffered from dyspepsia during the previous 12 months also from the cardiovascular and musculoskeletal system.
and gastroenteritis, which is commonly associated with Therefore the aetiology of abdominal pain is dependent on
abdominal pain, is extremely common. its cause. GI tract causes include poor muscle tone leading
Abdominal pain 179
Table 6.25
6
Causes of abdominal pain
Probability Cause
Upper abdomen Lower abdomen Diffuse
Most likely Dyspepsia Irritable bowel syndrome Gastroenteritis
Likely Peptic ulcers Diverticulitis (elderly) Not applicable
Unlikely Cholecystitis, cholelithiasis, renal colic Appendicitis, Endometriosis, renal colic Not applicable
Very unlikely Splenic enlargement, hepatitis, Ectopic pregnancy, salpingitis, Pancreatitis, Peritonitis
myocardial infarction intestinal obstruction
? Table 6.26
Specific questions to ask the patient: Abdominal pain
Question Relevance
Location of pain Knowing the anatomical location of abdominal structures is helpful in differential diagnosis
of abdominal pain (Fig. 6.13)
Presence only of abdominal In general, patients without other symptoms rarely have serious pathology. The symptoms
pain/discomfort are usually self-limiting and often no cause can be determined
Nature of the pain Heartburn is classically associated with a retrosternal burning sensation
Cramp-like pain is seen in diverticulitis, IBS, salpingitis and gastroenteritis
Colicky pain (pain that comes and goes) has been used to describe the pain of appendicitis,
biliary and renal colic and intestinal obstruction
Gnawing pain is associated with pancreatitis and pancreatic cancer and boring pain with
ulceration
Radiating pain Abdominal pain that moves from its original site should be viewed with caution
Pain that radiates to the jaw, face and arm could be cardiovascular in origin
Pain that moves from a central location to the right lower quadrant could suggest
appendicitis
Pain radiating to the back may suggest peptic ulcer or pancreatitis
Severity of pain Non-serious causes of abdominal pain generally do not give rise to severe pain. Pain
associated with pancreatitis, biliary and renal colic and peritonitis tends to be severe
(subjective scores higher than 6 out of 10)
Age of patient With increasing age, abdominal pain is more likely to have an identifiable and serious
organic cause. Appendicitis is the only serious abdominal condition that is much more
common in young patients
Onset & duration In general, if no identifiable cause can be found, abdominal pain with sudden onset is
generally a symptom of more serious conditions. For example, peritonitis, appendicitis,
ectopic pregnancy, renal and biliary colic.
Pain that lasts more than 6 hours is suggestive of underlying pathology
Aggravating or ameliorating Biliary colic can be aggravated by fatty foods
factors Vomiting tends to relieve pain in gastric ulcers
Pain in duodenal ulcer is relieved after ingestion of food
Pain in salpingitis, pancreatitis and appendicitis are often made worse by movement
Associated symptoms Vomiting, weight loss, melaena, altered bowel habit and haematemesis are all symptoms
that suggest more serious pathology and require referral
180 Gastroenterology
to reflux (e.g. lower oesophageal sphincter incompetence), to the pharmacist early in the course of the disease, often
infections that cause peptic ulcers (from H. pylori) and before the presenting symptoms have assumed the more
mechanical blockages causing renal and biliary colic. usual description. The low prevalence of serious disease
Cardiovascular causes include angina and myocardial inf- and overlapping symptoms with minor illness makes the
arction whereas musculoskeletal problems often involve task even more difficult. Single symptoms are poor predic-
tearing of abdominal muscles. tors of final diagnosis (except for reflux oesophagitis, in
which the presence of heartburn is highly suggestive). It is
therefore important to look for ‘symptom clusters’ and to
Arriving at a differential diagnosis
use knowledge of the incidence and prevalence of condi-
The main role of the community pharmacist is to identify tions to determine if referral is needed. This necessitates
patients in whom symptoms suggest more serious pathol- taking a very careful history and not relying on a single
ogy, so that they can be further evaluated. This is not symptom to label a patient with a particular problem.
easy, as many abdominal conditions do not present with Specific questions relating to abdominal pain should be
classical textbook symptoms and patients tend to present asked (Table 6.26).
Dyspepsia/gastritis
Patients with dyspepsia present with a range of symptoms that commonly involve vague
abdominal discomfort (aching) above the umbilicus (Fig. 6.16) associated with belching,
bloating, flatulence, feeling of fullness and heartburn. It is normally relieved by antacids
and aggravated by spicy foods or excessive caffeine. Vomiting is unusual. For further
information on dyspepsia see page 146.
Fig. 6.18 The position of pain associated with acute cholecystitis and cholelithiasis.
Hepatitis
Liver enlargement from any type of hepatitis will cause discomfort or dull pain around
the right rib cage (Fig. 6.19). Associated early symptoms are general malaise, tiredness,
skin rash and nausea. The most common causes of acute hepatitis are alcohol abuse and
viral infection.
Ulcers
Ulcers are classed as either gastric or duodenal. They occur most commonly in patients
aged 30 to 50 years old and are more common in men than women. Symptoms are
variable but typically the patient will have localised mid epigastric pain (Fig. 6.20)
described as ‘constant’, ‘annoying’ or ‘gnawing/boring’.
With gastric ulcers, symptoms are inconsistent but the pain usually comes on
whenever the stomach is empty – usually 15 to 30 minutes after eating – and is
generally relieved by antacids or food and aggravated by alcohol and caffeine. NSAID use
is associated with a three- to fourfold increase in gastric ulcers.
Duodenal ulcers tend to be more consistent in symptom presentation. Pain occurs 2
to 3 hours after eating and pain that wakes a person at night is highly suggestive of
duodenal ulcer.
Acute pancreatitis
Pain of pancreatitis develops suddenly and is described as agonising with the pain being
centrally located that often radiates into the back (Fig. 6.21). Pain reaches its maximum
intensity within minutes and can last hours or days. Vomiting is common but does not
relieve the pain. Early in attack patients might get relief from the pain by sitting
forwards. It is commonly seen in alcoholics and it is likely that the patient will have a
history of long-term heavy drinking. Patients are very unlikely to present in a community
pharmacy due to the severity of the pain but a mild attack could present with steady
epigastric pain sometimes centred close to the umbilicus and can be difficult to
distinguish between other causes of upper quadrant pain.
Renal colic
Urinary calculi (stones) can occur anywhere in the urinary tract, although most
frequently stones get lodged in the ureter. Pain begins in the loin, radiating round the
flank into the groin and sometimes down the inner side of the thigh (Fig. 6.22). Pain is
severe and colicky in nature. Attacks are spasmodic and tend to last minutes to hours
and often leave the person prostrate with pain. Symptoms of nausea and vomiting might
also be present. It is more common in men and usually occurs between the ages of 30
and 50 years old.
Myocardial ischaemia
Angina and myocardial infarction (MI) cause chest pain that can be difficult to
distinguish initially from epigastric/retrosternal pain caused by dyspepsia (Fig. 6.23).
However, pain of cardiovascular origin often radiates to the neck, jaw and inner aspect
of the left arm. Typically, angina pain is precipitated by exertion and subsides after a few
minutes once at rest. Pain associated with MI will present with characteristic deep
crushing pain. The patient will appear pale, display weakness and be tachycardic.
Cardiovascular pain should respond to sublingual glyceryl trinitrate therapy.
Fig. 6.25 The position of pain associated with irritable bowel syndrome.
184 Gastroenterology
Diverticulitis
The incidence of diverticulitis increases with increasing age. It is most prevalent in the
elderly and is characterised by constant pain and local tenderness. Pain is more
commonly seen in the left lower quadrant (Fig. 6.26) but can be suprapubic and
occasionally right lower quadrant. Pain tends to be cramp-like in nature. Fever is a
prominent feature and altered bowel habit is usual with diarrhoea more common than
constipation.
Intestinal obstruction
Intestinal obstruction is most prevalent in people over the age of 50. It has sudden and acute onset. The pain is described
as colicky and can be experienced anywhere in the lower abdomen. Constipation and vomiting are prominent
features.
Appendicitis
Classically, the pain starts in the mid-abdomen region, around the umbilicus, before
migrating to the right lower quadrant after a few hours (Fig 6.27), although right-sided
pain is experienced from the outset in about 50% of patients. The pain of appendicitis is
described as colicky or cramp-like but after a few hours becomes constant. Movement
tends to aggravate the pain and vomiting might also be present. Appendicitis is most
common in young adults, especially young men.
Patient presents
with abdominal pain
Yes
Danger signals ❶ Refer
No
Age
>50 years <50 years
Upper or lower
Refer ❷ abdominal pain
Upper Lower
Renal colic,
Radiating Severity History of diarrhoea
ectopic pregnancy
pain of pain or constipation
or appendicitis?
Salpingitis,
Type of pain Shingles? Biliary colic Type of pain endometriosis IBS?
diverticulitis?
❶ Danger signals are significant bleeding, vomiting and ❷ Organic disease is more likely to be the cause of abdominal
fever. pain in patients aged over 50, especially if symptoms are
new or more severe than normal.
Further reading Lucenti MJ, Nadel ES, Brown DF. Right lower quadrant pain.
Bagshaw EJ. Abdominal pain protocol: right upper J Emerg Med 2001;21:431–4.
quadrant pain. Lippincotts Prim Care Pract 1999;3: Miiller SK, Alpert PT. Assessment and differential diagnosis of
486–92. abdominal pain. Nurse Pract 2006 Jul;31(7):38–45, 47.
Guthrie E, Thompson D. Abdominal pain and functional
gastrointestinal disorders. Br Med J 2002;325:701–3. Web sites
Kalloo AN, Kantsevoy SV. Gallstones and biliary disease. Prim The Pancreatitis Supporters’ Network: http://
Care 2001;28:591–606. www.pancreatitis.org.uk/
Self-assessment questions 187
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
6
knowledge to be applied to a practice setting.
6.1 Which one of the following symptoms is most 6.5 What condition predisposes patients to oral thrush?
indicative of renal colic
a. Heart failure
a. Loin pain radiating to the groin b. Asthma
b. Left lower quadrant pain radiating to loin area c. Diabetes mellitus
c. Right lower quadrant pain radiating to loin area d. Hyperlipidaemia
d. Back pain radiating to loin area e. Parkinson’s disease
e. Localised loin pain only
6.6 Abdominal pain that starts centrally then moves to the
6.2 In the treatment of constipation which one of the right lower quadrant is indicative of?
following statements is true?
a. Irritable bowel syndrome
a. Bulk-forming laxatives usually act within 12 to b. Pancreatitis
24 hours c. Pyelonephritis
b. Senna tablets should be avoided in nursing mothers d. Appendicitis
c. Fybogel is not suitable for a patient with coeliac e. Renal colic
disease
d. Lactulose should not be taken by diabetics 6.7 Which condition is least likely to cause rectal
e. Liquid paraffin has been linked with causing lipid bleeding?
pneumonia
a. Haemorrhoids
b. Crohn’s disease
6.3 A man asks for the best thing to stop diarrhoea as he
c. Colorectal cancer
is going on holiday and he doesn’t want to be caught
d. IBS
short. Which of the following is the first-line
e. Anal fissure
treatment to be recommended?
a. Kaolin and morphine 6.8 Mrs Jones, a 44-year-old woman, asks for advice on a
b. Rehydration solution sore spot on the inside of her cheek. Based solely on
c. Antibiotics the sex of the patient and age, what is the most likely
d. Antispasmodics diagnosis?
e. Loperamide
a. Oral thrush
b. Lichen planus
6.4 Antacids that contain aluminium, calcium or
c. Herpetiform ulcers
magnesium salts inhibit the intestinal absorption of
d. Leukoplakia
which of the following?
e. Minor aphthous ulcers
a. Chloramphenicol
b. Cephalexin Questions 6.9 to 6.11 concern the following conditions:
c. Erythromycin
A. Irritable bowel syndrome
d. Tetracycline
B. Constipation
e. Phenoxymethylpenicillin
C. Diarrhoea
D. Haemorrhoids
E. Dyspepsia
188 Gastroenterology
Select, from A to E, which statement best relates to the 6.17 Which symptoms in a patient presenting with
conditions above: constipation should be referred?
6.9 Is characterised with epigastric pain a. Melaena
b. Greater than 7 days duration
6.10 Can be treated with antispasmodics
c. Abdominal pain
6.11 Is associated with left lower quadrant pain
Questions 6.18 to 6.20: these questions consist of a
Questions 6.12 to 6.14 concern the following OTC statement in the left-hand column followed by a
medications: statement in the right-hand column. You need to:
A. Gaviscon Liquid • decide whether the first statement is true or false
B. Asilone suspension • decide whether the second statement is true or false.
C. Milk of Magnesia
D. Sodium bicarbonate powder Then choose:
E. Aludrox liquid
A. If both statements are true and the second statement
is a correct explanation of the first statement
6.12 Is most suitable for treating heartburn, which tends to
B. If both statements are true but the second statement
get worse when lying down
is NOT a correct explanation of the first statement
6.13 Is most suitable to treat abdominal discomfort caused C. If the first statement is true but the second statement
by trapped gas is false
D. If the first statement is false but the second statement
6.14 Could be used to relieve constipation, as well as
is true
indigestion
E. If both statements are false
Questions 6.15 to 6.17: for each of these questions one or
more of the responses is (are) correct. Decide which of the Directions summarised
responses is (are) correct. Then choose: 1st 2nd
A. If a, b and c are correct statement statement
B. If a and b only are correct A True True 2nd explanation is a
C. If b and c only are correct correct explanation of
D. If a only is correct the first
E. If c only is correct
B True True 2nd statement is not
a correct explanation
Directions summarised of the first
A B C D E C True False
a, b and c a and b b and c a only c only
D False True
only only
E False False
6.15 When questioning a patient seeking advice for nausea
and gastrointestinal upset, which of the following First statement Second statement
symptoms would indicate the need for direct referral
6.18 IBS is common in people It can be caused by stress
to the general practitioner?
under the age of 40
a. Feeling of impending vomiting. 6.19 Gingivitis is caused by It is characterised by
b. Loss of appetite over the last 24 hours. plaque build up swollen and red gums
c. Dark coloured vomit.
6.20 Heartburn causes Sphincter incompetence is
retrosternal pain responsible for symptoms
6.16 A common presentation of minor aphthous ulcers is
a. Pain
b. Ulcers on the buccal mucosa and tongue
c. Occur in crops of between 1 and 5
Case Study 189
Case Study
CASE STUDY 6.1
6
Mrs SJ, a 28-year-old women, asks to speak to the c. Which questions would now allow you to
pharmacist because she wants something for differentiate between these conditions?
stomach ache. You find out that the pain is located
in the lower and upper left quadrant, but mainly MI is the most unlikely of the three conditions and one
the upper quadrant. would expect the patient to have more severe
symptoms. Questions asking about radiation of pain,
previous history of similar symptoms and precipitating/
a. From which conditions might she be suffering? relieving factors should be asked.
Reflux, non-ulcer dyspepsia, gastritis, primary You reach the differential diagnosis of non-ulcer
dysmenorrhoea, endometriosis irritable bowel dyspepsia but before you make any recommendations,
syndrome, pancreatitis, renal colic, MI and herpes you ask if she takes any medication from the GP, her
zoster. response is as follows:
Further questioning reveals Mrs SJ to be suffering with • Paracetamol prn: She has taken this for 6 months for
pain she describes as ‘an ache’. knee pain.
• Atorvastatin 40 mg od: She has taken for the last 3
years for familial hyperlipidaemia.
b. Name the likely conditions that she could be • Naproxen 500 mg bd prn: She has taken this for 6
suffering from? months for knee pain.
The use of the word ‘ache’ means you can rule out d. Which of these medications, if any, do you
those conditions that present with severe, stabbing, consider are contributing to Mrs SJ’s pain?
burning or gnawing pain: Explain your rationale.
• pancreatitis, renal colic: severe Of the three medicines that Mrs SJ is taking, the one
• reflux: burning most likely to cause GI irritation is naproxen.
• herpes zoster: severe, lancing. However, she has been taking this for the last 6
months and you would expect that dyspepsia
But it could still be any of: non-ulcer dyspepsia, symptoms would have been experienced already if she
gastritis, primary dysmenorrhoea, irritable bowel was going to have a reaction to naproxen. It is then
syndrome, endometriosis and MI. unlikely that naproxen has caused the problem, unless
the dose has recently been changed. Atorvastatin can
However, as the pain is primarily upper quadrant this also cause GI side effects but has been taken for the
makes primary dysmenorrhoea, endometriosis and last 3 years and is therefore almost certainly not the
irritable bowel syndrome less likely. cause of the symptoms. Paracetamol is not known to
cause GI irritation so can also be ruled out. In
This leaves non-ulcer dyspepsia, gastritis and MI as conclusion it is likely that none of the medicines have
possibilities. caused Mrs SJ’s symptoms.
190 Gastroenterology
When this information is applied to that gained asked that the most likely cause of his symptoms
from our patient (below) we see that the questions is infection.
Danger symptoms/signs (trigger points The question mark against ‘unable to drink fluids’
for referral) should be determined during advice and product
selection, and so in this context is not applicable.
As a final double check it might be worth making sure
the person has none of the ‘referral signs or symptoms’;
this is the case with this patient.
Other symptoms/ No other obvious symptoms Very unlikely Leukoplakia, squamous cell carcinoma
provokes
Additional questions No systemic symptoms (e.g.
Diagnostic pointers with regard to
fever, chills) symptom presentation
Previous history of Had something similar a Below summarises the expected findings for questions
presenting complaint couple of years ago and the when related to the different conditions that can be
other chemist gave me some seen by community pharmacists.
cream
Past medical history RA, HT, stroke 2 years ago
Drugs (OTC, Rx, and Ibuprofen 600 mg tds; aspirin
compliance) 75 mg od; Atenolol 25 mg od
Allergies None known
Social history Lives on her own and
Smoking watches TV most of the
Alcohol time–Loves quiz shows
Drugs
Employment
Relationships
Family history
On examination Discrete white patch. No
underlying redness
194 Gastroenterology
Thrush ’Singular patch’ Anywhere Irregular and variable size Young and No
elderly
Minor ulcers Up to 5 or so Lips and inside Less than 1 cm and round 10–40 years Yes
ulcers cheeks most common
Major ulcers Numerous Anywhere Large (and variable shape) All ages Yes
Herpetiform Very numerous Back of the mouth Pinpoint and round All ages Yes
Herpes simplex Numerous Anywhere Small Children Yes
Lichen planus Diffuse Tongue, cheek, gums ’Spiders web’ Adults No
Leukoplakia Singular patch Tongue or cheek Irregular and variable size Elderly No
Carcinoma Singular lesion Tongue, mouth, Irregular and variable size Elderly No, but latter
lower lip stages yes
When this information is applied to that gained from lady is not really complaining of pain, there is a
our patient (below) we see that from the questions possibility that this ‘white patch’ has to be deemed
asked the diagnosis is either thrush, lichen planus or potentially sinister, especially as she is of an age where
leukoplakia. Lichen planus can be ruled out because of leukoplakia is more likely. A positive smoking history
the appearance of the white patch (plus lichen planus would make leukoplakia even more of a possibility. This
also commonly has rash, but not always). This leaves a person must be referred.
diagnosis between thrush and leukoplakia. Although the
Thrush ✓ ✓ ✓ ✓ ✗
Minor ulcers ✗ ✓ ✗ ✗ ✗
Major ulcers ✗ ✓ ✗ ✗? ✗
Herpetiform ✗ ✗ ✗ ✓ ✗
Herpes simplex ✗ ✓ ✗ ✗ ✗
Lichen planus ✓? ✓ ✓ ✓ ✓?
Leukoplakia ✓ ✓ ✓ ✓ ✓
Carcinoma ✗? ✓ ✓ ✓ ✓?
Answers
1 = a 2 = e 3 = b 4 = d 5 = c 6 = d 7 = d 8 = e 9 = e 10 = a
11= a 12 = a 13 = b 14 = c 15 = e 16 = a 17 = d 18 = b 19 = b 20 = a
Chapter 7
Dermatology
In this chapter
Background 195 Hair loss (androgenetic alopecia) 218
General overview of skin anatomy 195 Warts and verrucas 222
History taking 196 Corns and calluses 227
Physical examination 196 Scabies 229
Hyperproliferative disorders 197 Acne vulgaris 232
Psoriasis 197 Cold sores 236
Dandruff (pityriasis capitis) 204 Eczema and dermatitis 239
Seborrhoeic dermatitis 207 Sun exposure and melanoma risk 245
Fungal skin infections 210 Self-assessment questions 250
Fungal nail infection (onychomycosis) 216
Openings of
sweat ducts
Hair shaft
Hair follicle
Subcutaneous layer
(hypodermis)
Sweat gland
Arrector pili muscle
Fig. 7.1 The epidermis, dermis and associated structures.
Conditions of the dermis usually result in changes in the Apocrine sweat glands are mainly located in the axilla and
elevation of the skin, e.g. papules and nodules. begin to function at puberty.
The hair
The primary function of hair is one of protection. Each
History taking
hair consists of a shaft, the visible part of the hair, and a
Unlike internal medicine, the majority of dermatological
root. Surrounding the root is the hair follicle, the base of
complaints presenting in community pharmacy can be
which is enlarged into a bulb structure.
seen. This affords the community pharmacist an excellent
opportunity to base his or her differential diagnosis not
Sebaceous glands only on questioning but also on physical examination.
General questions that should be considered when dealing
Sebaceous glands are found in large numbers on the face,
with dermatological conditions are listed in Table 7.1.
chest and upper back. Their primary role is to produce
Terminology describing skin lesions can be confusing and
sebum which keeps hair supple and the skin soft. During
the more common terms used are shown in Table 7.2.
puberty these glands become large and active due to hor-
monal changes. Frequently, sebum will accumulate in the
sebaceous gland, and is one of the factors that lead to acne
formation. Physical examination
A more accurate differential diagnosis will be made if the
Sweat glands
pharmacist actually sees the person’s athlete’s foot or ‘rash’
These are the most numerous of the skin glands and are on the back. Providing adequate privacy can be obtained
classed as apocrine or eccrine. Eccrine glands are located there is no reason why the majority of skin complaints
all over the body and play a role in elimination of waste cannot be seen. If examinations are performed, clearly
products and maintaining a constant core temperature. explain the procedure you want to perform and gain their
Psoriasis 197
Table 7.1
7
Questions to consider when taking a dermatological history
Question Relevance
Where did the problem first Certain skin problems start in one particular location before spreading to other parts of the
appear? body, e.g. impetigo usually starts on the face before spreading to the limbs
Patients might need prompting to tell you where the problem started as they are likely to
want help for the most obvious or large skin lesion but neglect to tell you about smaller
lesions that appeared first
Are there any other Many skin rashes are associated with itch and/or pain
symptoms? Mild itch is associated with many skin conditions including, psoriasis and medicine eruptions.
Severe itch is associated with conditions such as, scabies, atopic and contact dermatitis.
Occupational history This is particularly pertinent for contact dermatitis, e.g. do symptoms improve when away
(relevant to adults only) from work?
General medical history Many skin signs can be the first marker of internal disease, e.g. diabetes can manifest with
pruritus; fungal or bacterial infection and thyroid disease can present with hair loss and
pruritus
Travel More people are taking long-haul holidays and therefore expose themselves to tropical
diseases that can manifest as skin lesions
Family and household Infections such as scabies can infect relatives and others with whom the patient is in close
contact history contact
The patient’s thoughts on Ask for the patient’s opinion. This might help with the diagnosis or alternatively shed light
the cause of the problem on anxieties and theories as to the cause of the condition
Hyperproliferative disorders
Prevalence and epidemiology
Background
Psoriasis is a common skin disorder with an estimated
Hyperproliferative disorders are characterised by a combi- worldwide prevalence between 1 and 3%. In the UK it has
nation of increased cell turnover rate and a shortening of been reported to affect 1–2% of the population. However,
the time it takes for cells to migrate from the basal layer this is probably an underestimate, as many patients with
to the outer horny layer. Typically, cell turnover rate is ten mild psoriasis do not present to their GP.
times faster than normal and cell migration takes 3 or 4 Psoriasis can present at any time in life, although it
days rather than 35 days. appears to be more prevalent in the second and fifth
198 Dermatology
? Table 7.4
7
Specific questions to ask the patient: Psoriasis
Question Relevance
Onset Psoriasis can develop in patients of any age, although it first occurs most commonly in early adult life.
However, in young and elderly patients the lesions tend to be atypical, which can make the diagnosis
more difficult
Distribution of Psoriasis often presents in a symmetrical distribution and most commonly involves the scalp and
rash extensor aspects of the elbows and knees. The gluteal cleft and umbilicus can also be affected
(Fig. 7.2)
Conditions that resemble psoriasis, such as lichen planus (often inside of the wrists) and pityriasis rosea
(thighs and trunk) have a different distribution to psoriasis
Other symptoms Itch is not normally the predominant feature of psoriasis, unlike other conditions such as dermatitis
and fungal infections
Nail involvement in the form of pitting and onycholysis (separation of the nail plate from the nail bed)
is often seen and can involve one or more of the nails. This is normally observed in patients with
longstanding psoriasis and is therefore of little value in patients presenting with rash of recent onset
Look of rash Scalp and plaque psoriasis usually show scaling as an obvious feature. This is not seen with other
common skin conditions (e.g. dermatitis) or other forms of psoriasis
When scalp involvement is mild, psoriasis can be impossible to distinguish from seborrhoeic dermatitis
Previous history Psoriasis is a chronic relapsing and remitting disease and it is likely that the patient will have had
of lesions lesions in the past. Other skin diseases, such as fungal infections, are acute and patients do not
normally have a history of the problem
7
tify the initial ‘target’ lesion.
Medication-exacerbated psoriasis
A number of medicines can worsen or aggravate existing
psoriasis. Medication most commonly associated are
lithium, antimalarials and beta-blockers. Other less com-
monly implicated include digoxin, amiodarone, clonidine,
penicillin, tetracycline, terbinafine, bupropion and sul-
phonamides. In addition systemic corticosteroids have
been shown to induce flares in psoriasis patients.
Lichen planus
Lichen planus is an uncommon condition and is reported
! TRIGGER POINTS indicative of referral: Psoriasis
to only account for 0.2 to 0.8% of dermatological outpa- • Lesions that are extensive, follow recent infection or
tient consultations. The lesions are similar in appearance cause moderate to severe itching
to plaque psoriasis but are itchy and are normally located • Patients with psoriatic-type lesions but who have no
on the inner surfaces of the wrists and on the shins, family history or past personal history of psoriasis
an atypical distribution for psoriasis. Additionally, oral
• Pustular psoriatic lesions
mucous membranes are normally affected with white,
slightly raised lesions that look a little like a spider’s web.
The person will not have a family history of psoriasis. Evidence base for over-the-counter medication
Before any treatment is offered to the patient it is first
Pityriasis rosea
worth noting that simple OTC remedies should be limited
The condition is characterised by erythematous scaling to mild to moderate plaque psoriasis and scalp psoriasis,
mainly on the trunk, but also on the thighs and upper as these are most likely to respond to such measures. A
arms. The colour of the rash tends to be a lighter pink patient who presents with severe plaque psoriasis or
colour than psoriasis and can be mildly itchy. A ‘target’ another form of psoriasis should be referred.
disc lesion, often misdiagnosed as ringworm, is followed Any treatment recommended should also be in conjunc-
1 week later with an extensive rash. It most commonly tion with patient education. Reassurance should be given
affects young adults. The condition usually remits sponta- about its benign, non-contagious nature but it should be
neously after 4 to 8 weeks. An accurate history will nor- emphasised that the condition is chronic and long-term
mally eliminate pityriasis rosea from psoriasis, as the that has periods of remission and relapse.
202 Dermatology
Does the rash have Yes Is the rash located on/near No Consider guttate psoriasis,
a scaly appearance? elbows, knees, gluteal cleft? pityriasis rosea, lichen planus
No Yes
Plaque psoriasis
7
concluded that due to methodological flaws in many of
the trials it is impossible to objectively determine the effi- All emollients should be regularly and liberally applied
cacy of this regimen (Naldi et al 1992). with no upper limit on how often they can be used. All
are chemically inert and can therefore be safely used from
birth onwards by all patients. They do not have any inter-
Practical prescribing and product selection actions with other medicines. For more information on
emollients see page 242.
Prescribing information relating to the medicines used to
treat psoriasis discussed in the section ‘Evidence base for
Tar-based products
over-the-counter medication’ is summarised in Table 7.5;
useful tips relating to patients presenting with psoriasis are All patient groups, including pregnant and breastfeeding
given in Hints and Tips Box 7.1. women, can use the majority of products on either the skin
Table 7.5
Practical prescribing: Summary of tar-based products
Scalp, Skin Salicylic Sulphur Other Children Application
or both acid ingredients
Alphosyl 2 in 1 Shampoo Scalp No No No All ages Every 2 to 3 days
Capasal Scalp Yes No Coconut oil 1% All ages Daily
Carbo-Dome Cream No No No All ages Two or three times a day
Cocois Scalp Yes Yes No >6 years Weekly
Exorex Scalp No No No >12 years 2 to 3 times a day
Pentrax shampoo Scalp No No No All ages Twice weekly
Pinetarsol Skin No No No All ages Can be used as a soap
substitute
Polytar & Polytar Plus Scalp No No No All ages Once or twice weekly
Psoriderm Both No No No All ages Once or twice a day
SebCo Scalp Yes Yes No >6 years Daily when needed
T/Gel Scalp No No No All ages 2 to 3 times a week
Problems with tar and dithranol Coal tar and dithranol share common problems of patient compliance. Both are
products messy to use, have an unpleasant odour and can stain skin and clothing
UV Light 90% of patients with psoriasis improve when exposed to sunlight and most patients
notice an improvement when they go on holiday
Emollient use Remind patients that these should be used regularly and liberally
Emollient bath additives Some bath additives, for example oilatum, will make the bath slippery and patients
should be warned to exercise care when getting out of the bath
204 Dermatology
References
Harrington CI. Low concentration dithranol and coal tar
Prevalence and epidemiology
(Psorin) in psoriasis: a comparison with alcoholic coal tar Dandruff is very common and affects both sexes and all
extract and allantoin (Alphosyl). Br J Clin Pract age groups, although it is unusual in pre-pubescent chil-
1989;43:27–9.
dren. It has been estimated to affect 1–3% of the popula-
Mason AR, Mason J, Cork M, et al. Topical treatments for
tion (Gupta et al, 2004).
chronic plaque psoriasis. Cochrane Database of Systematic
Reviews 2009, Issue 2. Art. No.: CD005028. DOI:
10.1002/14651858.CD005028.pub2. Aetiology
Naldi L, Carrel CF, Parazzini F, et al. Development of anthralin
short-contact therapy in psoriasis: survey of published Increased cell turnover rate is responsible for dandruff but
clinical trials. Int J Dermatol 1992;31:126–30. the reason why cell turnover increases is unknown.
Tham SN, Lun KC, Cheong WK. A comparative study of Increasingly, research has focused on the role that micro-
calcipotriol ointment and tar in chronic plaque psoriasis. organisms have on the pathogenesis of dandruff, and in
Br J Dermatol 1994;131:673–7. particular the yeast Malassezia (previously known as Pity-
rosporum) ovale, although the evidence is inconclusive as
Further reading
to whether M. ovale is the primary cause of dandruff or is
Clark C. Psoriasis: first-line treatments. Pharm J
2004;274:623–6. a contributory factor. It has been shown that M. ovale
Dodd WA. Tars. Their role in the treatment of psoriasis. makes up more of the scalp flora of dandruff sufferers and
Dermatol Clin 1993;11:131–5. might explain why dandruff improves in the summer
Freeman K. Psoriasis: not just a skin disease. The Prescriber months (fungal organisms thrive in warm and moist envi-
2007;5th June:42–5, 49. ronments that exist on the scalp due to wearing of hats
Gelfand JM, Weinstein R, Porter SB, et al. Prevalence and and caps). Further evidence to support a role of M. ovale
treatment of psoriasis in the United Kingdom: a in the aetiology of dandruff is the positive effect that
population-based study. Arch Dermatol 2005;141:1537–41. antifungal therapy has on the resolution of dandruff.
Leary MR, Rapp SR, Herbst KC, et al. Interpersonal concerns
and psychological difficulties of psoriasis patients: effects
of disease severity and fear of negative evaluation. Health Arriving at a differential diagnosis
Psychol 1998;17:530–6.
MacKie RM. Clinical Dermatology. Hong Kong: Oxford Most patients will diagnose and treat dandruff without
University Press; 1999. seeking medical help. However, for those patients that do
Nevitt GJ, Hutchinson PE. Psoriasis in the community: ask for help and advice it is important to differentiate
prevalence, severity and patients’ beliefs and attitudes dandruff from other scalp conditions. Asking symptom-
towards the disease. Br J Dermatol 1996;135 (4):533–7. specific questions will help the pharmacist to determine if
referral is needed (Table 7.6).
