INTRODUCTION

With more time spent outdoors, the summer brings an uptick in many injuries and ailments. Many of these involve the skin, the body’s largest organ, covering the entire external surface.¹ The skin serves as a barrier against chemicals, mechanical injury, pathogens, and ultraviolet (UV) radiation. It also regulates body temperature and water release into the environment.¹

Sunburn prevention is a key component of summer health. Between 2013 and 2015, about 82,000 patients visited the emergency department (ED) for sunburn treatment, and 20% of those were for severe sunburns (i.e., second- or third-degree).² The highest rate of sunburn-related ED visits during that time occurred in June, followed by July, May, April, then August.² The average ED cost for severe sunburn treatment is $1,132.² This is roughly 10 times the cost of a safe day at the beach, complete with sunscreen, sunglasses, hat, a sun-protective shirt, and a beach umbrella.²

Insect bites are not as harmless as people may think. Vector-borne or arboviral diseases—those spread by blood-feeding arthropods—contribute to millions of infections globally each year.³ Another group of insects—members of the order Hymenoptera—are often equipped with the ability to sting humans and other animals.⁴ This group includes bees, wasps, and hornets that use their venom to cause injury ranging from minor irritation to life-threatening anaphylaxis.⁴ These insects are most abundant in the warmer months.

Swimmer’s ear is a common ailment in the summertime, causing pain and discomfort for people of all ages, but especially children aged 5 to 14 years.⁵ It is a common problem that prompts about 2.4 million health care visits in the U.S. annually.⁶ Cases peak during the summer months; 44% of cases occur in June, July, or August.⁶ In 2007, 1 in 123 Americans sought medical attention for swimmer’s ear.⁶

Poisonous plant species (e.g., poison ivy, poison oak, poison sumac) are found across the U.S. (except Alaska and Hawaii) in various locations, including along streams, roadsides, forests, fields, and wetlands.⁷ They also grow in urban environments like parks and backyards. Poisonous plants are a hazard year-round, but increased time spent outdoors in the summer months could produce an uptick in exposures.

Dr. Azi Shirazi, an urgent care provider in California, says, “In the summer, we see more skateboarding, biking, hiking, and scooter injuries in children and young adults.”⁸ She continues that, “As a result, lacerations and orthopedic injuries are very common." People often approach pharmacists about minor wound treatment. Pharmacy teams should be prepared to field questions about summer ailments and wound care, including when an ailment warrants further medical attention or emergency care.

TOO MUCH FUN IN THE SUN

Sunburns—accidental or as a result of purposeful suntanning—are a major health hazard. UV radiation causes a myriad of health concerns. Despite global efforts to educate the public about the dangers of sun exposure, people continue to overexpose themselves to UV radiation. A National Health Interview Survey between 2005 and 2015 found that more than one-third of adults in the U.S. experience at least 1 sunburn annually.⁹ Pharmacy teams should encourage individuals to use sun protection to prevent sunburn and advise them how to treat it properly, should it occur.

What Causes a Sunburn?

UV radiation damage from sunlight causes reactions ranging from mild sunburn and discomfort to blisters and third-degree burns.¹⁰ UVA and UVB radiation both contribute to sunburn, but UVB rays are responsible for direct deoxyribonucleic acid (DNA) damage.¹¹ In response to DNA damage, the body launches a repair response that induces cell apoptosis (death) and prompts an inflammatory reaction. This inflammatory reaction causes painful, red skin through vasodilation (dilated blood vessels) and edema (fluid collection).¹¹

Skin may also be warm to the touch, swollen, or itchy. Severe enough burns may also cause nausea, fever, and chills.¹¹ A deeper, partial thickness burn may cause blisters or peeling. This leaves the skin underneath unprotected from UV radiation and even more vulnerable to damage. Sunburn symptoms are not immediately apparent; they usually start about 4 hours after sun exposure and worsen in 24 to 36 hours.¹²

Mild burns typically resolve in 3 to 5 days, but severe burns can take weeks.¹² Pain usually worsens about 6 to 48 hours after sun exposure, and skin peeling usually occurs about 3 to 8 days after exposure.¹² Sunburn discomfort will fade, but lasting damage remains after redness and swelling subside. UV radiation is the most preventable cause of skin cancer, and the risk is cumulative over the course of a lifetime (i.e., the more someone burns, the higher the risk of cancer). UV radiation can also cause premature skin aging (e.g., bags, sags, wrinkles), eye damage, and immune system dysfunction.¹³

Sunburn Prevention

People should ideally wear sunscreen daily to protect themselves from UV radiation, especially when they anticipate spending time outdoors. There are 2 major sunscreen types: chemical and physical.¹⁴ Chemical sunscreen protects the skin by absorbing UV rays, most commonly using the active ingredients oxybenzone or avobenzone.^14,15 Other active ingredients of chemical sunscreens include ensulizole, homosalate, octinoxate, octisalate, and octocrylene.¹⁵ The active ingredients in physical (also known as mineral) sunscreens—titanium dioxide and/or zinc oxide—deflect UVA and UVB rays to protect the skin.^14,15

