Ascendis Digibook 2020

Brands proudly brought to you by

Medical Chronicle and Ascendis Pharma (Pty) Ltd

MEDChronicle

045 ZA Digi 102020

ASCENDIS FOCUS

Welcome to Medical Chronicle’s

Ascendis digibook

Here you will find some articles on this diverse and dynamic field that have been featured in Medical Chronicle.

Happy reading!

Contents

CTION

4 Focus on H. pylori | Managing side effects 6 OTC cough treatments: choosing the right one 8 Effective mucous clearance 10 Tips to treat common warts 12 The psychological impact of skin diseases 14 What you can do for paediatric influenza 15 Treating colds and flu in children 17 Managing colds and flu 18 Sinus infection or cold?

CLINICAL | WINTER AILMENTS

20 Probiotics impact on infantile FGIDs 21 Treating vaginal yeast infections 22 Common bacterial and fungal skin infections

Effective mucous clearance

To manage the symptoms of a wet cough, doctors often use treatments that clear mucous from the respiratory tract, but due to the sheer number of medicines available for this purpose, they must be discerning.

C

MEDICAL CHRONICLE 3 OUGH IS AN IMPORTANT physiological reflex that protects the airways from aspiration of foreign

including the eyes, airways, gastrointestinal tract and genitourinary tract. Its importance is revealed when the mucous barrier

excessive mucous or impaired clearance contributes to the pathogenesis of all the common airway diseases. Effective mucous

since airway inflammation, mucous hypersecretion and impaired mucociliary clearance are often major characteristics

ASCENDIS FOCUS

Focus on H. pylori Managing side effects

Helicobacter pylori (H. pylori) infection is a worldwide disease causing significant morbidity. H. pylori infection plays a crucial role in peptic ulcer disease, non-ulcer dyspepsia (chronic gastritis) and its involvement in gastric carcinogenesis is also of mounting concern.1a,2a,3a Sponsored content

T

HE NEED TO treat H. pylori infection is unequivocally related to these associated risks.1a

Mechanisms. H. pylori is known to stimulate both the gastric mucosa and lymphocytes, promoting the secretion of cytokines inducing inflammation in gastric mucosa and that causes gastritis.2b TREATMENT |ERADICATION RATES Usual treatment for H. pylori infection is one-week triple therapy combining acid suppression with a proton pump inhibitor and two antibiotics.1b,3b,4a Unfortunately, treatment failure is prevalent.1c,2a,3b,5a Eradication rates are clinically sub-optimal varying from 65 – 80 %.1a Reasons for poor treatment success include an increasing prevalence of bacterial resistance, poor patient compliance, and the occurrence of antibiotic side-effects.3b,6a COUNTERACTING TREATMENT FAILURE | THE ROLE OF PROBIOTICS Antibiotics with good acid resistance and bactericidal effects, such as metronidazole, clarithromycin, and amoxicillin, are the most commonly used drugs in H. pylori clinical therapy.7a The antibiotics play a major role in eradicating the pathogen, while the proton pump inhibitor acts to inhibit gastric acid secretion and thus enhance the effect of the antibiotics.7b However, the burden of antibioticassociated gastrointestinal (GI) side effects can represent a serious drawback to antiH. pylori therapies.4b With therapy failing to eradicate H pylori in up to 20 % of patients, approaches aimed to improve standard triple therapy efficacy are continually being investigated.2a,3b Here probiotics could Probiotics as a play a particularly possible tool relevant role by for improving treatment management1d tolerability and thereby increasing eradication rates.3c It has been reported that taking probiotics along with antibiotics as adjunct therapy can alleviate side effects.7c ROLE OF PROBIOTIC SUPPLEMENTATION IN H. PYLORI | L. REUTERI In clinical studies it has been shown that the eradication rate can be significantly influenced by probiotic supplementation.4c,5b Specifically looking at studies where H. pylori treatment was supplemented with L. reuteri, we have the following collection 4 MEDICAL CHRONICLE

of results; Emara MH, et al, performed a study wherein patients were treated with standard first-line triple therapy (PPI + amoxicillin + clarithromycin) for 2 weeks together with L. reuteri or placebo for 4 weeks.5c,d Results here show that patients treated with L. reuteri showed more improvement of gastrointestinal symptoms than the placebo treated group, with a significant difference regarding diarrhoea and taste disorders.5e Ojetti V, et al, showed that in H. pylori -positive subjects L. reuteri supplementation increased the eradication rate while reducing the incidence of the most common side effects associated with levofloxacin-based second-line H. pylori therapy. In particular symptoms with a lower incidence included diarrhoea and nausea.4c In children, Lionetti E and colleagues has demonstrated that L. reuteri is capable of reducing the frequency and intensity of antibiotic-associated side-effects during a sequential 10-day eradication therapy for H. pylori (PPI + amoxycillin + clarithromycin/ tinidazole).6b,c Probiotic use as adjunctive therapy to standard treatment will improve the eradication rates and improve tolerability by preventing the occurrence of treatmentrelated side effects.8a ADDRESSING THE CHALLENGE | ADJUVANT THERAPY BENEFITS In addition to infection, the combination of two antibiotics also causes damage to the host gastrointestinal microbiota and leads to an imbalanced microbial population.7d Probiotics are designed to improve imbalanced intestinal flora.2c A probiotic is defined as a living microbial species that, on administration, can have a positive effect on bowel microecology with improved health conditions.4d,e Among the most studied probiotics are lactic acid-producing bacteria, particularly Lactobacillus.4d On the subject of restoring the intestinal physiological microecology,4d it is possible to suggest that L. reuteri may exert an additional beneficial effect during H. pylori infection by a reduction of the bacterial load and consequently of gastric inflammation.1e-g Probiotics may hinder H. pylori colonisation by competing for binding sites or disturbing the adhesion process.

Probiotics with high affinity for epithelial cells can block the colonisation of pathogenic bacteria in gastrointestinal epithelial cells. It has been shown that L. reuteri can compete with H. pylori for binding sites in gastric epithelial cells, thereby inhibiting early H. pylori colonisation.7f

Though seen as beneficial in gastrointestinal health terms, a probiotics alone approach does not meet the clinical needs of H. pylori treatment and use of probiotics as auxiliary in antibiotic therapy achieves greater significant effects.7g Side effects of antibiotics in triple therapy include: Diarrhoea Nausea Vomiting Bloating Abdominal pain Taste disorders

THE LAST WORD |THE IMPORTANCE OF STRAIN SPECIFICITY. The choice to use L. reuteri is based on several factors including being extensively studied in human GI health, including acid resistance, good adhesion capacity and clear evidence of colonisation of the human stomach.1h-j Brought to you by Reuterina® /Ascendis Pharma {Sponsorship of article must be prominent.}

Note: As of April 2020, new names for probiotics belonging to the genus Lactobacillus was adopted. As a result, many of the most well-known commercial probiotics have been given new genus names. Lactobacillus reuteri is now named Limosilactobacillus reuteri.9 REFERENCES: 1. Francavilla RE, Lionetti SP, Castellaneta AM, et al.

