Case 1: Rash
Q: CL, a 37-year-old woman, is seeking advice regarding a rash on both her hands. The rash is erythematous and itchy with a burning sensation. CL recently started working for a home cleaning service. At work, she uses cleaning solutions that often contain bleach to clean bathrooms. CL says that she is confused about why she is experiencing this rash, given that she constantly washes her hands. She is healthy and reports no allergies or use of chronic maintenance medications. How should CL manage this irritant dermatitis?

A: Advise her that chemical irritants, specifically oxidizing agents such as bleach, can increase the permeability of skin by disrupting its natural barrier, making it more susceptible to irritation.1 Additionally, frequent handwashing may also erode skin and increase the likelihood of dermatitis.2 For this rash, CL will need to restore moisture by applying barrier creams and lipid-rich moisturizers to lock in moisture to rebuild her skin’s barrier.3 She can also take colloidal oatmeal baths to reduce the itching.3 CL should avoid topical OTC products containing caine-type anesthetics, such as benzocaine and lidocaine, as they may irritate the skin further.3,4 To prevent future occurrences, she should use rubber gloves at work to avoid chronic exposure to irritants, such as bleach and other cleaning solutions.3,5 Finally, if CL has another skin exposure to cleaning solutions, she should rinse with lukewarm water and then wash with a hypoallergenic, mild cleanser, such as Cetaphil or Dove, and then rinse and dry gently.5


Case 2: Osteoporosis
Q:
NM is a 63-year-old woman who is looking for something to help keep her bones strong. She says she feels as if she is getting weaker as she ages, and a few of her friends have broken their hips. NM is looking for something for bone health. She has been tested for osteoporosis using a dual-energy x-ray absorptiometry scan, and her doctor said that everything looked normal. However, NM’s doctor recommended that she take a daily calcium supplement. Upon questioning, NM says that she has a relatively healthy diet, though she does not generally eat dairy products. She has no other medical conditions. NM is overwhelmed by the amount of calcium products and does not know which one to take. She also says she is taking a multivitamin that has calcium in it. What recommendations do you have?

A: Advise NM that everyone should try to help build bones and use preventive strategies to decrease the chances of having osteoporosis. She can take calcium supplements, but let her know that multivitamins alone cannot provide adequate calcium. Based on NM’s age, she should get 1200 mg of calcium per day. Adults who are 50 years or younger should take about 1000 mg of calcium per day, and women 51 years or older should take 1200 mg per day. Experts also recommend a daily intake of vitamin D of about 600 IU, up to age 70.6 Although many brands are on the market, NM can take any one she chooses for calcium carbonate at 500 to 600 mg twice daily. Advise her to separate the dosing to get maximum benefit. If NM wants to get the calcium through her diet, she can try increasing her daily intake of oatmeal, sardines, soybeans, and tofu. If she can tolerate dairy, she can also try milk and yogurt.6 If NM is trying to obtain her calcium through her diet, let her know that she needs to be consistent and eat the appropriate food of her choice daily.3


Case 3: HPV Vaccine
Q:
RD is a 24-year-old woman who is looking for something to prevent human papillomavirus (HPV) infection. She says that her mother died from ovarian cancer, and she is looking for an OTC option to help boost her immunity. RD does not drink alcohol or smoke. She has been sexually active for the past 2 years. RD also says she started taking a daily calcium supplement, multivitamins, and omega-3 fish oil to stay healthy. She has no medical conditions. What recommendations do you have?

A: HPV is a sexually transmitted virus. Most infections go away by themselves within 2 years. However, some can last longer and cause cancers and other diseases. HPV can cause cancer of the anus, the back of the throat, the cervix, the penis, the vagina, and the vulva. About 33,700 cancers in the United States are caused by HPV each year. RD can still receive the vaccine; however, it is most beneficial when given before a child becomes sexually active. The CDC recommends that all boys and girls age 11 or 12 years be vaccinated against HPV.7 The vaccination series can be started as early as 9 years. The CDC advises that men can receive the vaccine until age 21 and women can receive the vaccination until age 26.7 RD falls into this range, so she can receive the vaccine today. Clinical trials show that HPV vaccines provide close to 100% protection against cervical precancers and genital warts. Data show a 64% reduction in vaccine-type HPV in the United States since the vaccine came to market. Advise RD that the HPV vaccine has adverse effects similar to those of other vaccines, such as fatigue, fever, headache, joint or muscle pain, nausea, redness, and swelling in the arm.