The American Academy of Dermatology (AAD) recommends that people use broad-spectrum sunscreen with a sun protection factor (SPF) of at least 30 (see Sidebar: Sun Protection Buzzwords Explained for further explanation of these terms).¹⁴ They also recommend against the use of sunscreens that also contain insect repellent. While both ingredients are important, especially in summer months, people should apply sunscreen liberally and often, whereas they should use insect repellent sparingly. They should not, therefore, be contained in the same product.¹⁴ Individuals using sunscreen and insect repellent should apply sunscreen first and insect repellent second because the sunscreen may inhibit the repellent’s evaporation, lowering its ability to deter insects.¹⁶

A sunscreen’s ingredients and SPF are useless if people apply it incorrectly. People should apply sunscreen liberally to all skin not covered by clothing and under clothing with low ultraviolet protection factor (UPF) at least 15 minutes before going outdoors.^15,21 Commonly-missed areas include the ears, face (including eyelids), neck, and feet. People should also use a lip balm with at least SPF 15 to protect their lips.²¹ People must reapply sunscreen every 2 hours and immediately after swimming or sweating, even if the product claims to be water resistant.²¹ Parents and caregivers should not apply sunscreen to children younger than 6 months old. Instead, they should utilize clothing with UPF protection and keep them in the shade as much as possible.²¹

Individuals can also utilize the UV Index scale to determine what level of sun protection is needed.²² Most weather apps and websites provide the UV Index on a daily and even hourly basis for any given location. The UV Index scale indicates how to use the UV Index to help avoid harmful radiation exposure, with a lower UV Index indicating a lower risk on a scale of 0 to 11 (see Figure 1). As UV Index increases, so does the recommended level of sun protection.^13,22

Drug-Induced Photosensitivity

A number of medications can cause photosensitivity (see Table 1). The number of photosensitivity-inducing drugs varies depending on the source, but some associate nearly 400 drugs with these reactions.²³ Four drug classes are consistently implicated in all lists of photosensitive drugs: nonsteroidal anti-inflammatory drugs (NSAIDs), antimicrobials, antihypertensives, and antineoplastic drugs.²³

As pharmacists, a major responsibility is informing patients of potential adverse effects (including photosensitivity). Pharmacists should always affix auxiliary labels to prescription bottles to notify patients of potential photosensitivity risk. Pharmacy technicians are often patients’ first point-of-contact and should recognize medications—prescription and over-the-counter (OTC)—that cause photosensitivity and promptly refer patients to the pharmacist. As noted, prevention is key when it comes to sun damage. Proactively advising patients to use adequate sun protection while using medications and products that can increase sensitivity to UV radiation is crucial.

Sunburn Treatment

People who develop a sunburn should immediately remove the stressor by getting out of the sun (preferably indoors) as soon as possible. Hydration is also essential, as sunburned skin draws fluid to the surface and away from the rest of the body, potentially causing dehydration.²⁴

For adult patients, the AAD recommends the following²⁴:

• Take frequent cool baths or gentle showers to relieve pain. Immediately upon exiting the bathtub or shower, gently pat dry but leave skin slightly moist.
• Apply a moisturizer to trap the water in the skin and ease the dryness. (Pro-tip: Cool moisturizer in the refrigerator for added cooling effect while applying.)
• If a particular area is especially uncomfortable, use over-the-counter (OTC) hydrocortisone cream. Pharmacy teams should remind patients to apply hydrocortisone sparingly 2 to 3 times daily and not to use occlusive dressings over it. (Of note, never use pain-relieving “-caine” products [e.g., benzocaine] to treat sunburn, as these may irritate skin or cause allergic reaction that exacerbates sunburn symptoms.)
• Consider taking aspirin or ibuprofen to reduce swelling, redness, and discomfort only if not contraindicated (e.g., NSAID allergy, peptic ulcers, stomach bleeding).

If skin blisters, this indicates a second-degree burn.²⁴ Pharmacy teams should advise patients not to pop blisters intentionally, as they form to help skin heal and prevent infection.

Younger skin is more vulnerable to UV radiation injury, but it also heals faster than older skin.¹⁰ If children develop a sunburn, parents and caregivers should do the following¹⁰:

• Bathe the child in clear, tepid water to cool the skin.
• Apply light moisturizing lotion to soothe the skin, but do not rub it in.
• Dab on plain calamine lotion if more relief is needed, but do not use one with an added antihistamine.

