Acne case 1:

1. Advice on the use of Adapalene?

-This medicine should be applied every night before going to bed.
-Wash the face with cleanser, then rinse and pat dry.
-Apply a thin film of gel to cover the pimples, and rub in gently to
ensure good absorption. A mild transitory sensation of warmth or slight
stinging may occur shortly after application.
-Do not forget to wash your hands afterwards.
-If using this preparation for the first time, start with applying on a
small area of affected part and increase gradually to other areas over
the following week if there is no skin irritation.
-Do not use the medicine on abraded, broken, eczematous, or
sunburned skin, mucous membranes, eyes, lips, and angles of the
nose. This medicine may irritate these sensitive areas.
-If you missed the dose, skip the missed dose. Do not apply more of it
to make up for the missed dose as it could result in severe irritation.
-Avoid washing your face too often, as this may cause excessive
dryness and peeling. Washing with a mild soap 2 to 3 times a day is
sufficient.
-Unless otherwise directed by your doctor, avoid using other drying
preparations on the same treated areas to prevent severe irritations.
These include abrasive soaps and cleansers, alcoholic preparations and
medicated cosmetics or soaps. You should also avoid other acne
preparations which contain peeling agents, for example benzoyl
peroxide, resorcinol or sulphur.
-During initial treatment, the skin may be more susceptible to sunburn.
If you cannot avoid exposure to too much sunlight, use a suitable
sunscreen with an SPF of at least 15 and wear face mask and
sunglasses.
-Light cosmetics may be applied over the sunscreen. However, in acne
you should generally avoid using oily cosmetics.
-Inform your doctor if you have ever had any unusual or allergic
reaction to topical adapalene
-If you notice severe irritation (burning, itching, swelling, blistering,
crusting) any time, stop this medication immediately and consult your
doctor
-Inform your doctor if you are pregnant or intending to conceive.
2. Side effects of adapalene use:
-Initially, you may experience peeling of the skin, with redness and
even a mild stinging sensation. If bad irritation results, you may stepdown the dosages, i.e. apply it less frequently.
-For acne treatment, after 2 to 3 weeks, your acne may sometimes
seem to get worse. This is a normal reaction. If you continue using this

medicine, you will notice improvement. The best results may be

achieved after 4 to 7 weeks of treatment.
-Skin photosensitivity. You may develop skin rashes or burns, even
after limited exposure to the sun.
3. Is Isotretinoin safe for pregnant woman? When can isotretinoin
be started in females of childbearing age?
-Isotretinoin belongs to FDA pregnancy category X, and is
contraindicated in women who are or may become pregnant. It is a
potent human teratogen and causes birth defects in newborns (central
nervous system abnormalities, craniofacial malformation).
-For females of childbearing age: Females of childbearing potential
must have two negative pregnancy tests with a sensitivity of at least
25 milliunits/mL prior to beginning therapy (the second performed at
least 19 days after the first test and performed during the first 5 days
of the menstrual period immediately preceding the start of therapy)
and testing should continue monthly during therapy. Females of
childbearing potential should not become pregnant during therapy or
for 1 month following discontinuation of isotretinoin. If pregnancy
occurs during therapy, isotretinoin should be discontinued immediately
and the patient referred to an obstetrician-gynecologist specializing in
reproductive toxicity. Upon discontinuation of treatment, females of
childbearing potential should have a pregnancy test after their last
dose and again one month after their last dose. Two forms of
contraception should be continued during this time.
4. Monitoring parameters when patient is on isotretinoin?
Topical: Serious skin reactions: severe burning, peeling, redness or itching of your
skin

Oral: FBC with differential and platelet count, baseline sedimentation rate,
glucose, creatine phosphokinase; signs of depression, mood alteration,
psychosis, aggression, severe skin reactions; changes in vision
Lipids: Prior to treatment and at weekly or biweekly intervals until response
to treatment is established. Test should not be performed <36 hours after
consumption of ethanol.
Liver function tests: Prior to treatment and at weekly or biweekly intervals
until response to treatment is established. (Lexicomp)
Measure hepatic function and serum lipids before treatment, 1 month after
starting and then every 3 months (reduce dose or discontinue if
transaminase or serum lipids persistently raised) (BNF)
5. What dose of doxycycline to take for her acne treatment?
Possible side effects?
Doxycycline: 100mg om
Common side-effects include nausea, vomiting and diarrhoea. Inflammation
and/or ulcers of the gastrointestinal tract (symptoms may include sore

mouth, sore throat, indigestion and difficulty swallowing). Take the

medication with a full glass of water to avoid gastrointestinal problems.
It may cause your skin to be more sensitive to the sun. Exposure to sunlight
may cause skin rash, itching or redness of the skin or a severe burn. Stay out
of direct sunlight especially between 10am and 3pm. Wear protective
clothing and also apply a sun block product that has a Sun Protection Factor
(SPF) of at least 15.

