InternPractice — Always a Step Ahead

Overview

Indications And Dose

Oral candidiasis ▶BY MOUTH ▶Child: 100 000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved ▶Adult: 100 000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved Oral and perioral fungal infections (dose approved for use by community practitioner nurse prescribers) ▶BY MOUTH ▶Neonate: 100 000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved, to be given after feeds. ▶Child: 100 000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved ▶Adult: 100 000 units 4 times a day usually for 7 days, and continued for 48 hours after lesions have resolved l UNLICENSED USE Suspension not licensed for use in neonates for the treatment of candidiasis but the Department of Health has advised that a Community Practitioner Nurse Prescriber may prescribe nystatin oral suspension for a neonate, in the doses provided in the BNF, provided that there is a clear diagnosis of oral thrush. The nurse prescriber must only prescribe within their own competence and must accept clinical and medicolegal responsibility for prescribing.

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Safety

Side Effects

Abdominal distress. angioedema. diarrhoea. face oedema. nausea. sensitisation. skin reactions. Stevens-Johnson syndrome. vomiting

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Dose and formulations

Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: tablet, capsule, oral suspension Oral suspension CAUTIONARY AND ADVISORY LABELS 9 EXCIPIENTS: May contain Ethanol ▶Nystatin (Non-proprietary) Nystatin 100000 unit per 1 ml Nystatin 100,000units/ml oral suspension | 30 ml P £2.74 DT = £2.69 Oropharyngeal viral infections Oropharyngeal viral infections Management Viral infections are the most common cause of a sore throat. They do not beneﬁt from anti-infective treatment. The management of primary herpetic gingivostomatitis is a soft diet, adequate ﬂuid intake, and analgesics as required, including local use of benzydamine hydrochloride p. 1280. The use of chlorhexidine mouthwash p. 1275 will control plaque accumulation if toothbrushing is painful and will also help to control secondary infection in general. In the case of severe herpetic stomatitis, a systemic antiviral such as aciclovir p. 670 is required. Valaciclovir p. 673 and famciclovir p. 672 are suitable alternatives for oral lesions associated with herpes zoster. Aciclovir and valaciclovir are also used for the prevention of frequently recurring herpes simplex lesions of the mouth, particularly when implicated in the initiation of erythema multiforme. Chapter 13 Skin CONTENTS Dry and scaling skin disorders page 1286 Infections of the skin Bacterial skin infections 2.1 Fungal skin infections 2.2 Parasitic skin infections 2.3 Viral skin infections 2.4 Inflammatory skin conditions Eczema and psoriasis 3.1 Perspiration Hyperhidrosis 4.1 Pruritus Rosacea and acne Acne 6.1 Skin conditions, management Vehicles The British Association of Dermatologists list of preferred unlicensed dermatological preparations (specials) is available at www.bad.org.uk/specials. Both vehicle and active ingredients are important in the treatment of skin conditions; the vehicle alone may have more than a mere placebo effect. The vehicle affects the degree of hydration of the skin, has a mild anti-inﬂammatory effect, and aids the penetration of active drug. Applications are usually viscous solutions, emulsions, or suspensions for application to the skin (including the scalp) or nails. Collodions are painted on the skin and allowed to dry to leave a ﬂexible ﬁlm over the site of application. Creams are emulsions of oil and water and are generally well absorbed into the skin. They may contain an antimicrobial preservative unless the active ingredient or basis is intrinsically bactericidal and fungicidal. Generally, creams are cosmetically more acceptable than ointments because they are less greasy and easier to apply. Gels consist of active ingredients in suitable hydrophilic or hydrophobic bases; they generally have a high water content. Gels are particularly suitable for application to the face and scalp. Lotions have a cooling effect and may be preferred to ointments or creams for application over a hairy area. Lotions in alcoholic basis can sting if used on broken skin. Shake lotions (such as calamine lotion) contain insoluble powders which leave a deposit on the skin surface. Ointments are greasy preparations which