Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

The COVID-19 pandemic has upended the world of respiratory diseases. Every cough and sniffle raises red flags in a clinical area that already was a drain on health care resources. Roughly 12% of adults in the United States have chronic sinusitis, and about 2.7 million physician and 234,000 emergency department visits are attributed to this diagnosis each year.

Drawing the line between acute sinusitis and other respiratory bugs can be difficult, though. As with many other conditions driven by viral infection, there is little clinicians can really offer patients for sinusitis other than supportive care and calls for patience.

As COVID-19 transmissions are lessening, patients and providers are equally concerned about respiratory symptoms, but experts say the pandemic isn’t really changing the game plan for sinusitis.

“I think the biggest thing I try to explain to patients is the disease process,” said Jane Carnazzo, MD, of Children’s Hospital and Medical Center in Omaha, Nebraska.

Observing mucus changes can help patients determine where they are in a bout with sinusitis, she explained; green mucus is common for about a week after infection and doesn’t signal a severe infection.

“When it comes to sinusitis, your acute sinusitis is going to be someone who is sick for 10 to 14 days. You have to give a cold a good week to get better,” she added.

A high fever or copious amounts of mucus right away is a different story, she said, but this level of infection isn’t common.

COVID-19 isn’t the only worry when it comes to respiratory symptoms, Carnazzo added. Antibiotic resistance is a real problem and one she said she tries to educate her patients about. Prescribing antibiotics may give patients a peace of mind regarding their symptoms, but Carnazzo said 75% of her patients don’t return for a prescription after a bit of education about what to expect and what is normal in terms of symptoms and progression of sinusitis.

Besides education, she says offering patients an alternative for symptom management can help. People like to turn to OTC remedies that dry out mucus at the first sign of illness— but, she explained, this is the opposite of how sinusitis should be managed.

“You want the nose to drain. When it comes to preventing a sinus infection, it’s the best you can do,” she said.

Saline rinses have become a popular choice among her patient population, Carnazzo added, but lavage can sometimes make symptoms worse. Instead, things like promoting crying, exposure to cold weather, and anything else that can help make the nose run work well.

The exception, she explained, is children who have issues that could increase mucus retention, immune deficiencies, and conditions including Down syndrome that may predispose a child to smaller sinus cavities. Even with these patients, though, Carnazzo explained that providers should use caution about jumping to antimicrobial treatments.

Time is an important tool in the provider’s arsenal, and many patients will improve in about a week with little intervention. It’s also to be expected that some children will appear to have chronic sinus problems, but constant antibiotic therapy isn’t an option, she noted.

“Kids in day care have runny noses all the time but you can’t just keep them on antibiotics,” she said. “It’s just a matter of trying to sort it out. Give it some time and try to get them to clear their nasal passages. Don’t try to dry it up too much.”

Pushing OTC medications isn’t much help, she added, and imaging studies like x-ray and computed tomography scans are not generally recommended for diagnosis.

The best thing health care providers can do is to get a good history and description of how symptoms developed, what they feel like, and when they are worse.

“History, symptoms, and presentation are key,” Carnazzo said, to management. “Chronic sinus issues may need imaging, but lab work and imaging are really not necessary. Just because the sinuses are plugged doesn’t mean they are infected.”

Purulent drainage is the key symptom in diagnosing an infection that needs more intervention, she said. Providers also need to remember a less common differential diagnosis: foreign objects.

Foul or smelly drainage—especially on just 1 side of the nose—is a red flag that something may be stuck in the nasal cavity, Carnazzo said.

Overall, the best practice for sinusitis is to stress patience and exercis- ing restraint when it comes to antibiotics and medications that dry mucus. Mucus is an annoying symptom, but drainage is what sinusitis needs.

“We’re always looking for a quick and easy fix, even if there isn’t one,” Carnazzo added.

For symptom relief, Carnazzo tends to point parents to menthol products, hydration, and humidifiers rather than OTC medications. If antibiotics are needed, Carnazzo says amoxicillin is the first choice, while zithromax is not recommended because of resistance. The lowest-spectrum antibiotic is always best to use first, she added.

“Just telling them it will take time and offering comfort is key,” she said

This article originally appeared in the June issue of our sister publication Contemporary Pediatrics®.