Seborrhoeic Dermatitis case 1:

1. Selenium sulphide suspension used for:
A 1% lotion of selenium sulfide is used to relieve the itching and flaking of
the scalp associated with dandruff. A 1% shampoo or 2.5% lotion of the
drug is used for the control of dandruff and of seborrheic dermatitis of the
scalp. Dandruff usually responds to treatment, but tends to relapse if
therapy is discontinued. If dandruff is left untreated, the resulting
problems are those of appearance, and generally no medical disability will
result. A 2.5% lotion of selenium sulfide has also been used for the
treatment of tinea versicolor.
2. How does it work?
Selenium sulfide is an anti-infective agent having antibacterial and
mild antifungal activity. The mechanism(s) of action of the drug in the
treatment of dandruff and seborrheic dermatitis has not been fully
determined. The drug is active against Pityrosporum ovale, a yeast-like
fungus that is part of the normal flora of the scalp. A definite causal
relationship between this organism and these conditions has not been
established. Its been suggested that the increased P. ovale may have
been related to sebum materials trapped in the dandruff scales on
which these organisms may feed. It has been suggested that selenium
sulfide, when absorbed into epithelial tissue, is converted into
selenium and sulfide ions, and that the selenium ions block the
enzyme systems involved in the growth of epithelial tissue. Selenium
sulfide has been shown to have a cytostatic (antimitotic) action
resulting in a decreased rate of cell turnover in cells with normal or
higher than normal turnover rates. The drug also has a local irritant
effect.
3. Explain on the use of the suspension:
Selenium sulfide suspension is applied topically to the scalp as a
shampoo. The suspension is intended for external use only. Patients
should be directed to wash their hands thoroughly following use of the
lotion. Patients should be advised to remove all jewelry before using
the lotion, since selenium sulfide may damage it. Contact with the eyes

should be avoided; if contact occurs, the affected eye(s) should be

rinsed thoroughly with water.
510 mL of the 2.5% selenium sulfide lotion is massaged into the wet
scalp. The lotion should be allowed to remain on the scalp for 23
minutes following application. The scalp should then be rinsed
thoroughly and application of the lotion and rinsing repeated. Initially,
the lotion is usually applied as a shampoo twice weekly.
Because of the risk of systemic toxicity (e.g. vomiting, abdominal pain),
selenium sulfide lotions should not be applied to damaged skin (e.g.,
open lesions or acute inflammation or exudation of the scalp).
4. Side effects of selenium sulfide:
Discoloration of various shades of natural and dyed hair has
occurred following topical application of selenium sulfide lotion. Hair
discoloration does not appear to be a common occurrence, and usually
is associated with poor or no rinsing following shampooing with the
lotion. The manufacturers state that hair discoloration can be
minimized by careful rinsing of the hair after treatment with the drug.
Shampooing with a 2.5% lotion of the drug has also reportedly caused
diffuse hair loss, which resolved 12 weeks following discontinuance
of the drug.
Contact of preparations containing selenium sulfide with mucous
membranes of the eye may cause irritation (e.g., stinging).
Selenium sulfide lotions can cause rebound oiliness of the scalp; this
effect has been reported following short-term application of a 2.5%
lotion.
5. Ketoconazole for the treatment of dandruff. What is it and its
MOA?
Ketoconazole is an anti-fungal medication that can kill fungi such as P.
ovale. Although the exact mechanism of action of ketoconazole has not
been fully determined, it has been suggested that the fungistatic
activity of the drug may result from interference with ergosterol
synthesis probably via inhibition of C-14 demethylation of sterol
intermediates (e.g., lanosterol). Ergosterol is a vital component of
fungal cell membrane. Without it, the cell membrane will become more
permeable and essential ions will leak out from the cell. As a result, the
fungi will stop growing and may eventually die.
Eczema dermatitis case 1:
1. Calamine lotion is for:
Calamine lotion contains calamine and zinc oxide. Calamine has a mild
astringent action of the skin which helps constrict the skin tissues and
relieve itching and skin irritation. Zinc oxide has a mildly antiseptic

action and is a mild astringent, it has soothing and protective

properties.
2. Why hydroxyzine is given to her today and can it be used for
other purposes?
Hydroxyzine is an antihistamine that blocks H1-receptor on effector
cells in the gastrointestinal tract, blood vessels, and respiratory
tract. It is prescribed to relieve pruritus due to eczema and urticaria.
It can also be used to treat anxiety, as adjunct to sedative before or
after operation and anti-vomiting (antiemetics)
3. Is hydroxyzine safe for use in elderly?
Hydroxyzine is not recommended in elderly patients because of a
decrease of hydroxyzine elimination in this population as compared
to adults and the greater risk of adverse reactions (e.g.
anticholinergic effects, CNS sedation). In elderly patients, it is
recommended to reduce the dose of hydroxyzine due to a possible
increase in the volume of distribution, prolonged action, and the
possible effect of age-related changes on pharmacologic functions,
including hepatic metabolism and renal excretion.
Because of its potential antimuscarinic actions, Hydroxyzine should
be used with caution in patients suffering from angle-closure
glaucoma, urinary retention, prostatic hyperplasia, or pyroduodenal
obstruction.
In the elderly, the maximum daily dose is 50 mg per day.
Nappy Rash and Dry Skin Case 1:
1. Nappy rash cream you have in your pharmacy:
Drapolene nappy rash cream (Benzalkonium Chloride 0.01%,
cetrimide 0.2%)
Egozite baby cream (Zinc Oxide 15%, Dimethicone 350 15%,
Light Liquid Paraffin 10%, Methyl Hydroxybenzoate 0.2%, Propyl
Hydroxybenzoate 0.1%)
Secura protective cream (10% zinc oxide, Allantoin, Vitamin E,
clove oil)
2. Active ingredients of Napitol? How do these ingredients
work?
It contains benzalkonium chloride 0.01%, cetrimide 0.2%.
Benzalkonium chloride is a quaternary ammonium compound
which has been used for many years as a surfactant and
antiseptic/disinfectant. It is known to be bactericidal in low
concentrations to a wide range of Gram-positive and Gramnegative bacteria, especially ammonium-producing bacteria.
Cetrimide is a quaternary ammonium disinfectant having
bactericidal activity against both gram-positive and gramnegative organisms.

