the otc treatment clinic

education
Supporting Training Initiatives
the otc
treatment clinic
Common conditions and their treatment options
This module has been endorsed with the NPA’s Training Seal as suitable for use by medicines counter assistants
as part of their ongoing learning. Complete the questions at the end to include in your self-development portfolio
module 194
Welcome to TM’s OTC
Treatment Clinic series. This
handy, four-page section is
specially designed so that
you can detach it from the
magazine and keep it for
future reference.
Each month, TM covers a
different OTC treatment area
to help you keep up-to-date
with the latest product
developments. In this issue,
we focus on itchy skin.
At the end of the module
there are multiple choice
questions for you to
complete, so your progress
can be monitored by your
pharmacist.
You can find out more in
the Counter Intelligence Plus
training guide.
The last six topics we have
covered are:
l Hair loss (alopecia)
l Heartburn and indigestion
l Ovulation and pregnancy
testing
l Dry skin – part 1
l Nasal health and hygiene
l Coughs
You can download previous
modules from
www.tm-modules.co.uk
Itchy skin
author: Jane Feely, PhD
for this module
OBJECTIVES: After studying this module, assistants will:
• Be aware of the structure of human skin and the various functions it performs
• Know that itching is a common symptom of many different skin-related conditions
• Be familiar with the common causes of itching, including dry skin, allergic conditions,
infections and insect bites
• Be able to advise on appropriate over-the-counter skin products
• Be able to suggest tips to help customers look after their skin and reduce itching.
An itch is such a common experience that it’s
not something we usually pay much attention to –
you’ll probably scratch a slight itch as you read this
OTC Treatment Clinic. But occasionally that itch can
become more noticeable and, rarely, more serious.
This month we’re taking a closer look at the skin
and what makes us itch, from common conditions
like allergies to infections like ringworm and
chickenpox. We’ll also look at some of the OTC
products available and pass along tips that can
help ensure skin stays healthy and itch-free.
A closer look at skin
Did you know that your skin is the largest organ in
your body? According to the British Association of
Dermatologists, the average adult has two square
metres of skin, accounting for about 16 per cent of
their weight.
On average, each half-inch square of skin contains
10 hairs, five sebaceous glands, 100 sweat glands
and a metre of tiny blood vessels.
As you may remember from our previous OTC
Treatment Clinic on dry skin, the skin is made up
of two main layers – the epidermis and the dermis.
The epidermis is comprised mostly of skin cells
called keratinocytes. These are formed in the lowest
layer of the epidermis and as they mature, they
move up towards the surface of the skin. Once
there, they are eventually worn off and lost, only
to be replaced by new cells following behind. On
average, it takes about 60 days for newly formed
skin cells to reach the surface and be shed.
The dermis layer is thicker than the epidermis
and contains many different types of structures to
keep the skin healthy. These include blood vessels
that bring nutrients to the cells, nerves that provide
our sense of touch, and proteins such as collagen
and elastin that give skin its strength and flexibility.
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the otc treatment clinic
reflective exercise
Alan Smith is a regular customer at the
pharmacy. He is in his early 30s and has
suffered from eczema for many years. He
usually obtains hydrocortisone cream on a
repeat prescription from his GP, but says he
would prefer to buy his supplies from you
to save him and his GP time. He shows you
the eczema on his hands, which is cracked
and weeping.
What would you recommend?
Refer Alan to the pharmacist as the eczema
on his hands appears to be infected. The
pharmacist will likely refer Alan to his GP.
A topical corticosteroid cream, for example,
should not be used on infected skin.
Later that day, Alan returns with a
prescription for flucloxacillin and
betamethasone ointment 1%. You give
Alan his completed prescription.
What other advice could you give?
Reassure Alan that the infection should
clear up within a week to 10 days. You
could also consider asking Alan about his
use of emollients. Which ones has he used
and how helpful have they been? Does he
use a bath oil? Does he apply emollient to
his skin following a bath or shower? What
Hair follicles also have their base in the
dermis, although the hair shaft itself extends
through to the skin’s surface. Each hair follicle
has a small sebaceous gland that produces an
oily substance to coat the hair.