Caregivers should not apply alcohol to the child’s skin, as this can overcool it.¹⁰ They should also not use medicated creams (e.g., benzocaine, hydrocortisone) without instruction from the child’s pediatrician. Caregivers should keep sunburned children out of the sun until sunburn heals completely and practice adequate sun protection moving forward to prevent burning again.¹⁰

When to Seek Medical Attention for Sunburn

Adults with sunburn should seek medical attention if their burn is accompanied by any of the following symptoms, as they could be indicative of infection or sun poisoning¹⁰:

• Feeling woozy or confused
• Fever and chills
• Headache or muscle cramps
• Popped blisters with red streaks or oozing pus
• Severe blistering over a large portion of the body

Parents and caregivers should always treat sunburn on an infant younger than 1 year old as an emergency.¹⁰ Advise them to call the child’s pediatrician or seek urgent or ED care if outside business hours. Children 1 year or older require medical attention if they have blistering, fever exceeding 101°F, lethargy, or severe pain.¹⁰ Caregivers should also contact a medical professional if their sunburned child is not urinating regularly, as this is a sign of dehydration and may be emergent.¹⁰

(For more information on sunburn prevention and treatment, including drug-induced photosensitivity, check out the “Too Much Fun in the Sun” module.)

WHEN CRITTERS STING AND BITE

Bug bites and stings can be painful, itchy, or uncomfortable. However, some carry risk of serious consequences, including disease or anaphylaxis. Pharmacy teams should know how to identify common insect bites and prevent and treat them appropriately.

Insect Bites and Stings and Their Risks

Mosquitoes are a nuisance for people spending time outdoors. When a mosquito bites, it penetrates the skin with its proboscis (a special mouthpart) and sucks blood.²⁵ During this feeding process, the insect also injects saliva into the skin, which results in a puffy, reddish bump within minutes. A day or so later, bumps may become hard, itchy, or reddish-brown or form into small blisters.²⁵ Children, adults bitten by a new mosquito species, and people with immune system disorders may experience more severe reactions to mosquito bites. While rare in the U.S., mosquitoes can also carry viruses like West Nile and dengue or parasites like malaria.²⁵

Tick bites can happen year-round, but these insects are most active during the warmer months (i.e., April to September).²⁶ When ticks bite, they don’t bite, suck, and quickly retreat like mosquitoes.²⁷ They use their curved teeth to dig into skin and stay attached for days. They can also secrete small amounts of saliva with anesthetic properties.²⁸ This numbs the area so the host cannot feel them attach.

Like mosquitoes, ticks can also carry a myriad of disease-causing pathogens, including those that cause anaplasmosis/ehrlichiosis, babesiosis, Lyme disease, Rocky Mountain spotted fever, tickborne relapsing fever, and tularemia.²⁹ However, bacteria that reside in a tick only spring into action when the insect starts to feed.²⁷ It takes about 36 hours for bacteria to make its way from the tick’s gut, to its bloodstream, into its salivary glands, and into the host.²⁷ Therefore, it must be attached for at least this long to transmit disease.²⁸

Medically-important Hymenoptera species are members of the Apoidea (bees) and Vespoidea (wasps, hornets, and yellow jackets; also known as vespids) superfamilies.⁴ Honeybees can only sting once. They have barbed stingers that stay behind in the skin after they sting, pulling the stinger and venom sac out of the bee’s abdomen. Soon after, the insect dies.⁴ Vespid stingers, however, are not barbed, so each insect can deliver multiple venom-injecting stings without dying.⁴

The venom of stinging insects contains many powerful allergens and pharmacologically-active compounds.⁴ A bee sting typically produces a red, swollen spot on the skin and patients feel burning, sharp pain. Later, they will experience severe itching, but if they are not allergic, this is where the trouble ends. Wasp sting symptoms are similar to those of a bee attack, but can be more painful.⁴ There may also be a hemorrhage on the skin. An area stung by a hornet becomes red and very swollen, and patients feel extreme pain. Patients’ skin may also blister. Hornet venom contains histamine and acetylcholine, and hornets’ larger size makes their poison even more toxic than other Hymenoptera species.⁴

Preventing Insect Bites and Stings

Environmental Protection Agency (EPA)-registered insect repellents are important for bite prevention.³⁰ EPA-registered repellents are safe and effective against mosquitoes and ticks, even for women who are pregnant or breastfeeding.³⁰ DEET (chemical name, N,N-diethyl-meta-toluamide) is a common active ingredient in insect repellent.^30,31 Its direct application to the skin makes it harder for biting bugs to smell humans. DEET is available in a variety of formulations, including liquids, lotions, sprays, and impregnated materials (e.g., roll-on products, towelettes) and a wide range of concentrations (i.e., 5% to 99%).³¹ When used correctly (see Table 2), DEET is not harmful, although some individuals experience skin or eye irritation.