Inhibition of Helicobacter Pylori Infection in Humans

by Lactobacillus Reuteri ATCC 55730 and Effect on Eradication Therapy: A Pilot Study. Helicobacter 2008;13(2):127-134.

2. Imase KA, Tanaka K, Tokunaga H, et al. Lactobacillus

Reuteri Tablets Suppress Helicobacter pylori Infection A Double-blind Randomised Placebo-controlled Crossover Clinical Study. Journal of the Japanese Association for Infectious Diseases 2007;81(4):387-393.

3. Efrati C, Nicolini G, Cannaviello C, Piazza O’Sed N, Valabrega S. Helicobacter pylori eradication: Sequential therapy and Lactobacillus reuteri supplementation.

World J Gastroenterol 2012;18(43): 6250-6254.

4. Ojetti V, Bruno G, Ainora ME, et al. Impact of Lactobacillus reuteri Supplementation on AntiHelicobacter pylori Levofloxacin-Based Second-Line Therapy. Gastroenterology Research and Practice 2012, doi:10.1155/2012/740381.

5. Lionetti E, Miniello VL, Castellaneta SP, et al.

Lactobacillus reuteri therapy to reduce side-effects during anti-Helicobacter pylori treatment in children: a randomized placebo controlled trial. Aliment Pharmacol Ther 2006;24:1461–1468.

6. Emara MH, Mohamed SY and Abdel-Aziz HR. Lactobacillus reuteri in management of Helicobacter pylori infection in dyspeptic patients: a double-blind placebo-controlled randomized clinical trial. Ther Adv Gastroenterol 2014;7(1):4–13.

7. Ji J and Yang H. Using Probiotics as Supplementation for Helicobacter pylori Antibiotic Therapy. Int J Mol Sci 2020;21, doi:10.3390/ijms21031136.

8. Goderska K, Agudo Pena S and Alarcon T. Helicobacter pylori treatment: antibiotics or probiotics.

Appl Microbiol Biotechnol 2018;102:1–7.

9. Data on File.

RECOMMENDATIONS: In assessing whether L. reuteri could be of help in ameliorating symptoms during H. pylori triple therapy, the results are clear: patients receiving probiotic supplementation experience a significant improvement of some gastrointestinal symptoms compared to those without probiotic supplementation,4e with emerging evidence of an auxiliary role of decreasing H. pylori bacterial load.1k,4f

Increase the odds of treatment success.1 With therapy failing to eradicate H pylori in up to 20 % of patients, how do you adjust your approach to improve standard triple therapy efficacy?1,2,3

Antimicrobial therapy

Acid suppressive therapy

H. pylori increases the risk of peptic ulcer disease, dyspepsia and gastric carcinoma.4 Proton pump inhibitors are used for the treatment of Helicobacter pylori-positive duodenal ulcers, as part of an eradication programme with appropriate antibiotics.5,6

Acid suppression with omeprazole.5

Probiotic therapy1,2,3,4

Treatment can cause damage to the host gastrointestinal microbiota and leads to an imbalanced microbial population.6 Probiotic use as adjunctive therapy to standard treatment will improve the eradication rates and improve tolerability by preventing the occurrence of treatmentrelated side effects.1,6

The Probiotic for Life.7,8,9

References: 1. Goderska K, Agudo Pena S and Alarcon T. Helicobacter pylori treatment: antibiotics or probiotics. Appl Microbiol Biotechnol 2018;102:1–7. 2. Imase KA, et al. Lactobacillus Reuteri Tablets Suppress Helicobacter pylori Infection. A Double-blind Randomised Placebo-controlled Cross-over Clinical Study. Journal of the Japanese Association for Infectious Diseases 2007;81(4):387-393. 3. Efrati C, et al. Helicobacter pylori eradication: Sequential therapy and Lactobacillus reuteri supplementation. World J Gastroenterol 2012;18(43): 6250-6254. 4. Francavilla RE, et al. Inhibition of Helicobacter Pylori Infection in Humans by Lactobacillus Reuteri ATCC 55730 and Effect on Eradication Therapy: A Pilot Study. Helicobacter 2008;13(2):127-134. 5. Nozer Approved Package Insert, July 2004. 6. Ji J and Yang H. Using Probiotics as Supplementation for Helicobacter pylori Antibiotic Therapy. Int J Mol Sci 2020;21, doi:10.3390/ijms21031136. 7. Reuterina® Drops Approved Package Insert, August 2009. 8. Reuterina Junior® Approved Package Insert, July 2010. 9. Reuterina Daily® Approved Package Insert, July 2010.

Note: As of April 2020, new names for probiotics belonging to the genus Lactobacillus was adopted. As a result, many of the most well-known commercial probiotics have been given new genus names.

Lactobacillus reuteri is now named Limosilactobacillus reuteri.9 S4 NOZER®. Each capsule contains 20 mg Omeprazole. Reg. No.: 36/11.4.3/0420.

Applicant: Dezzo Trading 392 (Pty) Ltd. Reg. No.: 2002/001923/07. Corner Birch Road and Bluegum Avenue, Anchorville, Lenasia, 1827.

Telephone: +27 11 075 8900. Facsimile: 086 664 6223. Marketed by: Ascendis Pharma (Pty) Ltd. Reuterina™ Drops 5 ml. Each 0,2 ml or 5 drops contain a minimum of 1 x 108 live freeze-dried cfu’s of Lactobacillus reuteri Protectis® (Strain DSM 17938) until expiry date. Reuterina™ Junior. Each chew tablet contains a minimum of 1 x 108 live freeze-dried cfu’s of Lactobacillus reuteri PROTECTIS® (Strain DSM 17938) until expiry date. Reuterina™ Daily. Each chew tablet contains a minimum of 1 x 108 live freeze-dried cfu’s of Lactobacillus reuteri Protectis® (Strain DSM 17938) until expiry date. For full prescribing information refer to the respective package insert approved by the Medicines Regulatory Authority.

Applicant: Ascendis Pharma (Pty) Ltd. 31 Georgian Crescent, Bryanston, South Africa. Customer Care: 011 036 9600. 039 ZA Reut 092020

ASCENDIS FOCUS

OTC cough treatments choosing the right one

Increasing financial pressure and access to online health information has resulted in more South Africans turning to self-medication.

But, when it comes to coughs, are they choosing the correct treatment?

A

CCORDING TO AN international market research company, the global over-the-counter (OTC) drug market will grow to about $162 billion by 2020. More than 80% of people across the globe are using OTC medications as the first response

to health issues, with respiratory drugs – including cough medicines – making up more than one-third of this market.

GROWING GLOBAL TREND A recent South African cold and flu study

found the sale of OTC medicines to treat colds and flu increased significantly last year. The most popular medications targeted pain and fever, followed closely by treatments for wet and dry coughs, and colds. Given the high cost of visits to the

GP, as well as the availability of tons of information on the Internet, it’s not difficult to see why more people are self-medicating.