Dandruff (pityriasis capitis) 205
? Table 7.6
7
Specific questions to ask the patient: No Consider psoriasis,
Is the problem
Dandruff tinea or seborrhoeic
confined to the scalp?
dermatitis
Question Relevance
Yes
Presence of Dandruff is not associated with scalp
erythema redness unless the person has been No Is there any well-
Recent use of new
scratching. Redness is characteristic circumscribed
hair products
of psoriasis and is common in adult hair loss
seborrhoeic dermatitis
Yes
Itch Dandruff tends to cause itching of the
Consider
scalp unlike psoriasis and seborrhoeic contact dermatitis
dermatitis
No Yes
Presence of An adult with scalp involvement only is
other skin likely to have dandruff, especially in Inflammation Consider
lesions the absence of erythema present tinea infection
Many patients who have scalp psoriasis
also have plaque psoriasis affecting No Yes
arms, legs and the back Consider psoriasis
Dandruff or seborrhoeic
dermatitis
Table 7.7
Practical prescribing: Summary of medicines for dandruff
Name of Use in Likely side effects Drug Patients in Pregnancy & Breastfeeding
medicine children Interactions which care
of note exercised
Coal tar products All ages Local irritation and None None OK
dermatitis
Selenium >5 years reported but rare Manufacturers state to avoid in
first trimester but safety data
shows it to be OK when used on
small areas over a limited time
No evidence to say it would be
absorbed into breast milk
Zinc pyrithione All ages OK
Ketoconazole All ages
7
should be avoided if the patient has inflamed or broken 1995;132:441–5.
skin because irritation can occur. Selenium can also cause Pierard-Franchimont C, Goffin V, Decroix J, et al. A multicenter
discolouration of the hair and alter the colour of hair dyes. randomized trial of ketoconazole 2% and zinc pyrithione
1% shampoos in severe dandruff and seborrhoeic
Zinc pyrithione (e.g. Head and Shoulders) dermatitis. Skin Pharmacol Appl Skin Physiol
2002;15(6):434–41.
Zinc-based products can be used by all patients and at any Rigoni C, Toffolo P, Cantu A, et al. 1% econazole hair shampoo
age. It should be used on a daily basis until dandruff clears. in the treatment of pityriasis capitis; a comparative study
Dermatitis has been reported with zinc pyrithione and versus zinc pyrithione shampoo. G Ital Dermatol Venereol
should be borne in mind when treating patients with pre- 1989;124:67–70.
existing dermatitis. Van Custem J, Van Gerven F, Fransen J, et al. The in vitro
antifungal activity of ketoconazole, zinc pyrithione and
Ketoconazole (Nizoral Dandruff and Nizoral selenium sulfide against Pityrosporum and their efficacy as
Anti-Dandruff Shampoo) a shampoo in the treatment of experimental pityrosporosis
in guinea pigs. J Am Acad Dermatol 1990;22:993–8.
Nizoral can either be used to treat acute flare-ups of dan-
druff or as prophylaxis. To treat acute cases adults and
children should wash the hair thoroughly, leaving the
shampoo on for 3 to 5 minutes before rinsing it off. This Seborrhoeic dermatitis
should be repeated every 3 or 4 days (twice a week) for
between 2 and 4 weeks. If used for prophylaxis, the Background
shampoo should be used once every 1 to 2 weeks. It can
cause local itching or a burning sensation on application There are two distinct types of seborrhoeic dermatitis: an
and may rarely discolour hair. infantile form, often referred to as cradle cap, and an adult
form. Seborrhoeic dermatitis can present with varying
degrees of severity, ranging from mild dandruff to a severe
References and explosive form in acquired immune deficiency syn-
Gupta AK, Batra R, Bluhm R, et al. Skin diseases associated drome (AIDS) patients.
with Malassezia species. J Am Acad Dermatol
2004;51:785–98. Prevalence and epidemiology
Manriquez JJ, Uribe P. Seborrhoeic dermatitis. 2007;
Clinical Evidence. BMJ Publishing Group Ltd. Estimates of the prevalence of clinically significant sebor-
www.clinicalevidence.com. rhoeic dermatitis range from 1 to 5% of the population,
although cradle cap is reported to be more prevalent than
Further reading the adult form (Naldi & Rebora 2009). Cradle cap usually
Arrese JE, Pierard-Franchimont C, De-Doncker P, et al. Effect
starts in infancy, before the age of 6 months and is usually
of ketoconazole-medicated shampoos on squamometry and
Malassezia ovalis load in pityriasis capitis. Cutis self-limiting; the adult form tends to be chronic and per-
1996;58:235–7. sistent. Seborrhoeic dermatitis is more common in adult
Danby FW, Maddin WS, Margesson LJ, et al. A randomized men than women, and also more common in people with
double-blind controlled trial of ketoconazole 2% shampoo underlying neurological illness, for example, Parkinson’s
versus selenium sulfide 2.5% shampoo in the treatment of disease (Johnson & Nunley 2000).
moderate to severe dandruff. J Am Acad Dermatol
1993;29:1008–12.
Nigam PK, Tyagi S, Saxena AK, et al. Dermatitis from zinc Aetiology
pyrithione. Contact Dermatitis 1988;19:219. Despite its name, there appears to be no changes in sebum
Orentreich N. Comparative study of two antidandruff
secretion. Like psoriasis and dandruff, seborrhoeic derma-
preparations. J Pharm Sci 1969;58:1279–84.
titis is characterised by an increased cell turnover rate. The
Pereira F, Fernandes C, Dias M, et al. Allergic contact
dermatitis from zinc pyrithione. Contact Dermatitis precise cause of seborrhoeic dermatitis remains unknown
1995;33:131. and several theories have been put forward, ranging from
Peter RU, Richarz-Barthauer U. Successful treatment and immunological, hormonal and nutritional mechanisms.
prophylaxis of scalp seborrheic dermatitis and dandruff Like dandruff, Malassezia ovale plays an important role in
with 2% ketoconazole shampoo: Results of a multicentre, the development of seborrhoeic dermatitis; however, it has
not yet been established whether it has a primary or
208 Dermatology
? Table 7.8
Specific questions to ask the patient: Seborrhoeic dermatitis
Question Relevance
Itching In cradle cap the rash does not itch. This is useful in differentiating cradle cap from atopic
dermatitis as there is often overlap in the age at which they present.
Location Infantile and adult forms of seborrhoeic dermatitis do present in different locations (Fig. 7.9).
Additionally, the distribution in the adult form varies from other similar skin conditions
(e.g. psoriasis – typically involves knees, elbows and sacral area).
Positive family history Patients tend not to have a family history in seborrhoeic dermatitis. This is in contrast to
patients with psoriasis and those patients suffering from atopic dermatitis.
Other symptoms Ear and eyelid problems are associated with seborrhoeic dermatitis.
The general health of a child with seborrhoeic dermatitis will be unaffected. In contrast a child
who is fractious and miserable is more likely to have atopic dermatitis.
Seborrhoeic dermatitis usually has yellow greasy scale, unlike psoriasis, which has a silvery scale.
Physical signs If you run your fingers through the hair of someone with seborrhoeic dermatitis little is felt. In
psoriasis, accumulation of scales give the scalp an uneven, lumpy feel.
7
riasis the plaques tend to be crusty and extend away from
the hairline where as seborrhoeic dermatitis causes scaling
with underlying redness. It also affects the eyebrows and
eyelids, unlike psoriasis.
Rosacea
Rosacea predominately affects the face – an area usually
involved in adult seborrhoeic dermatitis. For more infor-
mation on rosacea see page 233 under the acne section.
family history of the atopic triad of dermatitis, asthma or Evidence base for over-the-counter medication
hay fever is common. For further information on differen-
Treatment options for seborrhoeic dermatitis are the same
tiating atopic dermatitis see page 291.
as dandruff. Unfortunately, seborrhoeic dermatitis tends to
be more resistant to therapy and often recurs whatever
Psoriasis
treatment is chosen.
Adults with scalp psoriasis can be confused with those For infants with cradle cap simple measures are usually
patients who present with severe and persistent dandruff only required in most cases. Daily use of a baby shampoo
210 Dermatology
Table 7.9
Practical prescribing: Summary of medicines for cradle cap
Name of Use in children Likely side effects Drug interactions Patients in which Pregnancy &
medicine of note care exercised breastfeeding
Dentinox Cradle Birth onwards None reported None None Not applicable
Cap Shampoo
Aetiology due to maceration of the skin (Fig. 7.13). The feet often
7
smell. The usual site of infection is in the toe webs,
Dermatophyte infections are contagious and transmitted especially the fourth web space (web space next to the
directly from one host to another. They invade the stratum little toe).
corneum of the skin, hair and nails but do not generally Once acquired the infection can spread to other sites
infiltrate living tissues. The fungus then begins to grow including the sole and instep of the foot. Over time this
and proliferate in the non-living cornified layer of kerat- can infect the nails (see page 216 for fungal nail infec-
inised tissue of the epidermis. Transmission of athlete’s tion). Cases of tinea infection where the plantar surface
foot is thought to be commonly acquired from communal has become involved may be persistent and difficult
rooms (e.g. changing rooms) whereas infection of the groin to treat.
can be acquired from contaminated towels and bed sheets,
or by autoinoculation from an existing foot infection.
? Table 7.10
Specific questions to ask the patient: Fungal infections
Question Relevance
Age and sex of patient Athlete’s foot is most prevalent in adolescents and young adults, especially men
Nail involvement usually occurs in older adults
Infection in the groin is much more common in men than women
Presence of itch Fungal infections usually cause itch, irritation or burning sensations. This usually eliminates
conditions such as psoriasis but not dermatitis/eczema
Associated symptoms Fungal lesions tend to be dry and scaly (except athlete’s foot) and have a sharp margin
between infected and non-infected skin
Previous and family history Fungal infections are usually acute in onset with no previous episodes, although athlete’s
foot may become recurrent
For lesions that do not show a classic textbook description, a positive family history of
dermatitis or psoriasis might influence your differential diagnosis
212 Dermatology
Conditions to eliminate
Tinea faciei
Fungal infections on the face are rare and are consequently
often mistaken for other facial skin conditions. The lesions
are similar in appearance to tinea corporis in that they will
normally have a sharp well-defined border, show scaling
and be itchy. Conditions such as acne, rosacea and lupus
need to be considered in its differential diagnosis.
Tinea manuum
Tinea manuum is often misdiagnosed as eczema or psoriasis
Fig. 7.13 Athlete’s foot. Reproduced from AB Fleischer et al
2000, 20 Common Problems, with permission of the McGraw- due to its atypical tinea appearance. The patient usually
Hill Companies. suffers from chronic diffuse scaling of one palm. Often ath-
lete’s foot will be present, as the infection has spread to the
hands from the feet due to the patient scratching their feet.
The condition is not common and if no foot involvement is
implicated then the diagnosis strongly points to dermatitis.
Psoriasis
Isolated fungal body lesions can be difficult to distinguish
from plaque psoriasis. However, if the patient has psoriasis
there will normally be a family history of psoriasis and the
lesions tend not to itch, exhibit more scaling and do not
show central clearing.
Evidence base for over-the-counter medication over 30 years and features in the most recent United States
7
Pharmacopoeia. In a recent Cochrane review, undecenoic
Superficial dermatophyte infections can be treated effec- acid was said to be efficacious in treating fungal infections
tively with topical OTC preparations. Six classes of medi- for skin and nail infections of the foot (Crawford &
cines have proven efficacy in their treatment. Hollis 2007).
Allylamines Summary
Terbinafine has been exempt from POM control in the UK On current evidence, an imidazole or terbinafine would be
since 2000. It inhibits the biosynthesis of ergosterol – an first-line treatment for superficial fungal infection. Both
essential component of fungal cell membranes. Reviews have similar mycological and symptom cure rates, although
have shown terbinafine to have high cure rates, slightly terbinafine might be preferred because it clears symptoms
better than the imidazoles (Crawford & Hollis 2007). in a shorter space of time, although it is more expensive.
Table 7.11
Practical prescribing: Summary of medicines for tinea infections
Name of medicine Use in children Likely side Drug Patients in Pregnancy &
effects interactions which care breastfeeding
of note exercised
Imidazoles
Bifonazole All ages Mild burning or None None OK
itching
Clotrimazole
Miconazole
Ketoconazole
Imidazole/steroid combination >10 years
Tolnaftate
Mycil No lower age stated None reported None None OK
Tinaderm
Undecenoates
Mycota No lower age stated None reported None None OK
Benzoic acid
Whitfield’s Ointment No lower age stated None reported None None OK
Terbinafine
Lamisil range & Scholl Advance >16 years (>18 yrs Redness, itching None None OK
Athlete’s Foot Cream for Lamisil Once)
Griseofulvin (Grisol AF) No lower age stated Stinging None None OK
Miconazole (e.g. Daktarin range, continued for at least 1 week after the infection has cleared
Daktacort Hydrocortisone) up. Local irritation has been reported.
Products containing miconazole only are suitable for
patients of all ages and should be used twice a day. Treat- Benzoic acid (e.g. Whitfield’s ointment)
ment should continue for 10 days after all lesions have Benzoic acid (in combination with salicylic acid) is now
disappeared to prevent relapse. Daktacort hydrocortisone rarely used. However, it is a safe medicine and can be used
is suitable for children aged over 10 and is licensed for by all patients.
sweat rash and athlete’s foot.
Terbinafine (Lamisil range & Scholl Advance
Tolnaftate (e.g. Mycil, Tinaderm, Scholl Athlete’s Foot Cream)
Athlete’s Foot Powder, liquid & cream)
Terbinafine can be used to treat athlete’s foot, groin infec-
Products containing tolnaftate have no interactions or side tion and tinea corporis. The cream should be applied once
effects and can be used by all patients. They can be used or twice a day whereas the spray and gel should be used
for athlete’s foot and infections of the groin and should only once daily. It has no interactions, has few reported
be used twice a day with treatment continuing for at least side effects and can be used by all patients. All products
1 week after the infection has cleared up. are licensed for people aged over 16, except Lamisil Once,
which is for use in people aged over 18 years of age.
Undecenoates (e.g. Mycota)
Griseofulvin (Grisol AF spray)
Products containing undecenoates have no interactions
and can be used by all patients. They are licensed for Licensed for athlete’s foot, Grisol should be applied to the
athlete’s foot and should be used twice a day and treatment area once daily. Each spray delivers 400 µg of griseofulvin
Fungal skin infections 215
Table 7.12
7
Summary of antifungal products and formulations
Active ingredient Brand Formulations
Bifonazole Canesten Bifonazole Once Daily Cream
Clotrimazole 1% Canesten AF Cream, spray
Canesten Cream, spray, solution
Clotrimazole 1% & Hydrocortisone 1% Canesten Hydrocortisone Cream
Miconazole 2% Daktarin Activ Cream, spray, powder
Daktarin Cream and powder
Miconazole 2% & hydrocortisone 1% Daktacort Hydrocortisone Cream
Ketoconazole Daktarin Gold Cream
Terbinafine Lamisil AT Spray, cream, gel
Lamisil Once Solution
Scholl Advance Athlete’s Foot Cream Cream
Tolnaftate Mycil Ointment, spray, powder
Scholl Athlete’s foot Cream, spray, powder
Tinaderm Cream
Undecenoic acid Mycota Cream, spray, powder
Reinfection and It is not known if improving foot hygiene or changing footwear can help to cure athlete’s foot
transmission but measures to reduce transmission include:
1. Dry the skin thoroughly after showering or having a bath. Keep a personal towel and do
not share it to prevent the infection spreading from person to person
2. Wear cotton socks and change at least once a day
3. Avoid the use of occlusive non-breathable shoes
4. Dust shoes and socks with antifungal powder
5. Avoid scratching infected skin
6. Use flip-flops (or equivalent) when using communal changing rooms
Steroid containing The license states that the maximum period of treatment is 7 days. This limits their usefulness,
products as many fungal infections will take longer to clear than 7 days, especially as products need
to be used after the lesions have cleared to prevent reinfection. Therefore they are probably
best used to control initial symptoms of redness and itch before switching to an imidazole
only product after the initial 7 days of treatment
Further reading
Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for
superficial mycotic infections of the skin: tinea corporis,
tinea cruris, tinea faciei, tinea manuum, and tinea pedis.
Guidelines/Outcomes Committee. American Academy of
Dermatology. J Am Acad Dermatol 1996;34:282–6.
Elewski B. Tinea capitis. Dermatol Clin 1996;14(23–31).
Moriarty B, Hay R, Morris-Jones R. The diagnosis and
management of tinea. BMJ 2012;345:e4380.
Table 7.13
7
Main types of onychomycosis
Type Key characteristics Spread of infection
DLSO Mainly big toe Note yellowing starts at distal part of toe
or side of nail
Proximal subungual Immunocompromised patients Yellow spots appear at the base of the nail
onychomycosis (PCO) (i.e. in the half-moon area of the nail)
Superficial white Often occurs in previously damaged nails Located on the surface of the nail
onychomycosis Chalky-white in appearance and can be
scraped off the nail surface
Table 7.14
Practical prescribing: Summary of medicines for fungal nail infections
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Amorolfine >18 years Skin irritation (rare) None None Manufacturers state avoid,
although evidence
suggests it is safe to use
immunocompromised and diabetics). The manufacturer of hair loss can be observed. Hair loss affects both men
states it should not be used in pregnant or breastfeeding and women and is associated with strong emotional and
women. To apply amorolfine the nail must be first filed psychological consequences. People have been socialised
and cleaned. Files and cleaning pads are provided in the to link a full head of hair with youth and vitality, whereas
treatment pack and are not reusable. The lacquer should baldness portrays a feeling of unattractiveness and loss of
then be evenly applied and left to dry. Amorolfine is youth. Hair loss can be due to a number of aetiologies;
unlikely to cause side effects, but skin irritation has been however, this section concentrates on androgenetic alo-
reported. pecia (male pattern baldness) because it is the most
common cause of hair loss.
? Table 7.15
7
Specific questions to ask the patient: Hair loss
Question Relevance
Hair loss accompanied with other Androgenic alopecia is not associated with other symptoms. Itch and/or erythema are
symptoms indicators that another cause, e.g. fungal scalp infection, psoriasis or seborrhoeic
dermatitis, might be responsible for the hair loss
Pattern of hair loss In men, hair loss begins at the front of the head and recedes backwards or at the
crown. In women, hair loss tends to be generalised and diffuse. Presentations that
differ to this or are sudden in onset suggest another cause of hair loss
Deficiency states There is now strong evidence that iron deficiency in women can cause hair loss
Underlying pathology A number of endocrine conditions can cause hair loss, most notably thyroid disorders
Medicine induced hair loss A number of medicines can cause hair loss (Table 7.16)
Hair loss triggered by a specific Hair loss can be caused by a stressful event or following surgery or after childbirth
event
Conditions to eliminate
Is the hair loss associated Yes Consider other causes,
with marked e.g. tinea capitis, Telogen effluvium
inflammation? psoriasis
Telogen effluvium represents a shift of more hairs in to the
No resting phase (telogen) of the hair cycle, which results in
Is the patient under Yes shedding of hair. This can be caused by a number of
18 years? Refer factors:
No Postpartum
Yes Consider hair shaft
Is the hair loss patchy? During pregnancy, circulating levels of oestrogen increase,
defect
Refer with a resulting rise in the number of follicles in anagen
(growth phase); the hair therefore thickens. However, after
No
delivery the hair follicles return to the resting phase and
Is the patient taking Yes the hair is shed. Women might believe that they are expe-
medication that Conduct drug review riencing hair loss when in reality the hair is returning to
may induce hair loss? the normal pre-pregnancy state. Reassurance should be
given that this is a temporary and self-limiting problem.
No
The first signs of infection are the appearance of a well- Lithium carbonate Telogen effluvium in
circumscribed round patch of alopecia that is associated approximately 10%
with itch and scaling. Common areas of involvement
Interferons Telogen effluvium in 20 to 30%
include the occipital, parietal and crown region. Inspection
of the area might reveal erythema and ‘black dots’ on the Oral contraceptives Seen 2 to 3 months after
scalp as a result of infected hairs. stopping
Retinoids Approximately 20% of patients
Alopecia areata
Colchicine, Rare
Refers to hair loss of unknown origin, although there is
carbimazole
often an association with atopy and autoimmune disease
and a positive family history is found in up to 25% of
patients. It is relatively uncommon affecting 0.1 to 0.2%
of the UK population. Unlike androgenetic alopecia the
an unusual shape. It would be very unusual for such
hair loss is sudden and mainly affects children and ado-
patients to present to a community pharmacy.
lescents (60% will have had their first episode before the
age of 20). It most commonly involves only small patches
of hair loss although the whole scalp can be affected.
The condition is usually self-limiting and regrowth of
hair is often observed but repeated episodes are not ! TRIGGER POINTS indicative of referral: Hair loss
unusual. • Fungal infection of the scalp
• Patients under 18 years old
Traction alopecia • Possible endocrine cause
Most commonly seen in women, traction alopecia refers to
• Sudden onset
• Suspected iron deficiency for blood test
hair loss due to excess and sustained tension on the hair,
• Trichotillomania
usually as a result of styling hair with rollers or a particular
type of hairstyle. It is reversible if the tension on the hair
is removed.
Evidence base for over-the-counter medication
Medicine-induced causes
Currently, minoxidil is the only product marketed for
Many medicines can interfere with the hair cycle and cause
androgenetic alopecia. It is available as either a 2 or 5%
transient hair loss, cytotoxic medicines being one of the
solution.
most obvious examples. However, many medicines have
A number of clinical trials have investigated the effi-
been associated with hair loss. Table 7.16 lists some of the
cacy and safety of minoxidil at 2 and 5% concentrations.
more commonly implicated medicines. If medicines other
The majority of these have been conducted on precisely
than cytotoxics are suspected of causing hair loss, the
the population that would respond the best to treatment;
prescriber should be contacted to discuss other possible
men aged between 18 to 50, with mild to moderate thin-
treatment options.
ning of the hair at the vertex. Despite this, trial results are
not totally convincing. Minoxidil is superior to placebo
Trichotillomania
(although placebo does invoke a large initial response) and
Trichotillomania is a psychiatric disorder, which refers to promotes a small increase in re-growth of vellus hair and
patients who have an impulsive desire to twist and pull increases the diameter of the hair shaft. However, longitu-
scalp hair, but often deny it. Hair loss is asymmetrical and dinal studies show that less than half of patients treated
Hair loss (androgenetic alopecia) 221
experience moderate to marked hair growth. Hair counts treatment of patients with minoxidil are given in Hints and
7
appear to be greatest after 12 months of treatment but, by Tips Box 7.5.
30 months, hair counts have decreased (albeit still above
baseline) and the bald area increases back in size to its Minoxidil (e.g. Regaine range as either
initial diameter. solution or foam)
Minoxidil therefore appears to delay and slow down
The dose for minoxidil is 1 mL of solution (or 1 g of
hair loss in less than half of its target patient population.
foam – equivalent to half a capful) applied to dry hair to
Furthermore, if treatment is stopped any hair growth
the total affected areas of the scalp twice daily. If fingertips
achieved is lost within 6 to 8 weeks on discontinuation of
are used to facilitate drug application, hands should be
therapy and baldness returns to pretreatment levels.
washed afterwards. Although minoxidil is applied topi-
The situation in women is not too dissimilar, although
cally, absorption into the systemic circulation can occur
the 5% solution offers no advantage over the 2% solution
and result in chest pain, rapid heartbeat, faintness or diz-
and has therefore not been granted a product licence at
ziness, although these are rare. If these occur the patient
that strength.
should stop using the product immediately. Other less
important adverse effects associated with topical minoxidil
Summary
are local irritation, redness and itching but these appear
Minoxidil will not significantly help the majority of to be related to the vehicle – propylene glycol – rather
balding individuals. It will promote hair growth in approx- than minoxidil. Changes in blood pressure should not
imately 50% of minimally balding young men but, over occur because the serum level of minoxidil after topical
time, the effect tails off. After 30 months the effect is still application is below that needed to cause changes to blood
greater than baseline but, on the whole, will not achieve pressure, however as a precaution minoxidil should be
cosmetically acceptable hair growth. In other words the avoided in hypertensive patients if possible. Some patients
use of minoxidil is useful for specific patients who want also report a temporary increase in hair shedding 2 to 6
to ‘buy’ themselves time from the inevitable balding weeks after beginning treatment. This subsides and is most
process. likely due to the action of minoxidil, shifting hairs from
Oral finasteride (1 mg per day) can be used to treat the resting telogen phase to the growing anagen phase.
androgenic alopecia in men but currently there is no good
quality evidence that it is superior to minoxidil. Further reading
Burke KE. Hair loss. What causes it and what can be done
Practical prescribing and product selection about it. Postgrad Med 1989;85:52–8, 67–73, 77.
Gilhar A, Etzioni, A, Paus R. Alopecia areata. N Engl J Med
Prescribing information relating to minoxidil is discussed 2012;366:1515–25.
and summarised in Table 7.17; useful tips relating to the
Table 7.17
Practical prescribing: Summary of medicines for hair loss
Name of medicine Use in children Likely side effects Drug interactions Patients in which Pregnancy &
of note care exercised breastfeeding
Minoxidil (Regaine) Not applicable Skin irritation, None Avoid in hypertensive Avoid
headache patients
Changes to hair colour and Some patients have experienced changes in hair colour and/or texture with Regaine
texture use. The patient should be warned of this possible problem before using the product
How long should the patient It can take 4 months or more before evidence of hair growth can be expected. Users
use Regaine? should discontinue treatment if there is no improvement after 1 year
222 Dermatology
Katz HI, Hien NT, Prawer SE, et al. Long-term efficacy of Aetiology
topical minoxidil in male pattern baldness. J Am Acad
HPV gain entry to the host by epithelial defects in the
Dermatol 1987;16:711–18.
Koperaki JA, Orenberg EK, Wilkinson DL. Topical minoxidil
epidermis. It is transmitted by direct skin-to-skin contact,
therapy for androgenetic alopecia: a 30 month study. Arch although contact with an infected person’s shed skin can
Dermatol 1987;123:1483–7. also transmit the virus. Infection via the environment is
Price VH, Menefee E, Strauss PC. Changes in hair weight and more likely to occur if the skin is macerated and in contact
hair count in men with androgenetic alopecia, after with roughened surfaces, for example in swimming pools
application of 5% and 2% topical minoxidil, placebo, or no and communal washing areas. Once established in the
treatment. J Am Acad Dermatol 1999;41:717–21. epithelial cells, the virus stimulates basal cell division to
Rietschel RL, Duncan SH. Safety and efficacy of topical produce the characteristic lesion.
minoxidil in the management of androgenetic alopecia. Patients, especially children, should be warned not to
J Am Acad Dermatol 1987;16:677–85.
pick, bite or scratch warts as this can allow viral particle
Roberts JL. Androgenetic alopecia in men and women: an
shedding to penetrate skin breaks. This process is known
overview of cause and treatment. Dermatol Nurs
1997;9:379–88. as autoinoculation and is responsible for multiple lesions
Tosti A, Misciali C, Piraccini BM, et al. Drug-induced hair loss becoming established and transferred to other parts of
and hair growth: incidence, management and avoidance. the body.
Drug Saf 1994;10:310–17.
Arriving at a differential diagnosis
Web sites
British Association of Dermatologists’ guidelines for the Warts and verrucas are not difficult to diagnose. However,
management of alopecia areata (2012): http:// pharmacists must be able to recognise other similar condi-
www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20 tions that superficially look like warts and verrucas. Asking
Guidelines/Alopecia%20areata%20guidelines%202012.pdf
symptom-specific questions will help the pharmacist to
determine if referral is needed (Table 7.18). HPV infections
involving the anogenital area are outside the remit of
community pharmacists and must be referred.
? Table 7.18
7
Specific questions to ask the patient: Human papilloma virus
Question Relevance
Age of patient Warts are unusual in very young children, e.g. infants. Young children and adolescents are most likely
to get warts but this is also the age group in which molluscum contagiosum is most prevalent
The likelihood that nodular lesions are caused by seborrhoeic warts or carcinoma increases with
increasing age
Location Warts are common on the hands and knees; verrucas are usually on the weight-bearing parts of the
sole
Warts can occur on the face but so too can plane warts and carcinoma. Referral is always needed as
all OTC treatment can cause scarring
Associated Itching and bleeding is not associated with warts and verrucas and must be viewed with suspicion,
symptoms especially in older patients
Pain on walking is often associated with verrucas
Colour/appearance Typically warts have a ‘cauliflower’ appearance and are raised and pale
Warts with a reddish hue or change colour should be referred
Lesions that are raised, smooth and have a central ‘dimple’ suggests molluscum contagiosum
Conditions to eliminate
Plane warts (flat warts or verruca plana)
These most frequently occur in groups on the face and the
back of the hands. They are small in size (1 to 5 mm in
diameter), slightly raised and can take on the skin colour
Fig. 7.17 Common wart. Reproduced from J Wilkinson et al of the patient (Fig. 7.19). As drug treatment is destructive
2004, Dermatology in Focus, Churchill Livingstone, with in nature, plane warts located on the face should be
permission. referred to avoid the risk of scarring.
224 Dermatology
agent and can be found in many OTC treatments, both with liquid nitrogen have suggested liquid nitrogen is
7
alone and combined with lactic acid. superior (Gibbs et al 2002).
A recent Cochrane review (Gibbs & Harvey 2006) inves-
tigated topical treatments for the cure of warts. This review Summary
identified 60 trials that met their inclusion criteria. Overall,
Any salicylic acid-based product should have modest
the quality of the trials was low due to poor methodology
success rates in clearing warts and verrucas after a 12-week
and reporting. However, placebo was found to have a
treatment period, providing patient compliance is good. If
substantial effect although salicylic acid in comparison
treatment has been unsuccessful with salicylic acid then a
was significantly more effective. Cure rates for salicylic
second-line medicine such as glutaraldehyde or formalde-
acid (from pooled data) showed 73% cure rates compared
hyde could be tried. Cryotherapy is probably best left to
to control cure rates of 48% over a 6 to 12 week period.
the GP to perform rather than the patient due to its destruc-
However, there appears to be no evidence to suggest which
tive action on skin.
concentration of salicylic acid is most effective.
In addition, there is some evidence to show that common
warts are more responsive to keratolytic therapy than Practical prescribing and product selection
plantar warts and resolution might be enhanced by soaking
Prescribing information relating to specific products used
the wart or verruca prior to application and/or occlusion
to treat warts and verrucas in the section ‘Evidence base
of the site (by use of plasters or collodion-like vehicle) to
for over-the-counter medication’ is summarised in Table
aid penetration.
7.19; useful tips relating to patients presenting with warts
Compliance with treatment has been identified as a
and verrucas are given in Hints and Tips Box 7.6.
limiting factor in the cure rate for warts and verrucas. One
As the majority of warts and verrucas will spontane-
study that investigated Occlusal reported an 80% cure rate
ously resolve treatment is not necessarily needed. Pharma-
after only 2 weeks of therapy. This might be an alternative
cists should determine from the patient how much the wart
option for patients whose compliance could be questioned.
or verruca affects day-to-day life and also what social
However, the study suffered from poor design and had only
impact the lesions have on the patient. It is also worth
a small number of patients and the results must be viewed
assessing patient motivation to comply with medication
with caution.
regimens because treatment is over a period of months not
Salicylic acid is often combined with other ingredients,
days or weeks.
in particular lactic acid. However, there is no evidence to
Salicylic acid products (e.g. Compound W (17%),
support additionally efficacy when lactic acid is added.
Bazuka Extra Strength (26%), Occlusal (50%), Verrugon
Monochloroacetic acid has also been combined with sali-
(50%), Wartex (50%)) & Salicylic acid/lactic acid com-
cylic acid. Cure rates for this combination are comparable
binations (Bazuka, Cuplex, Duofilm, Salactol, Salactac).
to cure rates of salicylic acid alone or when monochloro-
There is a wide choice of salicylic acid-based products
acetic acid is used singly. It therefore appears that the
for the removal of warts, verrucas (and corns). Prior to
combination has no additional benefit than when active
using a salicylic acid-based product the affected area
ingredients are used as monotherapy. As far as the author
should be soaked in warm water and towelled dry. The
is aware, no commercially available preparation contains
surface of the wart or verruca should be rubbed with a
monochloroacetic acid.
pumice stone or emery board to remove any hard skin.
Other agents commercially available include, formalde-
This should be done at least once per week. A few drops
hyde, glutaraldehyde and silver nitrate pencils. Informa-
of the product should be applied to the lesion, taking
tion regarding their effectiveness stems from small-scale
care to localise the application to the affected area. The
or poorly designed studies, and they should not be rou-
procedure should be repeated daily. Salicylic acid can be
tinely recommended.
recommended to most patients, although diabetics are a
Cryotherapy using liquid nitrogen has been used for
notable exception. Salicylic acid does not interact with
many years as a treatment of recalcitrant or widespread
any medicines. It can cause local skin irritation and
warts. However, the limited comparisons between topical
because of its destructive action should be kept away
salicylic acid and cryotherapy have failed to show any
from unaffected skin.
difference in response rates (Gibbs et al 2002). OTC prod-
ucts containing volatile hydrocarbons are marketed as
Glutaraldehyde (Glutarol)
home cryotherapy solutions for the treatment of warts (e.g.
Wartner). There is a lack of data comparing salicylic acid Application of glutaraldehyde is the same as salicylic acid
preparations with home cryotherapy. However, compari- but it should be used twice a day. It can cause skin irrita-
sons between home cryotherapy solutions and cryotherapy tion and stains the outer layer of the skin brown.