The dermis is also where we find sweat
glands – ducts which also lead out onto the
surface of the skin.
Our skin performs a number of functions:
l A protective barrier – healthy, well-hydrated
skin is an excellent barrier against harmful
agents like chemicals and bacteria. By making
the brown pigment melanin, skin also helps
protect against the sun’s harmful UV rays
l Temperature regulation – when we’re warm,
the body produces sweat and when this
evaporates from the surface of the skin, it cools
us down. On the other hand, when we’re cold,
tiny muscles raise the hairs up off the skin’s
surface, trapping a layer of warm air next to
the skin
l Vitamin production – when the skin is
exposed to sunlight, it makes vitamin D, which
is important for the growth and maintenance
of bones and for healthy nervous and immune
systems.
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TM JUNE 2013
does he use to cleanse his skin? It is
important that standard soaps and bath
products are avoided. Emollient preparations
should be used as often as needed to keep
the skin moist and hydrated. Several and
frequent applications may be needed each
day to achieve this.
What if:
Alan comes to the pharmacy saying that he
is planning a walking holiday in Scotland. He
reacts badly to midge bites and wants to buy
a cream to treat any skin reactions to bites
he suffers while he’s away.
What would you recommend?
Alan could use a topical corticosteroid
cream (e.g. hydrocortisone or clobetasone
butyrate). A combination product (i.e. a
corticosteroid with an anti-itch ingredient)
could be useful. Another possibility would
be a topical antihistamine (but for no longer
than three days’ use due to the possibility of
increased skin irritation). Local anaesthetic
preparations containing, for example,
lidocaine or benzocaine can also help to
relieve the pain of an insect bite by numbing
the area. Alan should also ensure that he
uses insect repellent and covers as much of
his skin as possible (e.g. with long sleeves,
long trousers, long socks and possibly a hat).
What is an itch?
The correct medical name for itching is
pruritus. Put simply, an itch is any kind of
tingling or irritating sensation in the skin that
causes us to scratch the affected area. Itching
may occur all over the body (generalised) or
in one specific area (localised).
Scratching is a reflex action to an itch, but
unfortunately, the more a person scratches, the
more they itch. This is termed the ‘itch-scratch
cycle’ and breaking it can be an important part
of treating an itchy skin condition.
Skin that is scratched frequently is at greater
risk of bacterial infection, permanent scarring,
thickening or even changes in colour.
Itching is often triggered by the release of
the chemical histamine – something you will
be familiar with from modules on hayfever and
allergies. This is also why itching is a common
symptom of allergic conditions.
Ask questions
There are many different causes of itching,
ranging from a simple reaction to an insect bite
to a more serious systemic condition such as an
overactive thyroid gland.
Sometimes it is obvious what the cause is –
a visible rash is a good clue. At other times, the
cause won’t be immediately apparent and you
may have to ask questions. This will help you to
determine if your customer can self-treat or if
they should be referred.
Questions that can help you include:
l How long has the itching been present? Did
it come on suddenly or gradually? Is it there all
the time or does it come and go? Has this itch
occurred before?
l Where is the itch? Location is a key factor.
For example, itchy eyes and nose are indicative
of hayfever; an itchy scalp may suggest
headlice; vaginal itching is a symptom of
thrush; anal itching can be linked to
threadworms or haemorrhoids, etc
l Is there a rash? If so, what does it look like?
Does it appear to be spreading?
l Is anyone else affected? Chickenpox and
scabies are contagious, for example, and if
the cat has fleas or a friend has headlice, it
might provide valuable clues
l Does anything make it worse? Is it linked to
cosmetics, jewellery or washing powder? Is it
connected to a particular event (e.g. a recent
course of medicine, something unusual in the
diet, use of cleaning chemicals, etc)?
Common causes of itch
l Dry skin
Skin that loses moisture feels tight and prickly,
so it’s no surprise that dry skin is one of the
most common causes of itching. Some people
have naturally drier skin, while for others, dry
skin is a feature of ageing.