An antiseptic for prevention and treatment of nappy rash. Giving

soothing relief to skin. Also for the treatment of minor wounds
and burns. It physically blocks chemical irritants and moisture
from contacting the skin and minimize friction, fragrance-free
3. How does silicone cream help in nappy rash?
Silicone is a skin protectant. This will prevent urine from coming
into contact with the delicate skin on the bottom and acts as a
barrier against other forms of bacteria as well. While siliconebased creams are excellent for preventing nappy rash, they will
not cure it once it is present.
4. What topicals to prescribe for the patients dry skin
condition?
Moisturiser: QV cream/Cetaphil cream: (+) non-oily (-) less
occlusive than ointment, no keratolytic effect
Urea 10% cream: (+) keratolytic activity, urea (humectant) helps
increase skin water uptake and retention (-) cause mild irritation
when apply to skin fissures/crack
Solvit cream (Vitamin E 5%, Urea 10%, Vitamin C, AHA): (+)
vitamin C and E helps heal the skin cracks (+) non-greasy
Nivea cream: (-) very oily
Cetaphil cleanser: (+) moisturizing and gentle to the skin (-) have
alcohol that may cause drying to the skin, not suitable for
patients senstitive to alcohol
QV wash: (+) cleanser does not contain alcohol, less drying and
irritating the skin
Esemtan wash lotion: (+) can get used on the whole body (+)
contain allantoin (act as skin protectant) (-) expensive (+) pH
skin balanced
Lactacyd liquid: (+) can get used on the whole body (+) contain
allantoin (act as skin protectant) (-) expensive (+) pH skin
balanced
Aqueous cream: (-) may aggravate eczema, contain sodium
lauryl sulfate that causes skin irriation, significantly decreases
barrier function and increases skin permeability on chronic use
Psoriasis Case 1:
1. What is clobetasol propionate and whether she can use
it every day for a long period of time?
Clobetasol propionate ointment is a very potent topical
corticosteroid preparation, used for the short-term treatment
of psoriasis. It belongs to a group of medicines called steroids.
It helps to reduce swelling and irritation, the redness and
itchiness. Do not use the ointment longer than 4 weeks (28
days) as the preparation causes skin thinning. Do not use the

cream on your face more than 5 days. Do not let the cream
into your eyes. If continuous treatment is necessary, a less
potent preparation should be used. Therapy with clobetasol
should be gradually discontinued once control is achieved and
an emollient continued as maintenance therapy.
2. How long must she use calcipotriol ointment before her
condition improves? Frequency of use?
Improvement begins after 2 weeks. Marked improvement
seen after 8 weeks
Apply calcipotriol once a day in the morning while clobetasol
is applied every night.
3. What is calcipotriol and how does it work?
Psoriasis is caused by your skin cells being produced too
quickly. This causes redness, scaling and thickness of your
skin. Calcipotriol is a synthetic vitamin D3 analog which
regulates skin cell production and proliferation. It binds to
vitamin D receptors and inhibits keratinocyte proliferation and
enhances keratinocyte differentiation. Calcipotriol helps to
bring the rate of skin cell growth back to normal.
4. What else can coal tar used for? Side effects?
Seborrhoeic dermatitis, eczema, pruritus and scalp associated
with psoriasis, itchy, oily scalp, dandruff.
Side effects: Skin and subcutaneous tissue disorders:
Skin irritation, photosensitivity of the skin. In addition coal tar
may cause acne-like eruptions of the skin.
URTI Case 1:
1. Why was no antibiotics given to her? And other than the
medications, what should she do to speed up her
recovery?
Her common cold is caused by a variety of viruses. Rhinoviruses are
the most frequent culprits. Antibiotics are not useful for treating the
common cold; antibiotics are only used to treat illnesses caused by
bacteria, not viruses. Unnecessary use of antibiotics for the treatment
of the common cold can cause allergic reactions, diarrhea, or other
gastrointestinal symptoms in some patients. The symptoms of a cold
will resolve over time, even without any treatment as your bodys
immune system eventually gets rid of the viruses.
Besides medications, non-pharmacological measures:
-Hand washing can prevent the spread of infection. Hands should be
wet with water and plain soap, and rubbed together for 15 to 30
seconds. Alcohol-based hand rubs are a good alternative for
disinfecting hands if a sink is not available. In addition, tissues should