226 Dermatology
Table 7.19
Practical prescribing: Summary of medicines for warts and verrucas
Name of Use in Likely side effects Drug Patients in Pregnancy & breastfeeding
medicine children interactions which care
of note exercised
Salicylic acid
Compound W >6 years Local skin irritation None Avoid in diabetic OK
patients
Bazuka Extra >2 years
Strength
Occlusal No lower
age stated
Verrugon
Wartex
Salicylic acid and lactic acid
Bazuka No lower Local skin irritation None Avoid in diabetic OK
age stated patients
Cuplex
Duofilm >2 years
Salactol No lower
age stated
Salatac
Glutaraldehyde
Glutarol No lower Local skin irritation. None Avoid in diabetic OK
age stated Skin will be patients
stained brown
Formaldehyde
Veracur No lower No local affects None Avoid in diabetic Pregnancy
age stated reported patients Manufacturer advises
avoidance, although there are
no reports of teratogenicity
Breastfeeding
OK
Silver nitrate No lower Local skin irritation None Avoid in diabetic OK
(Avoca) age stated patients
Is it a verruca or a If diagnosis is uncertain then removal of the top layer of skin from the lesion can be performed.
corn? If black spots are not visible this implies the lesion is a corn and not a verruca
Length of Patients should be told that it is a slow process. Treatment commonly lasts 3 months. If OTC
treatment medication has been unsuccessful after this time then the patient could be referred to the GP
Salatac gel The gel forms an elastic film after application. This has to be removed each time before the gel
can be reapplied
Bazuka and Bazuka Don’t be fooled into thinking the extra strength has better cure rates. It has a higher
Extra Strength concentration of salicylic acid (26% as opposed to 12%) but this does not necessarily equate
to a more efficacious product
Corns and calluses 227
? Table 7.20
Specific questions to ask the patient: Corn/callus
Question Relevance
Location Lesions on the tops or between the toes suggest a corn compared with verrucas, which are on the
plantar surface of the foot
Aggravating or Pain experienced with corns is a result of pressure between footwear and the toes. If footwear is
relieving factors taken off then the pain is relieved
Pain associated with verrucas will be felt irrespective if footwear is worn
Appearance Corns and calluses appear as white or yellow hyperkeratinised areas of skin unlike verrucas that
show black thrombosed capillaries seen as black dots on the surface of the verruca
Previous history Patients with corns will often have a previous history of foot problems. The cause is usually due to
poorly fitting shoes, such as high heels. Prolonged wear of such footwear can lead to calluses
and permanent deformity of bunions
7
should form the mainstay of treatment. Correctly fitting
shoes are essential to help prevent corn and callus forma- Scabies is not gender or age specific. Infants to the elderly
tion. If pressure and friction still persist when correctly can acquire the infestation, although it is more common
fitted shoes are worn then patients can obtain relief by in the elderly. Outbreaks in schools and care homes are not
shielding or padding. Moleskin or thin podiatry felt placed uncommon. The incidence of scabies in the UK is low but
around the corn allows pressure to be transferred from the epidemics can occur on a cyclical basis approximately
corn to the padding. Specific proprietary products are every 15 years. In temperate climates (e.g. the UK), it
available for such purposes. In callus formation a ‘shock appears to be more prevalent in urban areas and in the
absorbing’ insert such as a metatarsal pad is useful to winter months.
relieve weight off the callus and so reduce stress on the
plantar skin.
Treatment should be avoided if possible, but if deemed
Aetiology
appropriate keratolytics can be used although there is no The mite is usually transmitted by direct physical contact
evidence to suggest that they are effective. (e.g. holding hands, hugging or sexual contact). Rarely, it
can be caught from bed linen because the mite can survive
Practical prescribing and product selection away from human skin for 24 to 36 hours at room tem-
perature. The female mite burrows into the stratum
Products used to treat corns and calluses are exactly the corneum to lay eggs. The faecal pellets she leaves in the
same as those used for warts and verrucas. Prescribing burrow cause a local hypersensitivity reaction and is
information relating to specific products used to treat assumed to cause the release of inflammatory mediators
corns and calluses is therefore discussed in the section that triggers an allergic reaction invoking intense itching.
‘Evidence base for over-the-counter medication for warts This normally takes 15 to 20 days in a primary infestation
and verrucas on page 224–225. However, a number of but can take up to 6 weeks to develop. In subsequent
proprietary products are marketed for sufferers with corns infestations this hypersensitivity reaction develops much
and calluses, for example products in the Carnation and more quickly. During the asymptomatic period the mite
Scholl range. These products contain high concentrations can be passed onto others unknowingly. The eggs hatch
of salicylic acid (usually 50%) that are surrounded by a and mature in 14 days after which the cycle can begin
non-medicated self-adhesive ring. again.
!
limited number of cases, it is best to
concentrate on other clinical signs TRIGGER POINTS indicative of referral: Scabies
rather than attempt to look for signs
of burrows Symptoms/signs Possible danger/reason
for referral
Location of Scabies classically affects the finger
rash webs, the sides of the fingers and Secondary infection of the May require antibiotics
wrists. skin
History of If contact dermatitis is suspected then Severe and extensive Outside scope of
presenting questioning should reveal a past symptoms community pharmacy.
complaint history of similar skin lesions Institutional outbreaks
Often people with scabies will be care Suspected dermatitis For institutional outbreaks
workers looking after institutionalised herpetiformis the Health Protection
people Agency need to be
A positive history in other family notified.
members increases the likelihood that
the patient has scabies
Evidence base for over-the-counter medication
The efficacy and safety of scabicidal agents is difficult to
Conditions to eliminate determine due to limited trial data. Benzyl benzoate, cro-
tamiton, permethrin and malathion have all been used. A
Insect bites
Cochrane review (Strong et al 2007) found permethrin to
A host of insects, fleas and mites can inflict a bite or sting. have high cure rates and more effective than any other
This usually results in an itchy papule that can become scabicidal agent.
firm and last several days. Occasionally, the rash can The efficacy of malathion is questionable as no random
become blistered, normally as a result of scratching, and controlled trials appear to have been conducted. However,
secondary bacterial infection can occur. Bites often tend case reports have suggested malathion is effective in
to be in groups and are asymmetrical. See page 325 for curing scabies with a cure rate of approximately 80%.
further information. Benzyl benzoate has been used to treat scabies for many
years. However, its efficacy has not been demonstrated in
Allergic contact dermatitis randomised controlled trials. In uncontrolled trials benzyl
benzoate has been shown to provide cure rates of approxi-
The condition presents as an area of inflamed, itchy skin
mately 50%. Unfortunately, up to 25% of patients experi-
with either papules or vesicles being present. However,
ence side effects such as burning, irritation and itching on
enquiry in to the patient’s history should reveal a past
application.
history of similar lesions in allergic contact dermatitis. For
further information on dermatitis see page 239.
Practical prescribing and product selection
Dyshidrotic eczema (pompholyx)
Prescribing information relating to specific products used
Pompholyx simply means bubble, and refers to the pres- to treat scabies in the section ‘Evidence base for over-the-
ence of intensely itchy vesicles or blisters on the palms of counter medication’ is discussed and summarised in Table
the hands and occasionally on the soles of the feet. Stress 7.22; useful tips relating to patients presenting with scabies
is known to precipitate the condition. are given in Hints and Tips Box 7.8.
Scabies 231
Table 7.22
7
Practical prescribing: Summary of medicines for scabies
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Permethrin >2 months Burning, stinging or tingling None None OK
Benzyl benzoate >12 years Burning, irritation
Malathion >6 months Skin irritation but rare
Application UK guidelines state that treatment should be applied to the whole body including the scalp, neck, face,
and ears. This is at odds with some manufacturer’s data
Itching after Pruritus can persist for 2 to 3 weeks after treatment and the patient might benefit from crotamiton.
treatment Antihistamines appear to have a limited role in relieving itch but their sedative effect (e.g.
chlorphenamine) might be useful for temporary help in aiding sleep
Hygiene Clothes, towels, and bed linen should be machine-washed (at 50°C or above) after the first application
measures of treatment, to prevent reinfestation and transmission to others
Bathing Treatment should not be applied after a hot bath because this increases systemic absorption and
removes the drug from its treatment site
? Table 7.23
7
Specific questions to ask the patient:
Acne vulgaris
Question Relevance
Severity Mild acne consists mainly of non-
inflammatory comedones.
Moderate acne can be described as
having many inflammatory spots that
are not confined to the face. Lesions
are often painful and there is a real
possibility of scarring.
Severe acne has all the characteristics of
moderate acne plus the development
of nodules and cysts. Lesions are often
widespread involving the upper back
and chest. Scarring will usually result.
Age of onset Patients presenting with acne-type
lesions who fall outside the normal age
Fig. 7.22 Rosacea. Reproduced from J Wilkinson et al 2004,
range should be closely questioned as
Dermatology in Focus, Churchill Livingstone, with permission.
an alternative diagnosis is more likely.
Occupation Certain jobs can predispose patients to
acne-like lesions and is commonly
associated with long-term contact with
oils
Conditions to eliminate
Rosacea
Rosacea is an inflammatory disease of the skin follicles. It
is uncertain what causes rosacea although successful treat-
ment with antibiotics suggests that bacterial pathogens
play a significant role in the disease. It is normally seen
in patients over 40 years of age and is classically charac-
terised by recurrent flushing and blushing of the central
face especially the nose and medial cheeks. Crops of
inflammatory papules and pustules are also a common
feature, although comedones are not present (Fig. 7.22).
Eye irritation and blepharitis is present in about 20% of
rosacea patients.
Perioral dermatitis
(Fig. 7.21). Mild acne will not cause permanent scarring. Perioral dermatitis tends to affect young women aged
Acne can sometimes consist predominately of blackheads between 25 and 40 and exhibits an acne-like rash gener-
and whiteheads with very few inflammatory lesions. This ally around the mouth and nasolabial folds (Fig. 7.23).
is termed comedonal acne and occurs most commonly in Itching and burning can also be present and the rash can
Asian and Afro-Caribbean patients. take on a dermatitis-like quality.
234 Dermatology
Myths surrounding acne Sun shine helps reduce acne – there is no convincing evidence that this is the case
Chocolate causes spots. There is no proof that any food causes acne
7
Stress causes acne. Stress cannot cause acne although it can make it worse
Applying benzoyl peroxide Benzoyl peroxide has a potent bleaching effect. It has the ability to permanently bleach
clothing and bed linen. Patients should be advised to always wash their hands after
applying the product
Table 7.24
Practical prescribing: Summary of medicines for acne
Name of Use in children Likely side effects Drug interactions Patients in which Pregnancy &
medicine of note care exercised breastfeeding
Benzoyl peroxide Not appropriate Skin irritation, None None OK
burning or peeling
? Table 7.26
Specific questions to ask the patient: Cold sores
Question Relevance
Appearance Patients with cold sores will often experience prodromal symptoms prior to the skin eruption whereas
no ‘warning’ symptoms are present with impetigo or angular cheilitis.
Location Cold sores typically occur around the mouth and for this reason are known as herpes simplex labialis.
They can also occur around and inside the nose, but this is less common
Impetigo also occurs in the same areas but is more prone to spread to other areas of the face or
move to other parts of the body, for example the arms.
Angular cheilitis occurs at the corners of the mouth and can be mistaken for cold sores due to their
similar locations.
Trigger factors Stress, ill health, sunlight, viral infection (e.g. the common cold) and menstruation are all implicated
in triggering cold sore attacks. These triggers are not associated with other similar conditions and
the patient should be asked if they can identify what brought on the lesions.
Sun-induced cold For those patients in whom the sun triggers cold sores, a sun block would be the most effective
sores prophylactic measure
Applying products Patients should be encouraged to use a separate towel and wash their hands after applying
products because viral particles are shed from the cold sore and can be transferred to others
Decrease Risk of transmission is highest during the first 1-4 days of symptoms and people should be
transmission advised not to kiss others
Eczema and dermatitis 239
Table 7.27
7
Practical prescribing: Summary of medicines for cold sores
Name of medicine Use in children Likely side Drug Patients in Pregnancy &
effects interactions which care breastfeeding
of note exercised
Aciclovir All (except Lypsyl Stinging None OK OK
product) state can
Lypsyl cold sore cream be used in children
Cymex Ultra but no lower age
limit stated
Virasorb
Zovirax
Penciclovir (Fenistil) >12 years None None None Manufacturers
recommend avoidance
Ammonia Yes, but no lower None None None OK
Blistex age stated
Phenol Yes, but no lower None None None OK
Colsor age stated
Zinc & lidocaine >12 years Stinging None None OK
Lypsyl cold sore gel
Urea Yes, but no lower None None None OK
Cymex age stated
is much more common than ACD and has been reported Table 7.28
to account for 80% of all occupational skin disorders. ACD Irritants and allergens known to
is said to affect 1 to 2% of the population with certain precipitate dermatitis
patient groups, such as patients with leg ulcers at higher
Irritants that can Allergens that can precipitate
risk of developing ACD.
precipitate ICD ACD
Detergents and Nickel (especially jewellery in
Aetiology
soaps women)
Different physiological mechanisms are responsible for ICD Chromate in cement
and ACD. In ICD, an agent must penetrate the outer layer
Solvents and Topical corticosteroids (5% of
of skin – the stratum corneum – to invoke a physiological abrasives patients)
response. The type of irritant, the concentration, quantity
involved and length of exposure will affect the severity of Oils Cosmetics – particularly fragrances,
reaction. This can occur with a single exposure, or more hair dyes, preservatives, and nail
commonly, with frequent exposures when the irritant varnish resin.
accumulates in the stratum corneum. For example strong Acids and alkalis, Rubber, including latex
acids and alkaline substances can produce ulceration on a including cement
single exposure, whereas other agents (e.g. zinc oxide tape)
potentially require multiple exposure and tend to invoke Reducing agents Dyes, formaldehyde and epoxy
a weaker reaction and cause a prickly heat type of and oxidizing resins
dermatitis. agents
ACD first requires sensitisation to occur. This leads to
specific cell-mediated sensitisation. Once the skin has
become sensitised to an allergen, re-exposure to the aller-
gen triggers memory T cells to initiate an inflammatory
response 24 to 48 hours after re-exposure. Because these ? Table 7.29
T cells are distributed throughout the body the reaction is Specific questions to ask the patient:
not limited to the site of exposure and explains why lesions Dermatitis
are seen away from the site of exposure. The risk of sen- Question Relevance
sitisation can depend on the individual’s susceptibility as
well as the particular allergen’s concentration and quan- Location The distribution of rash for contact
tity. Re-exposure can occur days and sometimes years after dermatitis is closely associated with
initial exposure. A list of common irritants and allergens clothing and jewellery (Fig. 7.26)
is shown in Table 7.28. Exposure A history of when the rash occurs gives a
Many causes of dermatitis are occupationally related. useful indication as to the cause, e.g. a
Questions about exposure to irritants and allergens at work construction worker might complain of
can often identify the cause of symptoms. sore hands whilst at work but when on
holiday the condition improves only for
it to worsen when they go back to work
Arriving at a differential diagnosis
Many patients will present in the pharmacy with an itchy
red rash. Gaining an accurate diagnosis can be difficult as
identification of the cause is difficult and clinical features
are similar. Generally speaking treatment is the same for hours – of contact. The skin appears red, itchy, inflamed
both forms of dermatitis so making a definitive diagnosis and might show papules and vesicles. Itching is a promi-
is less important. However, asking symptom-specific ques- nent feature and often causes the patient to scratch, which
tions will help the pharmacist to determine if referral is results in broken skin with subsequent weeping. In chronic
needed (Table 7.29). exposure, the skin becomes dry, scaly and can crack
and fissure (Fig. 7.27). The rash in ICD tends to be well
demarcated. In ACD, the rash tends to be less well defined;
Clinical features of ACD and ICD
milder involvement away from the site of exposure is seen
In both cases rash develops at the site of exposure. In the on repeated exposure and can reactivate at previously
acute phase, lesions appear rapidly – within 6 to 12 exposed sites.
Eczema and dermatitis 241
7
Ear rings ing location, and central clearing all point toward fungal
infection. For further information on fungal infections see
Necklace
page 210.
Discoid dermatitis
Studs from This differs from other forms of eczema as the lesions have
jeans clearly demarcated edges and are circular or oval. Lesions
tend to affect the arms and legs and are often distributed
symmetrically. It is more common in middle-aged people.
Urticaria
Urticarial rashes can result from many causes, most notably
due to food allergies, food additives (Table 7.30) and medi-
Fig. 7.26 Distribution of contact dermatitis. cines. Like dermatitis, the rash is itchy and red but resem-
bles the rash seen when stung by a stinging nettle (Fig.
7.28). In addition, the skin can be oedematous and blanches
when pressed. Urticarial reactions often respond well to
systemic antihistamines.
Conditions to eliminate
Psoriasis Evidence base for over-the-counter medication
Isolated lesions of psoriasis can be superficially similar to
All forms of dermatitis cause redness, drying of the skin
dermatitis; they appear red and scaly, although a key dif-
and irritation/pruritus to varying degrees. Treatment
ference is the general lack of itch in psoriasis. The distribu-
should include three steps: managing the itch, avoiding
tion of lesions is also usually different, and psoriasis is not
irritants and maintaining skin integrity.
precipitated by exposure to certain irritants or allergens.
Non-pharmacological interventions include avoidance
For further information on psoriasis see page 197.
of the causative agent, however determining the cause is
often difficult and avoidance is sometimes impractical.
Fungal infections
Sweating intensifies the itching so strategies to keep the
Fungal infections exhibit the classical dermatitis-type person cool will help; cotton and loose fitting clothing can
symptoms of itchy red rash and can therefore be easily be worn.
242 Dermatology
Table 7.30
Food additives known to cause allergic reaction
Sulphites (E220–E227) Sulphites are used to preserve smoked and processed meats, dried fruit (apricots) and salads.
They are commonly found in liquid form in cold drinks and fruit juice concentrates, and
wine and sprayed onto foods to keep them fresh and prevent discolouration or browning.
Benzoic acid and parabens Benzoates and parabens have antibacterial and antifungal properties for prevention of food
(E210–E219) spoilage. These agents are added to pharmaceutical and food products and occur naturally
in prunes, cinnamon, tea and berries.
Antioxidants (E320–E321) Fat and oils in food turn rancid when exposed to air. Synthetic phenolic antioxidants
butylated hydroxyanisole and butylated hydroxytoluene prevent this spoilage happening
but can trigger asthma, rhinitis and urticaria.
Flavour enhancers These are used to enhance food palatability, most notably aspartame which can trigger
(E620–E635) urticaria and swelling and monosodium glutamate (E620) which can trigger the ‘Chinese
restaurant syndrome’ of headache and burning plus tightness in the chest, neck and face.
Colourings (E100–E180) Colourings are used to make food visually more attractive, the azo dyes (Tartrazine, E102,
Sunset Yellow, E110) and non-azo dyes (erythrocine) have been associated with triggering
urticaria, asthma and generalised allergic reactions.
Rash which is
red and itches
Yes
No
Lesions thickened Yes Psoriasis or
and scaly Lichen planus?
No
Lesions located Yes
Fig. 7.28 Urticarial reaction to grass. Scabies?
around wrists
No
Table 7.31
7
Practical prescribing: Summary of medicines for dermatitis
Name of medicine Use in children Likely side effects Drug interactions Patients in which Pregnancy &
of note care exercised breastfeeding
Emollients From birth onwards None None None OK
Corticosteroids
Hydrocortisone >10 years None None None OK
Clobetasone >12 years
Patch testing If the rash persists despite avoiding likely irritants and allergens then patch testing
could be tried
How much to apply? Patients should be instructed to use a fingertip unit. This is the distance from the tip
of the adult index finger to the first crease. One unit is sufficient to cover an area
twice the size of an adult flat hand
Quantity required? The BNF gives the following guidance for a weeks use:
Both hands, 15 to 30 g
Both arms, 30 to 60 g
Both legs or trunk, 100 g
When to apply emollients and After using a corticosteroid an emollient can be applied to the same area 30 minutes
corticosteroids? later
50% liquid paraffin and 50% white soft paraffin. However, for over-the-counter medication’ is summarised in Table
patient acceptability of such products needs to be consid- 7.31; useful tips relating to using products to treat derma-
ered. Cream formulations rather than ointments tend to be titis are given in Hints and Tips Box 7.11.
more readily accepted by patients, as they are easier and
less messy to use. In general, skin which is moderately dry
to very dry will respond best to an ointment and skin Emollients
which is mildly dry, a cream. If the skin is broken or There are a large number of emollients on the market. They
weeping then a water soluble cream can be useful. To avoid come in a range of formulations to suit all skin types and
the drying effects of soap, a soap substitute should be used. patient preference (Table 7.32). Patients should be instructed
to apply emollients both liberally and whenever needed.
Steroids They are pharmacologically inactive and so can be used
In the UK, two steroids are commercially available OTC; by all patients regardless of age or medical status. A
hydrocortisone and clobetasone. Both have proven efficacy number of ingredients incorporated into emollients do
in treating dermatitis and should be considered first-line have the potential to sensitise skin and patients should be
treatment for acute dermatitis. Once symptoms are control- advised to patch test the product on the back of the hand
led then the patient should be instructed to revert back to before starting to routinely use it.
emollient therapy.
Cortiocsteroids
Practical prescribing and product selection
Although corticosteroids can be sold to patients OTC,
Prescribing information relating to specific products used there are a number of restrictions to their sale. In the UK
to treat dermatitis discussed in the section ‘Evidence base these are:
244 Dermatology
Table 7.32
Summary of proprietary emollient products
Product name Formulation Combination Contains potential
product sensitising agents
Aveeno Cream, bath oil, and lotion Yes
Aquadrate Cream Urea No
Aquamol Cream Yes
Balneum Bath oil Yes
Balneun Plus Bath oil, cream Urea (cream) Yes
Calmurid Cream Urea, lactic acid No
Cetraben Cream, bath oil Yes
Dermatonics Heel Balm Cream Urea Yes
Dermamist Spray No
Dermalo Bath oil No
Dermol shower and bath emollient, wash emulsion Antimicrobials Yes
Diprobase Cream, ointment Yes (cream)
Diprobath Bath oil No
Doublebase Bath oil, gel No
E45 Cream, lotion, bath oil, emollient wash cream Yes (cream and lotion only)
E45 Itch relief Cream Urea Yes
Emollin Spray No
Emulsiderm Bath emulsion Antimicrobials Yes
Epaderm Cream, ointment Yes
Eucerin Cream, lotion Urea Yes
Hewletts Cream Yes
Hydromol Intensive Cream Urea No
Hydromol Cream, ointment, bath and shower emollient Yes (cream and ointment)
Imuderm Bath oil Yes
Linola Gamma Cream Yes
Lipobase Cream Yes
Neutrogena Cream Yes
Nutraplus Cream Urea Yes
Oilatum Cream, junior, shower emollient, bath oil Yes
Oilatum Plus Bath oil Antimicrobials Yes
QV Cream, ointment, lotion, wash, bath oil Yes (except oil)
Sun exposure and melanoma risk 245
Ultrabase
Formulation
Cream
Combination
product
Contains potential
sensitising agents
Yes
7
Unguentum M Cream Yes
Vaseline Dermacare Cream, lotion Yes
ZeroAQS Cream Yes
Zerobase Cream Yes
Zerocream Cream Yes
Zeroguent Cream Yes
Zerolatum Bath oil No
Zerolatum Plus Bath oil Yes
Zeroneum Bath oil Yes
• the patient must be over 10 for hydrocortisone (over pharmacist choice in tailoring treatment to the severity of
2 years in Australia) and 12 for clobetasone; the condition. It would seem reasonable to reserve clobeta-
• duration of treatment is limited to a maximum of sone for more severe flare-ups of dermatitis, or those
1 week; patients in which hydrocortisone has in the past failed to
• a maximum of 15 g can be sold at any one time;
control symptoms. Like hydrocortisone, it should be
• they cannot be used on facial skin, the anogenital applied twice a day.
region, broken or infected skin.
In the opinion of the author, these restrictions limit their
usefulness and mean that many patients, who could be Further reading
otherwise treated successfully if the product licenses were Bellingham C. Proper use of topical corticosteroids. Pharm J
not so prohibitive, must be referred to a GP. For example, 2001;267:377.
1% hydrocortisone cream, if used short-term, is an ideal Clark C, Hoare C. Making the most of emollients. Pharm J
2001;266:277–9.
steroid to use on the face with no adverse events; also,
Cunliffe B. Eczema. Pharm J 2001;267:855–6.
15 g of product is often insufficient for surface areas such
as limbs and the body, even if used only for a week. Web sites
National Eczema Society: http://www.eczema.org/
Hydrocortisone National Eczema Association: http://www.nationaleczema.org/
Hydrocortisone can either be bought alone (e.g. Hc45,) or
in combination with other ingredients (e.g. Eurax HC, Can-
esten Hydrocortisone). It is prudent to use products solely
containing hydrocortisone for dermatitis, applying them Sun exposure and melanoma risk
twice a day for a maximum of 7 days. If secondary infec-
tion is suspected, for example with a fungal infection, then Background
products such as Canesten Hydrocortisone can be used.
The ultraviolet spectrum is subdivided in to three regions:
UVA (320 to 400 nm); UVB (290 to 320 nm); and UVC
Clobetasone (Eumovate eczema
(200 to 290 nm). Light from the UVA spectrum causes
and dermatitis cream)
skin tanning and UVB light sunburn, whereas UVC light
Clobetasone is classed as moderately potent, whereas is effectively filtered out by the ozone layer. It is now
hydrocortisone is classed as mild. This affords the well recognised that excessive or prolonged exposure to
246 Dermatology
the sun’s rays and inadequate skin protection can result Women Men
in pre-cancerous and cancerous neoplasms. There are
many types of skin cancer, but three types are associated 14% Head and neck 22%
with sun exposure – squamous cell carcinoma (SCC), basal
cell carcinoma (BCC) and malignant melanoma (MM) – and
are responsible for more than 95% of all skin cancers.
21% Arm 17%
SCC and BCC result from chronic long-term exposure
to sunlight whereas MM is associated with acute,
intense, and intermittent blistering sunburns. BCC and 17% Trunk 38%
SCC are often grouped together as non-melanoma skin
cancer (NMSC).
Aetiology
The body’s response to the effects of UVA and UVB light Clinical features of malignant melanoma
is protective. On exposure to ultraviolet light melanocytes MM is one of the few cancers which is associated with
increase production of melanin, thus causing a darkening young adults. It can appear on all body sites yet their
of the skin, the all-important suntan! Melanin absorbs both distribution between men and women does differ (Fig.
UVA and UVB and effectively protects the skin from 7.30). In the UK population the most common site is the
damage, unfortunately melanin synthesis is slow and skin lower leg in women, and on the back in men. Risk factors
damage might well have already occurred manifested as include early childhood sun exposure, people with multiple
sunburn. Sunburn is an inflammatory response to exces- moles and those with susceptible sunburn skin types. The
sive exposure to ultraviolet light whereby an increase first sign of melanoma is often a change in the size, shape,
in inflammatory mediators results in capillary vasodilata- or colour of a mole, although melanoma can also appear
tion and increased capillary permeability. In addition to on the body as a new mole (Fig. 7.31). Early identification
melanin production, epidermal hyperplasia occurs, causing is essential and two commonly used checklists are used to
the skin to thicken; this provides further protection against aid diagnosis; the ‘7 point’ check list and the ‘ABCDE’ list.
the skin.
1. The 7 point list
Arriving at a differential diagnosis This checklist consists of 3 major and 4 minor points:
Pharmacists have a major role to play in dealing with
Major (scores 2)
patients who have been exposed to excessive amounts of
1. Change in shape
sunlight. They can promote sun safety messages, both
2. Change in size
passively and actively (when dealing with requests for
3. Change in colour
sunburn) and make appropriate referrals with regard to
suspicious lesions. Pharmacists must be able to recognise
suspicious lesions, especially those resembling MM because Minor (scores 1)
it has the highest mortality of skin cancers, but if treated 1. Largest diameter 7 mm or more
early is curable. 2. Inflammation
Sun exposure and melanoma risk 247
7
end of a pencil (about 6mm across). Melanomas are
usually more than 7mm in diameter.
• Evolution – the symmetry, border, colour, or diameter
of a mole has changed over time.
It is likely that patients will ask for advice and reassur-
ance on skin lesions which they are concerned could
be melanoma. It is essential that these people are given
information, ideally both orally and written, regarding
the changes that might subsequently suggest MM and
instructed to seek medical help as soon as they notice
changes.
NMSC
NMSC are the most common cancers in the UK. They are
associated with older people, with the average age of
diagnosis in the early 70s. The cancers are rarely fatal but
can cause substantial morbidity. Both cancers commonly
occur on skin surfaces that are exposed to a lifetime accu-
mulation of UV radiation such as the hands, face and scalp.
They are more common in people who have worked out-
doors, in fair skinned people and those living in tropical
and subtropical climates. BCC and SCC vary in their
appearance. SCC initially present as raised lesions that
exhibit a horny or scaly appearance that later become
non-healing lesions often larger than 1 cm which can
ulcerate; BCC starts as small translucent papule with
Fig. 7.31 Superficial spreading melanoma. Irregular in colour obvious telangiectasia over the surface. Over time (growth
and shape. Reproduced from J Wilkinson et al 2004, Dermatol- can be very slow) the size of the papule increases and can
ogy in Focus, Churchill Livingstone, with permission. ulcerate and crust over.
Conditions to eliminate
3. Oozing
4. Change in sensation (e.g. itch or irritation) Actinic keratoses
Any lesion should be suspected as MM with a score of Actinic keratoses is the most common pre-malignant skin
3 or more. condition and affects the same group of people as SCC,
with approximately 1 in 1000 cases progressing to SCC.
2. The ABCDE Rule Lesions occur on parts of the body that are exposed to
long-term sun exposure (e.g. head, forearms, hands). They
In this checklist 5 points are used: begin as small rough spots. Roughness is a key feature –
often referred to as feeling like rubbing sandpaper. They
• Asymmetry – Ordinary moles are usually symmetrical
are generally flat and brown and have well demarcated
in shape. Melanomas are likely to be irregular or
asymmetrical. edges. Over a period of years they enlarge and often
become red and scaly.
• Border – Moles usually have a well-defined regular
border. Melanomas are more likely to have an irregular
Seborrhoeic warts
border with jagged edges.
• Colour – Moles are usually a uniform brown. Melano- These are benign flat or raised lesions that vary in colour.
mas tend to have more than one colour. They may be Initially, they take on the colour of the person’s skin but
varying shades of brown mixed with black, red, pink, gradually darken. They range in colour from light brown
white or a bluish tint. to jet black (Fig. 7.20). They are more usual on the trunk
248 Dermatology
and increase in incidence from 40 years onwards. Over is a measure of the protection from UVB radiation. This is
time they can become wart-like and have a stuck on waxy calculated under experimental conditions using four times
appearance. Occasionally, they can become inflamed, itchy the amount of sunscreen usually applied by consumers. It
or bleed but this is normally because they have been is important that patients and consumers do not assume a
caught on clothing. linear increase in protection as the SPF increases. For
example, a sunscreen with an SPF of 15 blocks 93% of
Table 7.33
Practical prescribing: Summary of sun protection products
Name of Use in children Likely side effects Drug Patients in Pregnancy &
medicine interactions which care breastfeeding
of note exercised
Chemical Infant upwards but some Allergic reactions but may be None None OK
sunscreens manufacturers do have linked to the vehicle and
lower age limits not the active ingredients
Physical None, but may be cosmetically
sunscreens unacceptable
Sun exposure and melanoma risk 249
Water-resistant
sunscreens
These are claimed to be effective after immersion in water. However, studies have shown
that sunscreen effectiveness decreases after water exposure. It would be prudent therefore
7
to re-apply sunscreens after swimming
Eye protection Prolonged (over years) sun exposure can contribute to age-related macular degeneration.
Therefore wraparound sunglasses and lenses that effectively filter UV light should be worn
Treatment of sunburn? Mild sunburn can be managed with a combination of topical cooling preparations, such as
calamine, moisturisers and systemic analgesia
Medicine-induced Piroxicam, tetracyclines, chlorpromazine, phenothiazines and amiodarone can cause pruritus
photosensitivity and skin rash when the skin is exposed to natural sunlight, primarily due to UVA radiation.
Patients on photosensitive drugs should use a broad-spectrum sunscreen as these filter
both UVA and UVB radiation
Sun protection and In February 2012 the DoH issued guidance to healthcare professionals on the danger of
vitamin D deficiency vitamin D deficiency. This, in part, has been caused by the use of sunscreens. Guidance is
not to stop using sunscreen but certain patient groups should take supplements
http://www.dh.gov.uk/health/2012/02/vitamin-d/ (accessed 22 November 2012)
http://www.npa.co.uk/resources/information-leaflets-and-factsheets/clinical/preventing-
vitamin-d-deficiency-in-at-risk-groups/ (accessed 22 November 2012)
General sites
Web sites http://www.sunsmart.com.au/ (Sunsmart website)
Charities http://www.cancer.org.au/ (Cancer Council Australia)
http://www.skincancer.org/ (The Skin Cancer Foundation) http://www.melanoma.org/ (Melanoma Research Foundation)
http://www.cancerresearchuk.org/home/ (Cancer Research UK) http://www.melanoma.com/
250 Dermatology
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
knowledge to be applied to a practice setting.