are normally anhydrous and insoluble in water, and are more occlusive than creams. They are particularly suitable for chronic, dry lesions. The most commonly used ointment bases consist of soft parafﬁn or a combination of soft, liquid, and hard parafﬁn. Some ointment bases have both hydrophilic and lipophilic properties; they may have occlusive properties on the skin surface, encourage hydration, and also be miscible with water; they often have a mild anti-inﬂammatory effect. Water-soluble ointments contain macrogols which are freely soluble in water and are therefore readily washed off; they Rosacea page 1339 6.2 Scalp and hair conditions Alopecia 7.1 Hirsutism 7.2 Skin cleansers, antiseptics and desloughing agents Minor cuts and abrasions 8.1 Skin disfigurement Skin Sun protection and photodamage Superficial soft-tissue injuries and superficial thrombophlebitis Warts and calluses have a limited but useful role where ready removal is desirable. Pastes are stiff preparations containing a high proportion of ﬁnely powdered solids such as zinc oxide and starch suspended in an ointment. They are used for circumscribed lesions such as those which occur in lichen simplex, chronic eczema, or psoriasis. They are less occlusive than ointments and can be used to protect inﬂamed, licheniﬁed, or excoriated skin. Dusting powders are used only rarely. They reduce friction between opposing skin surfaces. Dusting powders should not be applied to moist areas because they can cake and abrade the skin. Talc is a lubricant but it does not absorb moisture; it can cause respiratory irritation. Starch is less lubricant but absorbs water. Dilution The BP directs that creams and ointments should not normally be diluted but that should dilution be necessary care should be taken, in particular, to prevent microbial contamination. The appropriate diluent should be used and heating should be avoided during mixing; excessive dilution may affect the stability of some creams. Diluted creams should normally be used within 2 weeks of preparation. Suitable quantities for prescribing Suitable quantities of dermatological preparations to be prescribed for speciﬁc areas of the body Area of body Creams and Ointments Lotions 15–30 g 100 ml Face 25–50 g 200 ml Both hands 50–100 g 200 ml Scalp 100–200 g 200 ml Both arms or both legs 400 g 500 ml Trunk 15–25 g 100 ml Groins and genitalia These amounts are usually suitable for an adult for twice daily application for 1 week.The recommendations do not apply to corticosteroid preparations. For suitable quantities of corticosteroid preparations, see relevant table. Excipients and sensitisation Excipients in topical products rarely cause problems. If a patch test indicates allergy to an excipient, products containing the substance should be avoided. The following excipients in topical preparations are associated, rarely, with sensitisation; the presence of these excipients is indicated in the entries for topical products. . Beeswax . Benzyl alcohol . Butylated hydroxyanisole . Butylated hydroxytoluene . Cetostearyl alcohol (including cetyl and stearyl alcohol) . Chlorocresol . Edetic acid (EDTA) . Ethylenediamine . Fragrances . Hydroxybenzoates (parabens) . Imidurea . Isopropyl palmitate Skin . N-(3-Chloroallyl)hexaminium chloride (quaternium 15) . Polysorbates . Propylene glycol . Sodium metabisulﬁte . Sorbic acid . Wool fat and related substances including lanolin (puriﬁed versions of wool fat have reduced the problem) Dry and scaling skin disorders Emollient and barrier preparations Borderline substances The preparations marked ‘ACBS’ are regarded as drugs when prescribed in accordance with the advice of the Advisory Committee on Borderline Substances for the clinical conditions listed. Prescriptions issued in accordance with this advice and endorsed ‘ACBS’ will normally not be investigated. Emollients Emollients soothe, smooth and hydrate the skin and are indicated for all dry or scaling disorders. Their effects are short lived and they should be applied frequently even after improvement occurs. They are useful in dry and eczematous disorders, and to a lesser extent in psoriasis. The choice of an appropriate emollient will depend on the severity of the condition, patient preference, and the site of application. Some ingredients rarely cause sensitisation and this should be suspected if an eczematous reaction occurs. The use of aqueous cream as a leave-on emollient may increase the risk of skin reactions, particularly