Infectious Disease
Terri D’Arrigo
Antimicrobial-resistant ringworm made headlines last year when a New York City dermatologist notified public health officials of two patients whose ringworm did not improve with oral terbinafine. Since then, stubborn strains of the fungus, which causes itchy, scaly patches of skin, have appeared in at least 11 states, including New York.
“These resistant ringworm infections generally cannot be treated with topical antifungals or even first-line oral medications like terbinafine,” said Dallas Smith, PharmD, an epidemiologist at CDC’s Mycotic Diseases Branch in Atlanta. “We have to use oral medications such as itraconazole. Then we worry about drug interactions and adverse reactions like increased risk of QTc prolongation, hypertension, and effects on the liver.”
One challenge in addressing antimicrobial-resistant ringworm is that patients can buy OTC products they think might help, without ever having received a diagnosis. Community pharmacists can help curtail the spread of antimicrobial-resistant ringworm by offering education about ringworm and OTC antifungals and corticosteroids.
How to help patients
The first step is to grab patients’ attention with strategically placed educational materials, said Maya Patel, a student pharmacist at Belmont University College of Pharmacy and Health Sciences in Nashville.
“In a small- or medium-sized community pharmacy, positioning the product displays next to the pharmacy counter is a simple yet powerful technique to encourage consultations,” Patel said. “In a larger community pharmacy, displaying patient-friendly signs like an easy-to-read flowchart directing patients to which product to select could be another technique.”
However, Patel cautions against using pictures in these displays because ringworm doesn’t always have the same presentation for all skin types and skin tones, and it often resembles other skin conditions.
When a patient comes to the counter with questions about skin problems, community pharmacists can be prepared with a few questions of their own. The first is whether the patient has received a diagnosis, said Smith, adding that patients who have not yet been diagnosed should be encouraged to do so.
“If it’s a fungal skin infection, using an antifungal with a steroid cream could actually make it worse and not allow the immune system to fight it off,” Smith said. “If a patient does use an OTC antifungal medication without a steroid cream, we don’t want them using it for months at a time. You want a diagnosis after about 2 weeks of using the antifungal cream so you can make sure they’re getting the correct treatment.”
Smith said that the potency of prescription antifungals and corticosteroids is a major concern.
“When used together, these products can damage the skin and promote the spread of ringworm. Using antifungal-corticosteroid creams for ringworm is discouraged and in fact can make it worse,” he said. “If a patient hasn’t gotten a diagnosis or the prescriber gave a diagnosis without doing diagnostic tests, then the pharmacist can interact with the prescriber to change the treatment to monotherapy.”
However, some patients may lack access to health care outside the pharmacy, while others may want to try something over the counter before consulting with a physician. In that case, Patel advises asking patients if this is the first time they have experienced the condition and if they have already tried other treatments.
“This can determine if there’s a possibility of treatment failure due to resistance from overuse of OTC therapies,” she said. “Remember, the internet is full of self-treatment regimens; some of [these] can exacerbate the condition and be dangerous to patients.”
Antifungal stewardship
Pharmacists should also be careful about filling prescriptions for antifungals, Patel said.
“If a patient is taking antifungal medications every month, it’s a good idea to stop and investigate further before filling the prescription,” she said. “If you suspect antimicrobial resistance, it’s a good idea to call the prescriber to discuss it.”
Smith encourages pharmacists to participate in outreach and education in their communities.
“You can attend health events or provide information to other community health workers so they can provide the education. The materials don’t have to be in-depth, just enough to raise awareness and explain the importance of getting a diagnosis,” Smith said.
“Community pharmacists are going to play a huge role in antifungal stewardship going forward, so it is critical to be aware of what is happening from both the OTC and prescription standpoint at your pharmacy,” he said. ■