1. Centers for Disease Control and Prevention. Chronic sinusitis. Updated January 27, 2022. Accessed May 2, 2022. 

https://www.cdc.gov/nchs/fastats/sinuses.htm

Articles

Patience and antimicrobial stewardship are the keys to treating sinusitis

What to Consider with Sinusitis in 2022

Acne may be seen as a rite of passage in the adolescent years, affecting an estimated 85% of all teenagers at some point.1 However, newer reports suggest that the psychological effects of this inflammatory skin disorder may be underestimated and deserve more attention in treatment plans.

Multiple studies over the last several years have highlighted the impact of acne on adolescent mental health—especially since adolescence is already a time of intense transition. Self-esteem, social relationships, anxiety, and depression can all factor in to the effects of chronic acne in the teenaged years, according to researchers.1,2,3

Mohammad Jafferany, MD, a clinical professor of psychodermatology and psychiatry at Central Michigan University in Saginaw as well as a board-certified psychiatrist who co-authored a 2020 report on the psychodermatology of acne, said there are a lot of things at play when it comes to the psychological impact of acne.

Acne is the most common inflammatory condition of the skin, he stated, adding that hormones and stress in the adolescent years can increase prevalence. The fact that acne usually appears primarily on the face doesn’t help because it can be difficult to conceal or camouflage severe papules and comedones.

“They end up feeling very stigmatized,” Jafferany continued. “Their self-esteem is very, very low and very poor, and psychological conditions often develop around the same time [as acne appears].”

On top of stressing about their appearance and how acne can affect their social relationships, teenagers can also get easily frustrated by mixed messages about acne treatment, he explained.

Acne treatment should be holistic and multidisciplinary, he added, with diet, hormonal consideration, and psychological impact all considered in the overall clinical plan. Many teenagers turn to friends or social media for help in managing early acne, and then get frustrated when certain treatments fail to produce results. Without proper treatment early in the process, acne—and its psychological impact—usually gets worse, Jafferany continued. Adolescents with severe acne often stop going out with friends and interacting with others, and studies have shown that suicides rates are higher in teenagers with acne than those with clear skin.

The American Academy of Dermatology (AAD) clinical guidelines for acne treatment only briefly mention the mental impact of acne on teenagerss, or the risk of increased depression or suicidal ideation with certain treatment regimens.4

Oral isotretinoin is recommended in the AAD treatment guidelines for severe nodular acne. A number of studies in recent years have investigated the link between this popular medication and suicidality, but the strength of the association between isotretinoin use and suicide risk remains questionable. One 2020 report suggests that there doesn’t appear to be a definite risk, and that isotretinoin shouldn’t be completely avoided in teenagers with depression,5 but the American Academy of Pediatrics suggests that the medical be used “cautiously” in adolescent patients with depression, and that they be monitored during therapy by both a dermatologist and a psychiatrist.6

Jafferany agreed with this recommendation, noting that it’s not unusual for clinicians to send teenagers for a psychiatric screening prior to prescribing isotretinoin.

There are other treatment options besides isotretinoin, with the full AAD guidelines available 

Benzoyl peroxide alone or with other topical treatments for mild acne

Benzoyl peroxide plus topical retinoids or systemic antibiotics for moderate to severe acne

Retinoids alone for primarily comedonal acne

Retinoids plus oral or topical antimicrobials for mixed/primarily inflammatory acne

Topical dapsone 5% gel for inflammatory acne

Azelaic acid for post-inflammatory pigmentation problems

Hormonal treatments and antibiotics may also be considered, as well as complementary and alternative treatments that include:

There is limited evidence of benefit for physical treatment methods and therapies, although some options include things like:

Fractionated and non-fractionated infrared lasers

Intralesional corticosteroid injections for larger individual acne nodules

This article originally appeared on Contemporary Pediatrics.

Natsuaki MN, Yates TM. Adoelscent acne and disparities in mental health. 

. 2021;15(1):37-43. doi: 10.1111/cdep.12397.

Layton AM, Thiboutat D, Tan J. Reviewing the global burden of acne: how could we improve care to reduce the burden? 

. 2021;184(2):219-225. doi: 10.1111/bjd.19477.

Stamu-O’Brien C, Jafferany M, Carniciu S, Abdelmaksoud A. Psychodermatology of acne: psychological aspects and effects of acne vulgaris. 

. 2021;20(4):1080-1083. doi: 10.1111/jocd.13765.

Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines for the care and management of acne vulgaris. 