CHOOSING THE RIGHT COUGH MEDICATION Surveys suggest that at any one time, up to one in three children or adults are suffering from a cough. It’s not surprising then that coughs are among the most common complaints for which people seek medical advice at this time of year. Last year, South Africans spent about half a billion rand on cough syrup medications alone.

Unfortunately, self-medication with OTC products poses significant risks to consumers. The potential for misuse and abuse, as well as adverse effects when not used properly are a concern. The wrong choice or incorrect use of cough syrups can lead to potentially harmful medicine interactions and side-effects ultimately costing the consumer more in the long run.

In addition, the combination of ingredients found in some cough syrups may be counterproductive and addictive. Codeine is considered to be the most misused OTC drug sold in SA, with the abuse of codeinebased cough mixtures widely reported both domestically and internationally.

Abusing codeine, in whatever form, may be detrimental to one’s health. Like other opioid medications, abuse of codeine can result in vomiting and nausea, constipation, drowsiness, or even respiratory depression in severe cases.

The potential for misuse and abuse, as well as adverse effects when not used properly are a concern. The wrong choice or incorrect use of cough syrups can lead to potentially harmful medicine interactions and sideeffects ultimately costing the consumer more in the long run TREATING THE CAUSE, NOT THE SYMPTOM A cough is just a symptom rather than an actual infection itself which is why determining the cause of a customer’s cough is key to treating it properly.

6 MEDICAL CHRONICLE

ASCENDIS FOCUS respiratory airway, increasing airflow, and relieving the cough. They’re often used to treat long-term conditions (like asthma or chronic obstructive pulmonary disease) where the airways may become narrow and inflamed. Bronchodilators are either short-acting or long-acting. Short-acting medications provide quick or “rescue” relief from acute bronchoconstriction. Longacting bronchodilators help to control and prevent symptoms by keeping the airways open for up to 12 hours.

Suppressants There are also mixed feelings among the medical fraternity as to whether

suppressing a cough is a good idea as a cough is the body’s natural way of protecting the respiratory tract from infection and irritants. Suppressing a cough could potentially make things worse. Never prescribe a cough suppressant for a wet cough, even if pressurised to do so by the customer. Similarly, never advise a customer to use a cough suppressant to treat a cough that is caused by asthma, emphysema, chronic bronchitis, or smoking. Suppressing the cough reflex in these cases can lead to secondary infections. As such it is generally advised that suppressants or anti-tussive agents are only taken at night to aid in sleeping.

PHARMACIST KNOWS BEST Pharmacists and pharmacist assistants are uniquely positioned to advise patients intent on self-medication.

Make the most of any opportunity to educate patients on the medications they’re considering – what they treat, and how they work.

When dispensing OTC cold and flu medications, it’s important to ensure you recommend the product that will best treat the patient’s symptoms. Always ensure the new medication won’t interact negatively with other medication the patient is already taking and be clear on dosage and directions of use.

Last year, South Africans spent about half a billion rand on cough syrup medications alone.

Mucolytics An acute wet cough is caused by the build-up of mucus, so one way to treat it is by getting rid of the mucus causing the congestion. This is where OTC mucolytics have a key role to play. Mucolytics are drugs that loosen or break down mucus in the nose and chest, making it easier to cough up, and helping to reduce coughing and congestion quickly. They contain N-acetylcysteine (NAC) and are suitable for adults and children. Some come in the form of an effervescent tablet, making the medicine a lot easier to administer. They are alcohol-free, and because each tablet contains a fixed dose of NAC, it can be pre-mixed in a bottle of water, limiting the possibility of dosing errors.

An acute wet cough is caused by the build-up of mucus, so one way to treat it is by getting rid of the mucus causing the congestion

Expectorants The objective of using an expectorant is to move accumulated secretions and phlegm from the respiratory tract and to help stop a productive cough once the airway has been cleared. Expectorants work by signalling the body to increase the amount or hydration of secretions, resulting in more yet clearer secretions and as a by-product lubricating the irritated respiratory tract. Essentially thinning mucus, which makes it easier to cough up which helps to relieve chest congestion.

Bronchodilators Bronchodilators cause the widening of air passages by relaxing bronchial smooth muscle, decreasing resistance in the MEDICAL CHRONICLE 7

ASCENDIS FOCUS

Effective mucous clearance

To manage the symptoms of a wet cough, doctors often use treatments that clear mucous from the respiratory tract, but due to the sheer number of medicines available for this purpose, they must be discerning.

C

OUGH IS AN IMPORTANT physiological reflex that protects the airways from aspiration of foreign materials. It is commonly divided into productive and non-productive types.

Although fatal complications are rare, persistent coughing may cause considerable distress in a patient’s daily life.

The unifying symptom of conditions that produce a wet cough is the production of excessive mucous and sputum. However, despite the adverse impact of productive cough, there is a paucity of guidance on its evaluation and treatment, and in the absence of fixed airway obstruction, it has been excluded from professional COPD guidelines.

MUCOUS Mucous is an important defence against perturbations from the outside world at wet epithelial surfaces throughout the body,

including the eyes, airways, gastrointestinal tract and genitourinary tract. Its importance is revealed when the mucous barrier malfunctions in disorders such as dry eyes or inflammatory bowel disease. Mucous is a remarkable and versatile substance, with properties on the border between a viscous fluid and a soft elastic solid.

Airway mucous is a heterogeneous mixture of secreted polypeptides, cells and cellular debris that is present in the fluid lining the airway surface sub-phase or is tethered together at the fluid surface by oligomeric mucin complexes. Elevated mucin production increases the number of intracellular mucin stores contained within airway secretory cells; in addition, increased mucin exocytosis increases the thickness and viscosity of the extracellular mucous gel positioned above the surface epithelium.

Although a deficient mucous barrier leaves the lungs vulnerable to injury,

excessive mucous or impaired clearance contributes to the pathogenesis of all the common airway diseases. Effective mucous clearance is essential for lung health, and airway disease is a consistent consequence of poor clearance. Healthy mucous is a gel with low viscosity and elasticity that is easily transported by ciliary action, whereas pathologic mucous has higher viscosity and elasticity and is less easily cleared.

The conversion from healthy to pathologic mucous occurs by multiple mechanisms that change its hydration and biochemical constituents; these include abnormal secretion of salt and water, increased production of mucins, infiltration of mucous with inflammatory cells, and heightened bronchovascular permeability.

TREATMENT METHODS Treating a cough is not at all equivalent to treating the illness causing it. However,

since airway inflammation, mucous hypersecretion and impaired mucociliary clearance are often major characteristics of most conditions that produce a wet cough, any treatment approach that takes these into account will be at least partially successful. Cough-suppressant therapy, also known as antitussive therapy, incorporates the use of pharmacologic agents with mucolytic effects and/or inhibitory effects on the cough reflex itself.

The intent of this type of therapy is to reduce the frequency and/or intensity of coughing on a short-term basis. Numerous mucoactive agents with a variety of actions on the airways or secretions have been discovered and utilised. Patients who are most likely to benefit from mucoactive therapy usually have a history of increased sputum expectoration and a preserved airflow. However, the effectiveness of therapy in an individual patient can be

S1

S1 Sinucon® Nasal Drops 20 ml : Each 20 ml contains Naphazoline nitrate 5 mg, Phenylephrine HCI 50 mg, Chlorbutol 100 mg. Ref. No/Verw Nr. H1464 (Act/Wet 101/1965).