7.1 Which medicine has not been proven to be efficacious 7.6. A corn is caused by?
in treating dandruff?
a. Sweating feet
a. Coal tar b. Excessive pressure caused by ill-fitting shoes
b. Cetrimide c. Too much pressure caused by anatomical deformity
c. Ketoconazole d. Human papilloma virus
d. Zinc pyrithione e. None of the above
e. Selenium sulphide
7.7. In which condition is itching the least prominent?
7.2. Which form of psoriasis can be managed OTC?
a. Allergic dermatitis
a. Guttate b. Scabies
b. Pustular c. Fungal infection
c. Plaque d. Psoriasis
d. Seborrhoeic e. Lichen planus
e. Erythrodermic
7.8. What skin condition is characterised by silvery-white
7.3. Which medicine is known to cause hair loss? scaly lesions of salmon-pink appearance with well
defined boundaries?
a. Nifedipine
b. Simvastatin a. Contact dermatitis
c. Ranitidine b. Rosacea
d. Ibuprofen c. Plaque psoriasis
e. Warfarin d. Seborrhoeic dermatitis
e. Pityriasis versicolor
7.4. What symptom is least associated with psoriasis?
Questions 7.9 to 7.11 concern the following conditions:
a. Itch
b. Redness A. Dermatitis
c. Scaling B. Plaque psoriasis
d. Papules C. Fungal infection
e. Raised plaques D. Acne
E. Cold sores
7.5. Which form of tinea infection are imidazoles
ineffective? Select, from A to E, which of the above conditions:
a. Athlete’s foot 7.9. Is characterised by itching and scaling
b. Jock itch
7.10. Often has prodromal symptoms prior to the rash
c. Infection involving the body
appearing
d. Infection involving the nail
e. Infection on the hand 7.11. Has a strong genetic link
Self-assessment questions 251
Questions 7.12 to 7.14 concern the following medicines Questions 7.18 to 7.20: these questions consist of a
7
for fungal infection: statement in the left-hand column followed by a
statement in the right-hand column. You need to:
A. Hydrocortisone
B. Clotrimazole • decide whether the first statement is true or false
C. Amorolfine • decide whether the second statement is true or false
D. Tolnaftate
E. Bifonazole Then choose:
A. If both statements are true and the second statement
Select, from A to E, which of the above medicines:
is a correct explanation of the first statement
7.12. Is applied once daily B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
7.13. Is applied once weekly
C. If the first statement is true but the second statement
7.14. Should be used for no longer than 1 week is false
D. If the first statement is false but the second statement
is true
Questions 7.15 to 7.17: for each of these questions one or
E. If both statements are false
more of the responses is (are) correct. Decide which of the
responses is (are) correct. Then choose:
Directions summarised
A. If a, b and c are correct
B. If a and b only are correct 1st 2nd
C. If b and c only are correct statement statement
D. If a only is correct A True True 2nd explanation is a
E. If c only is correct correct explanation of
the first
Directions summarised B True True 2nd statement is not
A B C D E a correct explanation
of the first
a, b and c a and b b and c a only c only
only only C True False
D False True
7.15. For the following statements about cradle cap which E False False
is/are true?
a. There is normally a family history First statement Second statement
b. Ear and eye involvement is common
7.18 Benzoyl peroxide should It should be used for at
c. The rash tends not to itch
be used to treat mild least 6 weeks
acne
7.16. Warts and verrucas are:
7.19 Scabies is intensely itchy The mite’s faeces cause a
a. Caused by the human papilloma virus hypersensitivity reaction
b. Infections that never affect adults
7.20 Minoxidil is used to treat It works on over 80% of
c. Can develop in to pre-cancerous growths if left patients
hair loss
untreated
Case study
Mr RJ and his 9-year-old son Jimmy want to buy d. Why might this be the case?
something for Jimmy’s verruca. Mr RJ thinks that
Salicylic acid is destructive in nature and if the
Jimmy has had the verruca for about 4 to 6 weeks.
product comes in to contact with non-affected skin
He describes it as a circular discoloured piece of skin then it can damage skin and appear to the patient
that looks like the verrucas he used to get. that the lesion has indeed got bigger.
a. What course of action are you going to take? Mrs J wants to try Bazuka Extra Strength since the
Try and directly question Jimmy. See if Jimmy knows normal Bazuka isn’t helping.
how long the suspected verruca has been there. Ask if e. What are you going to do?
the lesion is causing any pain when walking. Instead
of asking for further descriptions of what the lesion You must try to stress to Mrs J that she continues with
looks like and where it is positioned ask if you can the normal Bazuka because 6 weeks of therapy is not
actually look at the lesion. Remember to wash your long enough to make a decision to alter therapy.
hands before and after inspecting the foot.
Reluctantly, Mrs J accepts your advice and leaves the
On further questioning and examination you concur pharmacy promising she will try for a bit longer. One
with the self-diagnosis of a verruca. The lesion is small week later she presents a prescription for Cuplex gel
(less than 0.5 cm in diameter) and causes no pain for Jimmy.
when direct pressure is applied.
f. What are you going to do?
b. What are you going to recommend?
It appears that Mrs J was not satisfied or convinced
A salicylic-acid based product is the most suitable with your advice and has decided to see the GP. You do
product, and you recommend Bazuka after first not know whether Mrs J told the GP about using an
making sure Jimmy is not diabetic. OTC product. You could ring the GP to tell him or her
that Mrs J has been using a salicylic-acid-based
Six weeks later Mrs J returns with Jimmy and demands product already, however, this is likely to have little
to see the pharmacist. She says the stuff you bearing on the outcome of product selection as Jimmy
recommended is rubbish and Jimmy’s verruca is bigger will still need to continue treatment with something
than it was before! for a few more weeks. The prescription should be
c. How are you going to respond? dispensed and Mrs J counselled appropriately. It would
be unprofessional to point out that Cuplex is unlikely
First, you must stay calm and not be defensive. Ask to be any better than Bazuka.
open questions to find out why Mrs J is unhappy; this
approach will generally reveal what the problem is. When you hand Mrs J the Cuplex she mentions that
Second, if the reason is not obvious then you must find the doctor said this was stronger than Bazuka and
out about compliance. Who has been responsible for should do the trick.
applying the product? If the parents have told Jimmy g. How do you reply?
to use it, has he been using the product correctly and
at the correct dosage frequency? In addition, many Be diplomatic and non-judgemental. It is likely that
patients have unrealistic expectations on how quickly the GP knows that Cuplex is no better than Bazuka
the verruca will resolve with therapy. Did you tell them but if the parent is convinced that what she is now
how long it would take before an affect will be seen? getting is superior to the previous product then her
This is a vital piece of information to ensure patients motivation to comply with directions might be better
realise that treatment is not a quick cure. and hence the outcome for Jimmy will be eradication
of the verruca. It might be worth asking the GP, next
You find out that Mrs J has been applying the Bazuka time you have a conversation, what his or her
and doing everything the instruction leaflet says. You rationale for prescribing Cuplex was.
inspect Jimmy’s feet again and from what you can
remember the lesion does look slightly larger.
Case study 253
You decide the child has cradle cap. e. What treatment, if any, are you going to
recommend?
b. What treatment are you going to recommend?
No treatment necessary but if the parent insists on
The use of a mild tar-based product every other day therapy then any product could be given, although
until the scalp clears would be appropriate. In between antiviral therapy is expensive and the cost difficult to
using the tar-based product the mother should be justify. In addition, advice on minimising transmission
instructed to use the baby shampoo. could be given such as not sharing towels and trying
to avoid kissing (e.g. mum and dad).
Ms AH returns to the pharmacy 2 weeks later with
another of her children. Impressed that her son’s scalp
is now clear she now wants some advice for her
7-year-old daughter. She has a sore on the corner of
her mouth.
254 Dermatology
Other symptoms/ Felt a bit unwell, slight loss of Family history Not asked
provokes appetite & headache. On examination Clusters of papules & vesicles
Any itching or pain? Some pain – rated as 4 on unilaterally along dermatome
scale of 1-10 affecting left chest and back.
Additional questions
Diagnostic pointers with regard to
Previous history of None similar
symptom presentation
presenting complaint
For skin rash seen on the trunk in the area observed then
Past medical history Slight stroke 1 year ago.
herpes zoster seems likely. The expected findings for
Hypertension controlled with
questions when related to the possible conditions that
medication
could be confused with herpes zoster that are seen by
Eczema, Contact dermatitis,
urticaria to some plants community pharmacists are summarised below.
When this information is applied to that gained from our patient (below) we see that his symptoms fit with
herpes zoster.
Case study 255
When this information is applied to that gained from our patient (below) we see that his symptoms most closely
match scabies.
Case study 257
Answers
1 = b 2 = c 3 = e 4 = d 5 = d 6 = b 7 = d 8 = c 9 = c 10 = e
11 = b 12 = e 13 = c 14 = a 15 = c 16 = d 17 = a 18 = b 19 = a 20 = c
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Chapter 8
Musculoskeletal conditions
In this chapter
Background 259 Acute low back pain 260
General overview of musculoskeletal Activity-related/sports-related soft tissue
anatomy 259 injuries 271
History taking 259 Self-assessment questions 277
Aetiology
Fig. 8.1 The knee joint: medial view. In the majority of cases an exact cause cannot be deter-
mined for the patient’s symptoms and is often referred to
as simple, non-specific or uncomplicated low back pain.
to come into the pharmacy then the injury is unlikely to Pain originates from the lumbosacral region and is often
be serious. Information gathering should concentrate on mechanical in origin (Fig. 8.2) and includes problems
when the injury occurred, what precipitated the injury, the caused by muscles, tendons, ligaments and discs. Contribu-
level of discomfort, any restriction in range of motion and tory factors in the cause of low back pain are a general
whether the injury appears to be worsening, and finding lack of fitness, occupational (as above) and psychosocial,
out what expectations the patient has. for example anxiety and depression. Serious underlying
In general, any patient who presents with an injury that pathology is very rare with infection and malignancy
is causing extreme discomfort or the pain is worsening, accounting for less than 1% of cases.
adversely affects mobility and has been present for more
than a week would probably be better managed by a GP
or physiotherapist/sports therapist and referral should Arriving at a differential diagnosis
be made. The vast majority of patients (95%) who present in the
pharmacy will have simple back pain that will, in time,
resolve with conservative treatment. The remaining cases
Acute low back pain will have back pain with associated nerve root compres-
sion. It is extremely unlikely that a pharmacist will
encounter a patient with serious spinal pathology, such as
Background
infection or malignancy. However, pharmacists should be
Acute low back pain is self-limiting. Over 90% of patients mindful that age can affect the diagnosis. Table 8.1 high-
will get better within 6 weeks, although up to two-thirds lights those conditions that can be encountered by com-
of patients will have a recurrence within one year munity pharmacists and their relative incidence.
after initial onset but fewer than 5% of patients go on to Taking a thorough history is of key importance when
develop back pain classed as chronic (persists for more evaluating a patient with low back pain. Begin questioning
than 12 weeks). the patient with traditional questions regarding the pain:
Low back pain is extremely common. For example, location, radiation, evidence of trauma, the effect pain has
in the US it is the fifth common reason patients see a on mobility and factors which aggravate or relieve the
medical practitioner and in the UK 7–8% of all adult GP pain. Asking a number of symptom-specific questions will
consultations are for low back pain. In 2004–2005, 4.5 aid differential diagnosis (Table 8.2).
Acute low back pain 261
Table 8.1
8
Causes of back pain and their relative incidence in
community pharmacy
Incidence Cause
Cervical
Most likely Simple back pain (usually associated
with physical activity)
Likely Nerve root compression (e.g. sciatica),
pregnancy, (osteoarthritis)
Thoracic
Unlikely Osteomyelitis, ankylosing spondylitis
Very unlikely Malignancy
Lumbar
Lower
back pain Bad posture when seated and poor lifting technique
Sacral when performing day-to-day tasks, such as, cleaning or
gardening are very common predisposing factors.
Conditions to eliminate
Likely causes
Sciatica
Sciatica typically occurs in the healthy middle-aged adult.
Pain is acute in onset and radiates to the leg. Pain starts
in the lower back and as it intensifies radiates into the
lower extremity. Disc herniation usually involves those
between L4 and L5 and L5–S1 vertebrae (Fig. 8.2), although
most occur between L5 and S1. If disc herniation is minimal
pain is characterised by being dull, deep and aching. It is
usually felt in the upper part rather than the lower part of
the leg and spreads from the lumbar spine. If the disc
ruptures or herniates under strain then the pain is usually
lancinating in quality, shooting down the leg like an elec-
tric shock. Valsalva movements, for example coughing,
Fig. 8.2 Location and distribution of lower back pain: L4–L5, sneezing or straining at stool, often aggravate pain. Refer-
pain radiates down outer calf and onto the top of the foot; ral is needed for confirmation of the diagnosis. GPs can
L5–S1, pain radiates to the outside and sole of the foot. perform a straight-leg raising test whereby the pain of
sciatica can be induced by elevating the leg of the patient
when lying down. Prognosis is good, although improve-
ment and recovery is often slower than in low back
pain alone.
Clinical features of acute low back pain
Osteoarthritis
Pain in the lower lumbar or sacral area is usually described Patients in whom pain lasts longer than 12 weeks are said
as aching or stiffness. Depending on the cause, pain might to suffer from chronic back pain. In the context of low
be localised (e.g. lumbosacral strains following physical back pain pharmacists should only manage acute prob-
activity) or more diffuse (e.g. from postural backache after lems; however patients will present with chronic symptoms
sitting incorrectly for a prolonged period). In cases of acute and seek advice, especially on drug management. Degen-
injury the symptoms come on quickly and there will be a erative joint disease is the most common cause of chronic
reduction in mobility. low back pain in people older than fifty. It is associated
262 Musculoskeletal conditions
? Table 8.2
Specific questions to ask the patient: Back pain
Question Relevance
Age Age does influence the relative incidence of conditions seen in the population
Under 15: Although back pain is uncommonly reported in children, children do have higher
incidence of identifiable and potentially serious causes, for example spondylolysis,
malignancy and Scheuermann’s disease (although pain is experienced in upper back and
neck, rather than the lower back). Also recent studies have linked weight of school bags to
back pain. It would seem prudent to refer all children unless backache is associated with
recent participation in sport
15 to 30: prolapsed disc, trauma, fractures, pregnancy and ankylosing spondylitis most likely.
30 to 50: degenerative joint disease (osteoarthritis), prolapsed disc, and malignancy most likely.
Older than 50: the incidence of serious underlying disorders increases, such as osteoporosis,
malignancy and metabolic bone disorders (Paget’s disease)
Location Pain that radiates into the buttocks, thighs and legs implies nerve root compression. If pain is
felt below the knee, this is highly suggestive of sciatica
Onset Low back pain that is acute and sudden in onset is likely to be muscle strain in the
lumbosacral region and not serious. However, acute low back pain in the elderly should be
referred as even slight trauma can result in compression fractures
The patient will normally remember performing some recent exertion (playing sport, gardening
etc) or say the pain started when they bent forward
Low back pain that is insidious in onset should be viewed with caution
Restriction of movement People with disc herniation usually have difficulty in sitting down for long periods
Mechanical causes of pain is exacerbated with physical activity and relieved by rest
Systemic causes of back ache are usually worse with rest and disturb sleep
Weakness or numbness Progressive muscle weakness must be referred for further evaluation
of symptoms to improve over a 4-week period all warrant that prolonged bed rest is counter-productive (Dahm et al
8
referral. 2010). The review found two trials (n = 401) that showed
improvements in pain relief and functional status in
Causes of low back pain not related patients with acute lower back pain (LBP) that were
to back pathophysiology advised to stay active compared to bed rest. The authors
conclude:
It must be remembered that acute illness, for example colds
and influenza, can give rise to generalised aching or pain. Moderate quality evidence shows that patients with acute
Likewise, pre-rash pain associated with shingles and LBP may experience small benefits in pain relief and func-
referred pain from abdominal organs (e.g. pyelonephritis) tional improvement from advice to stay active compared to
can present as low back pain. A careful history of the advice to rest in bed.
presenting symptoms should enable exclusion of such
Exercise programmes can help with acute back pain and
conditions.
have been shown to reduce recurrence.
the relief of symptoms of low back pain. A Cochrane D-glucosamine is used in the manufacture of gly-
8
review (Gagnier et al, 2006) reviewed three active con cosaminoglycan, a precursor to cartilage tissue. Early
stituents; Harpagophytum procumbens (Devil’s Claw), reviews of glucosamine reported favourable decreases in
Salix alba (white willow bark), and Capsicum frutescens pain and increase in joint function. However, a review by
(cayenne). Devil’s Claw (standardised daily dose of 50 mg Towheed and others (2005) including 20 studies with 2570
or 100 mg harpagoside) reduced pain more than placebo patients with osteoarthritis found mixed results. When
and a standardised daily dose of 60 mg was equally effec- studies of sound methodological quality were used the
tive as 12.5 mg of rofecoxib (Vioxx, now withdrawn from review failed to find any difference between glucosamine
the market). Similarly, Willow Bark (standardised daily and placebo with regards to pain and changes in the
dose of 120 mg and 240 mg of salicin) was also more Western Ontario and McMaster Osteoarthritis Index
effective than placebo and 240 mg of salicin was as effec- (WOMAC) function score. However, when all 20 trials were
tive as 12.5 mg of Vioxx. Cayenne (as a plaster) reduced included in the review, they found significant improve-
pain more than placebo. It therefore appears that these ments in pain and in functionality as measured by the
products can be used as viable alternatives to conventional Lequesne index. It still remains uncertain whether the two
medicine. salts of glucosamine available, sulphate and hydrochloride,
are equally active. Also studies so far have been relatively
Acupuncture short (2 to 3 months) and any long-term benefits are still
The available evidence for acupuncture in acute low back uncertain.
pain does not support its use, although if used in chronic
back pain acupuncture is more effective for pain relief than Chondroitin
no treatment in the short term. Early research into the benefit of chondroitin in reducing
pain and improving functionality in people with osteoar-
Massage therapy thritis showed chondroitin to be beneficial. Recent research
Thirteen RCTs (n = 1596) were identified for the review, of that involved larger trials, have shown no significant
which only five were considered of reasonable quality. benefit. Patients should be advised that if they use chon-
Overall, the review concluded that massage might be ben- droitin then benefits are likely to be modest at best and if
eficial in non-specific back pain, especially when com- they want to use a natural product that glucosamine would
bined with exercise and education. Acupuncture massage be a better choice.
(applying pressure, tension or motion to specific points on
the body) may be better than traditional massage. However, Summary
more evidence is required to confirm this. Based on evidence, patients with acute low back pain
should be encouraged to keep active and be given either
Superficial heat and cold paracetamol or a 7 day course of a systemic NSAID unless
Applying heat or cold to superficial musculoskeletal inju- contraindicated. Topical NSAIDs could also be recom-
ries such as non-specific back pain is a popular lay recom- mended for those patients in whom side effects need to be
mendation. These range from hot water bottles, heat pads minimised, for example elderly patients or patients who
and infrared lamps to ice packs. The Cochrane review have experienced gastrointestinal (GI) side effects with
identified nine trials that met their inclusion criteria (six previous NSAID use. The only complementary therapy that
trials involved heat and three trials cold therapy). The appears to have credible evidence are herbal remedies and
authors concluded that many of the studies were of poor their use might be justified.
methodological quality but evidence exists that continuous Compound analgesics should be avoided, although
heat wrap therapy reduces pain and disability in the short- patients might perceive they are getting a stronger pain
term to a small extent. No conclusions could be drawn on killer and the placebo response of such medicines should
cold therapy due to the limited nature of the three trials not be underestimated.
reviewed.
Practical prescribing and product selection
Glucosamine
Although glucosamine is not used for acute low back pain Prescribing information relating to systemic analgesics
it is widely advertised to the general public as a treatment reviewed in the section ‘Evidence base for over-the-
for osteoarthritis. Glucosamine is naturally found in the counter medication’ is discussed and systemic proprietary
body, especially in cartilage, tendons and ligaments and products summarised in Table 8.3; useful tips relating
must be synthesised by the body because significant to systemic analgesics are given in Hints and Tips
amounts are not found in the diet. Its active form, Box 8.1.
266 Musculoskeletal conditions
Table 8.3
Systemic proprietary analgesics available OTC (excludes paediatric formulations and products for period pain)
Product Aspirin Paracetamol Ibuprofen Codeine Other Children
Alka-Seltzer Original 324 mg >16 years
Alka-Seltzer XS 267 mg 133 mg Caffeine 40 mg >16 years
Anadin Extra Tabs; Sol. Tabs. 300 mg 200 mg Caffeine 45 mg >16 years
Anadin Ibuprofen; Anadin Joint 200 mg >12 years
Pain; Anadin Liquifast 200 mg
Caps; Anadin Liquifast Eff. Tabs.
Anadin Liquifast 400 mg Caps. 400 mg >12 years
Anadin Paracetamol 500 mg >6 years
Anadin Original 325 mg Caffeine 15 mg >16 years
Askit Powders 530 mg Aloxiprin 140 mg >16 years
Caffeine 110 mg
Aspro Clear 300 mg >16 years
Aspro Clear Maximum Strength 500 mg >16 years
Care ibuprofen tablets 200 mg >12 years
Care Extra Strength Ibuprofen Tabs. 400 mg >12 years
400 mg
Codis 500 500 mg 8 mg >16 years
Cuprofen 200 mg >12 years
Cuprofen Maximum Strength 400 mg >12 years
Cuprofen Plus 200 mg 12.8 mg >12 years
Disprin & Disprin Direct 300 mg >16 years
Disprin Extra 300 mg 200 mg >16 years
Double Action Pain Relief 12.5 mg Diclofenac K >14 years
Tablets 12.5 mg
Feminax Express (ibuprofen lysine 200 mg >12 years
342 mg)
Galprofen Ibuprofen long lasting 200 mg >12 years
capsules
Feminax 500 mg 8 mg >12 years
Hedex 500 mg >6 years
Hedex Extra 500 mg Caffeine 65 mg >12 years
Hedex Ibuprofen 200 mg >12 years
Ibufem 200 mg >12 years
Mandafen 400 mg >12 years
Acute low back pain 267
Children and aspirin Aspirin-taking in children has been linked to Reyes syndrome; a rare syndrome
in which encephalopathy occurs and if not diagnosed early can lead to death
Caffeine containing analgesics These might have a mild stimulant effect and should therefore be avoided before
going to bed
although most patients will need the higher dose of 400 mg Muscle Rub). They have no drug interactions and side
8
three times a day. The dose of diclofenac is 25 mg (two effects are localised to excessive irritation at the site of
tablets), and then one or two tablets every 4 to 6 hours as application. The majority of products contain two or more
needed, with a maximum of 6 tablets per day. Naproxen, compounds, although most contain nicotinates and/or sali-
is currently only licensed for period pain (see page 119 for cylates. Other compounds in rubefacients include: menthol,
more information). camphor, capsaicin and turpentine oil. They can be used
NSAIDs are best avoided in certain patient groups, such in all patient groups.
as the elderly, because they are more prone to GI bleeds
and have reduced renal function, patients with a history References
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CD007612.pub2.
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Topical NSAIDs
DOI: 10.1002/14651858.CD001351.pub2
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Reviews 2006, Issue 2. Art. No.: CD004504. DOI:
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Topical NSAIDs come in a range of formulations, acute and chronic pain in adults. Cochrane Database of
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market leader, although other NSAIDs are available and DOI: 10.1002/14651858.CD007403.pub2.
Roelofs PDDM, Deyo RA, Koes BW, et al. Non-steroidal
include, piroxicam, diclofenac, ketoprofen, felbinac, sali-
anti-inflammatory drugs for low back pain. Cochrane
cylic acid and benzydamine. Table 8.4 highlights all Database of Systematic Reviews 2008, Issue 1. Art. No.:
commercially available NSAIDs and summarises their pre- CD000396. DOI: 10.1002/14651858.CD000396.pub3.
scribing information. Towheed T, Maxwell L, Anastassiades TP, et al. Glucosamine
therapy for treating osteoarthritis. Cochrane Database of
Rubefacients (e.g. Deep Heat, Radain B and Systematic Reviews 2005, Issue 2. Art. No.: CD002946.
Ralgex ranges) DOI: 10.1002/14651858.CD002946.pub2.
Table 8.4
Proprietary topical NSAID analgesics available OTC
Product Formulation Strength Dosage Children
Ibuprofen
Care Gel 5 & 10% qds >14 years
Cuprofen Gel 5% tds–qds >12 years
Deep Relief Gel 5% tds >12 years
Fenbid Gel 5% Up to qds >14 years
Fenbid Forte Gel 10% Up to qds >14 years
Ibugel Gel 5% No dose stated >12 years
Ibuleve Gel 5% tds–qds >12 years
Ibuleve Maximum Strength Gel 10% tds >12 years
Ibumousse mousse
Ibuleve Speed Relief Gel 5 & 10% tds >12 years
Ibuleve Speed Relief Spray 5% tds >12 years
Ibuspray Spray 5% No dose stated >12 years
Mentholatum Gel 5% tds >14 years
Nurofen Back Pain Gel 5% qds >14 years
Phorpain & Phorpain Forte Gel 5% & 10% No dose stated >12 years
Proflex Cream 5% tds–qds >12 years
Radian B ibuprofen Gel 5% qds >14 years
Other NSAIDs
Difflam (benzydamine) Cream 3% tds but max of No lower age
six times limit stated
Movelat (mucopolysaccharide polysulpahate & Cream and Gel 0.2% & 2.0% qds >12 years
salicylic acid)
Oruvail (Ketoprofen) Gel 2.5% tds >12 years
Traxam Pain Relief (Felbinac) Gel 3% bd–qds >12 years
Voltarol Emulgel P & Voltarol Pain-Eze Emulgel Gel 1.16% tds–qds >14 years
(Diclofenac)
Henschke N, Maher CG, Refshauge KM. Screening for Maniadakis A, Gray A. The economic burden of back pain in
malignancy in low back pain patients: a systematic review. the UK. Pain 2000;84:95–103.
Eur Spine J 2007;16(10):1673–9. Reichenbach S, Sterchi R, Scherer M, et al. Chondroitin for
Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment osteoarthritis of the knee or hip. Ann Intern Med
of low back pain. Br Med J 2006;332:1430–4. 2007;146:580–90.
Activity-related/sports-related soft tissue injuries 271
8
BMJ article on sciatica (June 2007): http://www.bmj.com/cgi/ Patients will often state they have sprained or strained
content/extract/334/7607/1313
something. It is important to confirm their self-diagnosis
European guidelines on the prevention and treatment of low
as these terms are often used interchangeably. Although
back pain: www.backpaineurope.org
BackCare: the charity for healthier backs: http:// sprains and strains can be graded according to the severity
www.backcare.org.uk/ of the injury, it is of little practical value because it has
The National Ankylosing Spondylitis Society: http:// no therapeutic consequence; therefore the major role of
www.nass.co.uk/ the pharmacist is to determine if the patient can manage
the injury or whether referral is needed. This will be pri-
marily based on questions asked (Table 8.5) that can be
supported with the aid of a basic physical examination.
Shoulder-specific conditions
Background
The shoulder provides the greatest range of motion of any
Muscle, tendons, ligaments, fascia and synovial capsules joint. It is a very mobile and complex interconnected
are all soft tissue structures. Damage to any of these struc- structure (Fig. 8.3), consequently there are a number of
tures will result in pain and/or inflammation. The pharma- commonly encountered shoulder injuries, such as frozen
cist will encounter patients with soft tissue injuries, shoulder, impingement syndromes and rotator cuff syn-
although the majority of patients present to a GP, physi- drome. The prevalence of shoulder-related problems is
otherapist or casualty department. In a number of small uncertain, although estimates range from 4 to 20%, with
studies, most respondents did not consider the pharmacist rotator cuff syndrome accounting for up to 70% of shoul-
as a source of advice or help, although the minority who der problems.
had consulted a pharmacist were satisfied with the advice
received. This suggests that pharmacists could play a
greater role in managing patients with activity/sport
related problems.
Clavicle
? Table 8.5
Specific questions to ask the patient: Soft tissue injuries
Question Relevance
When did it happen and The closer these two events are the more likely the patient will be suffering from a serious
when did the patient problem that is outside the remit of the pharmacist, unless the injury was sustained in
present close proximity to the pharmacy and the patient has asked for first aid
Presenting symptoms Marked swelling, bruising and pain occurring straight after injury is suggestive of more
serious injury and referral to casualty for X-rays and further tests is needed
Nature of injury If the injury occurred in which impact forces were great then fracture becomes more likely
Sudden onset, associated with a single traumatic event suggests a mechanical problem such
as tendon/ligament tearing
If the person has a foot injury and is unable to bear their full weight whilst walking then
referral is needed
Range of motion If the affected joint shows marked reduction in normal range of motion this requires referral
for fuller evaluation
Nature of pain Referred pain suggests nerve root compression, for example a shoulder injury in which pain is
also felt in the hand
Pain that is insidious in onset and progressive is more likely to be due to some form of
degenerative disease and requires referral
Age of patient Children: Bones are softer in children and therefore more prone to greenstick fractures
(fracture of the outer part of the bone) and should be referred to exclude such problems
Elderly: Risk factors for fracture, such as osteoarthritis and osteoporosis should be established
Within the confines of the community pharmacy, the explanation and can vary in severity from day-to-day.
patient can be asked to perform certain arm movements NSAIDs could be offered but if symptoms fail to respond
that will allow the range of motion of the shoulder to be with treatment after 5 days then referral for alternative
determined (Fig. 8.4). Patients who show marked loss of treatment and physiotherapy should be considered.
motion should be referred.
Elbow-specific conditions
Rotator cuff syndrome
In primary care, pharmacists are only likely to see three
The rotator cuff refers to the combined tendons of the
elbow problems; tennis elbow (lateral epicondylitis);
scapula muscles that hold the head of the humerus in
golfer’s elbow (medial epicondylitis) and student’s elbow
place. Rubbing of these tendons causes pain. It is most
(bursitis).
often seen in patients over the age of 40 and is associated
Tennis elbow is characterised by pain and tenderness
with repetitive overhead activity. Pain tends to be worse
felt over outer aspect of the elbow joint that might also
at night and might disturb sleep. Reaching behind the back
spread up the upper arm. The patient should have a
also tends to worsen pain. Also, the patient cannot nor-
history of gradually increasing pain and tenderness. If
mally initiate abduction.
the patient tries to extend the wrist against resistance
then pain increases. In comparison, the pain of golfer’s
Frozen shoulder elbow is noticed on the inner side of the elbow and can
This term is used to describe the shoulder when it has radiate down the forearm. Both names are misleading
marked restriction in all the major ranges of motion. It is as these conditions are usually related to a repetitive
a relatively uncommon cause of shoulder pain accounting activity, which will often not be associated with
for 2% of cases. It often occurs without warning or sports activity.
Activity-related/sports-related soft tissue injuries 273
(b)
(a)
(c)
Fig. 8.4 Determining the shoulders range of motion: (a) ask the patient to raise the arm as if going to ask a question at school;
(b) ask the patient to touch the back of the neck with both hands; (c) ask the patient to touch the back of the scapulae with
both hands.
Knee-specific conditions anterior cruciate ligament, which prevents the tibia from
sliding forward on the femur (Fig. 8.5).
The knee is the largest joint in the body and is subject
to extreme forces. Unsurprisingly, it is one of the most Ligament damage
common sites of sport injuries, especially amongst foot- This is most often seen in footballers. Find out from the
ballers. To help maintain stability the knee has three main patient how the injury occurred. If the injury occurred
pairs of ligaments: the medial collateral ligament, which when twisting this implies damage to the medial meniscus
connects the femur to the tibia; the lateral collateral liga- (incomplete rings of cartilage that promote joint stability)
ment, which connects the femur to the fibula and the as the medial collateral ligament is attached to the
274 Musculoskeletal conditions
Common muscle strains Approximately 80% of cases affect the big toe. Gout is
8
more prevalent in men, especially over the age of 50.
Thigh strains
Tears of the quadriceps (front of the thigh) and hamstring Carpal tunnel syndrome
(back of the thigh) are very common. Patients will not At the base of the palm is a ‘tunnel’ through which the
always be able to recall a specific event that has caused median nerve passes; this narrow passage between the
the strain. Pain and discomfort is worsened when the forearm and hand is called the carpal tunnel. If the median
patient tries to use the muscle but daily activities can nerve becomes trapped, it can cause numbness and tin-
usually be performed. RICE followed by NSAID treatment gling in the hand. Often the patient will wake in the night
will usually resolve the problem, however, referral is with numbness and tingling pain that radiates to the
needed if daily activities are compromised. forearm, which sometimes extends to the shoulder.
!
Patients should be encouraged to properly stretch prior
to exercising to minimise the problem. No treatment is TRIGGER POINTS indicative of referral:
necessary. Soft tissue injury
Shin splint syndrome • Acute injuries which show immediate swelling and
severe pain
Recreational runners and people unaccustomed to regular • Children under 12 and elderly patients
running can experience pain along the front of the lower • Decreased range of motion in all direction involving
third of the tibia. Pressing gently on this area will cause the shoulder
considerable pain. It is caused by over stretching the tibial • Excessive range of movement in any joint (may
muscle and is usually precipitated by running on hard suggest major ligament disruption)
surfaces. Pain is made worse by continued running or • Patients unable to bear any weight on an injured
climbing stairs. Treatment involves running less frequently ankle/foot
or for shorter distances and NSAID therapy for approxi- • Suspected fracture
mately 1 week. • Treatment failure
Bursitis
Evidence base for over-the-counter medication
Bursae can become inflamed that leads to accumulation of and practical prescribing and product selection
synovial fluid in the joint. Housemaid’s knee and student’s
elbow are such examples. Clinically, joint swelling is Prescribing information relating to medication for soft
the predominant feature with associated pain and local tissue injuries is the same as acute low back pain. (see
tenderness. page 265). However, non-drug treatment plays a vital and
major role in the treatment of soft tissue injuries. Standard
Stress fractures advice follows the acronym RICE:
Most commonly associated with the foot. Patients experi- Rest Rest allows immobilisation, enhancing
ence a dull ache along the affected metatarsal shaft that healing and reducing blood flow
changes to a sharp ache behind the metatarsal head. It is Ice Ice should be applied whilst the injury
often seen in those patients that have a history of increased feels warm to the touch. Apply until the
activity or a change in footwear. skin becomes numb and repeat at hourly
intervals. Bags of frozen peas wrapped
Gout
in a towel are ideal to use on the injury
Acute attacks of gout are exquisitely painful, with patients as they conform to body shape and
reporting that even bedclothes cannot be tolerated. provide even distribution of cold
276 Musculoskeletal conditions
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
8
knowledge to be applied to a practice setting.
