- Email: [email protected]
Getting Ready for Summer Woes
Getting Ready for
Summer Woes With the approach of summer come some problems you will be seeing in your outpatient practice.
Sunburn Topical sunscreens contain a variety of chemicals.1 Chemical sunscreens include benzophenones (oxybenxone, sulisobenzone, dioxybenzone) and other substances (methyl anthranilate, butyl methoxydibenzoylmethane [avobenzone]). Inorganic physical sunscreens are zinc oxide and titanium dioxide. Products should protect against both UVB and UVA radiation. The sun protection factor (SPF) is a measure of the strength of protection.2 It is the theoretical number of hours required to produce redness. It is ideal if used perfectly; however, most people do not use enough or do not reapply frequently enough. It is recommended that everyone should wear sunscreen with a minimum of 30 SPF while outdoors. It should be reapplied every 2 hours and every hour if swimming or perspiring. Using a sunscreen with the insect repellent DEET (diethyltoluamide) decreases the SPF. Resistance to removal of sunscreen is called substantivity.3 Water resistant means the effect lasts for 40 minutes of water exposure. Very water resistant means the product will be effective for 80 minutes of water immersion. Toweling can remove up to 85% of sunscreen. A product can be labeled sweat resistant if it is water resistant. Durability is greater for water resistant sunscreens than regular sunscreens. Because some products need to dry to resist removal by water, it is prudent to wait 15 minutes after application before going into the water. Treatment of mild sunburn can usually be managed with cool compresses and various over-thecounter first-aid products. More severe sunburn www.npjournal.org
may require a medium-potency topical steroid, such as triamcinolone 0.1% twice daily. Nonsteroidal anti-inflammatory drugs can help pain and inflammation. Severe sunburn may require oral corticosteroids, such as prednisone 40 to 60 mg every day tapered over 7 to 10 days. For example, 60 mg for 4 days, 40 mg for 2 days, 20 mg for 2 days, then 10 mg for 2 days.
Insect and Tick Repellent DEET is the gold standard insect repellent.4 It is effective against the largest variety of insects— mosquitoes, chiggers, ticks, fleas, and biting flies.
PRESCRIPTION PAD Maren Mayhew
In general, the higher concentration, the longer the repellent lasts. Recommended strengths are listed in Table 1.
Table 1. DEET Strength Condition
Strength
Children
10% or less
Most conditions
10%-35%
Extreme conditions
Greater than 35%
The Journal for Nurse Practitioners - JNP
333
Table 2. Treatment of Early Lyme Disease Antibiotic
Dose
Frequency
Duration
Doxycycline*
100 mg po
q 12 h
21 days
Amoxicillin
500 mg
q8h
21 days
Cefuroxime axetil
500 mg po
q 12 h
21 days
First Line
Second Line Erythromycin
250-500 mg po
q6h
21 days
Azithromycin
500 mg
qd
7 days
*Do not use doxycycline in children younger than 8 years.
Long-acting formulations of DEET were originally developed for the US military. Ultrathon5 is manufactured by 3M and is available through Travel Medicine, Inc. It comes in two strengths, 25% and 33%, and provides 95% protection for 6 to 12 hours. There has been much controversy about the toxicity of DEET, especially with children. Proper usage should avoid toxicity. Avoid prolonged use and concentrations more than 50%. DEET can damage clothes, glass frames, and watch crystals. Citronella products, including the Avon product Skin-So-Soft Bug Guard (0.10% citronella), are less effective than DEET, work only against mosquitoes, and last about 1 hour. Citronella candles are not much better than plain candles at repelling insects. Other botanical products such as oils from soybean, geranium, coconut oil, and lemon eucalyptus are used, often in combination. Data are limited on these products, but they seem to be mildly effective, somewhat less than DEET 7%. Permethrin is a contact insecticide that is effective against mosquitoes, flies, ticks, fleas, lice, and chiggers. It should be applied to clothing and other fabrics and not to skin. A combination of a DEET repellent and permethrin on clothing is very effective. Picaridin6 is an insect repellent recently introduced in the Untied States that has been used overseas for years. It is effective against mosquitoes and ticks. It is available as Cutter Advanced in a 7% solution. Higher concentrations (20%) are used overseas. No incidents of toxicity have been documented. It has many advantages over DEET in that it is odorless, not greasy, less irritating to the skin, and does not damage fabric or plastics. It lasts 3 to 4 hours. The Centers for Disease 334
The Journal for Nurse Practitioners - JNP
Control and Prevention recommends it as an alternative to DEET.