Applicant: Ascendis Pharma (Pty) Ltd. Co. Reg. No.: 2002/001567/07.

1 Georgian Crescent East, Bryanston, South Africa.

Customer Care: +27 11 036 9500.

36 JULY 2019 | MEDICAL CHRONICLE

BREATHE FREE with Sinucon® Nasal Drops S1

8 MEDICAL CHRONICLE

023 ZA Sinu 082020

ASCENDIS FOCUS CLINICAL | WINTER AILMENTS difficult to assess. Common mucoactive medications include expectorants, mucolytics and mucokinetic drugs.

Expectorants are meant to increase the volume of airway water or secretion in order to increase the effectiveness of cough. Although expectorants, such as guaifenesin, are sold over the counter, there is no evidence that they are effective for the therapy of any form of lung disease, and when administered in combination with a cough suppressant such as dextromethorphan (the ‘DM’ in some medication names) there is a potential risk of increased airway obstruction.

EXPECTORANTS Expectorants are defined as medications that are taken to improve the ability to expectorate purulent secretions. This term is now taken to mean medications that increase airway water or the volume of airway secretions. The most commonly used of these are simple hydration including both bland aerosol administration and oral hydration, iodide containing compounds such as SSKI or iodinated glycerol, glyceryl guaiacolate or guaifenesin, and ion channel modifiers such as the P2Y2 purinergic agonists. Most of these medications or manoeuvres are ineffective at adding water to the airway and those that are effective are also mucous secretagogues increasing the volume of both mucous and water in the airways. Despite widespread use, iodinated compounds, guaifenesin, and simple hydration are ineffective as expectorants.

MUCOLYTICS Mucolytics are medicines that modulate mucous production and decrease mucous viscosity. Their mucous thinning effects may improve mucociliary transport and thereby facilitate expectoration of mucous out of the distal bronchial tree. Improved clearance and expectoration of mucous can prevent mucous plugging of small airways and may theoretically improve gas exchange and lessen the probability of post-obstructive infection. Through these complementary effects, mucolytics could potentially play a role in reducing exacerbations in chronic obstructive pulmonary disease (COPD).

Mucolytic medications depolymerise either the mucin network (classic mucolytics) or the DNA-actin polymer network (peptide mucolytics) and in so doing reduce the viscosity and elasticity of airway secretions. Mucous has viscoelastic properties of both liquids (viscosity) and solids (elasticity). Thus it is a gel and both the viscous (energy loss) and elastic (energy storage) properties are essential for mucous spreading and clearance.

Mucolytics such as bromhexine are often used in combination with bronchodilators such as theophylline (xanthine), and orciprenaline (β2 -adrenoceptor (AR) agonists) as their modes of action are considered to be complimentary.

BROMHEXINE Bromhexine (BHC) is a derivate of the Adhatoda vasica plant used in some countries for the treatment of various respiratory diseases. Bromhexine has been

found to enhance the secretion of various mucous components by modifying the physicochemical characteristics of mucous.

These changes, in turn, increase mucociliary clearance and reduce cough.

BHC is a widely prescribed mucoactive over-the-counter drug used to treat a range of respiratory conditions, mainly conditions associated with mucous secretion disturbances. These conditions are predominantly associated with augmented inflammation and vulnerability to the development of infections.

Studies have reported actions that influence the production of mucosubstances, sputum quality and quantity, ciliary activity, antibiotic penetration and cough severity and frequency. These actions characterise the basic mucoactive activity of BHC and differentiate it from other drugs.

Ambroxol, a metabolite of bromhexine, has been used in the prevention of neonatal respiratory distress syndrome with no reported maternal or foetal/neonatal side effects. Additionally, ambroxol and

bromhexine have been shown to be scavengers of both superoxide and hydroxyl radicals as determined by pulse radiolysis experiments. The dismutation of superoxide was accelerated 3-fold by bromhexine and 2.5-fold by ambroxol over the rate of spontaneous dismutation. These effects may be clinically relevant in the treatment of oxidant-associated lung damage induced by inflammatory agents and/or environmental pollutants.

References available on request.

This article is a synopsis of a CPD article that can be accessed at: www.medicalacademic.co.za

WET S2

COUGH RELIEF

Recommend Sinucon and help your patient’s BREATHE FREE S2

SA’s ONLY DUAL-ACTING1,2

BROMHEXINE MUCOLYTIC

SALBUTAMOL

BRONCHODILATOR

FROM THE iNOVA FAMILY TO YOUR FAMILY* S2 Sinucon® 20’s: Each tablet contains Paracetamol 200 mg, Ephedrine hydrochloride 6 mg, Caffeine 20 mg, Chlorpheniramine maleate 2 mg.

Ref. No/Verw Nr. G979 (Act/Wet 101/1965). * iNova also offers Pholtex: SA’s No. 1 prescribed cough brand for a dry cough relief Applicant: Ascendis Pharma (Pty) Ltd. Co. Reg. No.: 2002/001567/07. 31 Georgian Crescent East, Bryanston, South Africa.

References: 1. Duro-Tuss™ insert. 2. South African Medicine Price Registry. Database of Medicine Prices. [Online] 22 October 2018 [cited 07 November 2018]; Customer Care: approved +27 11 package 036 9500.

Available at URL: http://www.mpr.gov.za/PublishedDocuments.aspx#DocCatId=21.

033 ZA SinuS2092020 Scheduling status: Proprietary name: DURO-TUSS Linctus. Composition: Each 5 mL liquid contains Salbutamol sulphate 2.41 mg; Bromhexine hydrochloride 4 mg.

Preservative: Sodium Benzoate 0.2 % m/v. Registration number: A39/10.1/0390. Name and business address of applicant: iNova Pharmaceuticals (Pty) Ltd. Co. Reg. No. 1952/001640/07. 15e Riley Road, Bedfordview. Tel: 011 087 0000. www.inovapharma.co.za. For full prescribing information, refer to the package insert as approved by the SAHPRA (South African Health Products Regulatory Authority). Further information is available on request from iNova Pharmaceuticals. IN2936/18.

2 IK 05_10 5411_20 SINUCON TABS A4 PAGE AD MED CHRONICLE.indd 1

2020/10/05 09:51

MEDICAL CHRONICLE | JULY 2019 37 MEDICAL CHRONICLE 9

ASCENDIS FOCUS

Tips to treat common warts According to member dermatologists from the American Academy of Dermatology, children and teens, people who frequently bite their nails, and people with a weakened immune system are more prone to getting warts than others.

A

LTHOUGH WARTS CAN grow anywhere on the skin, they are most common on people’s hands and feet.

According to dermatologists, most warts are grey, brown, or skin-coloured rough bumps that may have little black dots on

them. People often call these dots “seeds,” but they are actually clogged blood vessels.