8.1 Which of the following is not used in topical 8.6 A strain is said to affect which structure?
formulations for musculoskeletal disorders?
a. Tendon
a. Nicotinates b. Ligament
b. Hyaluronidase c. Bursa
c. Choline d. Muscle
d. Menthol e. Cartilage
e. Capsaicin
8.7 From the following list, what common name is given
8.2 Which of the following statements is true of to inflammation of the bursa?
osteoarthritis?
a. Golfer’s elbow
a. Morning stiffness usually lasts less than 30 minutes b. Student’s elbow
b. Pain is eased by movement c. Tennis elbow
c. Pain is usually worst in the morning d. Repetitive strain injury
d. Osteoarthritis commonly affects small joints e. Shin splints
e. Inflammation is a key pathological finding
8.8 In which of the following conditions does pain often
8.3 Which patient group is least at risk of experiencing an wake the patient?
adverse event with ibuprofen when taking it for an
a. Rotator cuff syndrome
ankle sprain?
b. Frozen shoulder
a. Elderly c. Hamstring strain
b. Asthmatics d. Plantar fasciitis
c. Children under 16 e. Housemaid’s knee
d. Patients with a peptic ulcer
Questions 8.9 to 8.11 concern the following groups of
8.4 Vertebrae involved in sciatica are: people:
a. L1–L2 A. Runners/Joggers
b. L2–L3 B. Footballers
c. L3–L4 C. Squash players
d. L4–L5 D. Occasional gardeners
e. None of the above E. Swimmers
8.5 Which ligament is most often damaged in a sprained Select, from A to E, which of the above groups of people
ankle? are more prone to:
a. Cruciate ligament 8.9 Anterior cruciate ligament damage
b. Deltoid ligament
8.10 Plantar fasciitis
c. Medial collateral ligament
d. Posterior talofibular ligament 8.11 Tennis elbow
e. Anterior talofibular ligament
278 Musculoskeletal conditions
Questions 8.12 to 8.14 concern the following OTC Questions 8.18 to 8.20: these questions consist of
medications: a statement in the left-hand column followed by a
statement in the right-hand column. You need to:
A. Ibugel
B. Codis tablets • decide whether the first statement is true or false
C. Panadol tablets • decide whether the second statement is true or false
D. Radian B cream
E. Voltarol Emulgel Then choose:
A. If both statements are true and the second statement
Select, from A to E, which of the above medicines:
is a correct explanation of the first statement
8.12 Can only be given to children older than 16 B. If both statements are true but the second statement
is NOT a correct explanation of the first statement
8.13 Has no evidence of efficacy
C. If the first statement is true but the second statement
8.14 May cause constipation is false
D. If the first statement is false but the second statement
is true
Questions 8.15 to 8.17: for each of these questions one or
E. If both statements are false
more of the responses is (are) correct. Decide which of the
responses is (are) correct. Then choose:
Directions summarised
A. If a, b and c are correct
B. If a and b only are correct 1st 2nd
C. If b and c only are correct statement statement
D. If a only is correct A True True 2nd explanation is a
E. If c only is correct correct explanation of
the first
Directions summarised B True True 2nd statement is not a
A B C D E correct explanation of
the first
a, b and c a and b b and c a only c only
only only C True False
D False True
8.15 Which of the following measures should be E False False
recommended to a patient who has just suffered an
acute soft tissue injury?
First statement Second statement
a. Heat and massage of the affected area
8.18 Carpal tunnel syndrome Medial nerve impingement
b. Elevation of the affected area
causes hand numbness results in symptoms
c. Compression of the affected area by means of an
elastic bandage or support 8.19 Low back pain with Malignancy is the likely
associated fever should cause
8.16 Acute low back pain is characterised by: be referred
8.20 NSAIDs are the mainstay They should be used for
a. Insidious onset and progressively worsening pain
of systemic treatment 7–10 days. If symptoms
b. Radiating pain toward the thoracic vertebrae for soft tissue injuries do not improve referral is
c. Decreased mobility needed
Case study
CASE STUDY 8.1
8
Mrs BB, a 69-year old women, hobbles into your • Paracetamol and/or codeine: Cannot be bought as a
pharmacy, supported by her husband. She has just single agent. Combinations with aspirin need to be
slipped off the pavement edge and believes she has avoided. Paracetamol and codeine combinations
sprained her ankle. could be offered but the codeine content is likely to
cause constipation, which Mrs BB is already treated
a. To ascertain if referral is necessary, describe the for. Therefore codeine is likely to worsen her already
questions you would ask Mrs BB? existing constipation. Finally, OTC analgesic
combinations have been shown not to significantly
Find out exact nature of pain and its location. It is reduce pain compared to monotherapy. This leaves
likely that the anterior talofibular ligament has been paracetamol as the medicine of choice for Mrs BB.
damaged. Symptoms that would warrant referral are
severe pain in any bone prominence, if Mrs BB is Mrs BB asks if she should also use a topical
unable to walk unsupported for at least four steps and preparation on her ankle.
marked swelling and bruising occurred straight after
the fall. Mrs BB should be told to go to casualty if c. Describe the range of topical preparations available
these symptoms are present. to treat soft tissue injuries and which would be
suitable to recommend to Mrs BB, giving the
You decide that Mrs BB has indeed sprained her ankle reasons for your decision(s).
but referral is unnecessary. Mrs BB asks to purchase
some OTC analgesia to alleviate her pain. Her regular Rubefacients contain essential oils, salicylates,
medication is as follows: nicotinates, capsicum, camphor, terpentine and
menthol. They provide warmth to the injury site,
• Bendroflumethiazide 2.5 mg od: Used to treat except menthol and camphor which are cooling.
hypertension. Taken for 5 years Evidence is lacking with regard to their efficacy
• Fybogel sachets, 1 bd: taken for 4 years for in decreasing pain but they help in masking pain
constipation symptoms. These could be recommended to Mrs BB.
• Lansoprazole 15 mg od: maintenance therapy in
treatment of gastro-oesophageal reflux disease Ideally recommend a product with no salicylate
(GORD) associated with hiatus hernia. present as there is a low risk of systemic absorption
and gastric irritation.
b. Which OTC systemic analgesics would be most
suitable for Mrs BB. Explain how you arrived at Topical NSAIDs: relatively low doses reach the
your choice and why you eliminated others. bloodstream and there is therefore less risk of GI
problems than with systemic NSAIDs. Use of topical
• Aspirin: can cause GI disturbance; Mrs BB has NSAIDs are unlikely to cause side effects if used for
GORD, therefore, contraindicated. short periods of time (5 to 10 days) and could be given
• Ibuprofen: NSAIDs can cause fluid retention and to Mrs BB even though she has GORD. However, she
Mrs BB has hypertension. However, this is unlikely should be told that if she experiences any indigestion-
to be clinically significant, especially if only NSAIDs type symptoms to stop using the product.
are recommended for only a few days. Like aspirin,
ibuprofen can cause GI disturbances.
280 Musculoskeletal conditions
When this information is applied to that gained from are very suggestive of this condition despite their being
our patient (below) we see that his symptoms most no obvious cause.
closely match sciatica. Acute onset and radiation
Case study 281
Answers
1 = c 2 =a 3 = c 4 = d 5 = e 6 = d 7 = b 8 = a 9 = b 10 = a
11 = c 12 = b 13 = d 14 = b 15 = c 16 = e 17 = e 18 = a 19 = c 20 = b
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Chapter 9
Paediatrics
In this chapter
Background 283 Atopic dermatitis 291
History taking 283 Fever 296
Head lice 283 Infectious childhood conditions 300
Threadworm (Enterobius vermicularis) 287 Nappy rash 302
Colic 289 Self-assessment questions 306
transferred between heads. Once transmitted lice begin to Clinical features of head lice
reproduce. The adult louse lives for approximately 1
month. Throughout this time the female louse lays several Unless live lice have been found, most patients will present
eggs at the base of a hair shaft each night. Eggs hatch after with scalp itching. Itching is caused due an allergic
7 to 10 days, leaving the egg case attached to the hair shaft response of the scalp to the saliva of the lice and can take
(known as a ‘nit’). In the course of maturing to adulthood weeks to develop. However, only a third of patients experi-
the young louse (the nymph) undergoes three moults. ence itching. Head lice are most commonly found in the
Shortly after maturing, the female louse is sexually mature occipital and auricular areas.
and able to mate.
Conditions to eliminate
Arriving at a differential diagnosis
Dandruff
Most parents will diagnose head lice themselves or be
Dandruff can cause irritation and itching of the scalp.
concerned that their child has head lice because of a recent
However, the scalp should be dry and flaky. Skin debris
local outbreak at school. Occasionally parents will also
might also be present on clothing.
want to buy products to prevent their child contracting
head lice. It is the role of the pharmacist to confirm a self-
Seborrhoeic dermatitis
diagnosis and stop inappropriate sales of products. It
should also be remembered that an itching scalp in chil- Typically, seborrhoeic dermatitis will affect areas other
dren is not always due to head lice and other causes should than the scalp, most notably the face. If only scalp involve-
be eliminated. Asking a number of symptom-specific ques- ment is present then the child might complain of severe
tions should enable a diagnosis of head lice to be easily and persistent dandruff. In infants the child will have large
made (Table 9.1). yellow scales and crusts of the scalp (cradle cap).
? Table 9.1
Specific questions to ask the patient: Head lice
Question Relevance
Have live lice The presence of live lice is diagnostic
been seen Pharmacists can advise patients on how best to check for infection. Currently, both wet and dry combing
are advocated
Dry combing
Straighten and untangle the dry hair using an ordinary comb
Once the hair moves freely, switch to a detection comb. Starting from the back of the head, comb the
from the scalp down to the end of the hair
After each stroke examine the comb for live lice
Continue to comb all the hair in sections until the whole head has been combed
This process can take 5 or more minutes in people with shoulder length hair
Wet combing
Wash the hair with a normal shampoo
Apply hair conditioner
Repeat steps 1 to 4 as for dry combing
Rinse out the conditioner
Wet combing is more time consuming than dry methods and both should be performed on all family members
Empty egg This does not constitute evidence of current infection. This is a common misconception held by the
shells (nits) general public and the pharmacist must ensure that parents seeking treatment have observed live lice
Egg shells are not removed by using insecticides. Patients need to be reassured that the presence of egg
shells does not mean treatment failure
Presence of Itching is not always present in head lice. Inspection of the scalp should be made to check for signs of
itching dandruff, psoriasis or seborrhoeic dermatitis
Head lice 285
!
for 8 hours or overnight was compared to 0.5% malathion
TRIGGER POINTS indicative of referral: Head lice
9
liquid applied for 12 hours or overnight. The results found
dimeticone was significantly more effective than malathion,
• Parents who find cost of treatment prohibitive
with 30/43 (70%) participants cured using dimeticone com-
pared with 10/30 (33%) using malathion.
Isopropyl myristate is a recent introduction to the UK
Evidence base for over-the-counter medication
market. Like dimeticone it is pharmacologically inert but
Treatment options include insecticides, wet combing and works by blocking the tracheal breathing system and
physical agents. All treatments available in the UK have coating the surface of lice with a thin film of fluid (Drugs
shown varying degrees of clinical effectiveness. It is and Therapeutics Bulletin 2009). Evidence of efficacy
however difficult to assess which treatment is most effec- comes from 2 trials that compared isopropyl myristate
tive as very few comparative trials have been performed, against permethrin. Results found isopropyl myristate was
and insecticidal resistance varies from region to region. No significantly more effective than permethrin (82% vs 19%).
treatment is 100% effective and failure has been linked Although these results seem impressive, the comparator
with poor adherence to each treatment regimen. Of the drug was permethrin – a product not recommended due to
treatment approaches, insecticides have been most studied. its poor efficacy.
These include malathion, permethrin, carbaryl and phe- Other non-insecticidal methods of eradication are also
nothrin – the latter two are now not commercially avail- promoted. These include herbal remedies such as tea tree
able. Cure rates of 70 to 80% are reported with insecticides oil or essential oils (e.g. Lyclear SprayAway), coconut oil
in recent clinical trials, although resistance to insecticides (Lice Attack, Nitlotion) and electric combs. No credible
is now a serious problem and appears to be increasing. evidence exists on the effectiveness of these products and
Wet combing is an alternative treatment option, however, should not be recommended until such time that data sup-
cure rates are reported to be only 40 to 60% with the low ports their use.
cure rates attributed to poor adherence (Roberts et al 2000; In summary, treatment used will be driven by individual
Hill et al 2005). preference, the patient’s medical history and previous
Dimeticone is a recent introduction to the market, and exposure to treatment regimens. Wet combing (available
is thought to work by coating the lice both internally and as bug busting kits) is time consuming and requires patient
externally, which leads to disruption in water excretion motivation but is helpful in areas of high insecticidal
causing the gut of the lice to rupture from osmotic stress resistance. Insecticides, dimeticone and isopropyl myristate
(Burgess 2009). Its inclusion in treatment options seems to are simpler to use than bug-busting kits and appear to
stem from 1 robust trial conducted by Burgess et al (2005). have higher cure rates. Based on current evidence it seems
Dimeticone was compared against phenothrin with cure dimeticone is treatment of choice.
rates determined at days 9 and 14. Dimeticone was shown
to have comparable cure rates to phenothrin (69% com- Practical prescribing and product selection
pared to 78%). The study has been criticised for using dry
detection methods and using different detection days (days Prescribing information relating to medicines for head lice
5 and 12 as recommended by the department of health), reviewed in the section ‘Evidence base for over-the-
however a further trial in 2007 supports the 2005 trial counter medication’ is discussed and summarised in Table
results. In the latter study, 4% dimeticone lotion, applied 9.2; useful tips relating to patients presenting with head
Table 9.2
Practical prescribing: Summary of head lice medicines
Name of medicine Use in Likely side effects Drug interactions Patients in which Pregnancy &
children of note care exercised breastfeeding
Permethrin >6 months Irritation of scalp (rare) None None OK
Malathion
Dimeticone
Isopropyl myristate >2 years None reported OK
286 Paediatrics
Who to treat? Only those individuals with an active head lice infestation should be treated
Products for prevention No credible evidence exists for any product marketed for prevention. The patient/parent
should be counselled on when treatment is required
Treatment failure? It is recommended that detection combing is performed after any treatment to confirm
headlice eradication
For wet combing
Wet combing should continued if necessary until no full-grown lice have been seen for 3
consecutive sessions
For insecticides, dimeticone and Isopropyl myristate
Perform detection combing (wet or dry) 2–3 days after completing treatment. If no adult
or nymph lice are found, repeat detection combing 8–10 days after treatment. Treatment
is successful if no lice are found in both detection combing sessions after treatment
Myths Public misconception about head lice need to be dispelled
Head lice are not only associated with dirty hair
Head lice do not only affect children
Children should not be kept off school
lice are given in Hints and Tips Box 9.1. All products have Dimeticone 4% Lotion (Hedrin)
to be used more than once; insecticides have to be repeated
7 days after first application (this is based on expert Hedrin is applied to dry hair and the scalp ensuring that
opinion, as the second application is intended to kill the scalp is fully covered. The lotion should be spread
nymphs emerging from eggs that have survived the first evenly from the hair root to the tips. It has to be left on
application); wet combing every 4 days for at least 2 for a minimum of 8 hours (over night is preferable) before
weeks. Coating agents, dimeticone and isopropyl myristate being washed out with shampoo. (Note, a product contain-
also have to be repeated after 7 days. ing 92% dimeticone, NYDA spray, is available.)
All products, except isopropyl myristate, can be used
on children older than 6 months. Dimeticone or wet Isopropyl myristate in cyclomethicone
combing is recommended for pregnant and breastfeeding (Full Marks Solution)
women. When applying all products, pay particular atten- This is applied in the same manner as dimeticone but the
tion to the areas behind the ears and at the nape of the contact time is only 10 minutes. It is only recommended
neck, as these areas are where lice are most often found. for adults and children over the age of 2 years.
9
2000;356:540–4.
Eggs are transmitted to the human host primarily by the
Further reading faecal–oral route (autoinfection) but also by retroinfection
Anon. Management of headlice in primary care. MeReC and inhalation. Faecal–oral transmission involves eggs
Bulletin 2008;18 (4):2–7. lodging under fingernails, which are then ingested by
Burgess IF, Brown CM, Peock S, et al. Head lice resistant to finger sucking after anal contact. Retroinfection occurs
pyrethroid insecticides in Britain. Br Med J 1995;311:752. when larvae hatch on the anal mucosa and migrate back
Burgess IF, Lee PN, Matlock G. Randomised, controlled, into the sigmoid colon. Finally, threadworm eggs are
assessor blind trial Comparing 4% dimeticone lotion with highly resistant to environmental factors and can easily be
0.5% malathion liquid for head louse infestation. PLoS ONE transferred to clothing, bed linen and inanimate objects
2007;2(11):e1127. doi:10.1371/journal.pone.0001127 (e.g. toys) resulting in dust-borne infections. Once eggs are
Connolly M. Current recommended treatments for headlice
ingested, duodenal fluid breaks them down and releases
and scabies. The Prescriber 2011;Jan:26–39.
larvae, which migrate into the small and large intestines.
Dodd CS. Interventions for treating headlice. Cochrane
Database of Systematic Reviews 2006, Issue 4 (Status After mating, the female migrates to the anus, usually at
withdrawn Issue 2, 2012, pending update). night, where eggs are laid on the perianal skin folds, after
which the female dies. Once laid, eggs are infective almost
Web sites immediately. Transmission back into the gut can then take
Community Hygiene Concern: http://www.chc.org/bugbusting/ place again via one of three mechanisms outlined above
Pediculosis.com: http://www.pediculosis.com/ and so the cycle is perpetuated.
Once a week – take a peek: http://
www.onceaweektakeapeek.com/
Contact irritant dermatitis The difference in cure rates might be, in part, due to
their respective mechanism of action. Mebendazole inhibits
Occasionally, dermatitis can cause perianal itching (espe- the worm’s uptake of glucose, thus killing them, whereas
cially in adults). If there is no recent family history of piperazine only paralyses the worm (if paralysis wears off
threadworm or there is no visible sign of threadworm on then the worm might be able to migrate back into the colon
the faeces then dermatitis is possible. and thus treatment would fail). To optimise worm clear-
ance from the gut piperazine formulations also contain
senna.
! TRIGGER POINTS indicative of referral: Threadworm
Practical prescribing and product selection
• Medication failure
• Secondary infection of perianal skin due to Prescribing information relating to medicines for thread-
scratching worm reviewed in the section ‘Evidence base for over-the-
counter medication’ is discussed and summarised in Table
9.3; useful tips relating to patients presenting with thread-
worm are given in Hints and Tips Box 9.2.
Evidence base for over-the-counter medication
Treatment should ideally be given to all family members
Mebendazole and piperazine are available OTC for the and not only the patient with symptoms, as it is likely that
treatment of threadworm. There is a large body of evidence other family members will have been infected even though
to support the effectiveness of mebendazole in round- they might not show signs of clinical infection. A repeated
worm infections but for other worm infections, includ- dose 14 days later is often recommended to ensure worms
ing threadworm, cure rates are lower. For threadworm, maturing from ova at the time of the first dose are also
cure rates between 60 and 82% for single-dose treat- eradicated.
ment of mebendazole have been reported (Rafi et al 1997; Mebendazole and piperazine should be avoided in preg-
Sorensen et al 1996). nancy because foetal malformations have been reported
Piperazine appears to have less evidence supporting its but appear safe in breastfeeding. Pregnant women should
effectiveness than mebendazole. One study has compared be advised to practise hygiene measures for 6 weeks to
piperazine against mebendazole and found mebendazole break the cycle of infestation. If treatment is absolutely
to have a higher cure rate than piperazine; although the essential, piperazine has been used, although this should
number of patients in the trial was low. not be in the first trimester.
Table 9.3
Practical prescribing: Summary of medicines for threadworm
Name of Use in Likely side effects Drug interactions Patients in which Pregnancy &
medicine children of note care exercised breastfeeding
Mebendazole >2 years Abdominal pain, rash Phenytoin and None Avoid in pregnancy;
carbamazepine OK in breastfeeding
Piperazine >3 months Diarrhoea, rash None
Hygiene measures Complementary to drug treatment is the need for strict personal hygiene
Nails should be kept short and clean. Careful washing and nail scrubbing prior to meals and
after each visit to the toilet is essential to prevent autoinfection
Bed linen should be washed frequently, ideally every day although this might not be practical
Underwear should be worn underneath night clothes to prevent scratching
Shower daily, immediately on rising, washing around the anus
Damp dusting and daily vacuuming are recommended to remove eggs
Colic 289
Mebendazole (e.g. Ovex, Pripsen Mebendazole) (1954) and has come to be known as the ‘rule of threes’.
9
Wessel proposed that an infant could be considered to have
The dose for adults and children over 2 is 100 mg (either colic if it cries for more than 3 hours a day for more than
a single tablet or 5 mL of suspension). Young children 3 days a week for more than 3 weeks. However, the defini-
might prefer to chew the tablet and it has been formulated tion by Wessel is arbitrary and few parents are willing to
to taste of orange. Side effects reported include abdominal wait 3 weeks to see if the infant meets the criteria for colic.
pain, diarrhoea and rash but are very rare. It does interact As a result the third criterion is usually dropped in the
with cimetidine, increasing mebendazole plasma levels but clinical setting. In addition, some authors have defined
this is of little clinical consequence. However, phenytoin crying for as little as 90 minutes per day as excessive.
and carbamazepine decrease mebendazole plasma levels Regardless of which definition is used, persistent crying is
and the dose of mebendazole may need to be increased. a cause of stress and anxiety to parents.
? Table 9.4
Specific questions to ask the patient: Colic ! TRIGGER POINTS indicative of referral: Colic
Table 9.5
9
Practical prescribing: Summary of medicines for colic
Name of medicine Use in children Likely side effects Drug interactions Patients in which Pregnancy &
of note care exercised breastfeeding
Simeticone Infant upwards None None None Not applicable
Lactase
Review feeding technique Before recommending a product it is worth checking feeding technique. Underfeeding
the baby can result in excessive sucking resulting in air being swallowed leading to
colic-like symptoms. Additionally the teat size of the bottle should be checked.
When the bottle is turned upside down the milk should drop slowly from the bottle
? Table 9.6
9
Specific questions to ask the patient: Atopic dermatitis
Question Relevance
Is itching present Atopic dermatitis is classically associated with intense itching
Psoriasis and seborrhoeic dermatitis are not usually associated with itching
Distribution of rash Varies according to age (Fig. 9.1) but in infants the nappy area is not involved and is a useful
distinction between atopic dermatitis and seborrhoeic dermatitis
Age of child Presentation varies with age
Babies: facial involvement (the cheeks) is common along with patchy red scaly lesions on the
wrists and hands (Fig. 9.2)
Toddlers and older children: the antecubital (in front or at the bend of the elbow), popliteal
fossae (behind the knee), and ankles are more commonly involved (Fig. 9.3)
Family history of atopy If a parent has eczema, hay fever or asthma then the likelihood of atopic dermatitis rises
Psoriasis
Psoriasis can be mistaken for atopic dermatitis, because
the rash is erythematous and can occur on parts of the
body such as the scalp, elbows and knees, which is a
common location for atopic dermatitis in older children.
However, the rash is raised, has well defined boundaries
Fig. 9.3 Atopic dermatitis in the popliteal fossa (bend of
with a silvery-white scaly appearance that are typically
knee). Reproduced from DJ Gawkrodger, 2007, Dermatology:
symmetrical. Itch, if present, is mild (Fig. 7.3).
An Illustrated Colour Text, 4th edition, Churchill Livingstone,
with permission.
Contact dermatitis
tried some form of cream to help control the itch and rash.
Scratching can lead to broken skin, which can become Seen as a red itchy skin rash seen at any site related to
infected. There is a tendency to a dry sensitive skin even exposure border (Fig. 7.27).
in those who have ‘grown out’ of the disease.
Once a diagnosis has been established and before
treatment is considered it is important to make an assess- Fungal infection
ment on the severity and social impact of the condition The rash is pink or red, itchy, slightly raised annular patch
(Table 9.7). with a well defined inflamed border (Fig. 7.14). It can occur
on all body surfaces.
Conditions to eliminate
Seborrhoeic dermatitis Herpes simplex complications
Seborrhoeic dermatitis in infants typically occurs in the Children with atopic dermatitis are at risk of developing
first 6 months. Itching is generally not present and the more extensive and serious herpes simplex infection.
294 Paediatrics
Table 9.7
Severity and social impact of atopic dermatitis
Severity* Psychological impact*
Clear: normal skin, no evidence of active eczema. None: no impact on quality of life.
Mild: areas of dry skin, infrequent itching (with or without Mild: little impact on everyday activities, sleep, and
small areas of redness). psychosocial well-being.
Moderate: areas of dry skin, frequent itching, redness (with or Moderate: moderate impact on everyday activities and
without excoriation and localised skin thickening). psychosocial well-being, and frequently disturbed sleep.
Severe: widespread areas of dry skin, incessant itching, redness Severe: severe limitation of everyday activities and
(with or without excoriation, extensive skin thickening, psychosocial functioning, and loss of sleep every night.
bleeding, oozing, cracking, and alteration of pigmentation).
!
Despite a lack of high quality randomised controlled trials,
TRIGGER POINTS indicative of referral: emollients are well established as first line treatment for
Atopic dermatitis atopic dermatitis. In addition, no trials appear to have
addressed whether one emollient is superior to another.
• Children with moderate or severe atopic dermatitis
Patients might have to try several emollients before finding
• Medication failure – patient suffers two or more
one that is most effective for their skin.
flare-ups per month
• Presence of secondary infection (weeping and
crusting lesions) Antihistamines
There appears to be no clinical trial data on the use of
sedative antihistamine for reducing pruritus in atopic der-
matitis; however, they are often prescribed to children to
Evidence base for over-the-counter medication help with itching. The American Academy of Dermatology
guidelines on the treatment of atopic dermatitis report
The mainstay of treatment for atopic dermatitis consists of
there is little evidence for the use of antihistamines;
avoiding potential irritants, managing dry skin, controlling
however, they suggest that sedating antihistamines may be
itching and using topical corticosteroids to treat flare ups.
useful where there is significant sleep disruption due to
Unfortunately, the latter option is not available to children
itching (Hanifin et al 2004).
under the age of 10 due to OTC license restrictions.
Corticosteroids
Avoiding irritants
A substantial body of evidence exists for corticosteroids in
Where practical, factors that worsen dermatitis should be
controlling all types of dermatitis, including atopic derma-
avoided. The use of highly perfumed soaps and detergents
titis. If the symptoms warrant corticosteroid therapy then
should be discouraged and replaced with soap substitutes
the patient needs to be referred to the GP. Usually mild
(e.g. Alpha Keri, Neutrogena, Dove). Patients should be told
steroids such as hydrocortisone (1 to 2.5%), preferably in
to have lukewarm not hot baths, because in some patients
an ointment base should be prescribed twice daily.
hot water can aggravate the problem. In addition a bath
additive should be used (e.g. Balneum, Oilatum, Emulsi-
derm) to help hydration of the skin. Practical prescribing and product selection
Prescribing information relating to medicines for atopic
Emollients
dermatitis reviewed in the section ‘Evidence base for over-
It is believed emollients add moisture to the skin and repair the-counter medication’ is discussed and summarised in
the lipid barrier function whilst also helping to prevent Table 9.8; useful information regarding emollients con-
penetration by irritants and decrease the need for steroids. taining lanolin is given in Hints and Tips Box 9.4.
Atopic dermatitis 295
Table 9.8
9
Practical prescribing: Summary of medicines for atopic dermatitis
Name of medicine Use in Likely side Drug interactions of note Patients in which Pregnancy &
children effects care exercised breastfeeding
Emollients Birth onwards None None None Not
Applicable
Sedating antihistamines
Chlorphenamine >1 year Sedation Increased sedation with None Not
opioid analgesics, Applicable
Clemastine >1 year anxiolytics, hypnotics and
Cyproheptadine >2 years antidepressants. However,
it is unlikely a child will be
Promethazine >2 years taking such medicines
General self-help If possible avoid scratching. Keep nails short and rub with fingers to alleviate itch to minimise
skin trauma
Lanolin containing Emollients that contain lanolin (e.g. Keri Lotion and E45) should be avoided as they are
emollients known to cause sensitisation
Applying emollients They are best applied when the skin is moist, for example during bath times
Bath additives will make the bath slippery so care should be taken when getting the child out
Apply as frequently as possible
The more oily the emollient the more effective they tend to be
Aetiology
Reference
Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for Body temperature is regulated closely because temperature
atopic dermatitis, developed in accordance with the changes can significantly alter cellular functions and, in
American Academy of Dermatology (AAD)/American
extreme cases, lead to death. Thermoregulation is a balance
Academy of Dermatology Association ‘Administrative
between heat production and heat loss. Cellular metabo-
Regulations for Evidence-Based Clinical Practice Guidelines’.
J Am Acad Dermatol 2004;50(3):391–404. lism produces heat and this means that energy – in the
form of heat – is produced continually by the body. This
Further reading heat production is lost through the skin by radiation,
Brown S, Reynolds NJ. Atopic and non-atopic eczema. Br Med evaporation, conduction and convection. The thermoregu-
J 2006;332:584–8. lation centre located in the hypothalamus controls the
Clark C, Hoare C. Making the most of emollients. Pharm J whole process. When body temperature reaches its ‘set
2001;266:227–9. point’ (approximately 37°C) mechanisms to lose or con-
CG57 Atopic eczema in children: NICE guideline 2007. http:// serve heat are activated. When a person suffers from a
www.nice.org.uk/nicemedia/live/11901/38597/38597.pdf fever this suggests that there is some defect in the tem-
NICE Atopic dermatitis (eczema) – topical steroids (TA81)
perature regulating control system. In fact the system is
August 2004. Frequency of application of topical
functioning normally but with an adjusted higher ‘set
corticosteroids for eczema. http://www.nice.org.uk/
guidance/TA81/?c=91528 point’. This process is complex but involves the production
of pyrogens (fever-causing substances) that alter the set
Web sites point.
National Eczema Society: http://www.eczema.org/
General dermatology site: http://www.dermatologist.co.uk/
index.html
Arriving at a differential diagnosis
The parent, in nearly every instance, will diagnose fever
in the child. This is usually a subjective perception by the
parent that the child feels warm or is off colour. The
importance of the parent’s perception should not be under-
Fever estimated or dismissed if the child’s temperature has not
been taken. Many healthcare professionals often place too
Background
much value on an empirical figure when in many instances
Fever is simply a rise in body temperature above normal. the look of the child is more important than the height of
Normal oral temperature is 37°C (98.6°F), plus or minus the fever. Asking a number of symptom specific questions
1°C, although rectal temperature is about 0.5°C higher and should enable the pharmacist to treat or refer the child
under arm temperature 0.5°C lower than oral temperature. with fever (Table 9.9).
During the course of 24 hours minor fluctuations in tem- NICE in the UK recommend using a ‘traffic light’ system
perature are observed. Fever is often classified as being to assess the risk of serious disease (Table 9.10). In a phar-
either mild (low-grade) (up to 39°C) or high (above 39°C). macy setting any child that show symptoms or signs of
In a practice setting, for those aged under 5 years of intermediate (amber) or high (red) risk should be referred
age, the best temperature to take is under the arm using to the GP
an electronic or chemical dot thermometer. Infrared tym-
panic thermometers are also advocated (NICE guidance No. Clinical features of fever
47, May 2007) but a systematic review by Dodd et al (2006)
questioned their reliability. Forehead strip thermometers A child with fever will generally be irritable, off his or her
are popular because they are easy to use, but should not food and seek greater parental attention. Other signs that
be used as they are unreliable. might be seen include facial flushing and shivering.
Fever 297
? Table 9.9
9
Specific questions to ask the patient: Fever
Question Relevance
How old is the child? Children under 3 months should be referred automatically because diagnosis can be very
difficult and serious complications can arise
How poorly is the child? The parent will know how poorly the child is relative to normal behaviour. A child might have a
high temperature but appear relatively normal whereas a child with a mild temperature might
be quite poorly
Associated symptoms Viral upper respiratory tract infections are usually accompanied with one or more symptoms
including cough, cold or sore throat
Glandular fever is usually accompanied with fatigue and lymph node enlargement. (usually
teenagers)
If no other symptoms are present it suggests a bacterial infection, often a urinary tract infection
Table 9.10
Assessment of the seriousness of fever in children under 5 years of age
Green–low risk Amber–intermediate risk Red–high risk
Colour Normal colour of skin, lips and Pallor reported by parent/carer Pale/mottled/ashen/blue
tongue
Activity Responds normally to social cues Not responding normally to social cues No response to social clues
Content/smiles Wakes only with prolonged stimulation Appears ill to the pharmacist
Stays awake or awakens quickly Decreased activity Unable to rouse or if roused
Strong normal cry/not crying No smile does not stay awake
Weak, high-pitched or
continuous cry
Respiratory Nasal flaring Grunting
6–12 months, RR >50 breaths/minute RR >60 breaths/minute
>12 months, RR 40 breaths/minute
Hydration Normal skin and eyes Dry mucous membrane Reduced skin turgor
Moist mucous membranes Poor feeding in infants
CRT ≥3 seconds
Reduced urine output
Other NONE of the amber or red signs Fever ≥5 days 0–3 months ≥38°C
or symptoms Swelling of a limb/joint 3–6 months ≥39°C
Non-blanching rash
Neck stiffness
Bulging fontanelle
Seizures
Table 9.11
9
Practical prescribing: Summary of medicines for fever
Name of Use in children Likely side Drug interactions Patients in which Pregnancy &
medicine effects of note care exercised breastfeeding
Paracetamol >3 months None None None Not Applicable
Note: Paracetamol from
Ibuprofen GI disturbances Children with known
2 months for post-
hypersensitivity to
immunisation pyrexia
NSAIDs
RNA virus and spread by droplet inhalation. It is the most are red and inflamed (like the person has been slapped).
dangerous of childhood diseases because of the complica- Itch is often present and the rash can spread to the arms
tions that can occur. Approximately 7% of patients develop and legs.
respiratory complications such as otitis media and pneu-
monia but encephalitis is seen in about one in every 600 Glandular fever (infectious mononucleosis)
to 1000 cases of measles.