Lyme Disease Lyme disease is caused by the spirochete Borrelia burgdorferi, which is transmitted to humans by the Ixodes scapularis tick (deer tick).7 Prevention consists of avoiding ticks. The repellents most effective against ticks are DEET, picaridin, or permethrin on clothing. See the section on insect and tick repellents. The vaccine for prevention is no longer available. Prophylaxis of a tick bite is controversial. It may be advisable if it occurs in an endemic area when an engorged I scapularis tick has been attached for 48 hours or more. Doxycycline 200 mg once and amoxicillin 500 mg every 8 hours for 10 days have been used. The diagnosis of Lyme disease is difficult, especially in the early stages. About 70% to 80% of patients infected develop erythema migrans, the diagnostic skin lesion. It is important to start treatment as early as possible, before the dissemination of the spirochete. The current aggressive pressure to begin treatment for Lyme disease as soon as possible may mean that unnecessary treatment is started for some patients who turn out not to have Lyme disease.8 Laboratory tests will confirm the diagnosis, but many clinicians do not feel comfortable waiting for the test results. IgG antibodies to B burgdorferi are usually detectable 4 to 6 weeks after initial infection. The recommended antibiotic treatments are shown in Table 2. Length of therapy has not been established by scientific research, but most experts recommend 2 to 3 weeks of treatment. May 2006
Poison Ivy Poison ivy allergic contact dermatitis is caused by contact with the rhus oleoresin from the poison ivy plant.9 Patients may also develop the allergy through secondary contact, as in touching something that recently touched the plant. Prevention is important. Washing the skin with soap inactivates and removes the oleoresin. Washing must be done immediately. It is 50% effective after 10 minutes, 10% effective after 30 minutes, and ineffective after 60 minutes. A barrier cream of an organoclay compound (Ivy Block), applied before exposure, is 50% effective. Treatment begins with topical corticosteroids, cold compresses, and calamine lotion. Topical steroids, mild to medium strength, can help the erythema. They are not absorbed through blisters. Short, cool tub baths with colloidal oatmeal (Aveeno) can be soothing. Calamine lotion can excessively dry the skin. Oral hydroxyzine or diphenhydramine control itching and help with sleep. For severe cases, oral prednisone may be needed. Do not use the standard Dosepaks, because they do not contain sufficient prednisone. One must use enough initially and as soon as possible, then taper to avoid a rebound. Use prednisone 60 mg for 4 days, 50 mg for 2 days, 40 mg for 2 days, 30 mg for 2 days, 20 mg for 2 days, then 10 mg for 2 days. References 1. Rakel RE, Bope ET. Conn’s current therapy. 57th ed. Philadelphia: Saunders; 2005. p. 1002. 2. Prevention and treatment of sunburn. Med Lett. 2004;46(1184):4546. 3. Poh Agin P. Water resistance and extended wear sunscreens. Dermatol Clin. 2006;24(1):75-79. 4. Auerbach PS. Wilderness medicine. 4th ed. St. Louis: Mosby; 2001. p. 759-766. 5. Insect repellents. Med Lett. 2003;45(1157):41-42. 6. Picardin: a new insect repellent. Med Lett. 2005;47(1210):46-47. 7. Treatment of Lyme disease. Med Lett. 2005;47(1209):41-43. 8. Cohen J, Powderly WG. Infectious diseases. 2nd ed. St. Louis: Mosby; 2004. p. 599-600. 9. Habif TP. Clinical dermatology. 4th ed. St. Louis: Mosby; 2004. p. 88-89.
Legal Limits Continued from Page 297 into this regulatory scheme. The vision statement can be downloaded from the National Association of Clinical Nurse Specialists web site at www.nacns.org. Here are some recommendations for NPs who like to plan ahead. • If you want input into decisions being made, apply for positions on your state’s board of nursing. • Unless you have extensive experience in a specialty area as a registered nurse, do not seek or take jobs that are outside of your area of certification. Aside from potential hassles in getting your written agreement through the board, you may be exposing yourself to malpractice liability. • If certification is available in the specialty in which you are working and you like your work, go get the certification. Do not wait for a rule to come down that puts you out of a job. • If you think you want to practice in a specialty area, get the certification. If no certification is available, understand that, if you take the job, you will be in a precarious position in a health profession that already is in a precarious position. Cover your bases by putting every procedure you will perform in your written agreement and on your application for malpractice insurance.
Carolyn Buppert, CRNP, JD, practices law in Annapolis, MD. She can be reached at [email protected].
1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.009
Maren Mayhew, MS, ANP, GNP, is the author and editor of Pharmacology for Primary Care Providers, a textbook for NPs published by Mosby. She can be reached at maren [email protected]. This is a monthly column on medication news and controversies. Suggestions for topics are welcome.