Other warts are smooth, flat, pink bumps – often occurring on the face. “Warts are caused by a virus, and the virus can sometimes spread from one place on your

body to another or from person to person,” said board-certified dermatologist Adam J. Friedman, MD, FAAD, associate professor of dermatology, residency program director and director of translational research, George Washington School of Medicine and

Health Sciences. “However, each person’s immune system responds to the wart virus differently, so not everyone who comes in contact with the virus develops warts.”

To prevent warts from spreading, Dr Friedman recommends the following tips: • Do not pick or scratch warts, or touch someone else’s wart.

• Wash your hands after treating warts.

• Wear flip-flops in public showers and pool areas.

• Keep warts on your feet dry, as moisture tends to allow warts to spread.

Although most warts go away without treatment within two years, there are things you can do to help get rid of warts more quickly. However, says Dr Friedman, home treatment for warts is trial and error; what works for one person may not work for another and it is impossible to directly kill the wart virus. Home treatments are intended to irritate or inflame the wart area so that your immune system will fight off the virus. To treat common warts at home, Dr Friedman recommends one of the following methods: Apply a wart treatment product with salicylic acid to your wart: Available over-the-counter, this will help peel the wart-ridden skin and irritate the wart, which may trigger the immune system to respond.

Before applying the product, soak the wart in warm water and then sand the wart with a disposable emery board. Use a new emery board each time you do this, and keep in mind that it can take several months to see good results.

Cover the wart with duct tape: Although studies conflict about whether this gets rid of warts, changing the tape every few days may peel away layers of the wart-ridden skin and trigger the immune system to fight off the wart. To do this, soak the wart in warm water and then sand it with an emery board.

Afterwards, apply duct tape to the area.

Remove and reapply the duct tape every five to six days until the wart is gone.

If you notice that the skin around your wart is raw or bleeding, says Dr Friedman, stop treating the wart at home and see a board-certified dermatologist. You should also see a dermatologist if you cannot get rid of your wart; your wart hurts, itches, or burns; you have many warts; you have a wart on your face or genitals; or if you have a skin growth and are unsure if it’s a wart or something else, as some skin cancers can look like warts.

“Dermatologists can treat warts through prescription medications or in-office procedures,” said Dr Friedman. “However, it’s important to remember that there is no cure for the wart virus, so new warts can appear in a new spot at any time.”

10 MEDICAL CHRONICLE

ASCENDIS FOCUS

MEDICAL CHRONICLE 11

ASCENDIS FOCUS

12 MEDICAL CHRONICLE

PEDMED ASCENDIS FOCUS PAEDIATRIC WINTER AILMENTS

WHAT YOU CAN DO FOR

PAEDIATRIC INFLUENZA

Paediatric flu starts rapidly and is more intense than a cold. Paediatric patients tend to feel worse during the first 2 or 3 days that they're sick.

There are three main types of influenza viruses can spread influenza. Types A and B cause the yearly outbreaks. Type C leads to mild, random cases.

SYMPTOMS

• Headache and body aches • Dry, hacking cough • Sore throat • Vomiting and stomach pain.

Some parents mistake the flu for a

Symptoms include: • A high-grade fever up to 40°C • Chills and shakes with the fever • Extreme lethargy

stomach bug. That’s because unlike adults, children with the flu can have nausea, stomach pain, and vomiting.

HOW DOES IT SPREAD? The flu is highly contagious. In a recently released study, infectious influenza particles were present in fine aerosol exhaled breath samples collected from infected individuals, even when they were not coughing or sneezing.

An ongoing concern is that flu may be transmitted from infected patients not simply by coarse (>5μm) respiratory particles, but also by fine (≤5μm) respiratory particles that can persist in the air for prolonged periods.

Children can spread the flu a day before their symptoms start, and 5-7 days after they get sick. It can easily spread among siblings and classmates.

HOW TO AVOID THE FLU?

TO HELP LITTLE ONES WITH COLDS AND FLU

Aspirin FREE

1* Reference: 1. Corenza Cold and Flu Syrup Registered Package Insert, October 2009 S2 Corenza Cold and Flu Syrup. Each 5 ml contains pseudoephedrine HCl 15 mg; chlorpheniramine maleate 2 mg; paracetamol 120 mg. Reg. No. 37/5.8/0552 For full prescribing information refer to the package insert approved by the medicines regulatory authority. 1060272 12/2017 Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021, South Africa. Tel. +27 11 635 0000 www.adcock.com * For children aged 2- 12 years

The best way is to get a yearly vaccination. The CDC says all people six months and older should get one.

Pregnant women and caregivers of children younger than six months or of children with certain health conditions should get the vaccine, as should healthcare professionals.

COMORBIDITIES These can include a sinus infection, ear infection, or pneumonia. Young children under age two, even healthy children, are more likely than older children to be hospitalised from the complications of the flu.

CAN PAEDS TAKE ANTIVIRAL MEDICINE? If you foresee complications from the flu, oseltamivir or zanamivir can be used.

They can help if the patient receives them in the first two days of getting sick.

Antibiotics don’t work. They treat bacterial infections, and the flu is a viral infection.

Paediatric versions of acetaminophen or ibuprofen can lower fever and ease aches. Don’t prescribe aspirin to paediatric patients.

Chlorpheniramine is an antihistamine used to relieve symptoms of allergy, hay fever, and the common cold. These symptoms include rash, watery eyes, itchy eyes/nose/throat/skin, cough, runny nose, and sneezing.

References available on request.

22 APRIL 2018 | MEDICAL CHRONICLE 14 MEDICAL CHRONICLE

CLINICAL ASCENDIS FOCUS PAEDIATRIC PAIN

TREATING COLDS AND FLU IN CHILDREN

The treatment of an infant or child with a cold is different to the treatment recommended for adults.

Medications used to treat the symptoms of colds and flu in children have associated risks, particularly in young infants.

Symptoms need not be treated unless they bother the child.

MEDICATION PRECAUTIONS

When treating symptoms associated with colds and flu in children, use a single-ingredient product where possible to treat the most bothersome symptom. In other words, it is best to avoid multi-component remedies which remain unproven and have been associated with adverse effects, especially in children under the age of six years.

Over-the-counter medications available for the symptomatic treatment of colds and flu include antipyretics/analgesics, antihistamines, decongestants, expectorants, mucolytics, antitussives and combinations of these medications.

Antipyretics/analgesics: Paracetamol or ibuprofen are the preferred agents to lower fever and reduce aches and pains in children.

Avoid using aspirin in children under the age of 16 years. The dose of paracetamol and ibuprofen should be based on the child’s weight rather than on the child’s age.

Antihistamines: First generation antihistamines reduce some of the symptoms of a cold such as a rhinorrhoea and sneezing via their anticholinergic action. The older drugs such as chlorpheniramine have more pronounced anticholinergic actions than do the second-generation antihistamines such as loratadine.

Antihistamines are not effective at reducing nasal congestion and may cause thickening of nasal secretions.

Some antihistamines are included in cough and cold remedies for their supposed antitussive action or to help the patient to sleep.