be used to cover the mouth when sneezing or coughing. These used

tissues should be disposed of promptly.
-Take a rest. Staying at home will give the body a chance to recuperate.
-Drink lots of fluids, water, juice or warm lemon water. Avoid alcohol
and caffeine
-Warm, moist air helps relieve some cold symptoms
-Avoid sharing glasses, cups and other utensils to avoid transmission of
the infection.
2. How does choline salicylate work?
Choline salicylate belongs to a class of pain-killers, called NSAIDs,
which has anti-inflammatory effects. It irreversibly inhibits
cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, which results in
decreased formation of prostaglandin which is a mediator in pain and
inflammation. It helps with the relief of pain, discomfort and
inflammation (swelling, redness) caused by common mouth ulcers and
aids healing of sore spots.
3. How does chlorphenamine work and what are the side effects?
Chlorphenamine belongs to a class of anti-allergy medications called
antihistamines which helps reduce itching, sneezing and runny nose. It
competes with histamine for H1-receptor sites on effector cells in the
blood vessels and respiratory tracts, hence blocking the action of
histamine, an allergic reaction mediator. Side effects include
drowsiness (please refrain from operating machinery or driving while
on this medication), dry mouth and eyes and urinary hesitancy.
4. When should chlorphenamine and diphenhydramine be used
with caution?
These medications should be used with caution in the elderly (due to
sedation) and small children (paradoxical agitation, impaired school
performance), patients with cardiovascular disease (hypertension,
angina), glaucoma, prostatic hyperplasia, thyroid dysfunction.
In adults, these medications should be used with caution during
daytime as it causes drowsiness. Refrain from driving or operating
heavy machinery.
URTI case 2:
1. Difflam lozenges and how does it work?
Difflam lozenges contain benzydamine hydrochloride which is a
locally acting analgesic and anti-inflammatory treatment for the
relief of painful inflammatory conditions of the throat including
pharyngitis. It is a nonsteroidal anti-inflammatory drug; inhibits
production of proinflammatory cytokines to reduce local pain and
inflammation. It also has local anesthetic action and numbs the
pain.
2. Difflam for pregnant women?

Difflam lozenges should not be used in pregnancy. The safety of

Difflam has not been established in pregnant patients although
there is no evidence of an increased occurrence of fetal damage in
animals.
3. How should Eunice use the Difflam lozenges? Max dosage per day?
1 lozenge to be dissolved slowly in the mouth every 1 to 2 hours up
to a maximum of 12 lozenges per day.
4. How does dextromethorphan work and side effects?
Dextromethorphan, structurally related to codeine, is a cough
suppressant. It decreases the sensitivity of cough receptors and
interrupts cough impulse transmission by depressing the medullary
cough center through sigma receptor stimulation.
Side effects: occasional drowsiness, dizziness, rare gastrointestinal
disturbances (nausea and diarrhoea) and rare skin reactions
including rash.
LRTI Case 1:
1. Side effects associated with Cetirizine solution?
Minor side effects including headache or dizziness, drowsiness or
tiredness, restlessness, dry mouth.
2. Which class does co-amoxiclav belong to and how does it
work?
Co-amoxiclav is an antibiotic and works by killing bacteria that
cause infections. Co-amoxiclav contains 2 antibiotics: amoxicillin
and clavulanic acid. Amoxicillin belongs to a group of medicines
called penicillins that weaken bacterial cell wall and cause cell
death. Amoxicillin can sometimes be stopped from working
(made inactive) via degradation by beta-lactamases which are
enzymes found in some resistant bacteria. The other active
component (clavulanic acid) stops this from happening by
inactivating the enzymes. Clavulanic acid alone does not exert a
significant antibacterial effect.
3. Her mother worries that the duration of antibiotic
prescribed is too short.
The 7-day course is a typical duration of treatment for this
condition. A 7-day course is as effective as longer duration of
antibiotics in eliminating the harmful bacteria from the body. A
longer than necessary course may kill the good bacteria that
help keep the body healthy and cause more side effects such as
frequent diarrhea. Children with CAP who are appropriately
treated generally show signs of improvement within 48 to 72
hours. If Nina does not get better after 3 days (fever, persisting
cough), you may want to take her to see the doctor.

4. Pneumococcal vaccination after recovering from CAP?

How many doses of the vaccination does she need? Her
daughter has no existing medical problems.
Yes, her daughter can receive the vaccination. There are two
types of vaccines available:
-Pneumococcal polysaccharide vaccine (PPSV23) is meant for
those aged 65y and above or persons aged 2-64 years with
chronic diseases of the heart, lungs, liver, kidneys, diabetes and
immunocompromised patients.
- Pneumococcal conjugate vaccine (PCV13) is meant for infant
(>6 weeks old), children and adults
Nina can receive the PCV13, which protects against 13
pneumococcal serotypes. Assuming Nina is previously
unvaccinated, she can receive one single dose of 0.5ml
(according to PIL).
5. Is it possible to have both influenza and pneumococcal
vaccines done at the same time?
Yes. Pneumococcal vaccine may be given at the same time as
influenza vaccine but at a different site.
6. If a person has pneumonia after vaccinated with
pneumococcus, does it mean that the vaccine didnt
work?
Pneumococcal vaccine only protects people from pneumonia
caused by various serotypes of pneumococcus (Streptococcus
pneumonia), but not those other bacteria such as Haemophilus
influenza, Staphylococcus aureus, Moraxella catarrhalis and
atypical bacteria. It is only modestly protective against
community-acquired pneumonia which is often caused by
pathogens other than pneumococcus. Hence, if a person has
pneumonia after vaccinated, it does not mean the vaccine is
ineffective. Perhaps he/she is infected with another strain of
bacteria other than pneumococcus.
7. Can anyone catch the seasonal flu even though he/she is
vaccinated with a flu vaccine this year?
Influenza virus is remarkable for its high rate of mutation,
compromising the ability of the immune system to protect
against new variants. As a consequence, new vaccines are
produced each year to match circulating viruses. Currently,
vaccine production takes, on average, six months from the
selection of seed strains to the final vaccine product. The
decision of which influenza antigens to include in the vaccines is
made in advance of the influenza season and is based upon

