By Beau Harger, PharmD, PCCA Clinical Compounding Pharmacist

Compounders are the ultimate problem-solvers in the health care industry, and summer presents some potential opportunities for them that otherwise may not be considered. As the warm months approach, physicians and patients may look to compounding pharmacists to help address their seasonal and travel needs through customized medications. To give you some ideas to discuss in these conversations, below are common issues that come up in summer along with potential options that compounding pharmacies may be able to offer prescribers and their patients.

Sun Protection

Regular sunscreen usage has been shown to be protective against skin damage and also to slow skin aging.¹ However, common sunscreens contain organic ultraviolet filters like oxybenzone and octinoxate, which are sometimes referred to as “chemical sunscreens” and have caused concern for some due to potential health hazards and possible toxic effects on the environment.² Oxybenzone has been reported to cause topical allergic skin reactions, and there are concerns about it being an endocrine disruptor. Reports have shown oxybenzone in various concentrations in certain water systems as well.² If prescribers come to you with concerns about these issues, you might consider bringing up compounded sunscreens with inorganic ultraviolet filters such as zinc oxide, which are often referred to as “physical” or “mineral sunscreens” and may be alternatives as it relates to systemic absorption, topical allergic skin reactions and effects on the environment.³ It is important for compounders to know that compounded sunscreens cannot claim an SPF designation since they have not been tested as such.

Sunburn

As we all know, spending excessive time in the sun without adequate protection can lead to sunburn. This can even happen on overcast days in some circumstances. In fact, one poll showed that 42% of people experience at least one sunburn per year.⁴ However, a PCCA case study involving a compounded medication with our PracaSil^®-Plus as the base showed significant skin healing and regeneration of a second-degree burn.⁵ If prescribers or patients ask about customizable options, compounded formulations containing PracaSil-Plus as the vehicle could be considered for patients with sunburns.

Insect Bites

Summer is the season for spending more time in the great outdoors and enjoying activities such as hiking through a national park or spending time on the water. As refreshing as they are, though, these outdoor activities can lead to insect bites. Skin reactions caused by bites from mosquitoes, chiggers and other insects are characterized by inflammation and severe itching. Mosquito bite reactions can be relieved with antihistaminic drugs. ⁶ Both pramoxine and hydrocortisone have been shown to be effective for helping with itch.⁷ Agents such as menthol that provide a cooling effect can add temporary relief to itch associated with bug bites as well as dermatitis.^8,9 Compounders could work with prescribers and combine these to make custom preparations that are clinically relevant and convenient for the patient.

Poison Ivy

The great outdoors also means potential exposure to plants that can cause irritation. Poison ivy, for instance, is the leading cause of allergic contact dermatitis. Short-term therapy with topical steroids has been shown to help with symptoms of allergic contact dermatitis.^10,11 Therefore, combining the steroid hydrocortisone with the antihistamine diphenhydramine can help with itch and inflammation. ^7,10,11

Motion Sickness

For some people, traveling by car, boat or plane can cause motion sickness characterized by nausea and vomiting. The use of transdermal scopolamine has been shown to be effective in preventing motion sickness.¹² However, patch delivery systems may not be suitable for some patients because of topical hypersensitivity reactions and problems with the adhesives.^13,14 Promethazine is another option and has also been shown to be helpful for motion sickness.¹⁵ For patients with such issues, compounders may be able to work with prescribers to develop a custom topical preparation to deliver scopolamine or promethazine through the skin while avoiding side effects.

Toenail Fungus

Hot, humid conditions especially in footwear can lead to increased fungal infections, particularly toenail fungus.¹⁶ One challenge with traditional therapies such as oral antifungal medications, though, is that they may cause interactions with other medications and even require liver-function monitoring.¹⁷ However, topical fluconazole alone and in combination with urea has been shown to be effective for treating onychomycosis (toenail fungus).¹⁸ Ibuprofen has also demonstrated synergistic antifungal effects in combination with azole antifungals.¹⁹ Tea tree oil is another ingredient that has shown to be effective in treating toe nail fungus and could be incorporated into a formula.²⁰ This gives compounders options to present to practitioners for their patients who may need alternatives to commonly prescribed medications for toenail fungus.

