11.2 Dermatology, Ophthalmology & ENT

11.2 Dermatology, Ophthalmology & ENT

Quick Answer: Match topical steroid potency to site and severity, build acne and eczema plans around evidence-based steps and red-flag infection, never miss painful red eye with vision change, teach glaucoma drop technique with systemic beta-blocker awareness, and use stepwise allergic rhinitis care while distinguishing otitis externa from media for referral urgency.

Dermatology, eye, and ENT presentations are frequent community pharmacy workloads and appear in APC Intern Written scenarios under Standards 3.1–3.3. You must triage self-care versus referral, select appropriate OTC or prescribed therapy, counsel technique, and monitor adverse effects. AMH supports drug choice and cautions; APF supports counselling standards.

Topical corticosteroids — potency concepts and counselling

Topical corticosteroids reduce inflammation in eczema, contact dermatitis, psoriasis plaques (selected), and other steroid-responsive dermatoses. Australian practice groups products by potency (mild → moderate → potent → very potent). Exact brand rankings should be checked in AMH, but conceptual rules are stable:

• Face, eyelids, flexures, genitals, and large areas in children: prefer mild potency (e.g. hydrocortisone 1% concepts) and short courses
• Trunk and limbs with thicker plaques or severe flares: moderate to potent agents may be appropriate for limited duration under advice
• Very potent steroids: specialist/short-course territory; high risk of atrophy and systemic absorption if misused

Counselling essentials:

• Apply a thin layer to affected skin only
• Use fingertip units (FTU) as a practical quantity guide (one FTU covers roughly two adult hand areas — teach the concept rather than over-precise arithmetic unless asked)
• Emollients are foundational in dry/eczematous skin; apply liberally and often; leave a short gap if sequencing with steroids per product advice
• Course length: use until control, then step down; avoid abrupt “scare-stop” that leaves disease untreated
• Adverse effects of overuse: skin atrophy, striae, telangiectasia, perioral dermatitis, tachyphylaxis concerns, HPA-axis suppression with extensive potent use
• Steroid phobia is common — balance safety counselling with the harm of undertreating moderate–severe eczema

Occlusion increases potency/absorption. Infection under an inflamed rash may need antimicrobial assessment rather than escalating steroid alone.

Acne — benzoyl peroxide, topical retinoids, oral isotretinoin awareness

Acne pathogenesis involves follicular hyperkeratinisation, sebum, Cutibacterium acnes, and inflammation. Community stepped care (high-level):

1. General measures: non-comedogenic products, gentle cleansing (avoid harsh scrubbing), realistic timelines (weeks, not days)
2. Benzoyl peroxide: antibacterial/keratolytic; can bleach fabrics; start lower strength to reduce irritation
3. Topical retinoids (e.g. adapalene concepts): normalise follicular turnover; counsel initial irritation, photosensitivity, and night application habits; contraception awareness for people who can become pregnant because systemic retinoid teratogenicity frames class caution even when topical exposure is lower
4. Topical antibiotics: stewardship — prefer combination with benzoyl peroxide where used to reduce resistance; avoid long monotherapy
5. Oral antibiotics (prescribed): limited duration strategies; combine with topical non-antibiotic agents
6. Hormonal options in suitable females; spironolactone concepts in selected cases under medical care
7. Oral isotretinoin: for severe nodulocystic or treatment-resistant acne under specialist frameworks

Isotretinoin pregnancy program awareness is non-negotiable for pharmacists: major teratogen, mandatory contraception and pregnancy testing concepts, no sharing of capsules, dry skin/lips/eyes counselling, mood monitoring discussions as clinically framed, and interaction with vitamin A supplements. Even if you do not initiate therapy, dispensing and counselling must reinforce program rules.

