Insights From Fall Clinical: Using OTC Products

In this feature video, Dr Kirby shares her presentation at the 2023 Fall Clinical Conference on leveraging OTC products in her practice.

Joslyn R. Sciacca Kirby, MD, is a professor of dermatology at Penn State, Hershey, PA, and the president of the Hidradenitis Suppurativa Foundation.

Transcript:

The Dermatologist: Can you give us an overview of what was covered during your session at the Fall Clinical 2023?

Dr Kirby: So overview of what was covered during our over-the-counter talk at Fall Clinical. First was just how to introduce over-the-counter products into your toolbox to be creative but also anticipate maybe some of the barriers from patients and how to set their expectations. Talked a lot about tools in the toolbox for itch, antihistamines, how to use shelf stable orange juice when using low dose Naltrexone. There's a recipe for that in the JAD. Salicylic acid to help steroid penetration when we're using those two things topically and also N-acetylcysteine for picking behaviors.

So for itch, talked about antihistamines and how they are first line therapy for chronic spontaneous urticaria. Side benefit is you can use them for a little bit of sedation before a procedure. We also talked about N-acetylcysteine for picking behaviors, whether that's in addition to a primary dermatosis or more just from skin excoriation disorder. Talked about also for picking behaviors, the use of pimple patches to cover up some of those spots and interrupt that behavioral trigger to manipulate it.

Talked about Salicylic acid to help penetration of steroids as well as tacrolimus and shelf stable orange juice to mix Naltrexone for a low dose Naltrexone, since the compounded cost of those things can be pretty high. Spinning off from that, since I do a lot of Hidradenitis suppurativa, I can't give a talk and not talk about HS. Love topical Resorcinol but can be hard to get. So I substitute topical Ichthammol. It's just a brown salve that people can rub on.

Talked about zinc as a antibiotic substitute and nice over the counter supplement. And also over the counter Azelaic acid, not for HS, but for patients who might have rosacea and they don't have access to prescription Azelaic acid. Last take home in the acne category was taking that Adapalene, which is now an over-the-counter product. And spinning it off for patients with Acanthosis nigricans where maybe a prescription product wouldn't be covered for that indication, they can get the over-the-counter product.

The Dermatologist: Why use OTC products in your practice and how do they enhance patient care?

Dr Kirby: I use over-the-counter products in my patient care because sometimes I can't get a prescription medication for my patient, or the cost of that prescription ingredient is just too high. So I think over-the-counter products really help me add value for my patients and I use them in a few different ways. Most of the time I'm using an over-the-counter product in addition to a prescription product. Very rarely am I using an over-the-counter product in place of a prescription product because it's not available.

I think it is really important to anticipate that our patients are spending their dollars to come to a physician and sometimes they're not expecting us to talk about something that they could have gotten over- the-counter just as easily without coming to see us. So while I feel like MacGyver, when I'm putting together a plan and using over-the-counter products along with my prescriptions, I have to anticipate that my patients might not see it that way. So, how do I set people's expectations when I'm having so much fun putting together this plan?

Well, first I visit, what are their existing misconceptions or conceptions of a product that's over-the-counter? Did they have good luck with an OTC in the past or were they really put off by it? What information might they get from family or on social media from the ingredient that I'm about to give them? Because that might influence them after they leave my office and sometimes they've even read about it before they came in. And lastly, if I can convince them that the ingredient is actually a real medicine and that it does have efficacy, that's kind of a third point. But usually I have to hit the first two first.

The Dermatologist: What safety and usage guidelines should be followed when recommending OTC products to patients with conditions like psoriasis?

Dr Kirby: In addition, when it comes to safety and usage, the most common thing that I try and anticipate with my patients is that they might see a lot of language on a product saying, "Don't use it on broken skin." Or, "Don't use it on certain parts of the body." And I try to just tell them that I understand that's on there for some practical reasons from maybe the manufacturer's standpoint. But as a provider, a physician, I can override that. And especially with efficacy data or safety data, let the person know that it's still going to be fine for them to use.

The Dermatologist: How do you stay updated on OTC product developments, and how do you educate patients about them?

