PIBS - SELF CARE
1. Which of the following is NOT an appropriate recommendation? a. Wearing perfumes and scented lotions will act as a repellant when you are spending ample amounts of time outside b. Apply ice in 10 min increments to reduce swelling, pain, and itching of bite c. Cleaning the area with rubbing alcohol will help disinfect the skin d. All of the above are appropriate recommendations for self-treatment
a. Wearing perfumes and scented lotions will act as a repellant when you are spending ample amounts of time outside
1. A woman approaches the pharmacy counter asking for recommendations for a local anesthetic that she can apply to her arm. She states a wasp stung her this morning and she reports no excessive swelling, dizziness, difficulty breathing, vomiting, or hives. What will be the most appropriate recommendation for her? a. Benzocaine 20%; benzethonium chloride 0.2% spray applied to affect area 3 to 4 times per day for no longer than 10 days b. Camphor 1.24% ointment c. Benzocaine 20%; benzethonium chloride 0.2% spray applied to affected area 2 to 4 times per day for no longer than 7 days d. Diphenhydramine HCL 2% gel
c. Benzocaine 20%; benzethonium chloride 0.2% spray applied to affected area 2 to 4 times per day for no longer than 7 days
1. Charles is a 47 year old male who is a park ranger, spending most of his day outside, comes into your pharmacy asking what he can do to help repel bugs when he is in the stand. Which of the following is the most effective recommendation for Charles? a. Permethrin 0.5% spray applied to skin and uniform b. OFF! (DEET 25%) applied every 4-8 hours on skin and clothes c. Deep Woods OFF! For Sportsmen (DEET 100%) applied every 4-8 hours on skin and clothes d. Cutter Skinsations Pump (DEET 7%, aloe, vitamin E)
c. Deep Woods OFF! For Sportsmen (DEET 100%) applied every 4-8 hours on skin and clothes
Exclusion of Self-Treatment - Lice
•Hypersensitivity to chrysanthemums, ragweed, or other pediculicide ingredients •Presence of secondary skin infection in lice infested area •<2 years of age for pyrethrins (y for 2 years) •<2 months of age for permethrins (m for 2 months) •Lice infestation of eyelids or eyebrows •Pregnancy or breast-feeding •Presence of active tumors •Regional resistance to pediculicides
Exclusions for Self-Treatment - Insect Bites
•Hypersensitivity to insect bites resulting in systemic symptoms or symptoms away from bite area •<2 years of age •History of tick bite and systemic effects including possible infection •Suspected spider bite requiring medical attention •Signs of secondary infection of bite area Scabies, ticks, and spider are a referral Tick and spider are usually referral, but people do not go, and it is your job to make sure to tell them what to look for with these types of bites.
Pediculosis
•Lice infection •3 different types of lice infection •Head: most common •Person to person contact •Body: live and lay eggs in clothing •Poor hygiene Pubic: also referred to as crabs •High risk sexual contact Adults lay eggs or nits which hatch and begin to feed within 24 hours It takes 8-9 days for newly hatched lice to mature Repeats cycle in 3 weeks if not treated •Most common outbreaks occur in schools and day cares during fall months • •Itching is most common side effect and scratching can result in a secondary infection
chiggers
•Red Bugs. •Live in bushes, trees, grass. •Attach and excrete a digestive fluid which causes cellular disintegration and intense itching. Larvae are also deposited in skin.