Dry skin can also occur if a person doesn’t
drink enough water, if they are exposed to
drying chemicals such as harsh soaps or
solvents, or if the air where they live or work
is low in humidity.
l Allergic conditions
a) Atopic eczema
This is the most common form of eczema
and is primarily seen in children. According
to figures from the National Eczema Society
(NES), between five and 15 per cent of UK
children are affected by atopic eczema by
the age of seven. Many grow out of it though
– in approximately 74 per cent of children, the
eczema will have disappeared by the age of 16.
The exact cause of atopic eczema isn’t clear,
but research suggests that a combination of
genetic and environmental factors play a part.
Symptoms include dry, itchy, scaly skin,
typically affecting the insides of the elbows,
backs of the knees and the face. When the
eczema flares up, open, weeping or crusted
sores may develop as a result of scratching or
a secondary bacterial infection.
Flare-ups may be triggered by pollen, soaps,
detergents, house dust mites and animal hair.
the otc treatment clinic
fleas, ticks and
bedbugs.
Symptoms may
vary depending on
the type of insect,
how often the
person was bitten
and how sensitive
they are to the bites
in question. For
some, it may be
merely a couple
of small, itchy, red
bumps that fade
within a short period
of time. For others,
it can be numerous
Itchy skin can be a nuisance as well as a sign that something is wrong red, inflamed areas
with blisters or even
b) Contact dermatitis
a secondary bacterial infection.
This type of eczema occurs as a result of
Flea bites tend to be grouped in lines or
contact with irritants or allergens in the
clusters, often below the knees and commonly
environment. The NES states that nine per
around the ankles. Bedbug bites, which are
cent of the UK population is affected by this
becoming more of a problem in hotels
condition, which is the most common type of
worldwide, often occur on the face, neck,
work-related skin disease.
hands and arms.
Symptoms of contact dermatitis may range
Ticks often stay attached to the skin for
from mild dryness and skin redness to the
some time while they feed. They should be
appearance of skin burns with red, painful,
removed carefully to make sure that the
fluid-filled skin ulcers. Soaps, detergents,
mouthparts don’t remain in the skin and
chemicals, hair cosmetics, bleach and raw food
become infected. Ticks may also carry bacteria
are common triggers.
that cause Lyme disease – an infection with
symptoms such as a rash and high fever.
c) Urticaria
A repellent spray should be recommended
Urticaria, also known as hives or nettle rash, is
to customers who know they will be visiting
a raised, itchy rash that may be limited to one
places where insect bites are a possibility.
part of the body or spread across larger areas.
l Infections
Urticaria affects around one person in six at
some point in their lives. It is most common in
a) Chickenpox
children, women aged 30-60 and people with
This is an infection caused by the varicella zoster
a history of allergies.
virus. Most children seem to catch chickenpox
This condition occurs when a trigger
at some time – usually before the age of 10. It
causes high levels of histamine and other
causes a rash of red, itchy spots that turn into
chemicals to be released in the skin. Exactly
fluid-filled blisters before forming scabs that
what prompts this release may not be clear,
eventually drop off. Some children have only
but exposure to materials like latex and certain
a few spots, while others seem to be covered.
foods or drugs may be a factor. Symptoms may
The spots often appear first on the face,
also be triggered by non-allergic sources like
ears and scalp and then under the arms, on the
rubbing the skin, cold, heat, sunlight or
chest, stomach, arms and legs. A fever may also
physical exercise. In many people, the cause
be present. A child with chickenpox will be
remains unknown.
infectious from one to two days before the rash
The rash of urticaria may develop quickly
appears until after all the blisters have crusted
and then disappear within a few hours or days.
over (usually five to six days after the start of
If it clears completely within six weeks, it is
the rash).
called acute urticaria. Chronic, long-term
Paracetamol can be recommended to help
urticaria is much less common and may
reduce a fever, along with soothing lotions like
continue over many years.
calamine to address the itchy rash.
l Insect bites
When certain insects bite, they inject saliva
into the skin and this can trigger a reaction
that leads to itchy, red lumps. In the UK,
common culprits include midges, mosquitoes,
b) Tinea
Tinea is a fungus that thrives in human skin.