global surveillance of influenza viruses circulating at the end of

the prior influenza season.
As a result, rarely there are mismatches between the vaccine
strain and the circulating strain that result in reduced efficacy of
the vaccine. That means a person still can catch the seasonal flu
even if he is vaccinated this year.
Gum and Tooth Infection Case 1:
1. He is allergic to penicillin. What should you do?
I ask him to describe his allergic reactions to penicillin. After
confirming it is a true allergy, I will call the dentist to make an
intervention.
I may ask the following questions:
What were the symptoms and signs? What is known about the
reaction?
How long ago did the reaction take place?
Did the patient require medical treatment or hospitalization
because of the reaction?
Why was the medication taken (indication for use)?
The dose and route of medication taken (if known).
Had the patient taken the medication on a previous occasion?
Was the patient taking other concurrent medications when the
reaction occurred? Were any of these newly started?
2. What other antibiotic substitution should she use?
Clindamycin 450mg or clarithromycin 500mg PO or cephalexin
2g PO 1h before the procedure
3. What is chlorhexidine mouthwash for?
Oral antimicrobial rinses with 0.12 percent chlorhexidine help
to control dental plaque bacteria, preventing and treating
inflammation of the gum and tissues surrounding the teeth.
Chlorhexidine has activity against gram-positive and gramnegative organisms, facultative anaerobes, aerobes, and
yeast; it is both bacteriostatic and bactericidal, depending on
its concentration.
UTI Case 1:
1. Ciprofloxacin belongs to which class? And how does
it work?
Ciprofloxacin belongs to fluoroquinolone. As a
fluoroquinolones antibacterial agent, the bactericidal action of
ciprofloxacin results from the inhibition of both type II
topoisomerase (DNA-gyrase) and topoisomerase IV, required
for bacterial DNA replication, transcription, repair and
recombination.

2. His wife is currently 4 month pregnant complained

of having same UTI symptoms. He will ask the
doctor to prescribe the same medication
(ciprofloxacin). What is your opinion?
It is preferable to avoid the use of Ciprofloxacin during
pregnancy. Ciprofloxacin crosses the placenta and produces
measurable concentrations in the amniotic fluid and cord
serum. The drug could cause damage to articular cartilage in
the human immature organism/foetus. Hence, David should
not ask the doctor to prescribe ciprofloxacin. Augmentin
(amoxicillin/clavulanic acid) is a preferred choice.
3. Common side effects associated with ciprofloxacin.
Which side effects are associated with elderly
population?
Gastrointestinal: mild anorexia, nausea, vomiting, and
abdominal discomfort, infrequent diarrhea
CNS: mild headache and dizziness, seizure, peripheral
neuropathy (numbness of limbs)
Rash and allergic reactions
Muscular: joint inflammation, tendon rupture
Heart: QT interval prolongation and arrhythmia
Side effects associated with elderly:
Adverse reactions of the CNS are of particular concern for
the elderly population. Elderly patients with impairments of
the CNS (e.g. epilepsy, pronounced arteriosclerosis)
should be treated with fluoroquinolones only under close
supervision. Probably, many signs of possible adverse
reactions such as confusion, weakness, loss of appetite,
tremor or depression are often mistakenly attributed to old
age and remain unreported.
Fluoroquinolones can cause QT interval prolongation.
Therefore, they should be avoided in patients with known
prolongation of the QT interval, patients with uncorrected
hypokalaemia or hypomagnesaemia and patients receiving
class IA (e.g. quinidine, procainamide) or class III (e.g.
amiodarone, sotalol) antiarrhythmic agents.
Chronic renal diseases, concomitant use of
corticosteroids and age over 60 years have been
recognised as risk factors for fluoroquinolone-induced
tendon disorders.
Scabies and headlice case 1:

1. How to recommend them use the malathion?

To be applied at bedtime and wash off after 24hours. Repeat the
second application 1 week later if no improvement. The lotion
should be applied from the neck to the toes, as well as the head if
affected. Its important to be thorough and cover even those
seemingly unaffected areas such as the navel, between the toes
and fingers, the wrists, armpits, genital area, buttocks and other
body folds. Avoid contact with eyes, ears, nose, mouth or vagina.
All household members and anyone with close physical contact
(e.g. baby-sitter, domestic helper) must be treated, even if they do
not have any itch or rash. A second application a week later is
needed to kill any mites emerging from surviving eggs.
As itching can take a few weeks to resolve due to the allergic
reaction to dead scabies mites, their fingernails should be kept
trimmed.
2. Can malathion be used in pregnant women and young
children?
Only children over the age of six months can be treated with a
malathion lotion. Pregnant women can use malathion since
adverse events have not been observed in animal reproduction
studies. According to US Centre of Disease Control, pregnant and
nursing mothers should use malathion only after consulting their
physician.
3. Creams or medication to relieve itch?
Topical: calamine lotion, hydrocortisone cream
Medication: fexofenadine 60mg bd or fexofenadine 60mg om and
chlorphenamine 4mg on
4. Recommendation for head lice and scalp pruritus?
Malathion 0.5% lotion.
All members of the household should be examined for head lice
and should receive treatment if they are found to be infected.
Following the treatment, the hair should be wet combed every
three days for two weeks to remove the dead head lice. To wet
comb hair, you need to moisten the hair with a hair conditioner
and comb it from root to tip with a fine-toothed comb.
After head lice treatment, the patients bedsheets and clothing
should be washed in 60C hot water and dried under direct
sunlight, or in a hot cycle dryer. Items that cannot be washed e.g.
large blankets, stuffed toys, should be kept in sealed plastic bags
for at least one week to destroy the parasites.
5. How would you advice him on the use of malathion:

Apply to dry hair until the hair and scalp are wet. Leave it on for 12
hours before washing off with a non-medicated shampoo. The hair
should be left uncovered and heat sources should not be used to
dry the hair. Second application recommended only if live lice are
still present 7-9 days after treatment
Fungal infection case 1:
1. Itraconazole or griseofulvin can be used for treatment of
Tinea unguium. Dosage regimen and side effects:
Itraconazole: 200 mg per day for 6 weeks. Side effects: headache,
gastrointestinal effects, liver function abnormalities, worsening of
heart failure, leg swelling, hypertension, hypokalemia
Griseofulvin: 500 mg per day for 4-6 months. Side effects:
headache, sensitivity of skin to strong sunlight, diarrhea, rash,
confusion, dizziness.
2. His cousin was given amorolfine (Loceryl) for his nail
infection. How often should amorolfine be used and how
long does his cousin have to use it:
Amorolfine is applied once weekly after the surface of the nail is
filed with a disposable file and wiped with alcohol. Fingernails are
generally treated for six months. Toenails are treated for 9 to 12
months.
Genital infection case 1
1. How to use all her medications (include the usage of
pessaries, creams and wash):
Clotrimazole 100mg pessary: Wash your hands before
insertion. Insert 1 tablet in the evening for 6 consecutive days.
The pessary must be inserted as deeply as possible into the
vagina. This is best done in the lying position with the legs slightly
drawn up. The applicator should be used to assist insertion
(pregnant women should not use applicator). Can wear a
pantyliner during treatment in case of medication leakage which
will soil the underwear. Not to be used during menstruation. Avoid
sexual intercourse until treatment completed. Avoid tampons,
spermicides and vaginal douching during treatment.
How to apply using applicator:
Place the vaginal tablet into the applicator. Wet the vaginal
tablet with water for a few seconds.
Relax while lying on your back with your knees bent.
Hold the applicator in one hand. Insert it slowly into the vagina.
Stop when it becomes uncomfortable.
Slowly press the plunger until it stops.

 Withdraw the applicator. The medicine will be left behind in the

vagina.
Clean the applicator after use by pulling the plunger out of the
applicator and washing both parts completely in warm soapy
water.
Rinse well. After drying the applicator, replace the plunger
Clotrimazole 1% cream: apply the cream thinly to opening of
the vagina and surrounding tissue (inner and outer folds of the
vulva) twice a day (morning and evening) for 7 consecutive days
and gently rub the areas. In order to ensure complete healing, the
treatment should be continued for 2 weeks after the
disappearance of symptoms.
Potassium permanganate 0.1% external solution: Dilute the
concentrated 0.1% solution 1 in 10, to produce a 0.01% (1 in 10
000) solution before use as bath. Soak the vaginal area for 10
15 mins. Dispose of solution after use.
2. She asked if she can stop using the pessaries when she
menstruates or have sexual intercourse?
She should avoid sexual intercourse during treatment. If she
started to menstruate during treatment, he can continue using
the pessaries.
However, if she is menstruating and have not started using
pessaries, she should start the treatment after cessation of
menstruation.
3. Suzie finds it a hassle to use clotrimazole pessaries for 6
days. And she asked if there are alternative pessaries
available that does not require 6 days of continuous
usage.
Gyno-Travogen ovule (isoconazole nitrate 600mg): insert 1 ovule
once only
Clotrimazole 500mg pessary: Insert 1 pessary in the evening
4. Previously, the doctor gave her Metronidazole oral tablets
when she has VVC. How metronidazole works and what is
it commonly prescribed for?
Metronidazole is an antibiotics which interacts with DNA to cause
a loss of helical DNA structure and strand breakage resulting in
inhibition of protein synthesis and cell death in susceptible
organisms. Metronidazole has antiprotozoal and antibacterial
actions and is effective against Trichomonas vaginalis and other
protozoa including Entamoeba histolytica and Giardia lamblia and
against anaerobic bacteria.
It is commonly prescribed for trichomonal vaginitis (inflammation
of vagina caused by Trichomonas vaginalis), bacterial vaginitis,

amoebiasis (acute dysentery), trichomoniasis, giardiasis, surgical

prophylaxis, intra-abdominal infection
1.