Other active ingredients of EPA-registered insect repellents include IT3535, oil of lemon eucalyptus (OLE), para-menthane-diol (PMD), picaridin, and 2-undecanone.³⁰ Products containing OLE or PMD are not safe for children younger than 3 years old.³⁰

Upon returning indoors, people should check clothing for ticks hitching a ride into the house and remove any visible ones. Then, they should tumble dry clothing in a dryer on high heat for 10 minutes to kill ticks (even if clothes are already dry). If clothes must be washed first, hot water is preferred, as cold and warm water does not kill ticks.²⁶ Ticks can also travel on gear and pets and attach to a person later. Showering within 2 hours of coming indoors is also recommended. It may help wash off unattached ticks and also reduces the risk of Lyme disease and other tickborne pathogens.²⁶

The best way to prevent bee and vespid stings is to avoid the insects altogether. Honeybees are rather docile, only stinging to defend their hive against intruders, while vespids are much more aggressive.⁴ Typically, people and animals are stung accidentally by bees when they step on or otherwise disturb them.

Treating Insect Bites and Stings

When bitten by a mosquito, wash the area with soap and water and apply an ice pack for 10 minutes to reduce itching and swelling.²⁵ If patients need relief from itching, they can use OTC anti-itch or antihistamine creams.

Patients (or another trusted adult) should remove an attached tick as soon as possible. Pharmacy teams should advise them of the following tick-removal best practices^29,32:

• Grasp the tick with fine-tipped tweezers as close as possible to the skin’s surface.
• Pull upward with steady, even pressure.
• Twisting or jerking the tick can break off its mouthparts, which remain embedded in the skin.
  • If this occurs, remove mouthparts with clean tweezers if possible; if this is not easily doable, leave the mouthparts alone and let skin heal.
• Do not use folklore remedies (e.g., “painting” the tick with petroleum jelly, using heat to make the tick detach itself).
• After removal, clean the bite area and hands thoroughly with rubbing alcohol, iodine scrub, or soap and water.

The first step to treating an insect sting is to stay calm.³³ While bees can only sting once, wasps and hornets can attack again. Patients should calmly walk away from the area to avoid being stung again, and then do the following³³:

• Remove the stinger (if stung by a bee) by scraping over it with a fingernail or piece of gauze. Do not use tweezers. The venom sac often remains attached to the stinger, so squeezing it could release more venom into the skin.
• Wash the sting area with soap and water.
• Apply a cold pack to reduce swelling.
• Consider taking OTC pain medication (e.g., acetaminophen, ibuprofen).

When to Seek Medical Attention

Following mosquito bites, people should seek medical attention if they have the following signs of a more severe reaction²⁵:

• Large area of swelling and redness
• Low-grade fever
• Hives
• Swollen lymph nodes

Sometimes, antibiotics are indicated for prophylaxis following a tick bite, but only for Lyme disease, not other tickborne diseases. Guidelines recommend a single dose of doxycycline 200 mg for adults or 4.4 mg/kg for children weighing less than 45 kg after a high-risk tick bite in areas highly endemic for Lyme disease.³² Traditionally, doxycycline was not recommended for patients younger than 8 years old, but recent evidence has changed this practice. Doxycycline binds to calcium less readily than other tetracyclines, and is therefore not likely to cause tooth staining in children. Benefits of doxycycline prophylaxis may outweigh risks when all of the following are true^32,34:

• doxycycline is not contraindicated
• the attached tick is an adult or nymphal Ixodes scapularis tick
• estimated attachment time is 36 hours or more based on degree of tick engorgement with blood or likely time of exposure
• patient can start prophylaxis within 72 hours of tick removal
• Lyme disease is common where the bite occurred (i.e., Upper Midwestern and northeastern U.S.)

(For more information on signs and symptoms of mosquito- and tickborne diseases that should prompt referral for medical attention, check out the “When Critters Bite” module.)

A major risk of bee and vespid stings is allergic reaction, specifically anaphylactic shock. Advise patients that after a sting, they should have another adult watch them closely for signs of anaphylaxis. Signs of anaphylaxis that should prompt immediate medical attention include blue lips, difficulty breathing, dizziness, fainting, hives, nausea, pale skin, or sudden drop in blood pressure.³³ Additionally, if swelling moves to other parts of the body (e.g., face, neck), patients should go to the ED immediately.³³

Anaphylactic reactions are not dose-related and can be fatal, even after a single sting.⁴ The Centers for Disease Control and Prevention (CDC) reports that the number of U.S. deaths caused by bee, hornet, or wasp stings has risen every year since 2012.³⁵ Bee and vespid stings can lead to death in a few different manners. Most commonly, death is the result of immediate hypersensitivity, which leads to anaphylaxis.⁴ However, severe local reactions can also be fatal, especially if they involve the airways. Swarm attacks can cause death, even in nonallergic individuals.⁴ Regardless of signs and symptoms, patients should always seek medical attention if they have been stung multiple times, but the estimated lethal dose is about 500 stings for adults or 20 stings/kg for most mammals.^4,33

Patients who know they are bee allergic should always carry epinephrine in case of a sting. Pharmacy teams should be cognizant in the summer to watch patient profiles for reported bee allergies and make sure patients are up-to-date on epinephrine supplies. They should also remind patients to have 2 epinephrine doses available at all times, especially when spending time outdoors.