There are different types, but the most
common are tinea pedis, which causes athlete’s
foot, tinea corporis (ringworm) and tinea cruris
(dhobie itch or jock itch).
Athlete’s foot, as its name suggests, affects
the skin between the toes. The skin is itchy and
may appear red or white, cracked and peeling
or inflamed and weeping. The infection is
contagious and is often acquired by walking
barefoot in changing rooms at swimming pools
or gyms. This infection usually responds well to
OTC antifungal products.
Ringworm starts with a small area of
infection on the skin and then spreads outward,
with the centre of the rash healing as it goes.
This gives the infection its typical ring-like
appearance. The rash can range from being
mildly irritating to very itchy and inflamed.
Dhobie itch affects the skin around the
groin area and upper thigh. It is most common
in young people and in more obese individuals
and often occurs with athlete’s foot.
c) Scabies
This is a contagious skin condition caused by a
tiny mite that burrows into the skin. The main
symptom is intense itching. Scabies can be
spread by prolonged skin-to-skin contact or by
self care tips
l If itching is severe, apply an anti-itch
cream or lotion to the affected area
l Avoid scratching whenever possible
l Cover any itchy area that you can’t
avoid scratching
l Keep fingernails short, smooth and clean
to prevent scratching
l At night, wear cotton gloves or socks to
prevent scratching
l Protect skin from the sun
l Do not wear tight, occlusive clothing.
Choose smooth-textured cotton or silk
rather than synthetic fabrics. Remember
that wool can be itchy
l Choose mild soaps and rinse any soap
off your body
l Take comfortably cool (not hot) baths
and showers
l Use non-soap cleansers followed by
a liberal use of emollient
l Apply cool, wet compresses. This can
help protect the skin and prevent
scratching
l Use a mild, unscented laundry product
when washing clothes, towels and
bedding. Using the extra rinse cycle in the
washing machine may be helpful
l Avoid substances that irritate the skin
or cause an allergic reaction. These can
include nickel, jewellery, perfume, cleaning
products and cosmetics.
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the otc treatment clinic
sexual contact with an infected individual. The
infection may also be passed on by sharing
clothes, towels or bedding with an infected
person, but this is much less likely.
Specific antiparasitic products need to be
recommended for scabies infections (e.g.
Lyclear Dermal Cream).
When to refer to the pharmacist
In most cases, itching will resolve once the
underlying cause has been addressed.
However, there are occasions when customers
should be referred to the pharmacist:
l Itching that persists for longer than two
weeks or symptoms that keep returning
l Itching so severe that it prevents the sufferer
from carrying out their daily routine or
interferes with sleep
l Itching that appears to affect the whole body
l Sudden itching or rash where there is also
swelling and/or shortness of breath – this could
be a sign of a severe allergic reaction
l Itching accompanied by other symptoms
such as fever, abdominal pain, vomiting,
tiredness, weight loss, yellowing of skin or eyes,
changes in bowel habits or urinary frequency
l Itchy rash with inflammation, crusting or
oozing – this may be a sign of a secondary
bacterial infection
l Pregnant women or anyone being treated
for an underlying medical condition – e.g.
kidney, liver or thyroid disease, diabetes
l Symptoms that cannot easily be explained
or don’t improve with self-care measures.
OTC treatment choices
There are many different products available
over the counter. It can help to group these
active ingredients by their mode of action.
l Emollients
A mainstay in the relief of dry skin and eczema,
‘emollients’ is a term used to describe
moisturising products that restore the skin’s
water content, preventing scaling and cracking.
The regular use of emollients will help reduce
itching due to dry skin and help manage
eczema flare-ups.
Complete emollient therapy may involve
the use of different moisturising preparations
throughout the day and bath additives and
soap substitutes for cleansing. OTC examples
include Dermol, Doublebase, E45, Diprobase,
Epaderm and Oilatum.
l Antipruritics
As the name suggests, these ingredients are
designed to help soothe pruritus (itching).