. 2016;74(5):945-973. doi: 10.1016/j.jaad.2015.12.037.

Gieler U, Gieler T. Suicidal risk with isotretinoin treatment—A never-ending story. 

. 2020;34(6):1131-1133. doi:10.1111/jdv.16005.

Teens and acne treatment. HealthChildren.org Updated November 27, 2013. Accessed July 1, 2022.


https://www.healthychildren.org/English/ages-stages/teen/Pages/Teens-and-Acne.aspx

The effect of acne is more than skin deep.

Acne Treatments and Considering Mental Health

Vulvovaginal candidiasis (VVC)—commonly known as a yeast infection—is a problem many women face at some point. About half of all women have had at least 1 of these infections clinical diagnosed, and between 6% and 10% are believed to develop a recurrent form of this condition with 3 to 4 or more episodes in a single year, according to a new report.

These infections can cause symptoms like burning, itching, or even pain during and after intercourse. When these infections become chronic or recurrent, the women who experience them usually have to rely on symptomatic control rather than trying to actually resolve the fungal infection.

, sought to develop a consensus among vulvovaginal experts on the best ways to treat chronic or recurrent yeast infections.

For episodic yeast infections, over-the-counter antifungal treatments or a single oral dose of fluconazole are usually used and can resolve symptoms to produce a negative culture in up to 90% of women who complete the regimen.

Recurrent yeast infections, however, are rarely ever “cured.” Curing the fungal infection completely is nearly impossible, and most women with this condition aim instead for mycologic control. This usually takes more than a single course of oral fluconazole—normally 3 doses—or up to 2 weeks of topical treatment. Beyond this initial treatment strategy, however, there is little guidance on what it takes to maintain that control.

The CDC recommends the use of oral fluconazole weekly for 6 months as an initial first-line treatment for recurrent yeast infections. If oral antifungal medication can’t be used for a number of reasons, the CDC suggests that intermittent topical treatments can be used, but the type and frequency of these treatments isn’t specified.

The study authors noted that while most women prefer oral fluconazole over topical medications for convenience, its use may carry additional risk for women:

Additionally, the study reveals that fluconazole may not be effective against infections caused by the nonalbicans species of fungi, which is responsible for up to 20% of recurrent yeast infections. There are some other options for oral treatment, too, including ibrexafungerp. This medication was approved by the FDA in June 2021 and is taken in just 2 doses given the same day. It kills the fungus instead of just stopping its growth like fluconazole, but is also contraindicated during pregnancy.

Other management strategies for mycologic control in recurrent yeast infections may include things like:

Controlling blood glucose levels and/or diabetes

Minimizing the use of corticosteroids and antibiotics

When it comes to topical medication choices, the study concluded that clotrimazole, miconazole, terconazole, and intravaginal boric acid were ideal topical treatments for RVCC caused by 

. Nystatin ovules are also an option and may actually be more effective, according to CDC, but this medication isn’t commercially available in the United States and must be compounded by a specialty pharmacy.

After initial treatment, the experts polled in the study suggest that topical treatments of whatever medication is used by continued once to 3 times a week, depending on how often symptoms of infection return. In most cases, twice weekly use of topical treatments is sufficient, according to the report. In choosing a topical for maintenance use, the study notes that 

 from the International Society for the Vulvovaginal Disease (ISSVD) to help clinicians and patients match the best antifungal with the species of yeast that is causing the problem.

The study authors conclude by stating that while fluconazole may be enough to suppress RVVC in many women, some will need clinician guidance on identifying the cause of their recurrent infection and determining the best course of maintenance treatment.

This article originally appeared on Contemporary Ob/Gyn.

Phillips NA, Bachmann G, Haefner H, Martens M, Stockdale C. Topical treatment of recurrent vulvovaginal candidiasis: An expert consensus. 

. 2022;3(1):38-42. doi:10.1089/whr.2021.0065`

Between 6% and 10% of women diagnosed with vulvovaginal candidiasis are believed to develop a recurrent form of this condition with 3 to 4 or more episodes in a single year.

Maintenance Therapy Explored for Recurrent Yeast Infections

As featured in Asthma Care ComplicationsÂ from our September issue. Swipe through the images for product descriptions and links to prescribing information.Â 

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At a Glance: Asthma Biologics 

Managing asthma is both complicated and costly for patients, so pharmacists play a unique role in helping them navigate how to use their treatments effectively and prevent exacerbations. Keeping up with ever-evolving treatment strategies, guidance, medications, and patient experiences is key.