STEER CLEAR OF WATER-LOGGED EARS

Swimmer’s ear—also known as otitis externa—is an infection of the outer ear typically caused by water that remains in the outer ear canal for a long time.⁵ Water in a patient’s ear canal for an extended period of time provides the perfect environment for germs to grow and infect the skin.⁶ Signs and symptoms of swimmer’s ear typically onset within about 48 hours, including^5,36

• pain when tugging the outer ear or applying pressure to the tragus (i.e., part of the outer ear that sticks out in front of the ear canal)
• itchiness inside the ear
• drainage from the ear
• redness and swelling in the ear

Swimmer’s Ear Prevention

Exposure to water—through swimming, bathing, or other activities—coupled with a warm, humid environment increases the risk of swimmer’s ear.⁶ To prevent otitis externa, people should keep their ears as dry as possible.^5,6 They can use a bathing cap, ear plugs, or custom-fitted swim molds when swimming.⁵ This is especially important in a public pool or other recreational water venue, as these sources tend to be breeding grounds for infection-causing bacteria.⁶ Causative microbes are present in most swimming pools and hot tubs, even clean ones.³⁶

People should dry their ears thoroughly with a towel after swimming or showering and also^5,6

• tilt the head back and forth to allow water to drain from each ear canal
• pull earlobes in different directions with each ear facing down to help water drain
• use a hairdryer on the lowest heat and speed settings several inches from the ears to dry up excess moisture

Instruct patients with water-logged ears to refrain from putting objects (e.g., cotton swabs, keys, writing utensils) in the ear canal or removing ear wax on their own.⁶ Both of these can damage the skin inside the ear canal, potentially increasing infection risk. In fact, ear wax is protective against infection.^5,36 It creates a barrier to moisture and its slightly-acidic pH inhibits infection.³⁶

Swimmer’s Ear Treatment

Pharmacy teams can help patients differentiate between water-logged ears and otitis externa (see Figure 2). Water-logged ears are self-treatable, but patients should always seek medical attention for symptoms of otitis externa, as nearly all cases (98%) are bacterial and require antibiotic therapy.³⁶ People should especially consult with a health care provider if their ears are draining fluid, flaky, itchy, painful, or swollen.⁶

Alcohol-based drying ear drops—isopropyl alcohol 95% in anhydrous glycerin 5%—are available OTC to treat water-logged ears and prevent swimmer’s ear, but they are not appropriate for everyone.^5,37 People with ear tubes, punctured ear drums, active swimmer’s ear infection, or ear drainage should never use ear-drying drops.⁵ Patients using these OTC drops to prevent otitis externa or treat water-logged ears should tilt their head, instill 4 to 5 drops into the affected ear, and allow the solution to remain in the ear for 1 to 2 minutes.³⁷ If symptoms persist after several days of use, patients should seek medical attention. Advise patients not to use isopropyl alcohol alone to dry out water-logged ears, as repeated use of alcohol alone can over-dry ear canal tissue.³⁷ The glycerin in combination products prevents this over-drying effect.

Most cases of swimmer’s ear resolve in about 7 to 10 days with topical antimicrobial treatment.³⁶ Topical therapies are beneficial for swimmer’s ear, but oral antibiotics are less useful.³⁶ Pharmacists may still see prescriptions for oral antibiotics for otitis externa, as about 20% to 40% of patients still receive oral antibiotics, with or without topical therapy.³⁶ U.S. Food and Drug Administration (FDA)-approved otic medications for acute otitis externa include

• acetic acid 2%
• ciprofloxacin 0.2% + hydrocortisone 1%
• ciprofloxacin 0.3% + dexamethasone 0.1%
• hydrocortisone 1% + acetic acid 2%
• neomycin + polymyxin B + hydrocortisone
• ofloxacin 0.3%
• polymyxin B + hydrocortisone

Pharmacy technicians should always refer patients with ear drop prescriptions to the pharmacist for counseling to ensure adherence and proper administration. Pharmacists should counsel patients using otic therapies to³⁷

1. tilt the head or lie with the treated ear facing upwards
2. place the prescribed number of drops into the ear canal
3. allow the solution/suspension to sit in the ear canal for at least 1 to 2 minutes before bringing head upright

Pain relief is also an essential component of swimmer’s ear treatment.³⁶ Mild-to-moderate pain associated with swimmer’s ear typically responds to acetaminophen or an NSAID.

BEWARE THE POISON PLANTS

Poison ivy, poison oak, and poison sumac plants can cause allergic contact dermatitis (ACD).³⁸ These plants are members of the Toxicodendron genus, and they produce an oily sap called urushiol. ACD results from exposure to a foreign substance that acts as an allergen (in this case, urushiol), leading to a delayed hypersensitivity reaction presenting as a rash. Patients require 2 exposures to the same allergen to present with an ACD-associated rash.³⁸

About 80% of the U.S. population is estimated to be sensitive to urushiol.³⁸ If people are sensitive to 1 Toxicodendron plant, they are typically sensitive to them all. Upon exposure, urushiol absorbs into the skin within 10 minutes and starts the sensitization process.³⁸ Urushiol resides in the resin canals of the plants, so the substance is only released in the event of damage to a Toxicodendron plant (e.g., animals, insects, rain, wind).³⁸ Once released, however, the oil spreads easily. Unwashed, contaminated body parts or clothing can transfer urushiol to other parts of the body or another person.