Measles has an incubation period of between 7 to 14 Glandular fever is caused by the Epstein–Barr virus and is
days, which is then followed by 3 or 4 days of prodromal most commonly seen in patients aged between 15 and 24.
symptoms where the child will have a fever, head cold, In Western countries it is rare in children under 5 and less
cough and conjunctivitis. On the inner cheek and gums frequent in those aged between 5 and 14.
small white spots are visible, like grains of salt and are It is transmitted from close salivary contact and is also
known as Koplik’s spots; these are diagnostic for measles. known as the kissing disease and has an incubation period
A blotchy red rash appears around the ears before moving of 4 to 7 weeks. Symptoms are vague but characterised by
on to the trunk and limbs. Immediate referral to the GP is fatigue, headache, sore throat and swollen and tender
needed. lymph glands. A macular rash can also occur in a small
proportion of patients. The symptoms tend to be mild but
German measles (rubella) can linger for many months.
Rubella is caused by an RNA virus and spread by either To aid the differential diagnosis of childhood conditions
close personal contact or airborne droplets. It is less con- see Table 9.13.
tagious than measles and if contracted many people suffer
from mild symptoms and the infection passes undiagnosed. Web Sites
After the incubation period of 14 to 21 days the child Charities: www.meningitis.org and www.meningitis-trust.org
experiences up to 5 days of prodromal symptoms, which
include cold-like symptoms and swollen glands in the neck
before a rash appears on the face that quickly moves on Nappy rash
to the trunk and extremities. The rash tends to be pinpoint
and macular. The biggest threat posed by rubella is to Background
women in early pregnancy, as foetal damage is possible.
Napkin rash (also known as nappy dermatitis or diaper
rash) is a non-specific term used to describe inflammatory
Mumps
eruptions in the napkin area.
Mumps is caused by a paramyxovirus and is transmitted
by airborne droplets from the nose and throat. It is the Prevalence and epidemiology
least contagious of the childhood diseases and requires
close personal contact before infection can occur. There is The incidence and prevalence of napkin rash is difficult to
an incubation period of 16 to 21 days followed by fever; determine because of variability between studies. Napkin
this is followed by swelling of one or both parotid glands rash is most commonly seen between 6 and 12 months of
and the child will experience pain when the mouth is age and in one UK study 25% of infants aged under 1
opened. month had an episode of nappy rash.
Mumps is much more unpleasant if contracted as an
adult and in 20 to 30% of men the disease affects the Aetiology
testicles, with a serious infection possibly causing sterility.
The most serious complication from mumps is meningitis Nappy rash is caused by a number of contributory factors.
(seen in approximately 10% of people). Friction and maceration of the skin are key to its cause.
This is compounded by excessive heat and moisture com-
bined with the effect of faecal and urinary enzymes when
Erythema infectiosum
in prolonged contact with the skin (faeces breakdown
Erythema infectiosum is also called ‘slapped cheek disease’ produces ammonia, and is considered a contributory cause,
or ‘fifth disease’. It is caused by parvovirus B19 and pre- as ammonia is only irritant when in contact with damaged
dominantly affects children between the ages of 3 and 15. skin). Greater exposure of skin surfaces to moisture impairs
Cold-like symptoms appear a couple of days before the the skin’s barrier function and makes the skin more sus-
rash appears. Typically the rash appears on the cheeks that ceptible to secondary infection.
Table 9.13
Differential diagnosis of childhood conditions
Measles German Meningitis Glandular Chicken pox Molluscum Mumps Impetigo Erythema
measles fever contagiosum infectiosum
Prodromal stage
Fever Yes No Yes Yes Yes, in older No Yes No No
individuals
Swollen No Yes No Yes No No Yes No No
glands
Cold-like Yes Yes No No No No No No Yes
symptoms
Other signs Koplik’s spots Malaise Lethargy, stiff Malaise & Malaise & None None None No
neck, headache headache
vomiting,
photophobia
Rash
Location Ears & face Face moving Trunk and Trunk On trunk Face and Not Facial area Face before
progressing quickly to limbs & face, axillae Applicable especially moving to
to trunk & trunk rarely on around nose arms and
limbs extremities & mouth legs
Character Maculopapular Macules, Purplish Maculopapular Lesions Pink Vesicles that ’Slapped’ skin
often blotches. Do About 10% discrete pearl-like exude
pinpoint by not blanch have rash and appear spots with forming
2nd day in crops central yellow
punctum* crusts
Epidemiology
Age group Children & Children 90% before 15 to 24 year Very common Young Children School Children &
most adolescents under 12 age of 5 old most at in children children under aged children adolescents
affected risk 12
*Diagnostic.
9
Nappy rash 303
304 Paediatrics
Table 9.14
Differences in symptom presentation between the four causes of nappy rash
Irritant Candidal Seborrhoeic Psoriasiform
Arriving at a differential diagnosis from the napkin area is common and affects the limbs,
face and scalp. A small proportion, approximately 10%,
The diagnosis is straight forward although identifying the of infants go on to develop psoriasis.
cause is slightly more difficult. There are four forms of
nappy rash, with irritant nappy rash being the most
common. Table 9.14 highlights the key differences in
symptom presentation between the four forms.
! TRIGGER POINTS indicative of referral: Nappy rash
Preventative measures Leave the nappy off for as long as possible each day
Avoiding using soaps for cleaning
9
Washed nappies should be thoroughly rinsed to ensure that they do not contain residues of
soap and detergent
Change nappies as soon as they have been soiled
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
knowledge to be applied to a practice setting.
9.1 The common name of nits refers to: 9.6 What are the usual age children present with atopic
dermatitis?
a. An adult head louse
b. An immature head louse a. In the first month of life
c. Live eggs b. Before 6 months
d. Egg cases c. Before 1 year
e. None of the above d. Before 2 years
e. Before 5 years
9.2 Which antihistamine has a license for pruritus?
9.7 Mebendazole can be given to patients from what age?
a. Chlorphenamine
b. Clemastine a. 1
c. Cyproheptadine b. 2
d. Hydroxyzine c. 3
e. Azatadine d. 4
e. 5
9.3 A high grade fever is defined as a temperature above?
9.8 How many days after initial treatment should a
a. 37°C
second application of insecticide be used to eradicate
b. 37.5°C
head lice?
c. 38.5°C
d. 39.5°C a. 3
e. 40°C b. 5
c. 7
9.4 Which infection is most likely to present with fever as d. 10
the major symptom in children? e. 14
a. Upper respiratory tract infection
Questions 9.9 to 9.11 concern the following conditions:
b. Lower respiratory tract infection
c. Urinary tract infection A. Chicken pox
d. Skin infection B. Measles
e. None of the above C. German measles
D. Glandular fever
9.5 Fever in children with no associated symptoms or signs E. Impetigo
is usually due to:
Select, from A to E, which of the above conditions:
a. Gastroenteritis
b. Urinary tract infection 9.9 Is often caused by Staphylococcus
c. Upper respiratory tract infection
9.10 Is characterised by a vesicular rash
d. Bacterial tonsillitis
e. Impetigo 9.11 Is transmitted by close salivary contact
Self-assessment questions 307
Questions 9.12 to 9.14 concern the following medicines: Questions 9.18 to 9.20: these questions consist of a
9
statement in the left-hand column followed by a
A. Piperazine
statement in the right-hand column. You need to:
B. Mebendazole
C. Permethrin • decide whether the first statement is true or false
D. Dimeticone • decide whether the second statement is true or false.
E. Chlorphenamine
Then choose:
Select, from A to E, which of the above medicines:
A. If both statements are true and the second statement
9.12 Is associated with sedation is a correct explanation of the first statement
B. If both statements are true but the second statement
9.13 Is contraindicated in all trimesters of pregnancy
is NOT a correct explanation of the first statement
9.14 Can cause abdominal pain C. If the first statement is true but the second statement
is false
D. If the first statement is false but the second statement
Questions 9.15 to 9.17: for each of these questions one or
is true
more of the responses is (are) correct. Decide which of the
E. If both statements are false
responses is (are) correct. Then choose:
A. If a, b and c are correct Directions summarised
B. If a and b only are correct
C. If b and c only are correct 1st 2nd
D. If a only is correct statement statement
E. If c only is correct A True True 2nd explanation is a
correct explanation of
Directions summarised the first
Case study
CASE STUDY 9.1
Ms JP, a young mother of two children comes into high cure rates seen with dimeticone it would seem
the pharmacy one afternoon clutching a letter from reasonable to use this as treatment of choice.
the children’s primary school. The letter says that
there is a head lice outbreak and instructs parents Ms JP says she has heard that you can use
to treat their children for head lice. conditioner and that will get rid of the problem.
You need to find out if her children actually have head Ms JP is probably referring to the ‘bug busting’
lice or she is trying to buy a product to stop them technique. She should be told that the effectiveness of
getting head lice. She should be told that products bug busting is lower than using dimeticone or
cannot be bought to prevent her children contracting insecticides but can be tried. You should stress that it
head lice and she should inspect their heads regularly, is very important to adhere to the regimen, as poor
and only when live lice are found should a product be compliance with the bug busting method is probably
bought. Ms JP should be told how to inspect her why it has been shown to be less effective.
children’s hair for signs of head lice.
Ms JP returns to the pharmacy 4 days later and Ms JP then asks you whether her older daughter,
says her youngest daughter does now have head Samantha, should also be treated even though she
lice. She is 5 and suffers from no medical has not got head lice.
problems.
d. What do you say?
b. What product are you going to recommend?
Only those with a live lice infestation should be
Insecticides or a physical agent would be acceptable treated. Ms JP should be asked to keep checking
treatment options. Due to insecticidal resistance and Samantha’s hair on a regular basis.
Case study 309
All Mr PB is able to tell you is that his grandson has It appears that his grandson is not poorly and unless
been with him for the last day and he only noticed the he deteriorates there is probably no need to call out
rash this morning when he was dressing him. He is 4 the GP. You could recommend an antihistamine to help
years old and the rash is on his chest and back; Mr PB with the itching and reassure him that his grandson
describes them as spots. He thinks it is probably itchy will be OK, but if he becomes poorly the GP should be
because he saw his grandson scratching this morning. called out. You also tell him that the rash fits the
description of chicken pox but without seeing the rash
b. What do you think could be the problem? you cannot be sure. It would therefore be useful if you
could see the child or if the child could be seen by
Without seeing the child and the rash it is always someone over the next couple of days to confirm your
difficult to make a differential diagnosis from suspicions.
310 Paediatrics
When this information is applied to that gained from asked about regurgitation could be asked and also the
our patient (below) we see that everything points to a duration of crying.
diagnosis of colic. To further eliminate GORD, questions
Colic ✓ ✓ ✓ ✓
Infection ✗ ✓ ✗ ✓?
GORD ✓ ✓ ✓ ✗
Intolerance to cows’ milk protein ✓ ✗ ✓ ✗
Reassure the parent that symptoms are transient. worth starting with a dimeticone or Colief for 1 week. If
Although something has already been tried it is probably that fails to help then referral to the GP is appropriate.
Answers
1 = d 2 = d 3 = e 4 = c 5 = b 6 = b 7 = b 8 = c 9 = e 10 = a
11 = d 12 = e 13 = b 14 = b 15 = d 16 = a 17 = d 18 = b 19 = d 20 = b
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Chapter 10
Specific product requests
In this chapter
Background 313 Coronary heart disease 328
Motion sickness 313 Weight loss 330
Emergency hormonal contraception 316 Benign prostatic hyperplasia (symptoms of) 331
Nicotine replacement therapy 318 Chlamydia treatment 333
Malaria prophylaxis 322 Future deregulations 334
Bites and stings 325 Self-assessment questions 335
Table 10.1
Practical prescribing: Summary of medicines for travel sickness
Name of Use in Likely side Drug interactions of Patients in which Pregnancy &
medicine children effects note care exercised breastfeeding
Cyclizine >6 years Dry mouth, Increased sedation Angle-closure Standard references state
(Valoid) sedation with alcohol, glaucoma, OK, although some
opioid analgesics, prostate manufacturers advise
Cinnarizine >5 years analgesics, enlargement avoidance
(Stugeron 15) anxiolytics, hypnotics
Meclozine >2 years and antidepressants
(Sea-Legs)
Promethazine >5 years
(Avomine)
Hyoscine
Joy-Rides >3 years Dry mouth, Increased Angle-closure Avoid if possible in
sedation anticholinergic side glaucoma, pregnancy.
Kwells >10 years effects with TCAs prostate In breastfeeding, may cause
Kwells Kids >4 years and neuroleptics enlargement drowsiness, which would
lead to poor feeding in
long-term use but OK for
short journeys
identified four exploratory studies of ginger in the preven- Table 10.1. They are most effective when given prior to
tion of motion sickness. The results of these studies sug- exposure and products should be selected based on match-
gested ginger was better than placebo, and similar in ing the length of the journey with the duration of action
efficacy to other pharmacological agents. However, the of each medicine (see Hints and Tips Box 10.1).
studies were often in small numbers of patients, and of
uncertain quality; the authors of the review concluded that Antihistamines
further studies are required to confirm the effectiveness of
ginger for motion sickness. Antihistamines used in products for motion sickness are
Non-pharmacological approaches to the prevention of first generation H1 antagonists and are associated with
motion sickness using acupressure are also available OTC. sedation. They therefore have the same side effects, inter-
Bruce et al (1990) investigated the use of Sea Band acu- actions and precautions in use as other first generation
pressure bands versus hyoscine and placebo. Eighteen antihistamines used in cough and cold remedies. For
healthy volunteers were subjected to simulated conditions further information see page 8.
to induce motion sickness. The findings showed that whilst
hyoscine exerted a preventative effect, Sea Bands were no Cyclizine (Valoid)
more effective than placebo. Further trials have confirmed Cyclizine is prescribed very rarely. It is subject to abuse by
these findings, although 1 small trial by Stern et al (2001) drug misusers and many pharmacies do not stock it. If
reported positive findings. However, accurate placement of taken, adults and children over 12 should take one tablet
the Sea Band seems to be important, and further trials are (50 mg) three times a day. The dose for children over the
needed as acupressure has shown positive effects for age of 6 is half the adult dose.
nausea and vomiting associated with pregnancy.
Cinnarizine (Stugeron 15)
Practical prescribing and product selection
Adults and children over 12 should take two tablets 2 hours
Prescribing information relating to medicines for motion before travel. The dose can be repeated every 8 hours (1
sickness reviewed in the section ‘Evidence base for over- tablet) if needed. For children aged between 5 and 12 the
the-counter medication’ is discussed and summarised in dose is half the adult dose.
Motion sickness 315
Table 10.2
10
Practical prescribing: Summary of medicines for EHC
Name of Use in Likely side Drug interactions Patients in which care Pregnancy &
medicine children effects of note exercised breastfeeding
Levonelle® >16 years Nausea, headache, Anticonvulsants, Conditions in which Pregnancy – not
One-Step disturbed rifampicin, Levonelle® absorption applicable
menstrual cycle griseofulvin St. John’s may be impaired, for Breastfeeding –
Wort and ciclosporin example Crohn’s disease safe to use
• Is the patient already pregnant? Details about the advised to abstain or use additional contraception such as
patient’s last period should be sought. Is the period late, condoms for the next 2 days (48 hours after the pill has
and if so how many days late? Was the nature of the been taken). Emergency contraception may be indicated if
period different or unusual. If pregnancy is suspected a unprotected sex occurs during this 48-hour period.
pregnancy test could be offered. A number of useful checklists have been produced and
• What method of contraception is normally used? are used in practice. Many pharmacists ask patients to
Patients who take combined oral contraceptives might complete one of these forms, instead of asking potentially
not need EHC. Guidelines from the Faculty of Sexual embarrassing questions in the pharmacy. Once the details
and Reproductive Healthcare (2011) state: of the form are completed, the pharmacist can decide
whether EHC can be supplied to the patient.
For one missed pill (a missed pill is defined as one that is
more than 24 hours late)
Levonelle® One Step
No additional or emergency contraception is usually
necessary. The patient should take the missed pill and Levonelle® should be taken as soon as possible after unpro-
continue to take the rest of the pack as usual. Emergency tected sex or contraceptive failure. The dose consists of a
contraception may need to be considered if pills have been single tablet (levonorgestrel 1500 µg). About one in five
missed earlier in the packet or in the last week of the patients experience nausea but only 1 in 20 go on to vomit.
previous packet. If the patient vomits within 3 hours of the first dose she
For two or more missed pills: should be advised that a further supply of EHC would be
The patient should take the last pill they missed (even needed. Taking EHC can affect the timing of the next
if this means taking two pills in one day) and continue menstrual period and patients should be told that their
taking the rest of the pack as usual. An additional method period might be earlier or later than usual. However, if the
of contraception for the next seven days should be used. If period is different than normal or more than 5 days late
the person has had unprotected sex in the previous seven then she should be advised to have a pregnancy test.
days, and missed two or more pills (i.e. more than 48 hours A number of medicines do, theoretically, interact with
late) in the first week of a pack, emergency contraception Levonelle®, most notably those that are enzyme inducers
may be needed. and include anticonvulsants, rifampicin, griseofulvin and
If pills are missed in the first week (Pills 1–7). EHC St. John’s Wort, although the clinical significance of the
should be considered if unprotected sex occurred in the interactions appear low as only a handful of drug interac-
pill-free interval or in the first week of pill-taking. tion reports have been received by the manufacturers. It
If pills are missed in the second week (Pills 8–14). No seems prudent, until such time that more substantial evi-
indication for EHC if the pills in the preceding 7 days have dence is available, that patients taking these medicines are
been taken consistently and correctly (assuming the pills best referred to the GP. In such circumstances, increasing
thereafter are taken correctly and additional contraceptive the dose of Levonelle® is commonly practised (although
precautions are used). not licensed). If this is not the preferred option then an
If pills are missed in the third week (Pills 15–21). OMIT alternative form of EHC can be given.
THE PILL-FREE INTERVAL by finishing the pills in the Advanced sale of EHC is also permitted. However, phar-
current pack (or discarding any placebo tablets) and start- macists must consider the clinical appropriateness of a
ing a new pack the next day. supply, and should consider declining repeated requests for
If the patient uses a progestogen-only form of contra- advance supply and advise patients to use more reliable
ception. After a missed or late pill a woman should be methods of contraception. See Hints and Tips Box 10.2.
318 Specific product requests
Who is eligible? Only patients over the age of 16 can be supplied with Levonelle®, although family
planning services, doctors and pharmacists acting under a patient group direction
can supply EHC to patients under 16
Do you have to supply EHC? The supply of EHC is at the discretion of each pharmacist and some, for religious
beliefs, might choose not to supply EHC. However, the patient should be advised
on other local sources of supply so that she can obtain Levonelle®.
Aetiology
Nicotine replacement therapy Hundreds of compounds have been identified in tobacco
smoke, however only three compounds are of real clinical
Background
importance:
Smoking represents the single greatest cause of prevent-
able illness and premature death worldwide. In 2010, over • tar-based products, which have carcinogenic
properties
80 000 people in the UK died as a result of smoking;
putting this in context, smoking caused about 30% of all • carbon monoxide, which reduces the oxygen-carrying
capacity of the red blood cells
cancer deaths, 14% of all circulatory deaths and over 35%
of all respiratory disease deaths. • nicotine, which produces dependence by activation of
dopaminergic systems.
Prevalence and epidemiology Tolerance to the effects of nicotine is rapid. Once plasma
nicotine levels fall below a threshold, patients begin to
The number of smokers over the age of 16 in the UK is suffer nicotine withdrawal symptoms and will crave
falling – from a high of 45% in 1974 to 21% (21% of men another cigarette. Treatment is therefore based on main-
and 20% of women) in 2010. Smoking is most common in taining plasma nicotine just above this threshold.
Nicotine replacement therapy 319
Table 10.3
10
Practical prescribing: Summary of medicines used as nicotine replacement therapy
Name of Use in Likely side Drug interactions Patients in which Pregnancy & breastfeeding
medicine children effects of note care exercised
Nicorette >12 years* GI disturbances, None Patients with OK
headache, heart disease
Nicotinell dizziness and diabetes OK but manufacturers of
Nicotinell liquorice gum advise
NiQuitin it not to be used in pregnancy
*Note: some formulations are only licensed for people over 18 years of age, for example Nicotinell and NiQuitin lozenges.
highest strength patch for 8 weeks before stepping down cigarettes a day then they should start on the middle
10
to the middle strength for a further 2 weeks. The lowest strength patch.
strength patch should be finally worn for another 2 weeks.
Lozenge
Mouth spray (each spray delivers 1 mg nicotine) Low strength lozenges (1 mg) are recommended for those
The mouth spray can be used for either smoking cessation who smoke less than 20 cigarettes a day, whilst heavy
or smoking reduction. Smokers wanting to reduce the smokers should use the higher strength (2 mg). Patients
number of cigarettes smoked should use the mouth spray, should be instructed to suck one lozenge every 1–2 hours
as needed, between smoking episodes to prolong smoke- when they have the urge to smoke. The usual dosage is 8
free intervals. For smoking cessation, one spray should to 12 lozenges per day, with a maximum of 15 lozenges
be used when cravings emerge. If this first spray fails in 24 hours. Patients should be advised to gradually reduce
to control cravings a second spray can be used. Most the number of lozenges needed until they are only using
smokers will require one to two sprays every 30 minutes one to two lozenges per day. At this point they should stop
to 1 hour. The maximum number of sprays in a 24 hour treatment.
period is 64. Lozenges are mint flavoured and should be sucked until
the taste becomes strong and then placed between gum
Lozenge (2 mg) and cheek (similar to the gum) until the taste fades, when
Lozenges, like other dose forms, can be used for either sucking can recommence. Each lozenge takes approxi-
smoking cessation or smoking reduction. Most smokers mately 30 minutes to dissolve completely.
require 8 to 12 lozenges per day (maximum 15 lozenges
per day). Reduction strategies are the same as other dose NiQuitin
forms in that the lozenges are used when needed between
smoking cigarettes to prolong smoke-free intervals and NiQuitin is available as gum (2 or 4 mg), patches (7, 14
with the intention to reduce smoking as much as and 21 mg) and lozenge (2 and 4 mg or NiQuitin minis,
possible. 1.5 and 4 mg).
Nicotinell Patches
Like Nicotinell, patches are designed to be worn continu-
Nicotinell is available as gum (2 or 4 mg), patches (7, 14 ously (24 hour patch) and dosing is based on a sequential
and 21 mg) and lozenge (1 and 2 mg). The Nicotinell range reduction of nicotine over time. Patients who smoke more
is promoted for smoking cessation rather than smoking than 10 cigarettes a day should use the 21 mg patch (Step
reduction. 1) for 6 weeks, followed by the 14 mg patch (Step 2) for
2 weeks and finally the 7 mg patch (Step 3) for the last 2
Nicotinell gum weeks. If the person smokes less than 10 cigarettes each
Nicotinell gum is flavoured and available as fruit, mint or day the patient should start on Step 2 for 6 weeks followed
liquorice. The dosage and administration of Nicotinell gum by Step 3 for a final 2 weeks.
is the same as that for Nicorette gum, except that a
maximum of 25 pieces can be chewed in any 24 hour NiQuitin lozenge
period. Lozenges can be used for smoking cessation or smoking
reduction. The low strength lozenge (2 mg) is aimed at
Patches smokers who have their first cigarette of the day more than
The patches are worn continuously and changed every 24 30 minutes after waking up and the higher strength (4 mg)
hours, thus Nicotinell patches are suitable for those for those who smoke within 30 minutes of waking. Like
smokers who must have a cigarette as soon as they wake patches the dose of lozenges are marketed as Steps. For
up, as nicotine levels will be above the threshold of nico- smoking cessation the dosing schedule is:
tine withdrawal. Treatment is based on a stepwise reduc-
tion over a maximum period of 3 months. People who Step 1 × 6 weeks 1 lozenge every 1 to 2 hours
smoke more than 20 cigarettes a day should use the highest Step 2 × 3 weeks 1 lozenge every 2 to 4 hours
strength patch (TTS 30 patch, 21 mg) for 3 to 4 weeks, Step 3 × 3 weeks 1 lozenge every 4 to 8 hours
after which the strength of the patch should be reduced
to the middle strength (TTS 20 patch, 14 mg) for a further After this programme patients can use one to two loz-
3 to 4 weeks before finally using the lowest patch (TTS enges a day over the next 12 weeks when strongly tempted
10 patch, 7 mg). If the patient smokes less than 20 to smoke.
322 Specific product requests
Application of patches Patches should be applied to non-hairy skin on the hip, chest or upper arm. The next patch
should be placed on a different site to avoid skin irritation
16 or 24 hour patches? A 16-hour patch will be suitable for most patients, however, if a patient requires a cigarette
within the first 20 to 30 minutes after waking then a 24-hour patch should be given
If sleep disturbances are experienced with the 24 hour patches the patient can switch to a
16 hour patch or alternatively remove the 24 hour patch when they go to bed
Diabetics Should monitor their blood sugar levels more closely than usual when NRT started as
carbohydrate metabolism can be affected
Gum chewing technique The gum should be chewed slowly until the taste becomes strong, it should then be rested
– ‘chew and rest’ between the cheek and gum until the taste fades. The gum can then be re-chewed. Each
technique piece of gum lasts approximately 30 minutes.
Malaria prophylaxis 323
10
of malaria and is attributable for the majority of deaths
associated with malaria infection. The most common symptom is fever, although it may
initially present with chills, general malaise, nausea, vom-
iting and headache. Malaria should be considered as a
Prevalence and epidemiology differential diagnosis in anyone who presents with a febrile
illness whilst in or recently left a malarious area. P. falci-
Malaria is a leading cause of death in areas of the world parum is unlikely to present more than 3 months after
where the infection is endemic, with an estimated 650 000 exposure but symptoms associated with P. vivax malaria
deaths in 2010 (http://www.who.int/mediacentre/factsheets/ can take up to a year to manifest themselves.
fs094/en/). However, malaria is not only confined to
endemic malarial areas and the number of cases reported Evidence base for over-the-counter medication
in Western countries, for example the UK, is on the increase
as more and more people travel to countries where malaria Effective bite prevention should be the first-line of defence
is common. There are between 1500 and 2000 cases against malarial infection. Total avoidance of being bitten
reported in the UK each year. In 2010, there were 1761 is not practical and patients must ensure that protective
cases that resulted in 7 deaths. Figures for that year show measures from being bitten are always taken.
that P. falciparum accounted for 71% of cases (1261), Insect repellents containing N,N-diethyl-m-toluamide
P. vivax 20% (350), P. ovale 6% (99) and just 2% (37) for (DEET) in high concentrations is recommended (see Hints
P. malariae. and Tips Box 10.4). In controlled laboratory studies DEET
For people travelling to countries where malaria is provides the longest protection compared to other prod-
present, the risk of contracting malaria varies greatly. It ucts. Evidence for other insect repellents suggest they have
depends on the area visited, the time of year, altitude comparable efficacy to low concentrations of DEET but
(parasite maturation cannot take place above 2000 metres) have shorter duration of protection than DEET (Fradin &
and how many infectious bites are received. In general, Day 2002).
risk tends to increase in more remote areas than in urban/ Besides applying DEET, other preventative measures to
tourist areas, after rainy or monsoon seasons and at low reduce the chance of being bitten include wearing long,
altitude. It is therefore possible to have a different risk of loose-fitting, sleeved shirts and trousers, especially at
contracting malaria within the same country; for example, dawn and dusk. Protection of ankles appears to be particu-
visiting the southern lowlands of Ethiopia after the rainy larly important. Hotel windows should be checked to make
season would pose a very high risk whereas trekking in sure they have adequate screening, windows and doors
the Simien mountains in the north of the country during should remain closed and ideally the bed should have a
the dry season would pose minimal risk. mosquito net. Mosquito nets do reduce the incidence of
being bitten. Ideally they should be impregnated with
insecticide as they are more effective than non-impregnated
Aetiology nets (Lengeler 2004). If the person is travelling to more
remote areas they should purchase their own mosquito net
Malarial parasites are transmitted to humans when an
that has been impregnated with an insecticide. There are
infected female anopheles mosquito bites its host. Once in
a number of travel centres and specialist outdoor shops
the human host, the parasites (which at this stage of their
where such products, including insecticidal impregnated
life-cycle are known as sporozoites) are transported via the
clothes, can be bought.
bloodstream to the liver. In the liver they divide and mul-
tiply (they are now known as merozoites). After 5 to 16
Chemoprophylaxis
days the liver cells rupture, to release up to 400 000 mero-
zoites, which invade the human host’s erythrocytes. The In addition to taking precautions to avoid being bitten,
merozoites reproduce asexually in the erythrocytes before travellers should also take antimalarial medication. Chlo-
causing them to rupture and release yet more merozoites roquine and proguanil are licensed for pharmacy sale when
into the blood stream to invade yet more erythrocytes. Any used for prophylaxis of malaria and have proven efficacy
mosquito that bites an infected person at this stage will but drug resistance to these two medicines (e.g. chloroquine-
ingest the parasites and the cycle will begin again. It is resistant P. falciparum) is now widespread, and limits their
worth noting that P. vivax and P. ovale parasites can usefulness.
remain dormant in the liver, which explains why malarial It is important to check current guidelines for the
symptoms can manifest months after return from an destination the person is travelling to or through. Two
infected region. easily available UK reference sources in which
324 Specific product requests
Table 10.4
Practical prescribing: Summary of medicines for malaria prophylaxis
Name of Use in children Likely side effects Drug interactions Patients in which Pregnancy &
medicine of note care exercised breastfeeding
Chloroquine All ages GI disturbances and Amiodarone, ciclosporin, Avoid in epilepsy OK
visual problems cimetidine, digoxin
Proguanil Diarrhoea None Renal impairment
Application of The concentration of DEET in commercial products varies widely. Products with concentrations in
DEET excess of 50% can cause skin irritation and occasionally skin blistering. It is advisable that
these are patch tested first before widespread application
The higher the concentration of DEET, the greater length of protection:
• 50% DEET provides protection for up to 12 hours
• 30% DEET provides protection for up to 6 hours
• 20% DEET provides protection for 1 to 3 hours
Note-reapplication is necessary after swimming or sweating
DEET can damage certain plastics, for example sunglasses. It is important to emphasise to the
patient that they wash their hands after applying DEET
Make sure exposed areas such as feet and ankles are adequately protected
DEET reduces the effectiveness of sunblock but sunblock does not effect the effectiveness of DEET
Electronic These products are designed to repel female mosquitoes by emitting high-pitched sounds almost
mosquito inaudible to the human ear. There is no evidence in field studies to support any repelling
repellents effects
Alternative There is currently insufficient evidence supporting the use of vitamin B1, garlic, tee tree oil,
remedies herbal remedies, Marmite or repellents containing lemon eucalyptus (e.g. Mosi-guard) or
picaridin
They should not be routinely recommended
recommendations can be found are the British National Table 10.4; useful tips relating to patients travelling to
Formulary and MIMS. In addition a number of or regions where malaria is endemic are given in Hints and
ganisations produce reference material (e.g. the National Tips Box 10.4.
Pharmacy Association’s vaccination updates). In most
instances the MIMS would be a first-line reference
Medicine regimens
source as the guidelines are updated monthly (compared
to the British National Formulary’s biannual publication) Antimalarials need to be taken at least 1 week before
and are more likely to be still up to date. For people departure, during the stay in the malaria endemic region
who are travelling to very high risk areas (usually sub- and for 4 weeks on leaving the area. Taking the medication
Saharan Africa or south-east Asia) or for long periods prior to departure allows the patient to know whether they
of time it might be better to refer the person to a spe- are going to experience side effects and, if they do, still
cialist centre. have enough time to obtain a different antimalarial before
departure. It also helps to establish a medicine-taking
routine that will, hopefully, help with compliance. Medi-
Practical prescribing and product selection
cine taking for a further 4 weeks after leaving the region
Prescribing information relating to medicines for malaria is to ensure that any possible infection that could have
reviewed in the section ‘Evidence base for over-the- been contracted during the final days of the stay does not
counter medication’ is discussed and summarised in develop into malaria.
Bites and stings 325
Chloroquine (e.g. Avloclor, Nivaquine) infection. Cochrane Database of Systematic Reviews 2007,
10
Chloroquine, as a single agent, is now almost obsolete Issue 2. Art. No.: CD005434. DOI: 10.1002/14651858.
CD005434.pub2.
against P. falciparum but still remains effective against the
other forms of malaria.