Decongestants: Decongestants such as pseudoephedrine and phenylephrine can be effective in reducing nasal congestion. They cause vasoconstriction of the nasal mucosa which improves drainage of mucous and circulation of air, relieving nasal stuffiness. These medicines can be given orally or applied intranasally.

If nasal sprays/drops are to be recommended, the patient should not use the product for longer than 5 to 7 days as rebound congestion (rhinitis medicamentosa) can occur with topically applied decongestants.

Expectorants and mucolytics: Expectorants such as guaifenesin and

mucolytics such as carbocysteine and acetylcysteine help loosen and thin respiratory secretions, making them easier to expel. However, these agents have not demonstrated clinical efficacy in treating a productive cough in children.

Antitussives: Antitussive agents

such as dextromethorphan act on the cough centre to depress the cough reflex. Antitussive medications are not recommended to treat coughs in children associated with the common cold as their efficacy has not been proven and they have the potential for toxicity. Coughing is a physiological

response to airway irritation and functions to clear secretions from the respiratory tract. Suppression of a productive cough may result in retention of secretions and potentially harmful airway obstruction.

References available on request.

Trusted pain and fever relief for the whole family.

BRUFEN® ask for it by name.

S1 BRUFEN® 200. 10’s & 20’s: Each tablet contains 200 mg ibuprofen. Reg. No.: A/3.1/727. S1 BRUFEN® 400 EXTRA STRENGTH. Each tablet contains 400 mg ibuprofen. Reg. No.: H/3.1/39. For full prescribing information refer to the package insert approved by the Medicines Regulatory Authority. Further information is available on request from the holder of the registration. Abbott Laboratories S.A. (Pty) Ltd. Co. Reg. No. 1940/014043/07. Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709.

Tel: (011) 858 2000. Date of publication of this promotional material June 2017. Promotional material number ZAEBFN170112.

MEDICAL CHRONICLE | AUGUST 2017 37 MEDICAL CHRONICLE 15

16 MEDICAL CHRONICLE

ASCENDIS FOCUS

MEDICAL CHRONICLE 17

WINTER AILMEMNTS Focus

ASCENDIS FOCUS

SINUS INFECTION OR COLD? Patients often confuse sinusitis with a cold.

A patient comes to see you with pain behind her eyes, cheeks, and forehead. Sometimes she has sinus drainage, and occasionally accompanied by a low-grade fever.

Her symptoms often occur after she has had a cold or allergy symptoms.

She avoids taking antibiotics.

Acute bacterial sinusitis is a form of sinus infection, which are usually caused by bacteria growing in the sinuses. A cold or allergy attack causes mucous membranes in the sinuses to swell and block the tiny openings into the sinuses, which interferes with their ability to drain. The trapped mucus allows bacteria to breed, causing pain and pressure in the head and face.

Colds, caused by viruses, are often mistaken for a sinus infection.

While antibiotics can be helpful for those with sinus infections, they are useless when it comes to fighting cold viruses.

SINUS INFECTION OR COLD?

The main difference between the symptoms of a cold and sinus infection is how long they linger. Cold sufferers typically have a runny nose for two to three days, followed by a stuffy nose for two to three days. After that, most people begin to feel better. A sinus infection will hang around for seven days or more.

A fever may also signal a bacterial infection. Sinus infections are sometimes accompanied by a lowgrade fever, while colds typically are not. Other viruses (such as the flu) do cause fevers, however.

Some people have nasal polyps and allergies, which can increase their risk

of chronic sinus infections.

HOW TO TREAT A SINUS INFECTION

Rest, drinking lots of fluids, breathing steam, and irrigating the sinuses with saline spray or a neti pot, are advised.

Colds, caused by viruses, are often mistaken for a sinus infection

Over-the-counter decongestants can also be helpful, but should not be used for more than three days because some products can exacerbate congestion and raise patients’ blood pressure and heart rate.

Bacterial sinus infections typically last for about 14 days, but the use of antibiotics speeds up the recovery process by up to five days. Still, about 70% of sinus infections resolve on their own, and many patients prefer to let them run their course.

If left untreated, however, sinusitis can cause permanent damage to the sinuses and, in very rare cases, can lead to meningitis. If patients miss work or other activities due to sinus infections, or if their symptoms recur frequently, they should be evaluated.

Source: www.health.com

S1

S1 Sinucon® Nasal Drops 20 ml : Each 20 ml contains Naphazoline nitrate 5 mg, Phenylephrine HCI 50 mg, Chlorbutol 100 mg. Ref. No/Verw Nr. H1464 (Act/Wet 101/1965).

Applicant: Ascendis Pharma (Pty) Ltd. Co. Reg. No.: 2002/001567/07.

1 Georgian Crescent East, Bryanston, South Africa.

Customer Care: +27 11 036 9500.

BREATHE FREE with Sinucon® Nasal Drops S1

18 MEDICAL CHRONICLE

023 ZA Sinu 082020

S2

Recommend Sinucon and help your patient’s BREATHE FREE S2

S2 Sinucon® 20’s: Each tablet contains Paracetamol 200 mg, Ephedrine hydrochloride 6 mg, Caffeine 20 mg, Chlorpheniramine maleate 2 mg.

Ref. No/Verw Nr. G979 (Act/Wet 101/1965).

Applicant: Ascendis Pharma (Pty) Ltd. Co. Reg. No.: 2002/001567/07. 31 Georgian Crescent East, Bryanston, South Africa.

Customer Care: +27 11 036 9500.

033 ZA Sinu 092020

MEDICAL CHRONICLE 19

ASCENDIS FOCUS

Probiotics impact on infantile FGIDs

Functional gastrointestinal disorders (FGIDs) are defined as a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural

I

NFANTILE COLIC, GASTROESOPHAGEAL reflux, and constipation are the most common functional gastrointestinal disorders (FGIDs) that lead to referral to a paediatrician during the first six months of life and are often responsible for hospitalisation, feeding changes, use of drugs, parental anxiety, and loss of parental working days with relevant social consequences. Recent work indicates

a crucial role of the intestinal microbiota in the pathogenesis of gastrointestinal disorders as in FGIDs, and many studies target probiotic therapy for specific conditions such as colic, regurgitation, and constipation. The effect of a probiotic could play a crucial role in the modulation of intestinal inflammation.

RANDOMISED CLINICAL TRIAL:

Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation OBJECTIVE To investigate whether oral supplementation with Lactobacillus reuteri DSM 17938 during the first three months of life can reduce the onset of colic, gastroesophageal reflux, and constipation in term new-borns

and thereby reduce the socioeconomic impact of these conditions.

DESIGN A prospective, multi-centre, double-masked, placebo-controlled randomised clinical trial was performed on term new-borns (age <1 week) born at nine different neonatal units in Italy between 1 September 2010, and 30 October 2012.

SETTING Parents were asked to record in a structured diary the number of episodes of regurgitation, duration of inconsolable crying (minutes per day), number of evacuations per day, number of visits to paediatricians, feeding changes, hospitalisations, visits to a paediatric emergency department for a perceived health emergency, pharmacologic interventions, and loss of parental working days.