1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.012
www.npjournal.org
The Journal for Nurse Practitioners - JNP
335
Summer Woes With the approach of summer come some problems you will be seeing in your outpatient practice.
Sunburn Topical sunscreens contain a variety of chemicals.1 Chemical sunscreens include benzophenones (oxybenxone, sulisobenzone, dioxybenzone) and other substances (methyl anthranilate, butyl methoxydibenzoylmethane [avobenzone]). Inorganic physical sunscreens are zinc oxide and titanium dioxide. Products should protect against both UVB and UVA radiation. The sun protection factor (SPF) is a measure of the strength of protection.2 It is the theoretical number of hours required to produce redness. It is ideal if used perfectly; however, most people do not use enough or do not reapply frequently enough. It is recommended that everyone should wear sunscreen with a minimum of 30 SPF while outdoors. It should be reapplied every 2 hours and every hour if swimming or perspiring. Using a sunscreen with the insect repellent DEET (diethyltoluamide) decreases the SPF. Resistance to removal of sunscreen is called substantivity.3 Water resistant means the effect lasts for 40 minutes of water exposure. Very water resistant means the product will be effective for 80 minutes of water immersion. Toweling can remove up to 85% of sunscreen. A product can be labeled sweat resistant if it is water resistant. Durability is greater for water resistant sunscreens than regular sunscreens. Because some products need to dry to resist removal by water, it is prudent to wait 15 minutes after application before going into the water. Treatment of mild sunburn can usually be managed with cool compresses and various over-thecounter first-aid products. More severe sunburn www.npjournal.org
may require a medium-potency topical steroid, such as triamcinolone 0.1% twice daily. Nonsteroidal anti-inflammatory drugs can help pain and inflammation. Severe sunburn may require oral corticosteroids, such as prednisone 40 to 60 mg every day tapered over 7 to 10 days. For example, 60 mg for 4 days, 40 mg for 2 days, 20 mg for 2 days, then 10 mg for 2 days.
Insect and Tick Repellent DEET is the gold standard insect repellent.4 It is effective against the largest variety of insects— mosquitoes, chiggers, ticks, fleas, and biting flies.
PRESCRIPTION PAD Maren Mayhew
In general, the higher concentration, the longer the repellent lasts. Recommended strengths are listed in Table 1.
Table 1. DEET Strength Condition
Strength
Children
10% or less
Most conditions
10%-35%
Extreme conditions
Greater than 35%
The Journal for Nurse Practitioners - JNP
333
Table 2. Treatment of Early Lyme Disease Antibiotic
Dose
Frequency
Duration
Doxycycline*
100 mg po
q 12 h
21 days
Amoxicillin
500 mg
q8h
21 days
Cefuroxime axetil
500 mg po
q 12 h
21 days
First Line
Second Line Erythromycin
250-500 mg po
q6h
21 days
Azithromycin
500 mg
qd
7 days
*Do not use doxycycline in children younger than 8 years.
Long-acting formulations of DEET were originally developed for the US military. Ultrathon5 is manufactured by 3M and is available through Travel Medicine, Inc. It comes in two strengths, 25% and 33%, and provides 95% protection for 6 to 12 hours. There has been much controversy about the toxicity of DEET, especially with children. Proper usage should avoid toxicity. Avoid prolonged use and concentrations more than 50%. DEET can damage clothes, glass frames, and watch crystals. Citronella products, including the Avon product Skin-So-Soft Bug Guard (0.10% citronella), are less effective than DEET, work only against mosquitoes, and last about 1 hour. Citronella candles are not much better than plain candles at repelling insects. Other botanical products such as oils from soybean, geranium, coconut oil, and lemon eucalyptus are used, often in combination. Data are limited on these products, but they seem to be mildly effective, somewhat less than DEET 7%. Permethrin is a contact insecticide that is effective against mosquitoes, flies, ticks, fleas, lice, and chiggers. It should be applied to clothing and other fabrics and not to skin. A combination of a DEET repellent and permethrin on clothing is very effective. Picaridin6 is an insect repellent recently introduced in the Untied States that has been used overseas for years. It is effective against mosquitoes and ticks. It is available as Cutter Advanced in a 7% solution. Higher concentrations (20%) are used overseas. No incidents of toxicity have been documented. It has many advantages over DEET in that it is odorless, not greasy, less irritating to the skin, and does not damage fabric or plastics. It lasts 3 to 4 hours. The Centers for Disease 334
The Journal for Nurse Practitioners - JNP
Control and Prevention recommends it as an alternative to DEET.