Goals of therapy - Insect Bites and Stings
•Relieve symptoms •Pain, swelling, redness, irritation, anaphylactic type reactions •Prevent a secondary infection •Strep, staph, and impetigo •The insect is puncturing the skin so think of what bacteria are already on the skin but now the protective barrier that is your skin is compromised
Goals of Treatment - Pediculosis
•Rid the infested patient of lice by killing adult and nymph lice by removing nits from patient's hair •Using non-pharmacologic and pharmacologic interventions •Using the appropriate size comb to ensure you are getting both the lice and eggs •Limit Transmission •Making sure you are providing the appropriate directions and guidance for patient to follow and how to disinfect their home •Disinfect living environment to reduce risk of spread and transmission •Quick and easy way to limit transmission and getting another infection
Stings
•Stinging Insects Bees, wasps, hornets, yellow jackets, and fire ants •Injected venom contains allergenic proteins which cause hives, itching, swelling, burning, or pain •Rare: hypotension, dizziness, chest tightness, dyspnea, loss of consciousness •Honeybees have barbed stingers and can only sting once •Wasps, hornets, and yellow jacket stingers are not barbed and can sting multiple times
Hydrocortisone
•Hydrocortisone 1% •Application: applied to bite area 3-4 times per day for up to 7 days •Pearls •Indicated for temporary relief of minor insect bites •Do not use in individual with scabies, bacterial, or fungal infection without consultation of MD
flea
Bubonic plague and typhus •Found in humid climates. •Occur in groups on the ankles and legs. •Erythematous and associated with intense itching
Must make about ten million trips to collect enough nectar to produce 1 lb. of honey
HONEYBEE
mosquito
Malaria and West Nile Virus •Present with Flu like symptoms. •Can progress to muscle weakness, encephalitis, or meningitis
Pharmacologic Treatment - Lice- Permethrins
Permethrins •Head lice only •1% cream rinse •Application: applied to cover or saturate washed hair and scalp and left on for 10 mins. The hair is then combed with a lice comb. •Rinse has residual effects for 10 days, so you do not need to retreat in 10 days unless active lice are detected •Adverse effects: burning, itching, stinging, irritation of scalp. Avoid contact with eyes and mucous membranes Per: cell membranes inhibiting Na channels delaying repolarization and causing paralysis and death How to chose which product to use: age, duration of treatment (permethrins if they just want one treatment) but to date the efficacy shows no significant difference between the two products), type of pediculosis It is not necessary to treat whole family since it contributes to resistence to the pediculicides and should only be treated if they have an active infection (nonpharm comes into play)
Ticks
Rocky Mountain Spotted Fever and Lyme Disease •Introduce mouthparts to human skin to feed on blood. •If left attached can become engorged. •Remain for up to 10 days. •Remove with tweezers within 36 hrs. to decrease risk of infection and transmission of disease. •Do not remove with heat or painting over since that can cause tick to release more saliva and gut content to increase risk of infection.
Pharmacologic Treatment - Lice-Synergized Pyrethrins
Synergized Pyrethrins •Head and pubic lice •Effective conc include: 0.17% to 0.33% •Shampoos, foams, solutions, or gels •Application: applied to affected area for 10 mins and rinsed. Combing with a lice comb should follow treatment. Repeat in 7-10 days to kill remaining. •Do not apply twice within 24 hours •Adverse effects: irritation, erythema, itching, and swelling. Avoid contact with eyes and mucous membranes Py: block nerve impulse and paralyze the lice causing death
Case #1: Charlene and daughter Lauren: Charlene comes into the pharmacy this morning asking about OTC treatment options for her child Lauren (female, age 3) who started scratching her scalp frequently yesterday. A note was recently sent home from the daycare she attends that lice are going around. She is concerned her child may have lice but is not certain. If it is lice she is also worried about it spreading among herself, her husband, and their two other children. 1. If Lauren has lice, which treatment regimen below is appropriate to recommend? a. A-200 lice killing shampoo (pyrethrins 0.33% and piperonyl butoxide 3%) should be applied to dry hair and scalp, remain for 10 minutes, worked into a lather, then thoroughly rinsed. Retreat in 7 to 10 days. b. Using Nix appropriately will sufficiently kill the lice at all stages and therefore use of a nit comb will not be needed. c. Petroleum jelly or mayonnaise can be applied in place of commercial agents to treat the lice. d. Nix Lice Killing Cream Rinse (permethrin 1%) applied in sufficient quantities to cover washed hair and scalp, left on for 5 minutes before rinsing out and then combed with a lice comb. Re-treat in 7 to 10 days only if active lice are seen.
a. A-200 lice killing shampoo (pyrethrins 0.33% and piperonyl butoxide 3%) should be applied to dry hair and scalp, remain for 10 minutes, worked into a lather, then thoroughly rinsed. Retreat in 7 to 10 days.