2.

3.

4.

5.

Herpes zoster case 1:

How does aciclovir work:
The antiviral activity of aciclovir is due to intracellular conversion
to an active form that inhibits viral DNA synthesis and replication
by inhibiting the herpes virus DNA polymerase enzyme as well as
being incorporated into viral DNA. Herpes simplex virus type 1
appears to be the most susceptible, then type 2, followed by
varicella-zoster virus.
Aciclovir has no activity against latent viruses.
Is aciclovir safe for him?
Since his chronic renal disease is mild and aciclovir is only shortterm, aciclovir is considered safe for him. However, there is a risk
that aciclovir may worsen his kidney disease. Hence, I advise him
to maintain hydration to flush out all the aciclovir from his body,
preventing them from accumulating and causing side effects.
Is mefenamic acid safe for him? If NSAIDs have to be used
on the elderly, how should they be informed on the use?
Mefenamic (standard dose) is not very safe for his renal condition.
NSAIDs may compromise existing renal function. Patients with
impaired renal function and the elderly like Mr Tham are at greater
risk of renal toxicity (acute renal failure).
Elderly patients should be informed that NSAIDs can cause serious
gastrointestinal, cardiovascular, and/or renal adverse events. Use
with caution. Stop using the medication and seek medical
attention immediately if they develop difficulty breathing, chest
pain, leg swelling, black tarry stool, vomit of blood/coffee-ground
materials and severe gastric pain.
Amitriptyline or nortriptyline for his neuropathic pain?
Which one is better?
Amitriptyline has been the most widely studied TCA in chronic
pain. However, the drug has many anticholinergic side effects
including dry mouth, orthostatic hypotension, constipation, and
urinary retention. It also exacerbate gastrointestinal symptoms
and heart conditions in elderly. It is also very sedative for the
elderly. Nortriptyline, a secondary amine TCA, is likely to cause
those side effects and hence can be used safely in older patients.
Hence, nortriptyline is a better choice.
Who will benefit the most from herpes zoster vaccination?
Can his 3-month pregnant daughter receive the vaccine?
CDC recommends shingles vaccine for people age 60 years and
older. Even people who have had shingles can receive the vaccine

to help prevent future occurrences of the disease. In clinical trials,

the vaccine reduced the risk of shingles by 50%. It can also reduce
pain in people who still get shingles after being vaccinated.
In 2011, the Food and Drug Administration expanded the age
indication for Zostavax to include people 50 through 59 years
old for preventing herpes zoster. This decision was based on a
large study showing that the vaccine reduced the risk of zoster by
approximately 70%. For people 50 through 59 years old, the risk of
getting zoster and having prolonged pain from post-herpetic
neuralgia caused by zoster is much lower than for people 60 years
old and older.
Use during pregnancy is contraindicated. Women should avoid
becoming pregnant for 3 months after vaccination (4 weeks per
CDC). Risk to the fetus following exposure to wild-type varicella
zoster virus is small. Hence, his daughter should not receive the
vaccine.
6. His 4-year-old grandson never has chicken pox or chicken
pox vaccine. Is the child who is allergic to eggs eligible for
varicella vaccination?
According to Health Promotion Board, children below age 13 years
old need to receive only 1 dose of the chickenpox vaccine.
According to PIL of Varivax, the varicella vaccine is manufactured
via guinea pig cell cultures and contains trace amount of bovine
calf serum. Hence it is unlikely to contain egg proteins. His
grandson therefore can receive the vaccine.
7. Patient from Thailand asked for 2nd dose of chicken pox
vaccination. However, he was accidentally given Herpes
zoster vaccination instead of Varicella vaccine. Should the
nurse go ahead with the 2nd varicella dose?
If a dose of zoster vaccine was given accidentally in place of
varicella vaccine (Varivax) for a child or an adult, then that dose of
zoster vaccine should be counted the same as a single valid dose
of varicella vaccine. Thats because the level of protection against
varicella would probably be at least the same from zoster vaccine
as for the conventional dose of varicella vaccine. If the erroneous
dose was administered in lieu of the first dose of varicella vaccine,
a second dose of varicella vaccine is required at the normal time a
second dose would be given.
Hence the nurse can go ahead and administer the second dose of
Varicella vaccine.
Warts Case 1

