16.4 Referral Red Flags, Emergency Contraception & Skin

Universal Referral Red Flags (Safety-Netting)

Across every self-care presentation, the pharmacist applies a common safety-netting screen. Refer any patient with:

• Unintended weight loss
• Night sweats (possible TB, lymphoma, HIV)
• Unexplained bleeding — from any orifice, or blood in stool/vomit/sputum/urine
• Severe or sudden pain — possible surgical abdomen, MI, ectopic pregnancy, AAA
• High fever — especially with rash, neck stiffness, photophobia, or confusion (meningococcal/meningitis)
• Neurological deficit — focal weakness, slurred speech, sudden severe headache (stroke/Subarachnoid haemorrhage), visual loss
• Symptoms beyond the OTC treatment window — e.g. cough >3 weeks, dyspepsia >2 weeks, diarrhoea >48 h, fever >3 days (adults) or 24–48 h (children/elderly)
• Pregnancy, infants, frail elderly, immunocompromise — lower threshold to refer

Document the red flag, the advice given, and the timeframe for review.

Emergency Contraception

Emergency contraception (EC) is requested after unprotected intercourse or contraceptive failure. The pharmacist counsels on the three options, time windows, and limits.

Options

Counselling points

• Take as soon as possible — do not delay to wait for a "better time."
• If vomiting within 2 hours of LNG-EC (or 3 hours of UPA-EC), the dose may not be absorbed — return for a repeat dose or antiemetic cover.
• LNG-EC can be taken more than once in a cycle if needed (not a regular contraceptive).
• Does not protect against STIs — advise condom use and consider STI screening.
• Advise a pregnancy test if the next period is more than 7 days late, unusually light, or atypical.
• LNG-EC does not abort an existing pregnancy and is not an abortifacient.

Common Skin Self-Care

Mild eczema / contact dermatitis

• Emollients first and most frequently (apply ≥2×/day, immediately after bathing). Use generously; trial several to find one the patient will use.
• Topical hydrocortisone 0.5% or 1% — short course (up to 7 days) on inflamed areas only; apply thinly once or twice daily. Avoid face/flexures unless directed; do not use under occlusion without advice.
• Refer if: widespread, infected (weeping, golden crusting — possible Staph), not improving in 7 days, or affecting an infant's face.

Fungal skin infections (tinea, athlete's foot, ringworm)

• Clotrimazole 1% or miconazole 2% cream — apply 2–3 times daily to the affected area plus 2 cm margin, continue for 1–2 weeks after symptoms clear (typical course 2–4 weeks) to prevent relapse.
• Keep skin dry, change socks/towels daily, do not share.
• Refer if: nail involvement (onychomycosis needs oral antifungal), scalp (tinea capitis — systemic treatment), widespread, or no improvement at 4 weeks.

Cold sores (herpes labialis)

• Acyclovir 5% cream — apply at the first tingle/prodrome, 5 times daily for 5 days; early application improves efficacy.
• Avoid touching the sore; wash hands; avoid kissing and sharing towels/cutlery, especially around infants and immunocompromised contacts.
• Refer if: near the eye (herpetic keratitis risk — urgent ophthalmology), frequent recurrent episodes (>6/year — consider suppressive therapy), or in immunocompromised patients.

Acne

• Benzoyl peroxide 2.5–5% — once or twice daily; start low to reduce irritation; warn it bleaches fabrics.
• Topical retinoids (adapalene 0.1%) — apply at night; avoid pregnancy (retinoid teratogenicity, although topical absorption is low).
• Combine with a gentle cleanser; improvement takes 6–8 weeks.
• Refer nodulocystic or scarring acne, acne with psychological distress, or no improvement at 12 weeks — oral therapy (e.g. oral tetracycline class, and in severe cases isotretinoin under dermatology) may be needed.

Worked example — emergency contraception counselling

A 22-year-old requests EC 30 hours after unprotected intercourse. She is not on hormonal contraception, BMI 22, no vomiting. Levonorgestrel 1.5 mg as a single dose now is appropriate (within 72 h, BMI <25). Counsel: take immediately; if vomiting within 2 hours, return for a repeat dose; does not protect against STIs — advise condom use and STI screening; take a pregnancy test if the next period is >7 days late or unusually light; LNG-EC does not abort an existing pregnancy and can be used more than once in a cycle if needed. If she had presented at 4 days (96 h), ulipristal acetate 30 mg (within 120 h) or a copper IUD (within 5 days, most effective) would be preferred.

Worked example — skin referral

A 16-year-old has nodulocystic acne on the cheeks and back with early scarring, present for 8 months. Over-the-counter benzoyl peroxide 5% and topical retinoids (adapalene 0.1%) are reasonable first steps for comedonal/mild inflammatory acne, but nodulocystic or scarring acne needs referral for oral therapy (oral tetracycline class — avoid in pregnancy and under 12 years — or combined oral contraceptive in females; severe cases need isotretinoin under dermatology supervision). Also refer acne with psychological distress or no improvement at 12 weeks.

Skin red flags — REFER

• Weeping, golden crusting, spreading erythema (possible bacterial superinfection / cellulitis)
• Lesion near the eye (cold sore — herpetic keratitis risk; urgent ophthalmology)
• Widespread or rapidly spreading rash, or rash with systemic symptoms (fever, malaise)
• Suspected melanoma (changing mole, ABCDE criteria) or non-healing ulcer
• Tinea capitis or onychomycosis (need systemic antifungal)
• Infant with widespread eczema or facial involvement

Key exam traps

• LNG-EC efficacy declines with time and is reduced at higher BMI/weight; it is not an abortifacient and does not protect against STIs.
• Topical hydrocortisone should be short-course and thin, avoiding face/flexures unless directed.
• Complete the full antifungal course even after symptoms clear — stopping early causes relapse.
• Acyclovir cream is most effective when started at the first prodrome/tingle.
• Universal safety-netting red flags (weight loss, night sweats, unexplained bleeding, sudden severe pain, high fever, neurological deficit) override any OTC treatment plan.