1. Jennifer is a 4-year-old child that was just bit by fire ants after stepping on a colony at the park. You notice that there are about 5 raised bites on her foot and there is some redness and itching associated with the sting. What is the best recommendation for Jennifer? a. Hydrocortisone 1% ointment applied 3 to 4 times daily for up to 7 days b. Tiger Balm (Camphor) applied 2 times daily for up to 3 days c. Referral to Pediatrician d. Campho Phenique (Camphor 10.8% and Phenol 4.7%) applied to bite area 3-4 times per day up to 10 days.
a. Hydrocortisone 1% ointment applied 3 to 4 times daily for up to 7 days
1. James is a 35-year-old male who is an avid hunter and loves being outdoors but has extremely sensitive skin. For years he has used OFF Deep Woods as an insect repellant and every time his uses it he will break out into a rash and is looking for something less irritating. Which of the following would NOT be an appropriate herbal recommendation for James to try next time he goes hunting? a. Lemon oil b. Citronella Oil c. Lavender oil d. Garlic oil e. Tea tree oil
a. Lemon oil b. Citronella Oil c. Lavender oil d. Garlic oil e. Tea tree oil
1. What is the correctly matched up insect to the potential secondary disease that could be transmitted to the patient if bitten? a. Mosquito, Malaria b. Tick, bubonic plague c. Flea, typhus d. Tick, West Nile Virus
a. Mosquito, Malaria
1. A mother comes to your pharmacy to ask your advice on the best lice treatment for her son. She tells you her son has evidence of head lice and that there is a lice infestation going on at his local daycare center. She states that he is 9 months old and has no allergies. What product listed below would be the most appropriate recommendation for her son? a. Nix Crème Rinse (permethrin 1%) b. Nupercainal Ointment (dibucaine 1%) c. Pronto Lice Killing Shampoo (pyrethrins 0.33%; piperonyl butoxide 4%) d. Benadryl Gel (diphenhydramine 1%; zinc oxide 2%; camphor)
a. Nix Crème Rinse (permethrin 1%) b. Nupercainal Ointment (dibucaine 1%)
1. Which of the following pediculicide products has to be reapplied after 7-10 days to disinfect any remaining lice or eggs? a. RID Lice Killing Shampoo, Maximum Strength (pyrethrins 0.33% & piperonyl butoxide 3%) b. Nix Lice Killing Cream Rinse (permethrin 1%) c. LiceMD (Dimethicone 100%) d. Vamousse Lice Treatment (Natrum muriaticum 2X [HPUS])
a. RID Lice Killing Shampoo, Maximum Strength (pyrethrins 0.33% & piperonyl butoxide 3%)
Case #3: Jerry, a 22-year-old male, just got back into town after a morning fishing trip in the mountains. Although he took precautions to avoid mosquitoes by using a Thermocell repellent device while hunting and Deep Woods Off on his skin while back at camp, he failed to treat his hunting clothes with permethrin spray to prevent ticks and other insect bites. He comes into the pharmacy today and shows you a tick embedded on his leg. He asks you for the best course of action for this issue. 1. Select from the list below statements that are appropriate for his situation. a. Ticks should be removed quickly and appropriately, using tweezers to grasp the tick's head on the top and bottom, and then gently pulling the tick so that the head is removed. b. Nail polish or Vaseline should be used on the tick to cause the tick to release. c. Tick bites may result in development of Rocky Mountain Spotted Fever, Lyme Disease, West Nile Virus, or Zika Virus. D. Once the tick is removed, it should be retained in a sealed container for future identification if needed and the bite area should be disinfected with rubbing alcohol
a. Ticks should be removed quickly and appropriately, using tweezers to grasp the tick's head on the top and bottom, and then gently pulling the tick so that the head is removed. D. Once the tick is removed, it should be retained in a sealed container for future identification if needed and the bite area should be disinfected with rubbing alcohol
Can live and care more than fifty times their own weight
ants
1. A family with two small children, aged 5 and 7 years are about to go on their annual fishing trip in the mountains. The father asks your advice on a product to prevent insect bites for his children as they are fishing. Which of the following products will provide the most effective repellant and still be safe to use in his kids? a. Deep Woods Off! For Sportsmen (DEET 100%) b. Cutter Skinsations Pump (DEET 7%, aloe, vitamin E) c. Itch -X Spray (pramoxine, benzyl alcohol) d. Repel Lemon Eucalyptus Lotion
b. Cutter Skinsations Pump (DEET 7%, aloe, vitamin E)
1. Victoria's mom would also like to know what she can do at home to help limit transmission and disinfect her home and belongings. Which of the following is NOT an effective non-pharmacologic intervention for Victoria's mom? a. Vacuum living areas thoroughly and regularly through Victoria's treatment b. Objects or clothing that cannot be washed should be placed in a sealed bag for 7-10 days. c. Wash clothes, bedding, and towels in hot water (130 F) and dry on the highest heat seating d. Visually inspect the hair and scalp before, during, and after treatment using a nit comb for evidence of lice or nits.
b. Objects or clothing that cannot be washed should be placed in a sealed bag for 7-10 days.