1. How does salicylic acid work?

When applied topically, and in high enough concentrations,
salicylic acid (a keratolytic) acts by achieving a slow, painless
destruction of the thickened stratum corneum. It softens and
destroys the stratum corneum of the affected tissue by reducing
the adhesiveness of the corneocytes while causing the cornified
epithelium to swell, soften, macerate and finally desquamate. In
the treatment of warts, a mild irritant reaction, which may render
the virus more prone to immunologic stimulation or response, may
add to the mechanical removal of infected cells.
2. How long does he have to use the preparation?
The wart may take up to twelve (12) weeks to disappear and it is
important to persevere with the treatment.
3. Can duofilm be used in diabetic?
Duofilm is not recommended in patients with diabetes since
salicylic acid may erode the skin and create wound while diabetic
patients have poor blood circulation and impaired wound healing.
Its best for her to see a doctor.
4. What are the side effects associated with HPV
vaccination?
Common side effects of HPV vaccine include:
-Pain, redness, or swelling in the arm where the shot was given
-Fever
-Headache or feeling tired
-Nausea
-Muscle or joint pain
Brief fainting spells and related symptoms (such as jerking
movements) can happen after any medical procedure, including
vaccination. Sitting or lying down for about 15 minutes after a
vaccination can help prevent fainting and injuries caused by falls.
On very rare occasions, severe (anaphylactic) allergic reactions
may occur after vaccination. People with severe allergies to any
component of a vaccine should not receive that vaccine.
Skin and soft tissue infection case 1:
1. Mr Tommy is currently taking Warfarin for his stroke.
Will warfarin interact with his antibiotics?
Amoxicillin/clavulanic acid (systemic) may enhance the bloodthinning effect of warfarin. Penicillin antibiotics/amoxicillin with a
broader spectrum of activity (especially including those with a
concurrent beta-lactamase inhibitor such as clavulanic acid) may
be most likely to cause a significant interaction.

Monitor anticoagulation status more closely in vitamin K

antagonist-treated patients both during concurrent use of a
penicillin antibiotic and for at least several days after cessation of
the antibiotic. Monitor anticoagulation status more closely in
vitamin K antagonist-treated patients both during concurrent use
of a penicillin antibiotic and for at least several days after
cessation of the antibiotic. Similarly, advise patients to pay
particularly close attention to any signs or symptoms of bleeding.
Topical tetracycline ointment which is absorbed minimally into the
body is unlikely to interact with warfarin.
2. Which class is Co-amoxiclav and how does it work?
Co-amoxiclav contains amoxicillin (belongs to penicillin class) and
clavulanic acid (belongs to beta-lactamase inhibitor).
Amoxicillin is a semisynthetic penicillin (beta-lactam antibiotic)
that inhibits one or more enzymes (often referred to as penicillinbinding proteins, PBPs) in the biosynthetic pathway of bacterial
peptidoglycan, which is an integral structural component of the
bacterial cell wall. Inhibition of peptidoglycan synthesis leads to
weakening of the cell wall, which is usually followed by cell lysis
and death.
Amoxicillin is susceptible to degradation by beta-lactamases
produced by resistant bacteria and therefore the spectrum of
activity of amoxicillin alone does not include organisms which
produce these enzymes. Clavulanic acid is a beta-lactam
structurally related to penicillins. It inactivates some betalactamase enzymes thereby preventing inactivation of amoxicillin.
Clavulanic acid alone does not exert a clinically useful antibacterial
effect.
3. Which antibiotic class is tetracycline and how does it
work?
Tetracycline hydrochloride is a broad-spectrum bacteriostatic
antibiotic which belongs to tetracyclines class.
Tetracyclines are taken up into sensitive bacterial cells by an
active transport process. Once within the cell they bind reversibly
to the 30S subunit of the ribosome, preventing the binding of
aminoacyl transfer RNA and inhibiting protein synthesis and hence
cell growth. Although tetracyclines also inhibit protein synthesis in
mammalian cells they are not actively taken up, permitting
selective effects on the infecting organism.
4. He had severe diarrhea when given Erythromycin. Will
he also get diarrhea with Co-amoxiclav and tetracycline?
Are they in the same antibiotics class?

Co-amoxiclav and tetracycline do not belong to the same

antibiotics class as Erythromycin, hence the chance of getting
severe diarrhea with these two medication is very low. However,
Co-amoxiclav is also known to cause mild diarrhea.
5. Patient complained of diarrhea after taking Doxycycline
yesterday. Advice?
Establish a causal relationship between doxycycline and diarrhea
by excluding other causes (such as concomitant medications, poor
hygiene). Determine the severity of diarrhea (CTCAE grade 1, 2, 3,
4). If the patient present with both diarrhea (3 loose/watery stools
per day over baseline) and abdominal pain/nausea/vomiting and
recently hospitalized, test the stool for Clostridium difficile and
treat C.difficle infection accordingly if positive. If the diarrhea is
severe (grade 3 or above), discontinue doxycycline and initiate
another antibiotics of different class (e.g clarithromycin).
Moreover, the doctor can give patients probiotics (e.g Lacteol fort,
Lactoguard). Avoid anti-motility agents such as Lomotil or
Loperamide since they may delay the elimination of pathogen and
worsen the diarrhea. Supportive care with attention to correction
of fluid losses and electrolyte imbalances is also important.
Skin and soft tissue infection case 2
1. Which class of antibiotics does cephalexin belong to
and how does it work?
Cefalexin is an oral broad-spectrum antibiotic belonging to the
group known as cephalosporins. In adequate concentrations it is
bactericidal for sensitive proliferating microorganisms by
inhibiting the biosynthesis of the cell wall. It is active against the
following pathogens:
Gram Positive: Staphylococci, Streptococci, Pneumococci.
Gram Negative: Escherichia coli, Salmonellae, Shigellae, Neisseria.
2. Recommended dosage regimen for cephalexin in
patient with CrCl of 40ml/min?
There are no specific dosage adjustments for patients whose
CrCl is between 30 to 59 ml/min; however, the maximum
recommended daily dose: 1,000 mg/day.