Guidelines are continually updated to reflect new research, and Cleveland Clinic primary care clinical pharmacist 

, suggests making it a personal goal to review guidelines annually, and even regularly in between.

“I look for guideline changes,” Russo-Alvarez says. “We as pharmacists can be really helpful in reaching out to practices. We can provide small in-services to keep them informed, as well.”

Sometimes, changes are frequent and clinicians can’t keep up-even with major changes. Russo-Alvarez notes that some clinicians weren’t even aware of a major recent change that shifted decades of asthma treatment.

recommendation made in April 2019 by the Global Initiative for Asthma (GINA)

 to no longer treat teens and adults with asthma with short-acting bronchodilators alone. The recommendation has been hailed as a fundamental change to three decades of asthma management, but was made as a result of concerns over the effects of treating asthma with short-acting Ã2-agonists (SABA) alone. 

GINA was established in 1993 by the World Health Organization and the National Heart Lung and Blood Institute to improve global asthma prevention and management, and suggested in its latest annual report that teens and adults with asthma should receive symptom-driven or daily inhaled corticosteroid-containing (ICS) treatments as a way to reduce the risk of serious exacerbations. 

SABA risks were first identified in the 1980s and 1990s, according to GINA’s annual report, with evidence supporting an association between over-use of SABA and an increased risk of asthma-related deaths. Randomized controlled trials found no evidence to support the efficacy of regular, compared to as-needed, (PRN) use of SABA. Most guidelines were updated in the 1990s to support PRN rather than regular SABA use as a result of this research. 

Five Tools to Improve Your Customer Experience

Trials have also shown that low-dose ICS treatment could reduce exacerbations by up to 50% and help control symptoms, but daily uptake of ICS has been slow-going over physicians concerns about the side effects of corticosteroids, according to the report. The concerns about Ã2-agonists were then shifted to long-acting varieties, and short-acting varieties remained widely used as initial therapy for mild asthma. GINA began looking into the issue more extensively in 2007 and found a host of data to support a link between regular use of SABAs alone, and higher rates of exacerbations and asthma-related deaths. 

The paper goes on to list specific treatment recommendations, and 

, assistant professor of pharmacy practice at the University of Connecticut, says the new guidelines could result in a shake-up at the pharmacy counter.

“These guidelines recommend against using a SABA as-needed alone, even in the most mild asthmatics. They recommend ICS be used in all asthmatics, even if on a symptom-driven, as-needed basis,” Sobieraj says. “Pharmacists are more likely to see as-needed dosing of ICS with this recommendation, and fewer patients treated with a SABA PRN only. This is very different than what we have traditionally seen for many decades of asthma management.”

As if changes to fundamental treatments aren’t enough to keep a pharmacist on their toes, immunotherapy and biologics are changing the game when it comes to treating a host of conditions, including asthma.

Immunology is a developing field in asthma care, with 

researchers recently identifying genetic variants for all types of asthma

 that could lead to new treatment modalities. Pharmacists may also see more asthmatic patients being prescribed biologics, particularly for specific types of asthma, Sobieraj says. 

“The field of biologics continues to evolve, specifically for patients with what would be considered eosinophilic asthma, which represents a small proportion of asthmatics that are extremely difficult to control,” Sobieraj says. “The most recent FDA-approved therapy is dupilumab, which is also approved for steroid-dependent asthma.”

 as an add-on maintenance treatment for patients age 12 and older with moderate- to severe-asthma with an eosimophilic phenotype or who are dependent on oral corticosteroids. The medication inhibits overactive signaling of interleukin-4 and interleukin-13-both of which are proteins that may contribute to the inflammation that causes moderate- to severe-asthma. Dupilumab comes in two doses-200 mg and 300 mg-in pre-loaded syringes, and is given every other week at rotating injection sites after an initial loading dose. Dupilumab has also been approved to treat eczema, and studies are underway for a number of other uses like various allergies and pediatric asthma. 

This newest biologic joins four others already approved for asthma-omalizumab, mepolizumab, reslizumab, and benralizumab-and several more are in development, according to the 

American Academy of Allergy, Asthma & Immunology (AAAAI)

. Omalizumab works on the immunoglobulin E (IgE) antibodies that play a role in allergic asthma; and mepolizumab, reslizumab, and benralizumab all target pathways that affect eosinophils-the cell involved in allergic inflammation. 