Case 4: Fertility Monitoring
Q:
XU is a 36-year-old woman who is looking for something to track her ovulation. She says she has been monitoring her temperature to see whether she can predict ovulation for the past 6 months and has been unsuccessful in getting pregnant. XU’s friend used ovulation sticks and got pregnant. XU says that she feels frustrated because she and her partner have been trying consistently to get pregnant. She does not drink alcohol, smoke, or use illicit drugs. XU says she is relatively healthy and takes no medications. What recommendations do you have?

A: Because XU is older than 35 years, the first recommendation is to refer her to a reproductive endocrinologist for evaluation. Typically, evaluation by a physician should be initiated sooner in patients who have risk factors for infertility or if the female partner is older than 35 years. Generally, pharmacists should screen for modifiable risk factors, such as alcohol, drug, and tobacco use, as well as obesity. But because none of these apply in XU’s case, she should be evaluated by a physician.8 In the meantime, she can try ovulation tests, which are about 99% accurate in detecting the luteinizing hormone (LH) surge that precedes ovulation. Advise XU that she can use the ovulation test at any time of the day, but a more concentrated LH surge may be present first thing in the morning. There are multiple brands on the market, and some even have easy ways of identifying ovulation, such as a smiley face. It is important for XU to test at the same time every day and reduce her liquid intake 4 hours before testing. Let her know that 3 days after a positive test is the best time to have intercourse. Ovulation typically occurs 1 to 2 days after the LH surge.9 It is important that XU understand that she can use the ovulation predictor test until she sees her physician, but it is important to follow up to make sure there are no underlying issues.
 
Rupal Patel Mansukhani, PharmD, CTTS, FAPhA, is a clinical associate professor at the Ernest Mario School of Pharmacy at Rutgers University in Piscataway, New Jersey, and a transitions-of-care clinical pharmacist at Morristown Medical Center in New Jersey.

Ammie J. Patel, PharmD, BCACP, is a clinical assistant professor of pharmacy practice at the Ernest Mario School of Pharmacy at Rutgers University and an ambulatory care specialist at RWJBarnabas Health, part of the Barnabas Health Medical Group in Eatontown and Shrewsbury, New Jersey.


REFERENCES
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  2. Warner RR, Boissy YL, Lilly NA, et al. Water disrupts stratum corneum lipid lamellae: damage is similar to surfactants. J Invest Dermatol. 1999;113(6):960-966. doi: 10.1046/j.1523-1747.1999.00774.x.
  3. Fonacier L, Bernstein DI, Pacheco K, et al; American Academy of Allergy, Asthma & Immunology; American College of Allergy, Asthma & Immunology; Joint Council of Allergy, Asthma & Immunology. Contact dermatitis: a practice parameter-update 2015. J Allergy Clin Immunol Pract. 2015;3(suppl 3):S1-S39. doi: 10.1016/j.jaip.2015.02.009.
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  6. National Institute of Arthritis and Musculoskeletal and Skin Disease. Calcium and vitamin D: important at every age. National Institutes of Health website. bones.nih.gov/health-info/bone/bone-health/nutrition/calcium-and-vitamin-d-important-every-age. Updated October 2018. Accessed May 20, 2019.
  7. Human papillomavirus (HPV): questions and answers. CDC website. cdc.gov/hpv/parents/questions-answers.html. Updated August 23, 2018. Accessed May 20, 2019.
  8. Lindsay TJ, Vitrikas KR. Evaluation and treatment of infertility. Am Fam Physician. 2015;91(5):308-314.
  9. Ovulation kits & fertility monitors. American Pregnancy Association website. americanpregnancy.org/getting-pregnant/ovulation-kits/. Updated September 11, 2018. Accessed May 20, 2019.