Common OTC antipruritic ingredients include
calamine (e.g. Care Aqueous Calamine Cream,
Care Calamine Lotion), crotamiton (e.g. Eurax)
and urea (e.g. Aquadrate, E45 Itch Relief
Cream, Hydromol Intensive, Nutraplus Cream).
Some products are also available to help
cool and soothe the skin.
l Topical corticosteroids
Lower strength versions of some topical
corticosteroids are available over the counter,
while stronger products remain prescription
only. These products work by reducing
inflammation and are recommended for the
short-term treatment of eczema and dermatitis.
They can also be used to treat skin reactions
caused by insect bites. Hydrocortisone, in
strengths up to 1%, has been available OTC
for some time. Brands include Hc45 and
Lanacort. Also available OTC is clobestasone
butyrate 0.05% (e.g. Eumovate) and combination
products that provide a corticosteroid with
an antipruritic (e.g. Eurax HC). There are a
number of restrictions as to who can use OTC
topical corticosteroids, how long the product
can be used and for what conditions it can be
sold. Talk to your pharmacist about how you
should handle requests for these products.
l Topical antihistamines
These can be used in allergic skin conditions,
including insect bite reactions. Common
examples include mepyramine maleate (e.g.
Anthisan) and diphenhydramine hydrochloride
(e.g. Benadryl Skin Allergy Relief Cream).
These products may cause skin irritation, so
their use is not recommended for longer than
three days.
l Local anaesthetics
These products are designed to help relieve
the pain associated with skin conditions such
as insect bites and stings by numbing the
affected area. Common OTC ingredients
include benzocaine (e.g. Burn-eze, Wasp-eze,
Lanacane) and lidocaine (e.g. Dermidex
Dermatological Cream, Emla Cream, Savlon
Bites & Stings Pain Relief Gel).
l Topical antifungals
These products target topical fungal infections
such as athlete’s foot and ringworm. OTC
antifungals include a group of products called
imidazoles. Examples include clotrimazole (e.g.
Canesten AF, Care Clotrimazole 1%),
miconazole (e.g. Daktarin) and ketoconazole
(e.g. Daktarin Gold, Daktarin Intensiv).
Other antifungal ingredients include
terbinafine (e.g. Lamisil), tolnaftate (e.g. Scholl
Athlete’s Foot) and undecenoates (e.g. Mycota).
assessment questions: itchy skin
For each question, select one correct answer. Discuss your answers with your pharmacist.
1. Which of the following statements
is TRUE?
a) The skin is the largest organ in
the body
b) The epidermis is thicker than the
dermis
c) An average adult has one square metre
of skin
d) Sweat glands are found in the
epidermis
2. Which of the following statements
is FALSE?
a) The skin makes the pigment melanin
b) The skin produces vitamin C
c) The skin acts as a protective barrier
d) When sweat evaporates from the skin,
it cools the body’s temperature
n
n
n
n
n
n
n
n
3. The correct medical name for
itching is:
a) Urticaria
b) Psoriasis
c) Pruritus
d) Dermatitis
n
n
n
n
4. Which of the following customers is
most likely to be suffering from contact
dermatitis?
a) An adult who has suffered an insect
bite
n
b) A young child with asthma who also
has an itchy rash on her face
n
c) An adult with a red skin rash who has
recently started work as a hairdresser
n
d) An adult with an itchy rash caused by
a drug allergy
n
5. Which of the following customers can selfmedicate with an OTC corticosteroid cream?
a) A pregnant woman with a red, itchy
rash and an under-active thyroid gland
n
b) An adult with crusty, itchy rash who has run
out of his prescription corticosteroid cream
n
c) A child aged eight with a red rash on
his face
n
d) An otherwise healthy man with an itchy
rash on the back of his hand
n
6. OTC clotrimazole cream would be suitable
for which of these people?
a) A child with chickenpox
n
b) An adult with ringworm
n
c) An adult who has been stung by a wasp
n
d) A teenager with a red, itchy rash between
his toes
n
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