Patient Education, Exacerbation Prevention

Pharmacists are the front line to helping keep patients-particularly in the outpatient setting-compliant with their regimens, or signal to the clinician when a patient’s condition changes.

“I make sure I have a good understanding of what’s been happening recently with patients,” Russo-Alvarez says. She asks about recent changes like hospitalizations and exacerbations to guide her assessment and the questions she asks her patients. Ask about devices-patients may be using them at the wrong time or in the wrong way. Russo-Alvarez suggests asking both new and long-standing patients to demonstrate how to use inhalers, letting them lead the demonstration. It’s surprising what you can learn by watching a patient use a device, and asking the right questions, she says.

“At a minimum, pharmacists are really well-positioned to teach patients how to use these inhalers,” Russo-Alvarez says, adding that sometimes providers don’t have inhalers on hand to teach patients about their use, or patients become confused on how and when to use different types of inhalers.

She recommends using an inhaler technique training and assessment tool, which can mimic different types of inhalers.

“It can be set to mimic what breathing technique is used in soft mist versus dry powder and metered-dose inhalers,” she says. “You can use it to get feedback on how they are breathing, and the pharmacist can see what works best for the patient and reach out to the provider and maybe recommend an alternative, if needed.” 

Pharmacists are also crucial in signaling to clinicians when there may be a change in a patient’s condition. According to Russo-Alvarez, it is a red flag when patients are filling their rescue inhalers frequently, despite using them correctly.

Asthma Care Complications

Patient visits with physicians are jam-packed with things to discuss and interventions to perform; adult vaccinations can be missed in this process. Pharmacies can fill the gap, but a new report highlights barriers that need to be addressed first.

The study, published in the July issue of Vaccine, reviewed the role of U.S. pharmacies in administering vaccines and what barriers exist to their administration in pharmacies. Nearly 2,000 community pharmacies were studied 2016, and 79.5% reported offering at least one type of vaccine.

Pharmacies most commonly offered influenza vaccine, followed by pneumococcal 13-valent conjugate vaccine, herpes zoster vaccine, and pneumococcal polysaccharide vaccine. Two-thirds of the pharmacies polled also provided vaccination to teens in addition to adults.


	The report revealed several reasons why patients often had to be referred outside the pharmacy for vaccination, including the patient’s insurance not covering pharmacy administration, and patient age not being approved for pharmacy administration.

Brandon J. Patterson, PharmD, PhD, manager of U.S. Health Outcomes and Epidemiology at GSK and coauthor of the study, says the findings highlight the progress that has been made in advancing pharmacy-based immunizations as an additional access point for patients.

Pharmacists play an important role in vaccine education and vaccine recommendations, providing access to immunization services, and administering vaccines, says Patterson and coauthor Philip Buck, PhD, MPH, head of U.S. Health Outcomes and Vaccines at GSK.

The scope of what pharmacies are able to offer varied by pharmacy and location, the report noted, particularly when it came to the maintenance of immunization registries. Insurance policies affecting coverage of vaccines and different rates of copay between pharmacies and physician offices continue to act as barriers, according to Patterson and Buck.

Related: States hope to improve vaccination rates in low-income familes using state registries

“Barriers to vaccination are often due to cost to patients or lack of insurance coverage. Additional strategies are needed to remind patients about the value and importance of vaccinations, especially for vaccines with multiple doses,” Patterson says. “Increasing the use of immunization registries within and accessible across states is also needed to improve the services.”


	Pharmacies can help increase vaccine rates by reinforcing vaccine recommendations to patients and by helping to complete immunization series, say Patterson and Buck. Physicians can help by communicating to pharmacists how they would like to receive documentation of vaccine administrations.

“Ideally, communication between pharmacists and other providers should be a two-way process with physicians providing a referral to the pharmacy and the pharmacy closing the loop documenting and sending confirmation back to the patient’s primary care provider,” Patterson says. “Both groups need to report vaccinations administered to the immunization registry and utilize the registry in assessing patient immunization status.”

Patterson and Buck say they hope the report will motivate additional efforts to address provider and patient barriers that hinder the optimization of the pharmacist’s role in immunization.

This article originally ran in Drug Topics’ sister publication Medical Economics.

New study reveals that immunization registries, communication, and the completion of immunization series can increase pharmacists' role in the immunization process. 