Case #1: Charlene and daughter Lauren: Charlene comes into the pharmacy this morning asking about OTC treatment options for her child Lauren (female, age 3) who started scratching her scalp frequently yesterday. A note was recently sent home from the daycare she attends that lice are going around. She is concerned her child may have lice but is not certain. If it is lice she is also worried about it spreading among herself, her husband, and their two other children. 1. Which of the following nonpharmacologic measures is NOT appropriate for Charlene to use to help prevent infection of other family members and re-infection of Lauren? a. Wash all bedding, clothing, combs, and toys used by Lauren in water at a temperature of 130 °F (39.4 °C) or higher. b. Items that cannot be washed should be sealed in plastic bags for 2 weeks. c. Items that cannot be washed should be sealed in plastic bags for 2 weeks and sprayed with permethrin before use. d. All floors/rugs should be vacuumed regularly and thoroughly.
c. Items that cannot be washed should be sealed in plastic bags for 2 weeks and sprayed with permethrin before use.
all of the following are exclusions of self-treatment for pediculosis EXCEPT: a. Infestation of eyelids and/or eyebrows b. Patient has active history of cancer c. Pyrethrins is an appropriate self-treatment recommendation in a 2-month-old d. Permethrins is an appropriate self-treatment recommendation in a 4-month-old
c. Pyrethrins is an appropriate self-treatment recommendation in a 2-month-old d. Permethrins is an appropriate self-treatment recommendation in a 4-month-old
1. Victoria is a 12-year-old child who was at her cousin's house for a sleep over and when she came home her mom noticed she was itching her head. Victoria's mom looked and figured out that Victoria has lice. What would be the most effective choice for Victoria to eradicate her lice infection? a. Nix (Permethrins 1% cream rinse) applied to washed hair and scalp for 5 mins. Follow with a lice comb. Reassess in 10 days to see if retreatment is needed. b. RID (Synergized pyrethrins 0.33%) applied to affected area for 10 mins and rinse. Follow with a lice comb and reassess in 10 days to see if retreatment is needed. c. RID (Synergized pyrethrins 0.33%) applied to affected area for 10 mins and rinse. Follow with a lice comb and retreat within 7-10 days. d. Nix (Permethrins 1% cream rinse) applied to washed hair and scalp for 5 mins. Follow with a lice comb. Retreat in 10 days to get max pediculicide effects.
c. RID (Synergized pyrethrins 0.33%) applied to affected area for 10 mins and rinse. Follow with a lice comb and retreat within 7-10 days.
1. A gentleman tells you he was in the woods yesterday and now has two ticks attached to his skin that he did not notice until this morning. He has heard of several ways to remove them but wants to know your recommendation before he does anything. Which of the following is the best advice for him? a. Coat each tick with clear nail polish (suffocates tick) and allow to dry before pulling them off. b. Carefully scratch each tick off of the skin with credit card or fingernail. c. Remove each tick with tweezers intact within 36 hours. d. Carefully touch each tick with a heated match end or nail.
c. Remove each tick with tweezers intact within 36 hours.
Case #2: Sally, a 46-year-old woman, runs by your pharmacy every day while training for her next triathlon. Today while running she changed up her run and ran through the nearby park and stepped on a fire ant bed. She tells you that it happened about 5 minutes ago and that her ankle is starting to become red, swollen, and painful. She is becoming concerned as she has started to develop hives and is very itchy. 1. Which of the following below represents an appropriate statement? a. Hydrocortisone should be applied to the area b. An application of an ice pack to the area should be sufficient treatment. c. She is exhibiting signs of an allergic reaction. d. Immediate application of Benadryl Cream (diphenhydramine) to the area is the recommended treatment in this case.
c. She is exhibiting signs of an allergic reaction.