Web sites
Adults and children over 13 should take 300 mg of Fit for travel – provided by NHS Scotland: http://
chloroquine base each week; this is equivalent to two www.fitfortravel.nhs.uk/home.aspx
tablets. Chloroquine can be given to children of all ages The National Travel Health Network and Centre: http://
and is based on a milligram per kilogram basis. Nivaquine www.nathnac.org/travel/index.htm
is formulated as a syrup (50 mg of base/5 mL) and should Malaria Reference Laboratory: http://www.malaria-
be recommended for children because an accurate dose can reference.co.uk
be given according to their weight. Liverpool School of Tropical Medicine: http://www.liv.ac.uk/lstm
Chloroquine is associated with a number of side effects
including nausea, vomiting, headaches and visual distur-
bances. Most patient groups, including pregnant women
can take chloroquine, although it is contraindicated in Bites and stings
epilepsy because it might lower the seizure threshold and
tonic-clonics seizure have been reported with prophylactic Background
doses. Patients with psoriasis might notice a worsening of A whole host of animals (and plants) have the capacity to
their condition. Chloroquine should be avoided in patients cause injury to the skin, and depending on the severity
taking amiodarone because there is a risk of QT prolonga- can result in systemic symptoms. The majority of cases are
tion and ventricular arrhythmia. It should also be avoided caused by insects and are of nuisance value.
with ciclosporin (increased ciclosporin levels), cimetidine
(increased chloroquine levels) and possibly digoxin
(increased digoxin levels). Prevalence and epidemiology
The prevalence of bites and stings is largely unknown.
Proguanil (Paludrine) Most people self-treat and never seek advice. Biting and
Proguanil is always used in combination with chloroquine stinging insects are generally more common in warmer
unless the patient is contraindicated from taking chloro- climates, and in warmer months, with summer being the
quine. Adults and children over the age of 13 should take peak time.
200 mg (two tablets) daily. Like chloroquine, it can be
given to children of all ages and the dose ideally should Aetiology
be on a milligram per kilogram basis. To aid compliance
a travel pack suitable for adults on a 2-week holiday is Stinging insects are broadly defined as those that use some
available that combines 14 chloroquine tablets with 98 sort of venom as a defence mechanism or to immobilise
proguanil tablets. Side effects associated with proguanil their prey. Examples include bees, wasps and ants. The
are usually mild and include diarrhoea. Patients with venom is usually ‘injected’ using a stinger and include
known mild renal impairment should take 100 mg daily proteins and substances that help break down cells and
and the dose should be further reduced if renal impairment increase the penetration of the venom, e.g. phospholipase
is moderate or severe. A and hyaluronidase. People can develop allergic reactions
to these substances and, unlike most biting insects, can
occasionally suffer significant reactions, including ana-
References phylaxis, to stings. The severity of the reaction depends
Fradin MS, Day JF. Comparative efficacy of insect repellents on the quantity of the venom injected and the person’s
against mosquito bites. N Engl J Med 2002;347:13–18. predisposition to hypersensitivity.
Lengeler C. Insecticide-treated bed nets and curtains for
Biting insects are those that feed off the blood supply
preventing malaria. Cochrane Database of Systematic
Reviews 2004, Issue 2. Art. No.: CD000363. DOI:
of humans and other creatures. They include mosqui-
10.1002/14651858.CD000363.pub2. toes, ticks, and fleas. Apart from having some sort of
apparatus to draw the blood, these insects usually secrete
Further reading anticoagulant-like substances to facilitate feeding. It is
Enayati AA, Hemingway J, Garner P. Electronic mosquito these anticoagulant substances that people will react to.
repellents for preventing mosquito bites and malaria However, it is only after repeated bites that sensitivity
occurs.
326 Specific product requests
Clinical features of bites and stings Practical prescribing and product selection
Itching papules, which can be intense, is the hallmark Prescribing information relating to products for bites and
symptom of insect bites. Weals, bullae and pain can occur, stings is reviewed in the section ‘Evidence base for over-
especially in sensitised individuals. Lesions are often local- the-counter medication’ is discussed and summarised in
ised and grouped together and occur on exposed areas, e.g. Table 10.5.
hands, ankles and face. Scratching can cause excoriation, Before OTC treatment is offered, the severity of symp-
which might lead to secondary infection. In contrast, stings toms should be assessed, because small local reactions can
are associated with intense burning pain. Erythema and be managed primarily with topical products whereas large
oedema follow but usually subside within a few hours. If local reactions will generally require systemic treatment.
systemic symptoms are experienced, they occur within Patients with systemic symptoms should be referred.
minutes of the sting. If the person has been stung and the stinger is still in
situ then this should be removed. The best way of removal
is to scrape the stinger away with a sharp edge (e.g. card
or knife blade) or alternatively a finger nail.
Evidence base for over-the-counter medication
Avoiding bites and stings in the first place is obviously Small local reactions
important. This means using an effective insect repellant
and avoiding times and places when insects are about. Local pain and swelling is best treated with cold compresses/
DEET is the most effective insect repellant and found in ice and, if needed, oral pain killers (ibuprofen or paraceta-
most commercial preparations. For avoidance measures mol). Local itching can be treated with topical crotamiton
and more information on DEET see page 323. or low potency corticosteroids (hydrocortisone 1%). If
Topical OTC treatments for bites and stings include itching interferes with sleep then an oral sedating antihis-
local anaesthetics, corticosteroids and antihistamines. For tamine might be helpful at night.
local anaesthetics, there is a lack of clinical data to
support the use for stings and bites, either alone or in Large local reactions
combination with antihistamines. However, their use in
practice is well established as a local anaesthetic and is Occasionally, severe pain and swelling can extend beyond
appropriate on theoretical grounds. Hydrocortisone, like the immediate surroundings of the lesion. They should be
lidocaine, has a lack of clinical data for bites and stings, managed with oral pain killers and antihistamines.
but the use could be justified on theoretical grounds.
Crotamiton is also marketed for conditions associated Local anaesthetics (e.g. benzocaine (Lanacane),
with itching. Prodigy guidance (February 2013) recom- lidocaine (Dermidex & Savlon Vites and Stings Pain
mends crotamiton for local reactions to control itching, Relief Gel))
but there is a lack of evidence to support this and is Local anaesthetics can be used in adults and children over
based on expert opinion. 4 years (see Table 10.5) and are in general applied three
Stingose is a 20% aluminium acetate solution marketed times a day. They are safe to use in pregnancy and are
for the treatment of bites and stings. The proposed mecha- generally well tolerated. Local anaesthetics are known to
nism of action is that aluminium ions cause denaturing of be skin sensitisers and can produce contact dermatitis.
the proteins and bind polysaccharides in bites and stings
resulting in inactivation of the venom. There are no ran-
domised comparative or placebo controlled trials. However,
Local anaesthetic/antihistamine combination
a large case series of over 1000 patients found it to be
(Wasp-Eze Spray)
This product contains benzocaine 1% and mepyramine
effective in treating a range of marine, plant and animal
0.5%. It can be used on people over the age of 2 years.
bites and stings in over 99% of cases (Henderson &
The dose is one spray on to the affected area of skin for
Easton 1980).
two to three seconds. This dose can be repeated after 15
Antihistamines (both topical and systemic) have been
minutes if required.
used for their antipruritic properties. There are limited
studies in the treatment of insect bites and stings. Some
studies, with systemic antihistamines, have shown efficacy Hydrocortisone (e.g. Dermacort)
of the less sedating antihistamines for mosquito bites (Foëx Hydrocortisone is applied once or twice a day to the
& Lee 2006). They are probably most useful for their sedat- affected areas. It can be used in adults and children over
ing properties when itching is disturbing sleep. 10 years of age. It can be used for a maximum of 7 days.
Bites and stings 327
Table 10.5
10
Practical prescribing: Summary of medicines used for insect bites and stings
Name of Use in Likely side Drug interactions Patients in which Pregnancy &
medicine children effects of note care exercised breastfeeding
Benzocaine
Lanacane >12 years Can cause None None OK
sensitisation
reactions
Lidocaine
Dermidex >4 years Can cause None None OK
sensitisation
Dermidex & >12 years reactions
Savlon Bites
and Stings
Pain Relief Gel
Hydrocortisone >10 years None None None OK
Crotamiton >3 years None None None OK
Chlorphenamine >1 year Dry mouth, Increased sedation Glaucoma, Pregnancy OK. Standard
sedation and with alcohol, prostate references state OK,
constipation opioid analgesics, enlargement although some
anxiolytics, manufacturers advise
hypnotics and avoidance. This is
antidepressants presumably because it
has the potential to
cause drowsiness and
may lead to poor feeding
Aluminium Not stated None None None OK
acetate
Sedating antihistamines (e.g. chlorphenamine) times a day. Adults should take 4 mg (one tablet) three or
Chlorphenamine, as all antihistamines, are associated with four times a day.
sedation. They interact with other sedating medication,
resulting in potentiation of the sedative properties of the Crotamiton (Eurax)
interacting medicines. They also possess antimuscarinic Adults and children over 3 years of age should apply cro-
side effects, which commonly result in dry mouth and tamiton two or three times a day. A combination product
possibly constipation. It is these antimuscarinic properties containing hydrocortisone is available (Eurax HC) but is
that mean patients with glaucoma and prostate enlarge- best avoided if possible. This is to decrease the exposure
ment should ideally avoid their use, because it could lead of patients to unnecessary corticosteroids and their poten-
to increased intraocular pressure and precipitation of tial adverse effects.
urinary retention.
Aluminium acetate (Stingose)
Chlorphenamine (e.g. Piriton) Aluminium acetate is safe to use with any age and comes
Chlorphenamine can be given from the age of 1 year. in a spray and gel. It should be applied as soon as possible
Children up to the age 2 should take 2.5 mL of syrup after the sting, and is unlikely to be effective if used more
(1 mg) twice a day. For children aged between 2 and 5 the than 30 minutes after the sting or bite. It has no significant
dose is 2.5 mL (1 mg) three or four times a day and those side effects. However, some local skin reactions are
over the age of 6 should take 5 mL (2 mg) three or four possible.
328 Specific product requests
Table 10.6
10
Lifestyle measures to prevent CHD
Measure
Smoking cessation Stopping smoking has been shown in several large cohort studies to decrease
associated risks. For CHD, the risk of coronary events declines in 2–3 years to
that of people who have never smoked. The risk of stroke declines more slowly
Exercise People who are moderately physically active have a 30–50% lower risk of CHD
than people who are sedentary
Moderate-to-high physical activity also reduces the risk of stroke. It also helps
control weight, BP, and diabetes; protects against osteoporosis; and increases
well-being.
Offer advice on gradually increasing exercise, if appropriate; about 60% of men
and 70% of women in the UK are considered to be sedentary.
Brisk walking for half an hour (or more) per day reduces the relative risk of CHD
by about 20%.
It is not necessary to participate in sport or weight training activities to achieve
exercise targets: brisk walking, climbing stairs, and heavy housework are all
moderate-intensity physical activities.
Dietary management Replace saturated and trans-fats with unsaturated fats (especially
Up to 30% of all deaths from CHD monounsaturated and non-hydrogenated polyunsaturated fat).
have been attributed to unhealthy Increase consumption of omega-3 fatty acids from fish oil or plant sources.
diets Consume a diet high in fruits, vegetables, nuts, and whole grains and low in
refined grains.
Replace butter with olive oil and monounsaturated margarine (e.g. rapeseed- or
olive-oil based).
Eat less red meat (replace beef, lamb, and pork with poultry). If eating red meat,
use lean cuts. Remove the skin from poultry.
Eat more fish, including at least one portion of oily fish per week, e.g. mackerel,
herring, kipper, pilchard, sardine, salmon, or trout.
Eat more bread (especially wholegrain bread).
Eat more root vegetables and green vegetables.
Eat fruit every day.
Eat fewer commercial bakery and deep-fried foods (these contain high levels of
trans-fats and sugar),
Aim to eat five portions of fruit and vegetables every day.
Tinned and frozen fruit and vegetables are as good as fresh vegetables.
Reduce salt intake.
Weight control Encourage all obese and overweight* people to lose weight, aiming towards a
Excess weight is associated with raised BMI of less than 25.
BP, raised blood cholesterol, Type 2 Even if a BMI less than 25 cannot be achieved, a reduction in 5–10% of initial
diabetes, and low levels of physical bodyweight still has significant health benefits.
activity, all of which increase the risk The risk of CHD is 2–3 times greater in overweight women than in lean women.
of CHD The risks are further increased when fat is concentrated mainly in the abdomen
(central obesity).
Frequent fluctuations in weight are also associated with an increased risk of
CHD. Weight-management programmes must therefore aim to maintain
weight loss, not just to achieve initial weight loss.
Continued
330 Specific product requests
Alcohol consumption Up to 2 units of alcohol per day is associated with a 20% relative risk reduction
Men should limit their alcohol of CHD and all types of alcohol have been associated with lowering the risk of
consumption to a maximum of 21 CHD; the effect is not solely confined to red wine.
units per week (i.e. a maximum of 3 The pattern of drinking is also important. Consumption of alcohol on at least
units per day). For women, the 3–4 days per week has been found to be inversely associated with the risk of
maximum is 14 units per week (i.e. a myocardial infarction in men. Conversely binge drinking is associated with
maximum of 2 units per day) increased mortality and fatal myocardial infarction.
In the UK 26% of men already drink There is not enough information available to justify encouraging those who do
more than 21 units per week, and not drink alcohol to start doing so. Moderate drinking is likely to have most
15% of women drink more than 14 benefits in people who are at highest risk of CHD, i.e. middle aged and elderly
units per week. people. In younger people (who are at low risk of CHD) the risks of alcohol-
related problems, such as accidents, may outweigh the potential benefits.
There are also concerns that moderate drinking may increase the risk of breast
cancer in young women (less than 50 years).
More information on units available at http://www.alcoholandyou.org.uk/
default.html (accessed 27 November 2012).
Realistic weight loss goals Recommended goals are 1–4 kg per month in the short term, and 10–20% of body
weight in the medium to long term.
10
Exercise People should be encouraged to start with regular, moderate exercise (e.g. brisk walking)
three times a week, with the aim of increasing exercise to a minimum of 80 minutes
per day to maintain weight loss
overweight – 42% of men 32% of women. This equates to abdominal pain. These can be minimised by restricting fat
63% of adults being overweight or obese. Figures for Wales intake to less than 20 g per meal. Supplementation with
and Scotland are similar. fat-soluble vitamins (A, D, E and K) is recommended and
can be achieved by taking a multivitamin. Because of the
effect on vitamin K levels, patients on warfarin should
Aetiology
avoid using orlistat. Orlistat may decrease ciclosporin
Although a number of causes of obesity have been pro- levels and requires close monitoring. There is limited data
posed, and genetics may play an important role, for a of orlistat being used in pregnant and breastfeeding women
significant proportion of the population it results from an and is therefore not recommended.
imbalance between energy intake (food and beverages) and
energy expenditure (exercise). Other factors associated
with obesity include cultural norms, socioeconomic status, Reference
gender and ethnicity. See Hints and Tips Box 10.5 for Hill J, Hauptman J, Anderson J. Orlistat, a lipase inhibitor, for
weight maintenance after conventional dieting: a 1-y
guidance on weight loss.
study. Am J Clin Nutr 1999;69:1108–16.
10
Royal Pharmaceutical Society Guidance: http://
www.rpharms.com/practice–science-and-research-full- Background and prevalence
guidance/otc-tamsulosin-full-guidance.asp.
OTC tamsulosin: Information for pharmacists – Implementing Chlamydia trachomatis is the most common sexually
NICE guidance: http://www.google.co.uk/ transmitted bacterial infection in the UK, and the inci-
url?sa=t&rct=j&q=nice%20tamsulosin&source=web&cd=1 dence is increasing and in part due to it being asympto-
&ved=0CFMQFjAA&url=http%3A%2F%2Fwww.nice.org. matic. At least 70% of women and 50% of men infected
uk%2Fnicemedia%2Flive%2F12984%2F48572%2F48572. are asymptomatic. In 2010, young people, aged less than
doc&ei=IfcXUM6yL4fI0QX58oD4Dg&usg 25 years, accounted for 65% of chlamydia diagnoses. In
=AFQjCNEtTWWBC-SsnOoUtpvGMlcxAroX6g response to the growing problem, the DoH introduced
Prostate Help Association: www.prostatehelp.me.uk
the National Chlamydia Screening Programme (http://
www.chlamydiascreening.nhs.uk/; accessed 27 November
2012).
Table 10.7
Possible future deregulated medicines from POM to P
Oral contraception Low risk of side effects
Fits in with government sexual health policies, especially those tackling teenage
pregnancy
Successful PGD in South London reported on Jan. 2012 (http://ocsotc.org/
wp-content/uploads/2012/04/NHS-2012_Evaluation-of-pharmacy-provision-
of-OCs-in-London-1-2012.pdf; accessed 27 November 2012)
Salbutamol Already OTC in some countries, e.g. Singapore, New Zealand
ASDA started to sell salbutamol in July 2012 under a PGD
Doxycycline (and possibly others) for Given current resistance to proguanil and chloroquine deregulation seems likely
malaria prophylaxis
Topical antibiotics for impetigo (e.g. Strong support from a number of studies gaining GP opinion
fusidic acid, mupirocin) Condition easy to identify
Low risk of side effects
Topical antibiotics (e.g. erythromycin) Same reasons as indicated for impetigo
and azelaic acid for acne
Anti-retrovirals for influenza Already established PGDs through community pharmacy
Fits in with government public health policy
Antihistamines Desloratadine and fexofenadine available OTC in some countries, e.g. Australia
Steroid-based preparations Likely that topical and inhaled steroid products will become increasingly
available to treat allergic-type conditions
Metoclopramide Low risk of side effects
Available OTC in some countries already
NSAIDs Now that naproxen and diclofenac have been deregulated and others (e.g.
mefenamic acid) are available in other countries then it appears more NSAIDs
will become P medicines over time
Insomnia (‘Z’ drugs) Low risk of side effects
Practical prescribing and product selection However, the number of POM to P deregulations in the last
few years has slowed. There have been a number of reasons
Azithromycin was reclassified in 2008. It is indicated for cited for the recent lack of POM to P switches, which
men and women 16 years of age or older who are asymp- include over burdensome regulatory processes. This is evi-
tomatic and have tested positive for genital chlamydia denced by just nine switches between 2009 and 2012, with
infection. It is also indicated for treatment of their sexual only orlistat, tranexamic acid and tamsulosin coming from
partners without the need for a test. The dose is a single new therapeutic classes. Recent applications for oral anti-
stat. dose of 1 g (2 × 500 mg tablets). Side effects that biotics (trimethoprim and nitrofurantoin to treat uncom-
might be experienced are GI upset, namely nausea, vomit- plicated cystitis in women) were ultimately withdrawn in
ing and abdominal discomfort. 2010 due to concerns over increasing antibiotic resistance.
It appears that, for the time being, oral antibiotics, other
than azithromycin will not be deregulated from POM
control. Looking to the immediate future, it seems likely
Future deregulations that more medicines to treat acute conditions will become
P medicines.
Current UK government policy promotes self-care and con- Table 10.7 highlights some future candidates that are
sistently advocates the greater deregulation of medicines. potential POM to P switches.
Self-assessment questions 335
Self-assessment questions
The following questions are intended to supplement the text. Two levels of questions are provided; multiple choice
questions and case studies. The multiple choice questions are designed to test factual recall and the case studies allow
10
knowledge to be applied to a practice setting.
10.1 Which antihistamine used for motion sickness is 10.6 How long after unprotected sex can EHC be given?
subject to abuse?
a. 24 hours
a. Cinnarizine b. 48 hours
b. Cyclizine c. 72 hours
c. Promethazine d. 96 hours
d. Meclozine e. 120 hours
e. Hyoscine
10.7 What is regarded as the most important smoking-
10.2 What is the main side effect of Levonelle® One step? related disease?
a. Vomiting a. Lung cancer
b. Headache b. Chronic obstructive pulmonary disease
c. Diarrhoea c. Throat cancer
d. Nausea d. Motor neurone disease
e. Dizziness e. Ischaemic heart disease
10.3 In which group of the population is smoking on the 10.8 Patients with which condition should care be taken
increase? when recommending promethazine for motion
sickness?
a. Middle-aged males
b. Middle-aged females a. Glaucoma
c. Teenage females b. Hypertension
d. Teenage males c. Peptic ulceration
e. Elderly men d. Diabetes mellitus
e. Parkinson’s disease
10.4 Which patients should use 24-h patches?
Questions 10.9 to 10.11 concern the following NRT
a. People who smoke more than 20 cigarettes a day
products:
b. People who smoke more than 40 cigarettes a day
c. People who need a cigarette within 20 minutes of A. Patch
waking up B. Gum
d. People who need a cigarette before they go to C. Inhalator
sleep D. Lozenge
e. People who smoke cigars E. Microtab
10.5 Which dermatological condition can be worsened by Select, from A to E, which of the above products:
taking chloroquine?
10.9 Is most suitable for patients in which compliance may
a. Psoriasis be an issue
b. Acne vulgaris
10.10 Delivers constant levels of plasma nicotine
c. Eczema
d. Rosacea 10.11 Is useful for those people who need to have their
e. Atopic dermatitis hands occupied
336 Specific product requests
Questions 10.12 to 10.14 concern the following medicines: Questions 10.18 to 10.20: these questions consist of a
statement in the left-hand column followed by a
A. Chloroquine
statement in the right-hand column. You need to:
B. Proguanil
C. Hyoscine • decide whether the first statement is true or false
D. NRT • decide whether the second statement is true or false
E. Levonorgestrel
Then choose:
Select, from A to E, which of the above medicines:
A. If both statements are true and the second statement
10.12 Causes diarrhoea is a correct explanation of the first statement
B. If both statements are true but the second statement
10.13 Causes visual disturbances
is NOT a correct explanation of the first statement
10.14 Causes dry mouth C. If the first statement is true but the second
statement is false
D. If the first statement is false but the second
Questions 10.15 to 10.17: for each of these questions one
statement is true
or more of the responses is (are) correct. Decide which of
E. If both statements are false
the responses is (are) correct. Then choose:
A. If 1, 2 and 3 are correct Directions summarised
B. If 1 and 2 only are correct
C. If 2 and 3 only are correct 1st 2nd
D. If 1 only is correct statement statement
E. If 3 only is correct A True True 2nd explanation is a
correct explanation of
Directions summarised the first
10.15 When using DEET, the following rule(s) should be D False True
followed: E False False
a. It should be applied regularly
b. It should be kept away from plastic First statement Second statement
c. It should never be applied to the face
10.18 Antimalarials have to Side effects may preclude
be taken before travel patients from taking
10.16 Plasmodium falciparum is associated with: antimalarials
a. High levels of drug resistance 10.19 Malaria can be The liver holds a reservoir
b. The highest incidence of death compared to other contracted months after of parasites that are hard
forms of malaria return from an endemic to eradicate
c. Widespread distribution on the African continent area
10.20 Pregnancy is a Infants cannot take
10.17 What side effects can be seen in patients chewing contraindication for antimalarials
nicotine gum? malaria prophylaxis
a. Taste disturbance
b. Sweating
c. GI disturbances
Case study 337
Case study
CASE STUDY 10.1
10
Mr and Mrs J and their two children, Sammy aged 5 further 2-hour drive. Mr J gets seasick and neither
and Jessica aged 12 are going on their summer of the children like boats or car journeys. Jessica
holidays. They want to know what travel sickness also suffers from narcolepsy.
tablets they should take.
b. What would be the best drug regimen for the
a. What information do you need to know before family? State your rationale.
recommending a suitable product? For each
question state your rationale. It appears that the total journey time is relatively
short and a hyoscine-based product would be the most
You need to know: suitable product for the two children and their father.
Kwells Kids could be used by everyone; Mr J would
• Who is affected by travel sickness: this may influence have to take 2 tablets, Jessica 1 tablet and Sammy 1 2
recommendation, especially if it affects one of the a tablet. As Jessica has narcolepsy it is necessary to
parents who might be driving. see if she takes any medication to help with the
• The length of the trip: this will influence which product condition. If she does then checks would have to be
will be the most appropriate. It is sensible to match up made to ensure that Jessica could still take hyoscine.
the length of journey with a medicine that has the
same duration of action as the trip. c. What practical advice would you also offer
• Medication history: patients who are taking the family?
medication for glaucoma or prostate enlargement
should avoid taking OTC medicines. Additionally, Hyoscine will cause dry mouth and potential sedation.
medicines with anticholinergic side effects will Sucking sweets can compensate for a dry mouth.
potentiate the side effects of OTC travel medication. Sedation might be a problem for Mr J because he has
• Passed medication for similar journeys: it is likely that to drive after the ferry crossing. He should be told
the family have had to purchase such products in the about the possible effects of hyoscine. He might
past. It is worth finding out what they were and how choose not to take the medication, although no
well tolerated they were before potentially alternative is available that does not cause possible
recommending the same product. sedation.
You find out they are going to northern France by The two children might experience less nausea if they
ferry. This is a 2-hour boat journey followed by a are kept occupied by playing games.
338 Specific product requests
Ms HS walks into the pharmacy on Saturday morning b. What else do you need to know?
and asks to buy the morning after pill.
You also need to know about her pill-taking
a. What questions do you need to ask? compliance.
You need to discover: She says that she has not taken her last 2 days tablets
(Thursday and Friday) and doesn’t know whether she
• Her age should take today’s tablet. She has 3 tablets left before
• How long ago did she have unprotected sex? the end of the packet.
• Whether she used a form of contraception? If so, what
form c. What advice are you going to give her?
• The date of her last period and was it different than
normal. There is no need for EHC as she has forgotten to take
her tablets at the end of the cycle. She should be told
You find out she is 18 and had sex last night. She to continue taking the rest of her tablets but when the
normally takes Microgynon. Her period was about last tablet is taken she should not have a 7 day pill
3 weeks ago and was the same as previous periods. free period but go straight on to the next packet.
Answers
1 = b 2 = d 3 = c 4 = c 5 = a 6 = c 7 = e 8 = a 9 = a 10 = a
11 = c 12 = b 13 = a 14 = c 15 = b 16 = a 17 = e 18 = a 19 = a 20 = e
Abbreviations
µg microgram L litre
ACE angiotensin-converting enzyme MAOI monoamine oxidase inhibitor
ADR adverse drug reaction MAU minor aphthous ulcers
CB chronic bronchitis mEq milliequivalent
CSM Committee for the Safety of Medicines mg milligram
DEET diethyl toluamide MI myocardial infarction
DPH diphenhydramine mL millilitre
EHC emergency hormonal contraception mmol millimole
FDA Food and Drug Administration NRT Nicotine replacement therapy
(equivalent to the Medicines NSAID non-steroidal anti-inflammatory drug
Control Authority in the UK) ORT oral rehydration therapy
GORD gastro-oesophageal reflux disease OTC over-the-counter
GP general practitioner P pharmacy
GSL general sales list PD primary dysmenorrhoea
h hour PID pelvic inflammatory disease
IHS International Headache Society PMS premenstrual syndrome
HMG-CoA beta-hydroxy beta-methyl glutaryl POM prescription-only-medicine
coenzyme A PV per vagina
HPV human papilloma virus SSRI selective serotonin reuptake inhibitor
HSV herpes simplex virus STD sexually transmitted disease
IBS irritable bowel syndrome TB tuberculosis
IgE immunoglobulin E TCA tricyclic antidepressant
INR international normalised ratio UTI urinary tract infection
IUCD intrauterine contraceptive device WHO World Health Organization
KCS keratoconjunctivitis sicca
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Glossary of terms
Chapter 1 letters across the room and near visual acuity is the
person’s ability to read letters close to.
Atopy: A form of hypersensitivity characterised by a
familial tendency.
Chapter 3
Cervical lymphadenopathy: Enlargement of the cervical
lymph nodes. Conductive deafness: Sound waves are hindered from
Agranulocytosis: Acute deficiency of neutrophil white reaching the inner ear (e.g. by ear wax) resulting in
blood cells leading to neutropenia. distortion of sounds that impairs the understanding of
Auroscopical examination: Examination of the ear drum words.
by means of an apparatus that shines light onto the Effusion: Escape of fluid, e.g. exudates, from the ear.
ear drum. FDA: US Food and Drug Administration (equivalent to
Haemoptysis: Coughing up blood. the MCA in the UK).
Dyspnoea: Difficulty in breathing. Laceration: A tear in the skin causing a wound.
Malaise: General feeling of being unwell. Oedematous: Abnormal accumulation in intercellular
Gastro-oesophageal reflux: The back flow of gastric spaces of the body.
contents into the oesophagus. Tinnitus: A noise in the ears likened to ringing or
Orthopnoea: Difficulty in breathing when lying down. buzzing.
Pleurisy: Inflammation of the pleural membranes caused
by the two pleural membranes adhering to one Chapter 4
another.
Purulent: Term used to describe a material containing ADRs: Adverse drug reactions.
pus. Amenorrhoea: Absence or the stoppage of menstruation
Rhinorrhoea: Watery nasal discharge. Haematoma: A localised collection of blood, usually
Vascular engorgement: An area of tissue that has been clotted, in an organ, space or tissue.
excessively perfused with blood. Myalgia: Muscular pain.
Vasodilatation: Increase in the diameter of the blood Paraesthesia: An abnormal sensation, for example, a
vessels. burning or prickling sensation.
Pericranial: Area relating to around the skull.
Chapter 2 Purpuric rash: Rash with a distinctive red/purple
colouration caused by haemorrhage of small blood
Chalazion: Also referred to as meibomian cyst. vessels in the skin.
Conjunctivitis medicamentosa: conjunctivitis caused by
repeated administration of ocular eye drops, especially
Chapter 5
sympathomimetic agents. On withdrawal of the
medicine the patient suffers from rebound redness of Anovulatory: Term used to describe women that do not
the eyes. ovulate.
Glands of Zeiss and Moll: Both are located within the Bacteriuria: Bacteria in the urine.
eyelid. The gland of Zeiss secretes sebum and the Dyspareunia: Difficult or painful sexual intercourse.
gland of Moll secretes sweat. Dysuria: Painful or difficult urination.
Hordeola: Commonly known as styes. Haematuria: Blood in the urine.
Limbal area: Area where the cornea meets the sclera. Menarche: Onset of menstruation.
Meibomianitis: Inflammation of the meibomian gland. Nocturia: Excessive urination at night.
Photophobia: A dislike of bright lights. Perianal: The area around the anus.
Visual acuity: The ability to read text. For example, Perineal: The area around the perineum. The perineum
distance visual acuity is the person’s ability to read describes the area between the vulva and anus.
342 Glossary of terms
Postmenopausal women: Women that have finished Vesicles: Small, raised, fluid-filled lesions or blisters.
menstruating. The average age for women to be Wheal: Areas of transient dermal oedema. Classically
postmenopausal is 51. associated with urticaria and also following
Prostate gland: The gland that surrounds the neck of the insect bites.
bladder and urethra in men.
Pyelonephritis: Inflammation of the kidney due to Chapter 8
bacterial infection.
Suprapubic: Area above the pubic region. Abduction: The term used to describe movement of a
part away from the median plane of the body, for
Chapter 6 example, moving the leg straight out to the side.
Ankylosis: When the joint becomes stiff or fused in a
Annular lesions: Skin lesions that are circular. particular position.
Diverticulitis: Inflammation of a diverticulum, which is a Arthropathy: Pathology in a joint.
pouch or sac. It occurs normally after herniation. Articular cartilage: Cartilage occurring in the joint.
Halitosis: Bad breath. Disc herniation: Abnormal protrusion of the nucleus
Suprapubic: Area above the pubis area of the abdomen. pulposus of the disc, which may impinge on a
Tenesmus: Cessation of incomplete bowel evacuation. nerve root.
Ureter: Tube connecting the kidney to the bladder. Epicondylitis: Inflammation of the epicondyle, which is
the protuberance above the condyle. The condyle
Chapter 7 refers to the rounded part at the end of the bone used
Atopy: Literally means ‘strange disease’. The triad of for articulation with another bone.
atopic dermatitis, asthma and allergic rhinitis.
Comedone: A plug of oxidised sebaceous material Chapter 9
obstructing the surface opening of a pilosebaceous Erythema: Redness of the skin due to capillary
follicle, commonly referred to as a blackhead. vasodilation.
Crust: The term given to dried exudate. Intertriginous area: Skin eruption on apposed skin
Macules: Flat stains or spots of altered skin colour. surfaces.
Maculopapular: Literally a papule developed on a Lichenification: Thickening and hardening of the skin.
macule, i.e. a mixture of the two types of lesion.
Nodule: A solid elevation whose greater part lies beneath
Chapter 10
the skin surface.
Papules: Raised palpable spots Erythrocytes: Alternative name for red blood cells.
Punctiform: Pinpoint-like lesions. Melanocytes: Cells in the skin epidermis responsible for
Pustule: A pus-filled lesion. producing melanin.