Plantar Warts

Spending more time barefoot and using public swimming pools can also lead to warts, especially on the bottom of the feet. In-office cryosurgery, which is a common treatment, may lead to pain, blistering and scarring for some patients.²¹ Most people would understandably want to avoid this if possible. Fortunately, the combination of salicylic acid and fluorouracil in a topical preparation was shown to be safe and effective in treating plantar warts (Verruca plantaris).²² A topical solution with cantharidin, a natural toxin of the blistering beetle, has been shown to be effective for clearance of warts as well. There is currently no FDA-approved cantharidin product, so it must be compounded. ^23,24 These could be options to discuss with prescribers.

Marketing your compounding services according to the changing seasons is often overlooked and can give your pharmacy a new way of presenting your services to physicians and patients. The ideas presented above are not all inclusive, but they can get you started, and PCCA members with Clinical Services support can contact our clinical compounding pharmacists to discuss more options. They can also access a list of PCCA compounding formulas that are commonly requested during the summer.

Also on The PCCA Blog: Unique Dosage Forms and Flavor Ideas That Are Perfect for Summer 

Beau Harger, PharmD, is a graduate of the University of Mississippi. He joined the staff of PCCA in January 2015 as a full-time clinical compounding pharmacist after working as a part-time consultant for the previous year and a half. He came to PCCA with 15 years of compounding experience. He also taught pharmacology at William Carey College in Gulfport, Mississippi, and was the pharmacist in charge of Nucara Compounding Pharmacy in Austin, Texas, for eight years.

References

1. Hughes, M. C. B., Williams, G. M., Baker, P., & Green, A. C. (2013). Sunscreen and prevention of skin aging: A randomized trial. Annals of Internal Medicine, 158(11), 781–790. https://doi.org/10.7326/0003-4819-158-11-201306040-00002

2. DiNardo, J. C., & Downs, C. A. (2018). Dermatological and environmental toxicological impact of the sunscreen ingredient oxybenzone/benzophenone-3. Journal of Cosmetic Dermatology, 17(1), 15–19. https://doi.org/10.1111/jocd.12449

3. Mohammed, Y. H., Holmes, A., Haridass, I. N., Sanchez, W. Y., Studier, H., Grice, J. E., Benson, H., & Roberts, M. S. (2019). Support for the safe use of zinc oxide nanoparticle sunscreens: Lack of skin penetration or cellular toxicity after repeated application in volunteers. The Journal of Investigative Dermatology, 139(2), 308–315. https://doi.org/10.1016/j.jid.2018.08.024

4. Land, V., & Small, L. (2008). The evidence on how to best treat sunburn in children: A common treatment dilemma. Pediatric Nursing , 34(4), 343–348.

5. PCCA Science. (2018). Second-degree skin burn injury caused by domestic incident [PCCA Document #99516]. http://beta.pccarx.com/pdf_files/99516_CS_SkinBurn_SpiraPrac.pdf

6. Reunala, T., Brummer-Korvenkontio, H., Lappalainen, P., Räsänen, L., & Palosuo, T. (1990). Immunology and treatment of mosquito bites. Clinical and Experimental Allergy, 20(Suppl. 4), 19–24. https://doi.org/10.1111/j.1365-2222.1990.tb02472.x

7. Zirwas, M. J., & Barkovic, S. (2017). Anti-pruritic efficacy of itch relief lotion and cream in patients with atopic history: Comparison with hydrocortisone cream. Journal of Drugs in Dermatology, 16 (3), 243–247.

8. Liu, B., & Jordt, S.-E. (2018). Cooling the itch via TRPM8. The Journal of Investigative Dermatology, 138(6), 1254–1256. https://doi.org/10.1016/j.jid.2018.01.020

9. Tey, H. L., Tay, E. Y., & Tan, W. D. (2017). Safety and antipruritic efficacy of a menthol-containing moisturizing cream. Skinmed, 15(6), 437–439.