in eczema. Preparations such as aqueous cream and emulsifying ointment can be used as soap substitutes for hand washing and in the bath; the preparation is rubbed on the skin before rinsing off completely. The addition of a bath oil may also be helpful. Urea is occasionally used with other topical agents such as corticosteroids to enhance penetration of the skin. Emollient bath and shower preparations Emollient bath additives should be added to bath water; hydration can be improved by soaking in the bath for 10–20 minutes. Some bath emollients can be applied to wet skin undiluted and rinsed off. In dry skin conditions soap should be avoided. The quantities of bath additives recommended for adults are suitable for an adult-size bath. Proportionately less should be used for a child-size bath or a washbasin; recommended bath additive quantities for children reﬂect this. MHRA/CHM advice (updated December 2018): Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients Emollients are an important and effective treatment for chronic dry skin disorders and people should continue to use these products. However, healthcare professionals must ensure that patients and their carers understand the ﬁre risk associated with the build-up of residue on clothing and bedding and can take action to minimise the risk. There is a ﬁre risk with all parafﬁn-containing emollients, regardless of parafﬁn concentration, and it cannot be excluded with parafﬁn-free emollients. A similar risk may apply to products that are applied to the skin over large body areas, or in large volumes for repeated use for more than a few days. Healthcare professionals should advise patients not to smoke or go near naked ﬂames because clothing, bedding, dressings, and other fabrics that have been in contact with an emollient or emollient-treated skin can rapidly ignite. Washing these materials at high temperature may reduce emollient build-up but not totally remove it. Barrier preparations Barrier preparations often contain water-repellent substances such as dimeticone (see barrier creams and ointments below) or other silicones. They are used on the skin around stomas, bedsores, and pressure areas in the elderly where the skin is intact. Where the skin has broken down, barrier preparations have a limited role in protecting adjacent skin. Barrier preparations are not a substitute for adequate nursing care. Nappy rash The ﬁrst line of treatment is to ensure that nappies are changed frequently and that tightly ﬁtting water-proof pants are avoided. The rash may clear when left exposed to the air and a barrier preparation, applied with each nappy change, can be helpful. A mild corticosteroid such as hydrocortisone 0.5% or 1% p. 1313 can be used if inﬂammation is causing discomfort, but it should be avoided in neonates. The barrier preparation should be applied after the corticosteroid preparation to prevent further damage. Preparations containing hydrocortisone should be applied for no more than a week; the hydrocortisone should be discontinued as soon as the inﬂammation subsides. The occlusive effect of nappies and waterproof pants may increase absorption of corticosteroids. If the rash is associated with candidal infection, a topical antifungal such as clotrimazole cream p. 1298 can be used. Topical antibacterial preparations can be used if bacterial infection is present; treatment with an oral antibacterial may occasionally be required in severe or recurrent infection. Hydrocortisone may be used in combination with antimicrobial preparations if there is considerable inﬂammation, erosion, and infection. DERMATOLOGICAL DRUGS › BARRIER PREPARATIONS

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Clinical care

Patient And Carer Advice

Counselling advised with oral suspension (use of pipette, hold in mouth, after food). Medicines for Children leaflet: Nystatin for Candida infection www.medicinesforchildren.org.uk/nystatin-candida-infection l PROFESSION SPECIFIC INFORMATION Dental practitioners’ formulary Nystatin Oral Suspension may be prescribed.

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Dose text by age group

Child

100 000 units 4 times a day usually for 7 days,

First-line fragment. Read the complete Indications and Dose section above.

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Child

100 000 units 4 times a day usually for 7 days,

First-line fragment. Read the complete Indications and Dose section above.

PDF page 1306