Eczema flare care

Atopic eczema flares present with itch, dryness, and inflammation. Priority actions:

• Liberate emollient use (soap-free wash, frequent moisturiser)
• Identify triggers (soaps, wool, heat, allergens, infection)
• Apply appropriate-potency topical corticosteroid to inflamed areas for an adequate short course
• Antihistamines may help sleep when itch disturbs rest; they do not treat the skin inflammation itself
• Watch for infected eczema (crusting, weeping, rapid worsening, fever) → medical review; antiviral caution if herpetic eczema suspected

Failure of standard care, facial/eyelid disease needing more than mild steroid, or significant sleep loss/infection risk warrants GP or dermatology pathways.

Bacterial conjunctivitis versus red-flag eye disease

Typical bacterial conjunctivitis: sticky discharge, redness, gritty sensation, often bilateral sequential spread, vision usually preserved. Many cases are self-limiting; hygiene (no sharing towels, discard eye cosmetics) matters. Chloramphenicol eye drops/ointment are familiar Australian pharmacist-supply options within protocol for appropriate presentations — still assess red flags first.

Red flags — urgent medical/ophthalmology care, not routine OTC pathways:

• Moderate–severe eye pain (not just grittiness)
• Photophobia
• Reduced or blurred vision, halos, visual field loss
• Recent trauma, chemical exposure, or foreign body
• Contact lens wear with red eye (risk of microbial keratitis)
• Vesicular rash around the eye (herpes zoster ophthalmicus concern)
• Severe headache with eye symptoms, pupil changes, or proptosis
• Neonatal red eye

Do not let “pink eye” language hide acute angle-closure glaucoma, uveitis, keratitis, or orbital cellulitis. When in doubt, refer urgently.

Glaucoma drops — technique and systemic beta-blocker caution

Chronic open-angle glaucoma is often treated with topical agents (prostaglandin analogues, beta-blockers, carbonic anhydrase inhibitors, alpha-agonists — know class concepts). Pharmacist counselling focuses on technique and adherence:

• Wash hands; shake suspensions if required
• Tilt head, pull down lower lid, instil one drop into the conjunctival sac without touching the eye with the bottle tip
• Close eye gently; use nasolacrimal occlusion (pressure at inner corner) for 1–2 minutes to reduce systemic absorption and improve local effect
• Space different drops by several minutes
• Counsel expected effects (e.g. iris darkening/lash growth with prostaglandins) and adherence despite asymptomatic disease

Systemic beta-blocker caution: timolol and related topical beta-blockers can be absorbed enough to cause bradycardia, bronchospasm, or fatigue in susceptible people — caution in asthma/COPD and heart block history. Flag duplicate systemic beta-blocker load. Report breathing difficulty or marked bradycardia symptoms for medical review.

Allergic rhinitis — stepwise care

Allergic rhinitis (seasonal or perennial) features sneezing, rhinorrhoea, nasal itch, and congestion, often with allergic conjunctivitis.

Stepwise approach:

1. Allergen reduction where practical (bedding covers, pet measures, pollen timing)
2. Intranasal corticosteroids as highly effective first-line for persistent moderate symptoms — counsel correct spray direction (away from septum), regular use for days–weeks for full benefit, and epistaxis precautions
3. Oral non-sedating antihistamines for itch/sneeze-predominant symptoms
4. Intranasal antihistamines or combination products in selected cases
5. Saline irrigation as supportive care
6. Short courses of oral decongestants or topical decongestants with strict limits to avoid rhinitis medicamentosa

Refer for unilateral persistent blockage, blood-stained discharge, severe facial pain, or poor response suggesting chronic rhinosinusitis or other pathology.

Otitis externa versus otitis media (high-level)

Do not put drops in the ear if tympanic membrane integrity is uncertain without clinical advice. Distinguish pain origin: canal tenderness points to externa; systemic childhood AOM patterns point to media and often medical assessment.

Integrated safety habits

• Match steroid potency to skin site; pair with emollients in eczema
• Acne: benzoyl peroxide/retinoid foundations before escalating; isotretinoin = pregnancy program
• Eyes: vision/pain/photophobia/contact lens = escalate
• Glaucoma: technique + systemic beta-blocker risk
• Nose/ear: stepwise rhinitis; externa vs media triage

These patterns convert common counter presentations into safe, exam-ready clinical decisions.