Case #1: Charlene and daughter Lauren: Charlene comes into the pharmacy this morning asking about OTC treatment options for her child Lauren (female, age 3) who started scratching her scalp frequently yesterday. A note was recently sent home from the daycare she attends that lice are going around. She is concerned her child may have lice but is not certain. If it is lice she is also worried about it spreading among herself, her husband, and their two other children. 1. Which statement below is true related to the case above (select only one.) a. If lice are found on one family member, all family members should be treated with a pediculocide. b. Outbreaks of lice infestations are not common in places such as schools and day care centers so you should investigate other causes for the itching. c. When hair is parted for general inspection, nits and nit casings generally can be found at the base of the hair shaft and are commonly found near the ears, base of the neck, and crown of head. d. Reassure Charlene that baby shampoo will help this subside and she should use that daily for one week.
c. When hair is parted for general inspection, nits and nit casings generally can be found at the base of the hair shaft and are commonly found near the ears, base of the neck, and crown of head.
Case #2: Sally, a 46-year-old woman, runs by your pharmacy every day while training for her next triathlon. Today while running she changed up her run and ran through the nearby park and stepped on a fire ant bed. She tells you that it happened about 5 minutes ago and that her ankle is starting to become red, swollen, and painful. She is becoming concerned as she has started to develop hives and is very itchy. 1. What is the proper recommendation for Sally at this point? a. Apply ice to the area in 10-minute intervals followed by a topical anesthetic. b. Due to the possibility of anaphylaxis a hydrocortisone injection should be given immediately c. Apply Cortizone-10 three to four times daily to the site and monitor for worsening of the swelling dictating need to seek medical care. d. She should seek medical attention due to the risk of anaphylaxis
d. She should seek medical attention due to the risk of anaphylaxis
1. Which of the following are appropriate exclusions to self-treatment for lice according to the text? a. Hypersensitivity to chrysanthemums, ragweed, or pediculicide ingredients. b. Lice infestation of eyelids or eyebrows. c. <2 years of age for pyrethrins and < 2 month for permethrins d. Pregnancy e. All of the above are exclusions.
e. All of the above are exclusions.
HB is a 28-year-old male who presented to your pharmacy with a new bug bite that he got while camping last weekend. When you take a closer look, you see that it has a bullseye appearance with a dark read center. What other disease is HB at risk of? a. Human Papilloma Virus (HPV) b. Rocky Mountain Spotted Fever c. Malaria d. Lyme's Disease e. B and D
e. B and D
1. MJ and her family were enjoying a nice picnic at Central Park and Benjy (her 18-month-old son) was stung by a wasp on his cheek. She states that he is not allergic, but his father has an allergy to bee stings. Benjy has no significant past medical history. What are, if any, exclusion of self-treatment for Benjy? a. Benjy is a great candidate for self-treatment b. Location of sting c. Age d. Family history of allergy to bee stings e. C and D
e. C and D
Insect replaces their body water with this which acts as an "antifreeze" in the winter to combat freezing temperatures
glycerol
Pharmacologic Treatments of Bites and Stings
local anesthetics topical antihistamines counterirritants hydrocortisone
This insect can grow from the size of a grain of rice to the size of a marble
tick
This insect is known to get "drunk" and pass out from feeding on fermenting fruits and their juices
wasps
Topical Antihistamines
•Diphenhydramine hydrochloride (0.5%-2%) •Most common product in this class of medications •MOA: Relief of pain and itching by depressing cutaneous receptors •Application: applied to bite area up to 3-4 times daily and no longer than 7 days •Pearls: •Can cause photosensitivity and hypersensitivity reactions •Continued use of these agents for 3-4 weeks increases the risk of contact dermatitis This is a valid option but systemic use would most likely be most effective
bedbugs
•Hide in crevices of walls and furniture. •Bite at nighttime. •Bites found usually around head, neck and arms
Non-Pharmacologic Treatment of Insect Bites
•Apply Ice (10 mins on/off) to bite area to reduce swelling, itching, and pain •Avoid scratching affected area and keep fingernails trimmed •Remove ticks with tweezers like previously discussed •Do not wear rough irritating clothing covering the bite area Tweezers: grasping the ticks head and gently pulling. The head should be removed. Monitor for symptoms. Clean area with rubbing alcohol to disinfect the skin Preventative •Insect repellents such as DEET •Limit time spent outside •Wear protective clothing •Avoid physical contact with infected person such as scabies •Avoid moist areas such as swamps and dense woods
Local Anesthetics
•Benzocaine, pramoxine, benzyl alcohol, lidocaine, dibucaine, and phenol •MOA: block the conduction of nerve impulses (phenol depresses sensory receptors) •Application: applied to bite area up to 3 to 4 times daily and no longer than 7 days •Adverse Effects: skin irritation (allergic contact dermatitis) •Pearls: •Phenol >2% may cause irritation and sloughing of skin •Usual OTC range is 0.5% to 1.5% •OTC containing alcohol should not be applied to extensive areas of the body especially under bandages for risk of skin damage and systemic absorption Pramoxine and benzyl alcohol are safer with fewer side effects than others Dibucaine is a common allergen and can cause systemic toxicity with excessive absorption
scabies
•Burrow into skin and deposit eggs in tunnels. •Intense itching. •Not self-treatable.