10. Kaidbey, K. H., & Kligman, A. M. (1976). Assay of topical corticosteroids. Efficacy of suppression of experimental Rhus dermatitis in humans. Archives of Dermatology, 112(6), 808–813. https://doi.org/10.1001/archderm.112.6.808

11. Nassau, S., & Fonacier, L. (2020). Allergic contact dermatitis. The Medical Clinics of North America, 104(1), 61–76. https://doi.org/10.1016/j.mcna.2019.08.012

12. Spinks, A., & Wasiak, J. (2011). Scopolamine (hyoscine) for preventing and treating motion sickness. The Cochrane Database of Systematic Reviews, 2011(6). https://doi.org/10.1002/14651858.CD002851.pub4

13. Olthoff, M. V., Kunkeler, A., van Hunsel, F., Beekwilder, J., & Borgsteede, S. D. (2019). Overgevoeligheid voor hulpstoffen in pleisters [Hypersensitivity reactions to excipients in patches].Nederlands Tijdschrift voor Geneeskunde [ Dutch Journal of Medicine], 163.

14. Romita, P., Foti, C., Calogiuri, G., Cantore, S., Ballini, A., Dipalma, G., & Inchingolo, F. (2018). Contact dermatitis due to transdermal therapeutic systems: A clinical update. Acta Bio Medica, 90(1), 5–10. https://doi.org/10.23750/abm.v90i1.6563

15. Southard, B. T., & Al Khalili, Y. (2020). Promethazine. In StatPearls.

16. Sasagawa, Y. (2019). Internal environment of footwear is a risk factor for tinea pedis. The Journal of Dermatology, 46(11), 940–946. https://doi.org/10.1111/1346-8138.15060

17. Haria, M., Bryson, H. M., & Goa, K. L. (1996). Itraconazole. A reappraisal of its pharmacological properties and therapeutic use in the management of superficial fungal infections. Drugs, 51 (4), 585–620. https://doi.org/10.2165/00003495-199651040-00006

18. Bassiri-Jahromi, S., Ehsani, A. H., Mirshams-Shahshahani, M., & Jamshidi, B. (2012). A comparative evaluation of combination therapy of fluconazole 1% and urea 40% compared with fluconazole 1% alone in a nail lacquer for treatment of onychomycosis: Therapeutic trial. The Journal of Dermatological Treatment, 23(6), 453–456. https://doi.org/10.3109/09546634.2011.588191

19. Pina-Vaz, C., Sansonetty, F., Rodrigues, A. G., Martinez-de-Oliveira, J., Fonseca, A. F., & Mårdh, P. A. (2000). Antifungal activity of ibuprofen alone and in combination with fluconazole againstCandida species. Journal of Medical Microbiology, 49(9), 831–840. https://doi.org/10.1099/0022-1317-49-9-831

20. Buck, D. S., Nidorf, D. M., & Addino, J. G. (1994). Comparison of two topical preparations for the treatment of onychomycosis:Melaleuca alternifolia (tea tree) oil and clotrimazole. The Journal of Family Practice, 38(6), 601–605.

21. Clebak, K. T., Mendez-Miller, M., & Croad, J. (2020). Cutaneous cryosurgery for common skin conditions. American Family Physician, 101(7), 399–406.

22. Young, S., & Cohen, G. E. (2005). Treatment of Verruca plantaris with a combination of topical fluorouracil and salicylic acid. Journal of the American Podiatric Medical Association, 95 (4), 366–369. https://doi.org/10.7547/0950366

23. Vakharia, P. P., Chopra, R., Silverberg, N. B., & Silverberg, J. I. (2018). Efficacy and safety of topical cantharidin treatment for molluscum contagiosum and warts: A systematic review. American Journal of Clinical Dermatology, 19(6), 791–803. https://doi.org/10.1007/s40257-018-0375-4

24. Al-Dawsari, N. A., & Masterpol, K. S. (2016). Cantharidin in dermatology. Skinmed, 14(2), 111–114.

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.