PARTICIPANTS In total, 589 infants were randomly allocated to receive L reuteri DSM 17938 or placebo daily for 90 days.

INTERVENTIONS Prophylactic use of probiotic.

MAIN OUTCOMES AND MEASURES Reduction of daily crying time, regurgitation, and constipation during the first three months of life. Cost-benefit analysis of the probiotic supplementation.

RESULTS At three months of age, the mean duration of crying time (38 vs 71 minutes; P < 0.01), the mean number of regurgitations per day (2.9 vs 4.6; P < 0.01), and the mean number of evacuations per day (4.2 vs 3.6; P < 0.01) for the L reuteri DSM 17938 and placebo groups, respectively, were significantly different. The use of L reuteri DSM 17938 resulted in an estimated mean savings per patient of R1 478 for the family and an additional R1 747 for the community.

CONCLUSIONS AND RELEVANCE Prophylactic use of L reuteri DSM 17938 during the first three months of life reduced the onset of functional gastrointestinal disorders and reduced private and public costs for the management of this condition.

IMPORTANT Different probiotic strains have different effects on the human body â&#x20AC;&#x201C; the strain and dosage on the commercially sold product should always be the same as the clinical trial in order to ensure the claim is correct.

SOURCE: Indrio F, Di Mauro A, Riezzo G, Civardi E, Intini C, Corvaglia L, Ballardini E, Bisceglia M, Cinquetti M, Brazzoduro E, Del Vecchio A, Tafuri S, Francavilla R. Prophylactic Use of a Probiotic in the Prevention of Colic, Regurgitation, and Functional ConstipationA Randomized Clinical Trial. JAMA Pediatr. 2014;168(3):228â&#x20AC;&#x201C;233. doi:10.1001/ jamapediatrics.2013.4367

20 MEDICAL CHRONICLE

ASCENDIS FOCUS

MEDICAL CHRONICLE 21

ASCENDIS FOCUS

Common bacterial and

fungal skin infections

A skin infection occurs when thereâ&#x20AC;&#x2122;s a breach in the skin barrier due to causes like injury, diseases, inoculation, warmth, humidity, and poor hygiene.

O

UR SKIN SERVES various functions and protecting us from external noxious substances is one of them. It acts as a barrier to the external environment, protecting us from the sun, heat, cold, pollutants, maintaining our water balance,

producing hormones and vitamins among others. Skin also acts as a sexual organ, defining our identity and acting as a window to the health of our internal organs. Many clues to systemic diseases can be picked up by examining the skin, making a good skin

examination vital. In addition to acting as a solid wall with its various keratin layers, the skin defence also comprises various cytokines and defence cells (like Langerhans cells) guarding us from intruders. However, before meeting the keratin blocks, the

organisms must compete against the normal flora of the skin that provides an ecological competition for pathogenic microorganisms. The normal flora composed of aerobic cocci, aerobic and anaerobic coryneform bacteria, gram-negative bacteria and yeasts, also hydrolyse lipids of sebum to produce free fatty acids, which are toxic to many bacteria.

A skin infection occurs when there is a breach in the skin barrier due to causes like injury, diseases, inoculation, warmth, humidity, and poor hygiene. Once the organism enters the skin, it can cause infections at various levels, even gaining entry to our circulatory system in severe cases, leading to a septicaemia. Most primary pyodermas are secondary to infections with Staphylococcus aureus or group A streptococci. Staphylococci are not part of the normal skin flora but may colonise the skin either transiently or more permanently in certain sites such as the nose, axillae, groin, and perineum.

They are common invaders of eczematous, traumatised, or immunecompromised skin and are responsible for impetigo, folliculitis, and surgical wound infections and may produce toxins. These include toxic shock syndrome, enterotoxins, Panton-Valentine Leucocidin, and exfoliative toxins (staphylococcal scalded skin syndrome).

IMPETIGO Impetigo is a common, highly contagious, superficial skin infection that primarily affects children. Most lesions occur on the face; however, other body surfaces can also be affected. Impetigo tends to start as small blisters, which becomes filled with pus. These lesions rupture and the purulent exudate dries to form golden-coloured crusts. These lesions can be very infectious.

Secondary skin infections of existing skin lesions (e.g., cuts, abrasions, insect bites, chickenpox, eczema) can also occur, leading to an acute, disseminated impetigo.

It is commonly caused by S. aureus bacteria, Streptococcus pyogenes or mixed infections. Methicillin-resistant S. aureus (MRSA) and gentamicin-resistant S. aureus strains have also been reported to cause impetigo. Impetigo is classified as either non-bullous (impetigo contagiosa â&#x20AC;&#x201C; about 70% of cases) or bullous types.

PAEDIATRIC IMPETIGO Children with non-bullous impetigo commonly have multiple coalescing lesions on their face (perioral, perinasal) and extremities or in areas with a break in the natural skin defence barrier. The initial lesions are small vesicles or pustules (<2cm) that rupture and become a honey-coloured

22 MEDICAL CHRONICLE

ASCENDIS FOCUS

Many clues to systemic diseases can be picked up by examining the skin, making a good skin examination vital.

crust with a moist erythematous base.

Pharyngitis is absent, but mild regional lymphadenopathy is commonly present.

Non-bullous impetigo is usually a selflimiting process that may resolve within two weeks.

BULLOUS IMPETIGO Bullous impetigo is considered to be less contagious than the non-bullous form. It tends to affect the face, extremities, axillae, trunk, and perianal region of neonates, but older children and adults can also be affected. The initial lesions are fragile thin-roofed, flaccid, and transparent bullae (<3cm) with a clear, yellow fluid that turns cloudy and dark yellow. Once the bullae rupture, they leave behind a rim of scale around an erythematous moist base but no crust, followed by a brown-lacquered or scalded-skin appearance, with a collarette of scale or a peripheral tube-like rim.

Bullous impetigo also differs from nonbullous impetigo in that bullous impetigo may involve the buccal mucous membranes, however regional adenopathy rarely occurs.

At times, extensive lesions in infants may be associated with systemic symptoms such as fever, malaise, generalised weakness, and diarrhoea. Rarely, infants may present with signs of pneumonia, septic arthritis, or osteomyelitis. The diagnosis of impetigo is usually made based on the history and physical examination. However, bacterial culture and sensitivity can be used to confirm the diagnosis and are recommended in the following scenarios: • When MRSA is suspected • In the presence of an impetigo outbreak • In the presence of post-streptococcal glomerulonephritis (PSGN); in such cases, urinalysis is also necessary Due to the contagious nature of this disease, utmost care must be taken to limit the spread to other children. Mild, uncomplicated cases can be easily treated with topical antibiotics and proper cleaning of the lesions with antiseptics. Several agents can be used, however, topical retapamulin is the first pleuromutilin antibacterial approved for the treatment of uncomplicated superficial skin infections caused by S. aureus and Step. Pyogenes.