People can identify these plant species by their appearance. Many people use the “Leaves of 3, let it be!” rule, as most have 3 leaves emanating from a central stem.³⁸ Pharmacy teams should advise patients, though, that some plants in this group differ in the number of leaflets stemming from the central point. Major differences between poison ivy, poison oak, and poison sumac are shown in Figure 3.

Urushiol-induced ACD presents only on oil-exposed areas, generally about 24 to 48 hours after contact.³⁸ Patients develop papules, small vesicles, and/or bullae over inflamed, swollen skin. Erythema and severe itchiness are also common. Lesions are often not well-circumscribed and disseminate. Severe reactions include vesicle rupture, leading to oozing, weeping, and subsequent crusting.³⁸

Prevention of Urushiol-Induced Rash

Plant rashes cannot spread from person to person once the urushiol is washed off.³⁹ Even if rash blisters break open, the fluid inside cannot further spread the rash. The plant oil, however, can linger on virtually any surface, sometimes for years, until someone washes it off with water or rubbing alcohol.³⁹ A common misconception is that scratching will spread a urushiol-induced rash, and people often believe this because it appears over time as if spreading, rather than all at once. However, this occurs because different parts of the body absorb the oil at different rates, the oil is trapped under fingernails, or the patient has repeated contact with a contaminated object.³⁹

Pharmacy teams should advise people of the following tips to avoid urushiol-induced ACD³⁹:

• Learn what Toxicodendron plants look like to avoid them while outdoors (see Figure 3).
• Wash garden tools and gloves regularly.
• If contact with poison plants is expected, wear long sleeves, pants tucked into boots, and impermeable gloves.
• Wash pets with shampoo and water while wearing gloves if they may have brushed up against Toxicodendron plants (most pets are not sensitive to urushiol, but they can spread the oil).
• Following known contact with a poison plant, wash skin with soap and cool water as soon as possible to prevent oil absorption into skin.

Urushiol-Induced Rash Treatment

Patients with urushiol-induced ACD should first remove and avoid further contact with the offending agent.³⁸ Next, the goal is to reduce inflammation. Patients can use OTC hydrocortisone cream on localized areas to reduce inflammation and itching. Cream is preferred over ointment, as it allows weeping lesions to dry rather than occluding them and trapping moisture.³⁸

People with urushiol-induced ACD should avoid scratching any blisters that form, as itching increases infection risk.³⁹ Rash, blisters, and associated itching typically self-resolve in several weeks. Patients looking for itch relief should use wet compresses on affected areas or soak in cool water if the rash is widespread.³⁹ Pharmacy teams should advise patients that hot showers typically intensify itching and can scald or burn rash-affected areas.³⁸ Other OTC products help with itch, including zinc-containing skin protectants. Calamine products also help to dry the oozing and weeping of Toxicodendron-induced rashes, and protectants like baking soda or colloidal oatmeal help relieve itching and minor irritation.³⁹

Patients can also use the astringent aluminum acetate—available in a powder or tablet that dissolves in water—to relieve rash symptoms.^38,39 This product complexes with proteins, altering their ability to swell and hold water.³⁸ Pharmacists should be prepared to instruct patients how to use this drying agent for weeping or oozing³⁸:

1. Prepare a 1:40 aluminum acetate solution (add 1 to 3 tablets or powder packets to 1 pint of cool tap water and stir/shake until fully dissolved).
2. Soak affected area(s) for 15 to 30 minutes 3 to 4 times daily OR loosely apply a compress to affected area(s).
   1. Soak a washcloth, cheesecloth, or small towel in the prepared solution and gently wring it out.
   2. Apply to the affected area(s) for 20 to 30 minutes.
   3. Rewet the compress and repeat this process 4 to 6 times daily.
3. Prepare a new solution for each soak or compress application.

When to Seek Medical Attention

Some symptoms of urushiol-induced ACD should prompt patients to seek medical attention. Parents or caregivers should always seek medical attention for patients younger than 2 years old with this condition.³⁸ Pharmacy teams should refer patients with any of the following symptoms to a health care provider for treatment^38,39:

• Difficulty breathing
• Fever more than 100°F
• Itching worsens or interrupts sleep
• Pus, soft yellow scabs, or tenderness
• Rash fails to show some improvement within 1 week
• Involvement of the eyes, genitals, or mouth
• Rash is widespread (i.e., more than 20% to 25% of body surface) and severe

Pharmacy teams can recommend that patients use the Rule of Nines (see Figure 4) to quickly establish the percentage of an adult body that is covered by a rash or burn.⁴⁰ This only applies to people with body weight 10 kg to 80 kg not classified as obese on the body mass index scale.