Dr Kirby: There’re a few main places where I get my education about over-the-counter products. One is from the peer reviewed literature from going on PubMed and just looking for a tool to help me with a patient. Grand Rounds, journal clubs where we're trying to find creative solutions to patient care. But the other big place is from my patients who come in asking, "I read something about this ingredient, Manuka honey, what does that mean for me?" And I say, "I'm not really sure, but let me go look it up."

So I guess the two ways that I think about it are, it's the almost fed to me information that either comes through journal clubs or talks or it's the, I need to go find it answers, that come from patient care.

The Dermatologist: Could you share examples of successful OTC product integration in your practice and their impact on patient outcomes?

Dr Kirby: During my talk, I tried to hit some of the most consistent over-the-counter tools that I use. I have a whole set that I focused on for itch. And number one thing that I wanted to emphasize is for chronic spontaneous urticaria.

We've been seeing more and more in the pipeline of therapeutics that are being developed for this indication, which is really challenging to treat. But the first step in the international guidelines of treatment for chronic spontaneous urticaria is over- the-counter, second generation antihistamines. And most of my patients come in saying, "Oh, I failed Fexofenadine or Loratadine or Cetirizine, but they failed it at one pill a day. The guidelines say that we can go up to four times the daily dose.

And so using something that is relatively affordable and instead of just one pill a day, helping them understand that this drug is actually needed at a much higher dose and it's safe. So two in the morning, two in the evening is usually what I pretty quickly jump people up to for chronic spontaneous urticaria. And again, any of those second generation antihistamines. The other thing for antihistamines, not related to itch, but related to procedures.

So sometimes I'll have people come in, whether they're kids or they're adults, they're a little bit concerned about this procedure. You can have diphenhydramine, which is Benadryl, in your office. It's over-the-counter and it's indicated for sedation. So if we're trying to make people just a little bit dozy during their procedure, this is where diphenhydramine can be useful. And there's dosing all the way down to the age of two.

So I'm looking at my dosing right here in front of me. For adults, it's 25 to 50 milligrams, 30 minutes before the procedure. For kids 12 and older, similar dose 25 to 50, but for kids two to 11, it's going to be 12 and a half to 25 milligrams. And so this is instead of maybe hydroxyzine or a benzodiazepine. Other use for itch, Salicylic acid is available over- the-counter and has been shown to help accelerate the improvement that you can get from topical steroids.

So it helps improve, itch faster, redness faster and certainly take down scaling since that's what salicylic acid is good for. But improves penetration of steroids. And there are studies showing that can help improve the penetration of topical Tacrolimus. So we compare this together with treatments for sebderm, for psoriasis, anything that's scaly and inflamed, that salicylic acid might help penetration and accelerate improvement.

One more tip on itch. This is related more to that itch, scratch, itch cycle. We've been hearing lots of things around prurigo nodularis and how there actually is some systemic itch probably implicated in that condition. But part of it or whether it's patients with prurigo nodularis or even psoriasis or eczema, we get into this itch, scratch, itch cycle, and there's a bit of a behavior that develops from that uncontrolled itch.

Treatment called N-Acetylcysteine has actually been shown to help with that picking behavior, whether that's picking on skin, picking at the nail folds, biting nails or even pulling or twisting at hair and the dose is just over-the-counter N-acetylcysteine or NAC, 600 to 2,400 milligrams a day. People usually see improvement over the course of about 12 weeks. Tolerated pretty well, a little bit of GI upset now and again, but people usually get used to that with time.

The Dermatologist: Are there any tips or insights you would like to share with your dermatology colleagues regarding the use of OTC products in your practice?

Dr Kirby: My biggest tip for myself is just remembering them. And so I'm usually only thinking about it at the end of a visit when I'm talking to my patient about, if we can't get this, then we're going to do this. And I think there's just a place maybe closer to the beginning to explore with them. Here are these two options, we can go after this prescription. Here are the pros and cons. Sometimes the con is cost or here's this over the counter option. Here's the data about what I know about how it works and here's the relative price of it.