Lyme Disease Lyme disease is caused by the spirochete Borrelia burgdorferi, which is transmitted to humans by the Ixodes scapularis tick (deer tick).7 Prevention consists of avoiding ticks. The repellents most effective against ticks are DEET, picaridin, or permethrin on clothing. See the section on insect and tick repellents. The vaccine for prevention is no longer available. Prophylaxis of a tick bite is controversial. It may be advisable if it occurs in an endemic area when an engorged I scapularis tick has been attached for 48 hours or more. Doxycycline 200 mg once and amoxicillin 500 mg every 8 hours for 10 days have been used. The diagnosis of Lyme disease is difficult, especially in the early stages. About 70% to 80% of patients infected develop erythema migrans, the diagnostic skin lesion. It is important to start treatment as early as possible, before the dissemination of the spirochete. The current aggressive pressure to begin treatment for Lyme disease as soon as possible may mean that unnecessary treatment is started for some patients who turn out not to have Lyme disease.8 Laboratory tests will confirm the diagnosis, but many clinicians do not feel comfortable waiting for the test results. IgG antibodies to B burgdorferi are usually detectable 4 to 6 weeks after initial infection. The recommended antibiotic treatments are shown in Table 2. Length of therapy has not been established by scientific research, but most experts recommend 2 to 3 weeks of treatment. May 2006
Poison Ivy Poison ivy allergic contact dermatitis is caused by contact with the rhus oleoresin from the poison ivy plant.9 Patients may also develop the allergy through secondary contact, as in touching something that recently touched the plant. Prevention is important. Washing the skin with soap inactivates and removes the oleoresin. Washing must be done immediately. It is 50% effective after 10 minutes, 10% effective after 30 minutes, and ineffective after 60 minutes. A barrier cream of an organoclay compound (Ivy Block), applied before exposure, is 50% effective. Treatment begins with topical corticosteroids, cold compresses, and calamine lotion. Topical steroids, mild to medium strength, can help the erythema. They are not absorbed through blisters. Short, cool tub baths with colloidal oatmeal (Aveeno) can be soothing. Calamine lotion can excessively dry the skin. Oral hydroxyzine or diphenhydramine control itching and help with sleep. For severe cases, oral prednisone may be needed. Do not use the standard Dosepaks, because they do not contain sufficient prednisone. One must use enough initially and as soon as possible, then taper to avoid a rebound. Use prednisone 60 mg for 4 days, 50 mg for 2 days, 40 mg for 2 days, 30 mg for 2 days, 20 mg for 2 days, then 10 mg for 2 days. References 1. Rakel RE, Bope ET. Conn’s current therapy. 57th ed. Philadelphia: Saunders; 2005. p. 1002. 2. Prevention and treatment of sunburn. Med Lett. 2004;46(1184):4546. 3. Poh Agin P. Water resistance and extended wear sunscreens. Dermatol Clin. 2006;24(1):75-79. 4. Auerbach PS. Wilderness medicine. 4th ed. St. Louis: Mosby; 2001. p. 759-766. 5. Insect repellents. Med Lett. 2003;45(1157):41-42. 6. Picardin: a new insect repellent. Med Lett. 2005;47(1210):46-47. 7. Treatment of Lyme disease. Med Lett. 2005;47(1209):41-43. 8. Cohen J, Powderly WG. Infectious diseases. 2nd ed. St. Louis: Mosby; 2004. p. 599-600. 9. Habif TP. Clinical dermatology. 4th ed. St. Louis: Mosby; 2004. p. 88-89.
Legal Limits Continued from Page 297 into this regulatory scheme. The vision statement can be downloaded from the National Association of Clinical Nurse Specialists web site at www.nacns.org. Here are some recommendations for NPs who like to plan ahead. • If you want input into decisions being made, apply for positions on your state’s board of nursing. • Unless you have extensive experience in a specialty area as a registered nurse, do not seek or take jobs that are outside of your area of certification. Aside from potential hassles in getting your written agreement through the board, you may be exposing yourself to malpractice liability. • If certification is available in the specialty in which you are working and you like your work, go get the certification. Do not wait for a rule to come down that puts you out of a job. • If you think you want to practice in a specialty area, get the certification. If no certification is available, understand that, if you take the job, you will be in a precarious position in a health profession that already is in a precarious position. Cover your bases by putting every procedure you will perform in your written agreement and on your application for malpractice insurance.
Carolyn Buppert, CRNP, JD, practices law in Annapolis, MD. She can be reached at [email protected].
1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.009
Maren Mayhew, MS, ANP, GNP, is the author and editor of Pharmacology for Primary Care Providers, a textbook for NPs published by Mosby. She can be reached at maren [email protected]. This is a monthly column on medication news and controversies. Suggestions for topics are welcome.
1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2006.03.012
www.npjournal.org
The Journal for Nurse Practitioners - JNP
335