Counterirritants
•Camphor and Menthol •MOA: relief of itching due to depression of cutaneous receptors •Application: applied to bite area 3-4 times daily for up to 7 days •Pearls •Camphor: dangerous if ingested and need to be kept out of reach of children •Menthol: considered a safe and effective antipruritic when applied to affected area at conc. of 0.1%-1%
Bites
•Common in individuals that spend ample amount of time outdoors •Mild local allergic reactions à life threatening anaphylaxis •Mosquitoes, fleas and bedbugs •Ticks, Scabies and Chiggers (arachnids) •Have biting organs that have salivary secretion which lead to signs and symptoms associated with a bitten patient
Insect Repellants
•DEET = N,N-Diethyl-m-Toluamide (most effective repellant) •Application: applied to skin and clothing every 4-8 hours •Do not use in children <2 months old and <30% conc. is best for children •Adults is 10%-40% (higher conc such as 50%-100% should be reserved for adults that spend extensive time outdoors) •Considered safe in pregnancy and breastfeeding •Picardin is a DEET alternative promoted as less odoriferous and irritating •Permethrin 0.5% is effective as a repellant but should not be applied to skin but only clothing and camping gear Herbal alternatives : citranellla, lemon oil, eucalyptus oil, soybean oil, cedar oil, lavender oil, garlic oil, tea tree oil, scented moisturizer in mineral oil (Skin so soft)
Exclusions for Insect Stings
•Hives, excessive swelling, dizziness, weakness, nausea, vomiting, difficulty breathing •Significant allergic response away from site of sting •Previous sting by honeybee, wasp, or hornet (development of hypersensitivity) •Previous severe reaction to insect bites •Personal or family history of allergic reactions •<2 years of age
Non-Pharmacologic Treatment of Insect Stings
•Use the edge of a credit card to scrape the stinger away is most effective •Try not to squeeze or rub the stinger; you can release more venom •Use an ice pack or cold compress on sting site to reduce irritation, swelling, and pain •Avoid scratching affected area and keep fingernails trimmed (gloves and mittens may be used for small children) •Avoid attraction of sting insects by not wearing perfumes, scented lotions, and brightly colored clothes •Even smelling like summer fruits or foods can be an attractant •If hypersensitive to stings wear a bracelet or have a card showing the nature of your allergy Meat tenderizer breaks down proteins in venom and can also use ammonia and baking soda. If someone has a known allergy you want them to have access to an epi-pen
Non-Pharmacologic Treatment - Lice
•Wash hairbrushes, combs, and toys of infested patients in water (130 ℉) or higher for 10 mins •Avoid close contact with infested patient and do not share articles such as combs, brushes, towels, caps, and hats •Use water (130 ℉) or higher to wash clothes, bedding, towels, and dry at the hottest setting •Objects or clothing that cannot be washed seal in a bag for 2 weeks (lifespan of louse) •Vacuum living areas thoroughly and regularly during treatment period •You can also trim hair •Visually inspect the hair and scalp before, during, and after treatment for evidence of lice or nits Top right block Use a nit comb diligently to remove nits Part hair into segments and comb the hair •New Treatment: using Cetaphil cleanser on scalp and then blow dry to create a seal and suffocate lice and nits