It can be safely used in small children as well. While more widespread cases do require oral treatment and at times antipyretics to deal with systemic symptoms. Oral penicillin or erythromycin are easy to administer and cure most

cases. Of course, the addition of a topical antibacterial, as above, does speed up the response time and decrease the infectivity of the lesions. For resistant cases, culture and sensitivity will guide the therapy.

BACTERIAL SKIN LESIONS Bacterial infections can also cause folliculitis. This is an infection or inflammation of the hair follicles most commonly caused by S. aureus. Other organisms, like fungi and viruses are rarely implicated. This condition appears as small papules or pustules mainly on the limbs, that is pruritic and heals with post-inflammatory scars. It can last for a few years, before the patient seeks help. Fortunately, the use of oral antibiotics, like penicillin, are very effective in most cases and tend to cure the conditions.A furuncle, or boil, is an acute, round, tender, circumscribed, perifollicular staphylococcal abscess that generally ends in central suppuration.

A carbuncle is merely two of more confluent furuncles, with separate head.

These lesions begin in hair follicles and often continue for some time, before rupturing through the skin, discharging purulent, necrotic debris. Sites of predilection are the nape, axillae groin, and buttocks, but boils can occur anywhere. Most cases can be treated with oral antibiotics, topical antibiotics for open areas and antiinflammatories for pain.

ECTHYMA Ecthyma is an ulcerative staphylococcal or streptococcal pyoderma, nearly always of the shin or dorsal feet. The disease begins with a vesicle or pustule, which enlarges in a few days and becomes thickly crusted.

When the crust is removed, there is a superficial ulcer with a raw base. Treatment entails the use of antiseptic soaps, followed by the application of fusidic acid, mupirocin, retapamulin, or bacitracin ointments twice daily. Oral dicloxacillin or cephalosporins is also indicated with adjustments made according to the cultured organisms.

ERYSIPELAS Erysipelas is a superficial infection of the skin with the involvement of the dermal lymphatics. It is commonly caused by the Beta-haemolytic group A streptococcal infection, though other types of strep may be involved. It is characterised by local redness, heat, swelling, and a highly characteristic raised indurated border.

The onset is often preceded by malaise, followed by fever, headaches, vomiting, and joint pains. The skin lesions may vary from transient hyperaemia, followed by slight desquamation, to intense inflammation with vesicles and bullae. Common areas of involvement are the face and legs, with operative wounds, fissures, abrasions, or scratches being some of the predisposing factors. Erysipelas can become serious condition, leading to septicaemia, deep cellulitis, or even necrotising fasciitis.

Prompt treatment with oral penicillin and even hospitalisation may be required.

CELLULITIS Another deeper infection of the skin is called cellulitis. This is a suppurative inflammation, involving the subcutaneous tissues, caused most frequently by S. pyogenes or S. aureus.

Usually, mild local erythema and tenderness, malaise and chills may be present at the onset. The erythema becomes more intense and the area becomes more infiltrated and pits on pressure. Streaks of lymphangitis may spread from the area to neighbouring lymph glands and in some cases, gangrene, metastatic abscesses and severe sepsis may follow, especially in immunocompromised patients. Keeping these in mind, one must be very aggressive in treating the patients, with oral or intravenous antibiotics for long enough periods of time. Anti-inflammatories, antipyretics, and good supportive management should also be put in place.

SUPERFICIAL INFECTIONS Our skin also keeps fungi from entering our body. Candidiasis, pityriasis versicolor, and the dermatophyte infections are traditionally known as superficial infections in that they do not penetrate the superficial layers of the skin, except sometimes in the immunocompromised. These infections are very common and can affect the skin, nails and hairs in patients of any age.

Dermatophytes are composed of three genera of fungi: Trichophyton, Epidermophyton, and Microsporum.

Dermatophytes are keratinophilic fungi, living only on superficial dead keratin. They cause inflammation due to permeation of the metabolic products of the fungus into the skin or due to induction of delayed hypersensitivity. The dermatophytes are responsible for tinea infections affecting all the skin surface of the body, manifesting differently on different sites.

Candidal skin infections are commonly caused by candida albicans, which is a normal skin commensal. This fungus becomes pathogenic in the presence of predisposing factors, like diabetes, obesity, immunosuppression, intake of antibiotics, and sometimes due to oral contraceptives.

Candida infection can manifest in various forms like intertrigo, paronychia, oral and genital infections. Others are more sinister, like chronic mucocutaneous and systemic candidiasis infections. Treatment with topical and oral antifungals tends to be very effective.

TINEA CAPITIS Tinea capitis (also known as ringworm) is

common in children of lower socioeconomic areas. It occurs almost exclusively before puberty as the secretion of sebum has a protective effect in adults. The clinical picture tends to vary in severity, depending on the source of the fungus. Basically, human infections produce quite minor degree of erythema and scaling. However, zoophilic dermatophytes can induce considerable inflammation because the host resistance is usually high.

This may result in a boggy mass of inflamed and purulent skin, known as a kerion. If left untreated, it may result in permanent patches of hair loss and therefore early diagnosis is very important.

The treatment consists of a sulphurcontaining shampoo together with oral antifungals (griseofulvin) for at least 6-12 weeks. Tinea lesions on other skin areas tend to be annular or arcuate plaques that spread centrifugally. The edge shows papulovesiculation, pustulation, and scaling, while the centre is usually relatively clear, though in chronic lesions, there may be nodules, hyperpigmentation and even lichenification in the centre. Tinea pedis (athlete’s foot) appears as scaling and emaciation of the interdigital spaces of the feet or a scaling plaque on the sole.

Athlete’s foot tends to recur if not treated properly. Fortunately, most of the infections respond to topical imidazoles or allylamines.

Allylamine anti-fungal, is widely available as terbinafine and tends to be very effective with dermatophytes resulting in less frequent recurrences. In severe cases, oral antifungals can supplement the treatment.

Pityriasis versicolor is caused by Malassezia furfur, which is a normal flora on the skin. It represents a shift in the relationship between the host and resident yeast flora. The yeast overgrows in hot and humid conditions and releases carboxylic acid, which causes hypopigmentation due to reduced tanning of the skin. The lesions are common on the chest and back, and sweaty areas and can even look erythematous or hyperpigmented. They can coalesce into large macules and tend to have a fine scale, accentuated by scratching. Treatment is easy with topical antifungals or sulphurcontaining shampoos. In severe cases, the use of oral antifungals like ketoconazole can help decrease the relapse rates.

CONCLUSION There are hundreds of organisms that are barred from penetrating the bodies by our skin. The skin barrier is very effective in most instances. However, some of them do gain access via the respiratory system or by vertical transmission.

Maintaining a good skin barrier, taking extra precautions, as well having certain immunisations can help keep us healthy.

Not everything can be prevented. However, most can be identified early and treated appropriately. Early lesions do respond to topical treatments, while oral treatment is reserved for more widespread and serious conditions. People who are immunocompromised or suffer from eczema, diabetes, or other diseases affecting their skin barrier or immunity, may need more prolonged and aggressive treatment.

MEDICAL CHRONICLE 23