CUTS AND SCRAPES AND BRUISES, OH MY!

People often present to pharmacies with minor cuts, scrapes, and bruises looking for guidance. Cuts and scrapes in the skin happen for all different reasons, but in the summer, increased outdoor activities like bike riding and hiking increase their prevalence. To understand the extent of these types of injuries, first consider the 3 layers of the skin, which vary in structure and function.¹

The epidermis is the outermost layer of the skin made up of mostly keratinocytes but also melanocytes, Langerhans’ cells, and Merkel cells.¹ Keratinocytes form the epidermal water barrier by making and secreting lipids. Melanocytes’ primary function is to produce melanin, the product responsible for skin pigmentation. Langerhans’ cells function as part of the immune response, and Merkel cells are mechanoreceptors essential for light touch sensation.¹

The dermis is the middle layer of the skin connected to the epidermis at the basement membrane level. It houses blood vessels, hair/hair follicles, muscles, sensory neurons, and sweat glands.¹ The hypodermis, the deepest layer of the skin, lies below the dermis and is otherwise known as the subcutaneous fascia. It contains adipose lobules and some skin appendages (e.g., blood vessels, hair follicles, sensory neurons).¹

Cuts and Scrapes

Providers define wounds based on their depth within the skin’s layers (see Table 3), and each wound type requires different care.⁴¹ Pharmacy teams should gather as much information as possible about the injury before recommending treatment, including what caused the injury, how long ago it happened, and its depth and size. Exclusions for self-treatment of a skin wound include⁴¹

• animal or human bite wounds
• deep partial thickness, full thickness, or subdermal injury
• face, hands, feet, major joints, genital, or perineum involvement
• foreign matter in the wound that remains after irrigation
• injury that is a suspected non-accidental injury
• preexisting medical conditions that affect wound healing (e.g., autoimmune conditions, diabetes)
• signs of infection (e.g., fever, pus)
• worsening symptoms or lack of improvement within 7 days

It is important to assess whether a health care provider should close a wound. Wounds with smooth edges that stay together during normal body movement and shallow wounds less than 0.25 inches deep and 0.75 inches long generally do not require provider attention.⁴² Wounds that require stitches, staples, or liquid stitches should ideally be closed within 6 to 8 hours of the injury.⁴² The following wounds require medical attention⁴²:

• Wounds more than 0.25 inches deep, that have jagged edges, or that gape open
• Wounds longer than 0.75 inches that are deeper than 0.25 inches
• Deep wounds that penetrate fat, muscle, bone, or other deep structures
• Deep wounds over a joint, especially if the wound opens when the patient moves the joint
• Deep wounds on hands or fingers
• Wounds that continue to bleed after 15 minutes of direct pressure

The goals of treating minor skin injuries, including abrasions (scrapes) and lacerations (cuts), are to relieve symptoms, promote healing by preventing infection and further trauma, and minimize scarring.⁴¹ Pharmacists should recommend that patients with minor skin injuries follow basic support measures, including cleansing the wound, applying moist wound care, and relieving any pain or discomfort.

Wound cleansing prevents infection and promotes safe healing, which is also the best way to prevent excessive scarring.⁴¹ Clean tap water is the preferred method of irrigation, as it is inexpensive and readily available in first-aid situations. Saline irrigation offers no added benefit. Patients should irrigate uncontaminated wounds gently so as to not further damage the area. Contaminated wounds, however, require more aggressive irrigation to remove foreign bodies or debris.⁴¹ Pharmacy teams should ensure patients know not to pull or peel loose skin, as removing viable skin could delay healing. Whenever a break in the skin occurs, pharmacy teams should also assess a patient’s tetanus vaccination status.⁴¹

Old guidance suggested that people should leave wounds open to the air or cover them with nonocclusive dressings.⁴¹ However, open-air wounds are more likely to scab, which impedes the skin’s ability to re-grow and may exacerbate scarring. Wound dehydration can also increase risk of bacterial reentry into the wound and delay healing.⁴¹

Use of a moist, occlusive wound dressing is recommended for superficial partial thickness injuries to keep the area moist.⁴¹ A moist environment promotes cell proliferation and stimulates epithelial cells to migrate to heal the wound. Occlusive dressings also prevent bacteria entry into the affected area and may provide some pain relief.⁴¹ Gauze is a readily-available, cost-effective option for wound dressing that comes in pads and rolls, but it is dry and does not keep wounds moist.⁴¹ Patients can use products that contain skin protectants, including glycerin and petrolatum.⁴¹

Other more expensive products are available as well, including Tegaderm products. Patients may prefer these over plain gauze or non-stick pads because they are self-adherent and provide a moist healing environment without the need for additional products.⁴¹ These are very protective and comfortable, but they are less cost-effective and unable to absorb excess wound fluid. Pharmacists should advise patients to keep their dressings clean and change them according to product instructions, but they should also limit changes or use non-stick gauze pad products to prevent damaging the healing skin.⁴¹

People apply liquid adhesive bandages by either spraying or brushing on liquid that forms a clear, flexible coating over the injury.⁴¹ Little evidence supports their regular use, but they can be helpful for aesthetic reasons (e.g., on the face) or when a more flexible dressing is needed (e.g., on a finger or elbow). They may also burn upon application. Advantages of these products include high bonding strength and water resistance; they can stay on for 5 to 10 days at a time.⁴¹ Patients should never use liquid adhesive bandages over large areas of the body, over sutures, near the eyes, or on mucous membranes.