Index
Page numbers followed by ‘f’ acquired immune deficiency causes, 26–27, 26t
indicate figures, ‘t’ indicate tables, syndrome (AIDS), clinical features, 26
and ‘b’ indicate boxes. seborrhoeic dermatitis in, conditions to eliminate, 26–27
207 differential diagnosis, 26–27, 28f
acrivastine, allergic rhinitis epidemiology, 25
A treatment, 29–30, 31t–32t evidence base for OTC medicines,
abdomen, location of organs in, actinic keratoses, 247 27
178f activity-related soft tissue injuries persistent, 26
abdominal pain, 177–186 see soft tissue injuries prevalence, 25
aetiology, 178–180 acupressure, motion sickness specific questions to ask, 26t
anatomy in relation to, 178f prevention, 314 treatment
background, 177–185 acupuncture allergen avoidance, 27
case study, 189–194 acute low back pain treatment, medication, 27–30
causes of, 179t 265 prescribing and product
conditions affecting women, 185 dysmenorrhoea management, 118 selection, 30, 31t–32t
differential diagnosis, 180, 186f acute closed-angle glaucoma, 48, systemic therapy, 29–33,
diffuse, 185 48f 31t–32t
epidemiology, 177–178 Adcortyl, 138b topical therapy, 29–30, 31t–32t
lower abdomen, 183–184 adenovirus, gastroenteritis, 154 trigger points for referral, 27b
prevalence, 177–178 adverse drug reactions (ADRs), 5 viral, 25
specific questions to ask, 179t agranulocytosis allylamines, fungal skin infections
treatment, 185 bleeding gums, 144 treatment, 213
trigger points for referral, 185b medications causing, 21t almond oil, 71
upper abdomen, 180–185 medicine-induced sore throat, 20 alopecia
upper quadrants signs, 20, 22f androgenetic see hair loss
left, 180 ALARM symptoms, 146–147 areata, 220
left and right, 182–183 alcohol traction, 220
right, 181 causing insomnia, 91t aloxiprin, 266t–268t
see also specific conditions coronary heart disease prevention, Alphosyl 2 in 1 Shampoo, 203t
causing 329t–330t alternative therapies see
abscess, lung, 6 excess consumption, 96, 146 complementary and
ACE inhibitors, coughs, 5 alginates, dyspepsia treatment, 149, alternative therapies
acetic acid, 74 151t, 152 aluminium acetate, bites and stings
Achilles tendon injuries, 274 alkalinising agents, cystitis treatment, 327, 327t
aciclovir, cold sore treatment, 238, treatment, 109–111 aluminium salts, dyspepsia
239t allantoin, haemorrhoid treatment, treatment, 149, 151, 151t
Acnecide, 235t 176 alveoli, 2
acne vulgaris, 196, 232–236 allergens alverine
aetiology, 232 allergic conjunctivitis, 50 dysmenorrhoea management, 118
background, 232–235 allergic rhinitis, 25, 25t irritable bowel syndrome
clinical features, 232, 233f precipitating dermatitis, 240t treatment, 172
conditions to eliminate, 233–234 allergic conjunctivitis, 46f, 47t, amenorrhoea, 118
differential diagnosis, 232–234 50–52, 51t, 62–65 ammonia
epidemiology, 232 allergic contact dermatitis, 212, 230 cold sore treatment, 239t
mild, 232, 233f aetiology, 240 in nappy rash, 302
myths surrounding, 235b clinical features, 240 ammonium salts, 6–8
prevalence, 232 prevalence, 239–240 amorolfine, onychomycosis,
specific questions to ask, 233t allergic reactions 216–218, 217b, 217t
treatment early phase, 25 Anacal, 177t
evidence base for OTC peanuts, 71b anal cushions, 173
medication, 234 allergic rhinitis, 25–34, 30b anal fissure, 174
prescribing and product aetiology, 25 analgesia/analgesics
selection, 235, 235t allergens responsible for, 25t acute low back pain treatment,
trigger points for referral, 234b background, 25–33 263
344 Index
aphthous ulcers (mouth ulcers) bites and stings treatment, 326, artificial tears, 57
treatment, 138, 138t 327t Aspergillus niger, otitis externa, 72
compound see compound common cold treatment, 15, 17, aspirin
analgesics 17t acute low back pain treatment,
headache treatment, 85 insomnia treatment, 92–93 263, 268
proprietary, available OTC, motion sickness prevention, in children, 268b
266t–268t 313–314, 314t gargles, sore throat treatment, 23
sore throat treatment, 23 non-sedating, 30–32 headache treatment, 85
anal itching, 174 possible future deregulation, 333t proprietary brands, 266t–268t
Anbesol, 139 in pregnancy, 30 asthma, 5
androgen antagonists, dry eye, 57t sedating, 32, 295–296, 327 astringents, haemorrhoid treatment,
androgenetic alopecia see hair loss anti-inflammatory drugs 176
angina haemorrhoid treatment, 176 atherosclerosis, 328
atypical, 148 sore throat treatment, 23–24, 24t athlete’s foot, 210–211, 212f
pain, 182 see also non-steroidal anti- atopic dermatitis, 208–209, 291–296,
see also coronary heart disease inflammatory drugs 295b
angiotensin-converting enzyme (NSAIDs) aetiology, 292
(ACE) inhibitors, coughs, 5 antimalarial medication, 323–324 background, 291–296
angular cheilitis, 237, 237f antioxidants in food, 242t clinical features, 292–293,
ankle antipyretics, 298 292f–293f
anatomy, 274f anti-retrovirals, possible future conditions to eliminate, 293
soft tissue injuries, 274 deregulation, 333t differential diagnosis, 292
sprains, 274, 279–281 antispasmodics, irritable bowel distribution, 292f
ankylosing spondylitis, 262, 280t syndrome treatment, epidemiology, 291–292
Anodesyn, 177t 169–170 prevalence, 291–292
Anopheles mosquito, 322–323 antitussives (cough suppressants), severity and social impacts of,
antacids, dyspepsia treatment, 8–9, 10t, 11 294t
148–152, 151t, 152b antivirals, cold sore treatment, 238 specific questions to ask, 293t
antazoline Anusol, 177t treatment
allergic conjunctivitis treatment, anxiety, 121 evidence base for OTC
51t aphthous ulcers (mouth ulcers), 22f, medication, 294
allergic rhinitis treatment, 29, 134–139 prescribing and product
31t–32t aetiology, 134 selection, 294–296, 295t
anterior chamber angle, 43 background, 134 trigger points for referral, 294b
anterior cruciate ligament, 273 causes of, 135–137, 135t atrophic vaginitis, 109, 113
antibacterial agents/antibiotics clinical features, 135 Audax, 74
aphthous ulcers (mouth ulcers) conditions to eliminate, 135–137 auricular haematoma, 73
treatment, 138, 138t differential diagnosis, 134, 137f Auspitz’ sign, 199
bacterial conjunctivitis treatment, epidemiology, 134 autoinoculation, human papilloma
48–50 herpetiform, 136, 136f virus, 222
possible future deregulation, 333t major, 135, 136f Avloclor, 325
sore throat treatment, 21–23 medicine-induced, 136 Avoca, 226t, 227
styes treatment, 55–56 minor, 134–135, 135f, 140 Avomine, 314t, 315
sulphur-containing, 21t prevalence, 134 Axsain, 264
anticholinergics specific questions to ask, 135t azelastine, allergic rhinitis treatment,
as a cause of dry eye, 57t trauma-related, 136, 136f 29, 31t–32t, 33
motion sickness prevention, 313 treatment, 138b azithromycin, chlamydia treatment,
antiepileptics, insomnia-causing, 91t evidence base for OTC 334
antifungal agents medication, 137–138
fungal skin infections treatment, prescribing and product
B
213–215 selection, 138–139, 138t
sore throat treatment, 21–23 trigger points for referral, 137b babies, crying, 289–290, 290t,
antihistamines apocrine sweat glands, 196 310b–311b
acute low back pain treatment, appendicitis, 184 Bacillus cereus, diarrhoea, 154
264 aqueous, 43 back pain, low see low back pain,
allergic conjunctivitis treatment, arachis ear drops, 70–71 acute
51t ARIA (Allergic Rhinitis and its bacterial infections
allergic rhinitis treatment, 29–33 Impact on Asthma) conjunctivitis see conjunctivitis
as antitussives, 8, 10t, 11 guidelines, 25 diarrhoea, 154
atopic dermatitis treatment, arrector pili muscle, 195–196 meningitis, 300
294–296, 295t arteritis, temporal, 84 pneumonia see pneumonia
Index 345
rhinosinusitis, 13 bites see insect bites and stings calcium antacids, 151, 151t
sore throat see sore throats bladder inflammation see cystitis calluses see corns and calluses
see also specific infections bleeding Calpol, 77b, 299
bacterial vaginosis, 111, 113 dysfunctional uterine, 118 Calprofen, 299
Balmosa, 264 heavy menstrual see menorrhagia camphor oil, 71
barrier creams, nappy rash, 304–305 rectal, 173–174, 173t, 175f Campylobacter gastroenteritis, 154
basal cell carcinoma, 224, 245–246 upper gastrointestinal tract, 174 Candida albicans, 112, 139
eyelid, 55 blepharitis Candida sp.
pinna, 73 aetiology, 53 oral, 22f
basal cell papilloma, 224, 224f as a cause of dry eye, 56 skin, 210
Bazuka, 226b, 226t clinical features of, 53–54, 54f candidiasis
Bazuka Extra Strength, 226b, 226t treatment, 55 nappy rash, 304, 304t
beclometasone, allergic rhinitis unresponsive to therapy, 54 oral see oral thrush
treatment, 31t–32t, 32 Blistex, 239t vulvovaginal see vulvovaginal
Beconase Hayfever, 32 body lice, 283 candidiasis
Behcet’s syndrome, 137 body mass index (BMI), 330 Canesten Bifonazole Once Daily 1%
Bell’s palsy as a cause of dry eye, body temperature, 296 w/w Cream, 213
57 bone, 259 Canesten Oasis, 111t
Benadryl Allergy Oral Syrup, 30 Bonjela Cool, 138–139 Canesten oral, 115
Benadryl Allergy Relief, 30 brain, 79 Canesten range, fungal skin
Benadryl One-a-Day, 30 Brevoxyl, 235t infections treatment, 213
benign prostatic hyperplasia British Thoracic Society Guidelines, Capasal, 203t
symptoms, 331–333, 332b cough, 2 capsaicin, acute low back pain
Benylin, 9 Brochlor Eye Ointment, 50 treatment, 264
benzalkonium chloride, 58b Brolene and Golden Eye drops, Capsicum frutescens, 264–265
benzocaine 50–51, 52b captopril, 21t
aphthous ulcers (mouth ulcers) bronchi, 2 carbaryl, head lice treatment, 285
treatment, 138t, 139 bronchiectasis, 5 carbimazole, 21t
bites and stings treatment, 326, bronchioles, 2 Carbo-Dome, 203t
327t bronchitis carbomer 940, dry eye treatment,
haemorrhoid treatment, 176 acute, 4 58–59, 58t
sore throat treatment, 21, 23–24, chronic, 4 carbon dioxide, 1
24t viral, 2–3 carcinoma
benzoic acid Buccastem M, 87, 88t, 97 basal cell see basal cell carcinoma
as a food additive, 242t buclizine, headache treatment, 85, endometrial and cervical, 123
fungal skin infections treatment, 87 gastric, 148
213–214, 214t budesonide, 32 laryngeal, 21
benzoyl peroxide bulk-forming laxatives, 164–165, of the lung, 6
acne vulgaris treatment, 234–235, 165t oesophageal, 148
235t bullae, 198t oral, 137
products containing, 235t bunions, 228 rectal, 174
benzydamine, sore throat treatment, bursae, 259 squamous cell see squamous cell
23–24, 24t bursitis, 275 carcinoma
benzyl benzoate, scabies treatment, Buscopan tonsillar, 21
230–231, 231t dysmenorrhoea management, cardiac arrhythmic drugs, dry eye,
beta-blockers 118–119 57t
as a cause of dry eye, 57t irritable bowel syndrome cardiovascular system and
insomnia-causing, 91t treatment, 171–172 abdominal pain, 178–180
sympathomimetic interaction, butterbur, allergic rhinitis treatment, carmellose
17–18 33 aphthous ulcers (mouth ulcers)
Bifidobacterium, irritable bowel treatment, 138–139, 138t
syndrome treatment, 171 dry eye treatment, 58–59, 58t
C
bifozanole, fungal skin infections carpal tunnel syndrome, 275
treatment, 213, 214t caffeine case studies
biliary colic, 181 acute low back pain treatment, allergic conjunctivitis, 62–65
bisacodyl, constipation treatment, 264 central nervous system, 100–105,
165t, 166b, 167 and insomnia, 91 103b–105b
bismuth, haemorrhoid treatment, proprietary brands, 266t–268t children, 308–311
176 calcium, premenstrual syndrome conjunctivitis, 65b
bismuth subsalicylate, diarrhoea management, 121–122, cough, 37–42, 40b–42b
treatment, 158, 159t, 160 122t dermatology, 252–257
346 Index
ear conditions, 77, 77b Chlamydia trachomatis, 109, cold sores, 236–239, 238b
gastroenterology, 189–194, 333–334 aetiology, 236
190b–194b chloramphenicol, bacterial background, 236–238
musculoskeletal conditions, conjunctivitis treatment, case study, 253b
279–281, 280b–281b 50, 51t, 52b clinical features, 237, 237f
ophthalmology, 62–65, 65b chlorhexidine conditions to eliminate, 237
red eye, 63b–65b aphthous ulcers (mouth ulcers) differential diagnosis, 236–237
respiratory system, 37–42 treatment, 138, 138t epidemiology, 236
sore throat, 38b–39b gingivitis treatment, 145 prevalence, 236
specific product requests, 337–338 mouthwashes, 144 treatment
women’s health, 127–131, chloroquine, malaria prophylaxis, evidence base for OTC
128b–131b 323, 324t, 325 medication, 238
cauliflower ear, 73 chlorphenamine, 30 prescribing and product
cayenne, 264–265 allergic rhinitis treatment, selection, 238, 239t
Celevac, 166 31t–32t, 32 trigger points for referral, 237b
cellulitis, orbital, 54–55 atopic dermatitis treatment, 295, cold therapy, acute low back pain
central nervous system (CNS), 295t treatment, 265
79–105 bites and stings treatment, 327, colic, 289–291, 291b
anatomy, 79 327t aetiology, 289
background, 79–89 cholecystitis, acute, 181 background, 289–291
case studies, 100–105 cholelithiasis, acute, 181 case study, 310b–311b
headache see headache choline salicylate, 74 clinical features, 289–290
history taking, 79 aphthous ulcers (mouth ulcers) conditions to eliminate, 290
insomnia see insomnia treatment, 138–139, 138t differential diagnosis, 289
nausea and vomiting see nausea cold sore treatment, 238 epidemiology, 289
and vomiting chondroitin, acute low back pain prevalence, 289
self-assessment questions, 98–99 treatment, 265 rule of threes, 289
cerumen, 67–68 chondromalacia, 274 specific questions to ask, 290t
cerumenolytics, 70–71 chronic obstructive pulmonary treatment
ceruminous glands, 67–68 disease (COPD), 4 evidence for OTC medication, 290
Cerumol Ear Drops, 70 ciclosporin, 144 prescribing and product
Cerumol Olive Oil Drops, 70–71 ciliary body, 43 selection, 290–291, 291t
cervical carcinoma, 123 cimetidine, dyspepsia treatment, 149 trigger points for referral, 290b
cetirizine, allergic rhinitis treatment, cinchocaine, haemorrhoid treatment, Colief, 291
29–30, 31t–32t 176 Colofac IBS, 172
chalazion, 54 cinnarizine, motion sickness colorectal cancer, 157, 162, 174
chemical irritants, vaginal thrush, 113 prevention, 313–314, 314t colourings, food, 242t
chemoreceptor trigger zone, 95 Clarityn Allergy, 32 Colpermin IBS Relief, 172
chicken pox, 300, 301f, 303t, 309b clemastine, atopic dermatitis Colsor, 239t
children, 283–311 treatment, 295, 295t comedones, 198t
aspirin in, 268b Clinical reasoning, xi–xii common cold, 12–19, 16b
atopic dermatitis see atopic Clinitas Gel, 59 aetiology, 12
dermatitis clobetasone, dermatitis treatment, background, 12–18
background, 283–287 243, 243t, 245 causes of, 12t
case studies, 308–311 clotrimazole clinical features, 13
colic see colic fungal skin infections treatment, conditions to eliminate, 13–14
cough medication for, 9 213, 214t differential diagnosis, 12–14
coughs in, 2 vaginal thrush treatment, 114–115 epidemiology, 12
fever see fever in children cluster headache, 79–80, 81f, 83 prevalence, 12
functional constipation, 162 coal tar specific questions to ask, 13t
head lice see head lice dandruff treatment, 205–206 treatment
history taking, 283 psoriasis treatment, 202, 203t alternative therapies, 15–16
infectious diseases, 300–302 Cocois, 203t antihistamines, 15, 17, 17t
insomnia in, 91 coconut oil, head lice treatment, 285 evidence base for OTC
laxatives in, 165 codeine, 11 medication, 14
nappy rash see nappy rash as an antitussive, 8, 10t multi-ingredient preparations, 15
nausea and vomiting in, 96 headache treatment, 85 prescribing/product selection,
self-assessment questions, proprietary brands, 266t–268t 16–18, 17t
306–307 coeliac disease, 157 sympathomimetics, 15, 17–18,
threadworm see threadworm coffee and insomnia, 91 17t
see also infants; neonates colds see common cold trigger points for referral, 14b
Index 347
proximal subungual onychomycosis red eye, 44–52 rubefacients, acute low back pain
(PCO), 217t aetiology, 45 treatment, 264, 269
pruritus, anal, 174 background, 44–45 rubella, 302, 303t
pseudoephedrine, common cold case study, 63b–65b runners knee, 274
treatment, 17t, 18 causes, 45–48, 45t Rynacrom 4% Nasal Spray, 33
Pseudomonas aeruginosa, 72 conditions to eliminate, 45–48
psoriasis, 197–204 differential diagnosis, 45, 49f
S
aetiology, 198 epidemiology, 45
background, 197 prevalence, 45 St John’s wort, 94b
clinical features, 199, 199f specific questions to ask, 46t Salactol, 226t
conditions to eliminate, 200–201 treatment Salatac, 226b, 226t
differential diagnosis, 198–199, evidence base for OTC salbutamol, possible future
202f, 209, 212, 241, 293 medicines, 48–50 deregulation, 333t
epidemiology, 197–198 prescribing/product selection, salicylic acid
erythrodermic, 200 50, 51t acne vulgaris treatment, 234
guttate (raindrop), 200, 201f trigger points for referral, 48b dandruff treatment, 206
medication-exacerbated, 201 Regaine, 221, 221t psoriasis treatment, 202
in nails, 216 Regulan, 165–166 warts and verrucas treatment,
plaque, 197–201, 199f–200f, 202f regurgitation, 96 224–225, 226t
prevalence, 197–198 renal colic, 182 saline sprays, common cold
pustular, 200, 200f repetitive strain injury, 275 treatment, 16
scalp, 198–199, 201 respiratory syncytial virus, 4 Salix alba, 264–265
seborrhoeic (flexural), 200 respiratory system, 1–42 Salmonella gastroenteritis, 154
specific questions to ask, 199t anatomy, 1–2 salpingitis, 185
treatment, 203b case studies, 37–42 salt water gargles, sore throat
evidence base for OTC cough see cough treatment, 23
medication, 201–203 history taking, 2 Sarcoptes scabiei, 229
prescribing and product lower, 1–2 Savlon Bites and Stings Pain Relief
selection, 203–204, 203t physical exam, 2 Gel, 326, 327t
trigger points for referral, 201b self-assessment questions, 35–36 scabies, 229–232
psoriasisiform nappy rash, 304t upper, 1–3, 12, 298 aetiology, 229
Psoriderm, 203t retina, 44 background, 229–231
PSORS1, 198 Reyes syndrome, 268b case study, 256b–257b
puberty and acne vulgaris, 232 rhinitis, 13 clinical features, 229
pubic lice, 283 allergic see allergic rhinitis conditions to eliminate, 230
pupil, 43 infective, 26 differential diagnosis, 229–230
pustular psoriasis, 200, 200f medicine-induced, 27 epidemiology, 229
pustules, 198t of pregnancy, 27 prevalence, 229
pyelonephritis, 108 vasomotor (intrinsic), 26–27, specific questions to ask, 230t
pyloric stenosis, 96 28f treatment
pyridoxine see vitamin B6 rhinitis medicamentosa, 27, 37 evidence base for OTC
(pyridoxine) Rhinolast Allergy, 33 medication, 230
rhinosinusitis, 14f prescribing and product
acute, 13 selection, 230–231
Q rhinovirus, 4 trigger points for referral, 230b
quadriceps tears, 275 RICE, 275–276 scalp
Quinoderm, acne vulgaris treatment, rice-based oral rehydration solution, dandruff see dandruff
234, 235t 158 fungal infection of the, 201
ringworm, 210 psoriasis, 198–199, 201
Robitussin, 9, 11 Scholl Advance, 214, 214t
R rofecoxib, 264–265 Scholl Athlete’s Foot products, 214
rabeprazole, dyspepsia treatment, rosacea, 209, 233, 233f sciatica, 261, 280t
151t, 153 as a cause of dry eye, 57 sclera, 43
Radian B, 269 roseola infantum, 298 scleritis, 47
raindrop psoriasis, 200, 201f Rotarix, 158 sclerosing agents, haemorrhoid
Ralgex, 264, 269 RotaTeq, 158 treatment, 176
ranitidine, dyspepsia treatment, 149, rotator cuff syndrome, 272 scopolamine, motion sickness
152–153 rotavirus prevention, 313
Ranzac, 152–153 gastroenteritis, 154 Sea Bands, 314
rectal bleeding, 173–174, 173t, 175f vaccine, 158 Sea-Legs, 314t, 315
rectal carcinoma, 174 roundworms, 287 sebaceous glands, 195–196
358 Index
SebCo, 203t cancer see basal cell carcinoma; causes of, 19–21, 19t
seborrhoeic dermatitis, 201, 205, malignant melanoma; clinical features, 19
207–210 squamous cell carcinoma conditions to eliminate, 19–21
aetiology, 207–208 fungal infections see fungal differential diagnosis, 19–21, 22f
background, 207–210 infections, of the skin epidemiology, 19
clinical features, 208, 208f–209f slapped cheek disease, 302 medicine induced, 20, 21t
conditions to eliminate, 208–209 sleep physical examination, 19
differential diagnosis, 208, 284, daytime, 91t prevalence, 19
293 disorders see insomnia specific questions to ask, 20t
epidemiology, 207 hygiene, 92, 93t streptococcal, 19–20
medications that trigger, 209 need for, 90 trauma-related, 20, 22f
nappy rash, 304, 304t patterns, 91t treatment
prevalence, 207 small round structured virus (SRSV), analgesia, 23
specific questions to ask, 208t gastroenteritis, 154 antibacterial and antifungal
treatment SMART cancer prevention, 248 agents, 21–23
evidence base for OTC smoking, 318 anti-inflammatories, 23–24, 24t
medication, 209–210 cessation, 329t–330t (see also aspirin and salt water gargles,
prescribing and product nicotine replacement 23
selection, 210, 210t therapy) evidence base for OTC
trigger points for referral, 209b and chronic bronchitis, 4 medication, 21
seborrhoeic (flexural) psoriasis, 200 sneezing, 28f local anaesthetics, 21, 23–24,
seborrhoeic wart, 224, 224f, 247 Snellen charts, 44 24t
sebum, 196 Sno Tears, 59 prescribing/product selection,
sedating antihistamines, 32, sodium bicarbonate 23–24, 24t
295–296, 327 cystitis treatment, 109 trigger points for referral, 21b
selective serotonin reuptake ear drops, 71 viral, 19, 21t
inhibitors (SSRIs) sodium citrate, cystitis treatment, space-occupying lesions, 84
as a cause of dry eye, 57t 109 Spasmonal
insomnia-causing, 91t sodium cromoglicate dysmenorrhoea management, 118
selenium sulphide, dandruff allergic conjunctivitis treatment, irritable bowel syndrome
treatment, 206–207 51, 51t treatment, 172
Selsun, 206–207, 206b allergic rhinitis treatment, 29–30, specific product requests
senna, constipation treatment, 165t, 31t–32t, 33 benign prostatic hyperplasia
167 sodium hyaluronate, dry eye symptoms, 331–333
Senokot, 167 treatment, 59 bites and stings see insect bites
sensory conflict hypothesis, 313 sodium picosulphate, constipation and stings
sexually transmitted diseases, 109 treatment, 165t, 167 case studies, 337–338
shark liver oil, haemorrhoid sodium salts, dyspepsia treatment, chlamydia treatment, 333–334
treatment, 176 149, 151, 151t coronary heart disease see
Shigella gastroenteritis, 154 soft corns, 228 coronary heart disease
shingles, 183, 254b–255b, 300, soft tissue injuries, 271–276 emergency hormonal
301f aetiology, 271 contraception see
shin splint syndrome, 275 background, 271 emergency hormonal
shoulder case study, 279–281 contraception
anatomy, 271, 271f clinical features, 271–275 malaria prophylaxis see malaria,
frozen, 272 conditions to eliminate, 275 prophylaxis
injuries, 273f differential diagnosis, 271 motion sickness see motion
range of motion, 273f epidemiology, 271 sickness
soft tissue injuries, 271–272 prevalence, 271 nicotine replacement therapy see
silver nitrate, warts and verrucas specific questions to ask, 272t nicotine replacement
treatment, 226t, 227 sprains, 271 therapy
simeticone, colic treatment, strains, 271 possible future deregulations,
290–291 treatment, 275–276 333t, 334
Simple eye ointment, 59 trigger points for referral, 275b self-assessment questions,
simvastatin, 328, 330 Sominex, 94 335–336
sinuses, 13, 14f sore throats, 19–25, 23b weight loss see weight loss/
sinusitis, 83 aetiology, 19 obesity
sixth disease, 298 anatomy, 20f spinal cord, 79
Sjögren’s syndrome, 56–57 background, 19–24 splenic enlargement/rupture, pain in,
skin bacterial, 19–20, 21t 180
anatomy, 195–196, 196f case study, 38b–39b sponging, fever treatment, 298
Index 359
sports-related soft tissue injuries see conditions to eliminate, 247–248 clinical features, 287
soft tissue injuries differential diagnosis, 246 conditions to eliminate, 287
sprains, 271, 274, 279–281 treatment differential diagnosis, 287
sputum, 3–5, 3t, 7f evidence base for OTC epidemiology, 287
squamous cell carcinoma, 245–246 medication, 248 prevalence, 287
oral, 141 prescribing and product treatment, 288–289, 288t
on the pinna, 73 selection, 248–249, 248t trigger points for referral, 288b
squill, 6–8 trigger points for referral, 248b throat
Staphylococcus aureus sun protection factor (SPF), 248 anatomy, 20f
diarrhoea, 154 sunscreens, 248 sore see sore throats
impetigo, 300–301 chemical, 248–249, 248t thrush
Staphylococcus sp. physical, 248t, 249 oral see oral thrush
conjunctivitis, 45 superficial white onychomycosis, vulvovaginal see vulvovaginal
cystitis, 107–108 217t candidiasis
otitis externa, 72 suppositories, constipation Tinaderm, fungal skin infections
steam inhalation, common cold treatment, 166b treatment, 214
treatment, 16 sweat glands, 195–196 tinea capitis, 201, 205, 210, 220
steatorrhoea, 157 sympathomimetics tinea corporis, 201, 210, 212, 212f
sterculia, 165–167, 165t allergic conjunctivitis treatment, tinea cruris, 210, 212
stimulant laxatives, 164, 165t, 167 51, 51t tinea faciei, 212
stimulants, insomnia-causing, 91t allergic rhinitis treatment, 29–30, tinea manuum, 212
Stingose, 326–327 31t–32t, 33 tinea pedis, 210–211, 212f
stings see insect bites and stings common cold treatment, 15, tinea unguium, 210, 216f
stomach 17–18, 17t see also onychomycosis
anatomy, 133 drug interactions, 17–18 toenails, fungal infection see
cancer, 146–148 headache treatment, 87 onychomycosis
stool softeners, 164, 165t, 167 systemic, 17t, 18 toki-shakuyaku-san, 118
strains, 271, 275 topical/nasal, 17t, 18 tolnaftate, fungal skin infections
Strefen, 24 Syndol, 264 treatment, 213–214, 214t
streptococcal sore throat, 19–20 synovial joints, 259 tonsillar carcinoma, 21
Streptococcus pneumoniae toothbrushing, 144
conjunctivitis, 45 trachea, 2
T
pneumonia, 5 traction alopecia, 220
Streptococcus pyogenes, 19 tamsulosin, 331–332, 332b tranexamic acid, heavy menstrual
impetigo, 300–301 tapeworms, 287 bleeding, 123–124
otitis externa, 72 tar-based products, psoriasis transcutaneous electrical nerve
stress treatment, 203–204, 203t stimulation (TENS),
and hair loss, 219 tartar, 143 dysmenorrhoea
and irritable bowel syndrome, Tavegil, 295 management, 118
168–169 tears trauma
stress fractures, 275 composition, 56 aphthous ulcers (mouth ulcers),
Sturgeon 15, 314, 314t underproduction of see dry eye 136, 136f
styes tea tree oil ear canal, 69
aetiology, 53 acne vulgaris treatment, 234 head, 84
clinical features of, 54, 54f head lice treatment, 285 nail, 216
treatment, 55–56 telogen effluvium, 219 sore throats, 20, 22f
subarachnoid haemorrhage, 84 temporal arteritis, 84 trauma-related sore throats, 20, 22f
subconjunctival haemorrhage, tendon injuries see soft tissue traveller’s diarrhoea, 158
45–46, 47f injuries travel sickness see motion sickness
Sudafed, 18 tennis elbow, 272 triamcinolone, 31t–32t, 33, 137–138
Sudocrem, 304–305 tension-type headache, 79–82, 81f triazoles, vaginal thrush treatment,
sulfasalazine, 21t terbinafine, fungal skin infections 114
sulphites, 242t treatment, 213–214, 214t trichiasis, 53–54
sulphur, acne vulgaris treatment, T/Gel, 203t trichomoniasis, 111, 113
234 theophylline avoidance, 10b Trichophyton sp., 216
sulphur-containing antibiotics, 21t thermoregulation, 296 trichotillomania, 220
sumatriptan, headache treatment, thiamine see vitamin B1 (thiamine) trigeminal neuralgia, 84
87–89 thigh strains, 275 trimethoprim, 109, 334
sun exposure, 245–249, 249b threadworm, 287–289, 288b triptans, 87–88
aetiology, 246 aetiology, 287 tuberculosis (TB), 5–6
background, 245–249 background, 287–289 tympanic membrane, 67–68
360 Index
background, 222–227
U W
case study, 252–257
ulcerative colitis, 155, 174 clinical features, 222–223, 223f warfarin
ulcers conditions to eliminate, 223–224 interaction with miconazole,
mouth see aphthous ulcers (mouth differential diagnosis, 222–224, 142–143
ulcers) 228 medicine-induced gum bleeding,
peptic see peptic ulceration epidemiology, 222 144
ulipristal, 316 prevalence, 222 Wartex, 226t
ultraviolet spectrum, 245–249 specific questions to ask, 223t warts, 222–227, 226b
undecenoates, fungal skin infections treatment aetiology, 222
treatment, 213, 214t evidence base for OTC background, 222–227
upper airways cough syndrome, 4 medication, 224–225 clinical features, 222, 223f
upper gastrointestinal tract bleeding, prescribing and product conditions to eliminate, 223–224
174 selection, 225–227, 226t differential diagnosis, 222–224
upper respiratory tract, 1 trigger point for referral, 224b epidemiology, 222
infection, 2–3, 12, 298 Verrugon, 226t prevalence, 222
urea, cold sore treatment, 239t vesicles, 198t specific questions to ask, 223t
urea hydrogen peroxide, 71 Vicks, 9 treatment
urinary calculi, 182 Vioxx, 264–265 evidence base for OTC
urinary tract infections (UTIs) viral infections medication, 224–225
in children, 290 bronchitis, 2–3 prescribing and product
cystitis see cystitis common cold see common cold selection, 225–227, 226t
fever in, 298 conjunctivitis see conjunctivitis trigger point for referral, 224b
urticaria, 241, 242f cough, 3–4 Wasp-Eze Spray, 326
uterine bleeding, dysfunctional, 118 diarrhoea, 154 Waxsol, 71
UVA, 245–249 meningitis, 300 weight loss/obesity, 330–331, 331b
UVB, 245–249 rhinitis see rhinitis aetiology, 331
UVC, 245–249 sore throat see sore throats background, 330–331
uveitis, 47–48, 48f Virasorb, 238, 239t coronary heart disease prevention,
UV light Viscotears, 58–59 329t–330t
psoriasis treatment, 203b vitamin B6 (pyridoxine), premenstrual epidemiology, 330–331
see also UVA; UVB; UVC syndrome management, evidence base for OTC medication,
121–122, 122t 331
vitamin B1 (thiamine), prescribing and product selection,
V
dysmenorrhoea 331
vaccines management, 118 prevalence, 330–331
Hib, 300 vitamin C, common cold treatment, Wessel’s criteria, 289
MMR, 300 15 wheeze, medicine-induced, 5
rotavirus, 158 vitamin D deficiency, 249b white willow bark, 264–265
vaginal discharge, 111–116 voice box, 1 Whitfield’s ointment, fungal skin
background, 111–115 Voltarol Pain-Eze, dysmenorrhoea infections treatment,
causes of, 112t management, 119 213–214, 214t
conditions to eliminate, 113 vomiting see nausea and vomiting women’s health, 107–131
differential diagnosis, 112 vomiting centre, 95 abdominal pain, 185
epidemiology, 112 vomiting reflex, 95 background, 107–111
prevalence, 112 vulval itching, 112 case studies, 127–131
specific questions to ask, 112t vulvovaginal candidiasis, 111 cystitis see cystitis
vaginitis, 109 aetiology, 112 dysmenorrhoea see
atrophic, 109, 113 case study, 130b–131b dysmenorrhoea
vaginosis, bacterial, 111, 113 clinical features, 112 history taking, 107
valerian, 93 differential diagnosis, 112, 114f menorrhagia see menorrhagia
Valoid, 314, 314t epidemiology, 112 period pain see dysmenorrhoea
vapour inhalation, common cold medicine-induced, 113 premenstrual syndrome see
treatment, 16 prevalence, 112 premenstrual syndrome
varicella zoster virus, 300 recurrent, 113 (PMS)
vasomotor (intrinsic) rhinitis, 26–27, treatment self-assessment questions,
28f evidence base for OTC 125–126
Veracur, 226t, 227 medication, 114 vaginal discharge see vaginal
verruca plana, 223 prescribing and product discharge
verrucas, 222–227, 226b selection, 114–115, 115t wool fats, dry eye treatment, 58t,
aetiology, 222 trigger points for referral, 113b 59
Index 361