Patients who require pain relief should use OTC acetaminophen or NSAIDs at their recommended dosing.⁴¹ Topical anesthetics are also available OTC, including benzocaine and lidocaine.⁴¹ These drugs have a rapid onset, but relief often doesn’t last very long. Many also choose to use OTC topical antimicrobial products (i.e., those containing bacitracin, neomycin, and/or polymyxin C) to prevent infection. Ensure that patients understand that these products are for infection prevention and not meant to treat an actively-infected wound.⁴¹ Also, to prevent contamination, people should apply the product to a clean gloved hand or gauze to apply to the injury site rather than using a bare finger.

Pharmacy teams should also encourage scar prevention, as scarring secondary to a minor injury can lead to negative aesthetic, physical, psychosocial, and social consequences for patients.⁴¹ UV radiation can increase scar pigmentation, worsening their clinical appearance.⁴¹ Patients should use sunscreen generously when scars are exposed outdoors.

Scar management guidelines recommend silicone therapy as the only evidence-based, non-invasive preventive, and therapeutic measure.⁴¹ Silicone occludes and hydrates scar tissue and may help with itching and discomfort associated with scar formation. Silicone is available OTC in sheet and gel formulations. Sheet formulations may be difficult to use on large areas or near joints, so sometimes gels are a better option. Pharmacy teams should advise patients to follow instructions specific to the product they select.

Bruising

A bruise—also known as a contusion—is skin discoloration that results from blood pooling under the skin following an injury.⁴³ The injury damages blood vessels under the skin and they leak. Most bruises start off black and blue, brownish, or purple and change color as they fade, often turning yellow just before they disappear.⁴³ People with darker skin may experience dark brown or black bruising. There are different classifications of bruising, including⁴³

• black eye: blood and fluid pool under the eye following a blow to the head, causing swelling and a discolored ring around the eye
• hematoma: collection of blood outside blood vessels, leading to pain and swelling
• petechiae: pinpoint areas (i.e., less than 2 mm) of reddish dots on skin that do not turn white with gentle pressure applied
• purpura: small bleeding that occurs under the skin

Everyone experiences bruising, but some characteristics, medical conditions, and medications make people more prone to it, including⁴³

• bleeding disorders (e.g., hemophilia, von Willebrand disease)
• blood thinning medications (e.g., aspirin, warfarin)
• cancer or liver disease
• older age
• regular NSAID use
• thrombocytopenia (low blood platelet count)
• vitamin C or vitamin K deficiency

Most bruises are self-limiting and heal within 2 weeks without treatment.⁴³ Severe bruising or hematomas, however, may take up to a month or longer to fade away. Patients hoping to heal bruises faster should rest and elevate the injured area to reduce pain and prevent swelling.⁴³ Patients may also use ice or heat to heal bruises. Ice packs are best for the first 24 to 48 hours after the injury, but patients should not apply them directly to skin. Best practice is to wrap the ice pack in a towel and apply it for no more than 15 minutes at a time. They can repeat this many times throughout the day.⁴³

After 2 days, heat is better for bruises than ice. Patients can apply a heating pad or warm compress to the area several times throughout the day. If patients are looking for pain relief, pharmacy teams should recommend acetaminophen, as patients with active bleeding or bruising should not use NSAIDs without checking with a provider first.⁴³

Patients with bruising should seek medical attention if they experience⁴³

• a lump in the bruised area
• bruising that lasts more than 2 weeks
• frequent, large bruises
• painful swelling or pain that lingers many days after the injury
• recurring bruising in the same area
• unexplained bruising
• unusual bleeding (e.g., blood in urine/feces, nosebleed)
• vision problems following a black eye

CONCLUSION

The summer is not always fun-in-the-sun. It also brings an increase in some ailments and injuries given the extra time that people spend outdoors. Sunburn has a detrimental effect on skin health, overall health, and cancer risk. Insect bites and stings can be more than just a nuisance; they can carry disease-causing microbes. Swimmer’s ear can be incredibly painful and uncomfortable, and children are the most common group affected. Toxicodendron-induced rashes and minor abrasions and lacerations can be itchy, painful, and even create the opportunity for infection or scarring. Pharmacy teams should be prepared to help patients prevent and treat these common summer ailments to ensure they do not create lasting injuries and negative effects on overall health.

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