Antifungals: it’s a section of the pharmacy that doesn’t have a lot of glamour, and often doesn’t attract a lot of attention
Customers are often embarrassed and prefer to self-select where possible, and with so many products scheduled Pharmacy Only, the interaction is often handled not by pharmacists, but by pharmacy assistants.
But the antifungals section in pharmacy is an underutilised area that’s crying out for what Sydney pharmacist Nick Logan calls a “white coat moment”.
“The thing is that with something like tinea pedis, or Athlete’s Foot, if you don’t treat it properly it will come back straight away,” Logan, a former Pharmacist of the Year and Pharmacy of the Year winner, told the AJP.
“The symptoms will disappear before the infection has been eradicated. And that’s why adherence in the antifungal category is so poor: the symptoms often disappear before the actual infection is resolved.
“Even though most of the antifungal products are self-select in NSW at least, it’s important for pharmacy staff to engage with them and give them really clear directions on eradicating it properly.”
In an ideal interaction, it would be the pharmacist on the floor talking to the patient about dosage, frequency of application or dosage, and a timeframe for eradication of the infection, Logan says.
“That would be the gold standard – dose, frequency and duration alongside printed lifestyle tips and other information, so that they remember it when they get home.
“It’s a really good opportunity for a white coat to be out there on the floor, and to remind consumers of the value of the pharmacy as a health centre in their community.
“Pharmacists should be thinking about what they can add to a sale that will increase loyalty – and antifungal is a good opportunity to have that ‘white coat moment,’ get out there and have a meaningful talk.”
A valuable service
The Chemmart Pharmacy Samford, north-west of Brisbane, is renowned for its customer service: in 2016 it took out the Community Engagement award in the Guild Pharmacy of the Year Awards.
The store’s Professional Care Pharmacist, Jacqui Hagidimitriou, is out on the shop floor most of the time – alternating with owner Karen Brown – and says that despite the prevalence of self-selection in the category, a lot of customers do not understand their fungal condition or how best to manage it well at all.
A pharmacist helping educate customers on the subject is vital because so many customers incorrectly self-diagnose, or are unaware of the significance of repeat infections, Hagidimitriou says.
“Because of our forward dispensing model I tend to be on the floor most of the time, and so I make a point of finding out what customers have come in for,” she says.
“If they say, ‘antifungal cream,’ I would open up a conversation about why they think they need an antifungal, because there’s a lot of misconceptions out there about what fungal infections are.
“Some come in really scared, because they think their ringworm is a worm – they don’t realise that it’s a colloquialism for a fungal infection, because of that characteristic ring-like appearance. They think they got it from their cat.
“From a customer perspective, they don’t realise that tinea isn’t just a disease that affects the feet. They don’t realise that tinea is just the name for the fungal infection and that you can get it anywhere, and that it’s the same thing as jock itch or ringworm.”
Tinea can appear on the foot (Athlete’s Foot), body (ringworm), nails, scalp, groin (jock itch) or the breast fold.
The converse also applies: consumers tend to assume any foot infection is tinea as well, Hagidimitriou says.
“And a lot of people don’t realise that fungus, like bacteria, live on our body anyway – it’s when it gets the opportunity to grow beyond what’s normal that you get a rash.”
According to the American Academy of Dermatology, about half of nails with suspected fungus do not have a fungal infection at all.
“As other nail conditions, such as nail dystrophies, may look similar in appearance, it is important to ensure accurate diagnosis of nail disease before beginning treatment,” the Academy wrote for the Choosing Wisely initiative, in suggesting several dermatological issues which should be questioned by health professionals and patients before proceeding with testing or treatment.
“By confirming a fungal infection, patients are not inappropriately at risk for the side effects of antifungal therapy, and nail disease is correctly treated.”
Once a fungal nail infection has been identified, the customer needs to have a conversation with a pharmacist about realistic expectations of treatment time and adherence to the treatment regime, say both Logan and Hagidimitriou.
“This time of year, until about March, is very relevant for fungal nail infections,” Logan says, due to people wanting to wear open-toed shoes in summer.
“The thing is that people have always treated these infections very haphazardly. You need to give them really clear directions on eradicating it properly, because the efficacy of the preparation suffers greatly from the poor adherence to the instructions.
“You need discipline to treat them. It can take six to nine months or more to treat the infection topically.
“But if we get the interaction right, we can show that we can give really valid professional advice that improves their outcome and ability to treat the condition.”
Hagidimitriou cautions that topical treatments available in pharmacy may not be effective once the infection reaches the lunula, and the customer may again need to be referred to a doctor.
“And picking something they’re going to be compliant with can be difficult,” she says.
“In some cases it can be better to choose a product that’s applied daily, instead of once a week, because you get into the habit of applying it every day.
“With other products, once a week can become once every two weeks, or then it’ll be a month before you remember to apply it again.”
Candida albicans is the most prevalent fungal pathogen in humans, and globally, more than 100 million women will suffer recurrent thrush infections each year.
Thrush is also the archetypal example used to question how discreetly pharmacy manages awkward questions and product requests – and while many customers are embarrassed about seeking help, it’s important that they do so.
“Thrush is always an interesting one, because there’s some customers that will shout [the request] across the room and others are really embarrassed,” says Hagidimitriou.
“A lot of women think they have thrush but they could really have dermatitis, which wherever it appears is often mistaken for a fungal infection. The symptoms can be similar.”
Latex allergy in women who use condoms may be a likely suspect, she says.
“We had a customer not long ago who was breastfeeding, and said that she had thrush but made the connection that she only seems to get it when she’s breastfeeding and has to use condoms.
“That’s a good example of someone who needs to go to the doctor if it keeps happening, because it may not be thrush at all.
“In older women, what they think is thrush may actually be vaginal dryness due to hormonal changes, so it’s really important that it’s the pharmacist that’s involved in the conversation, particularly if a customer is repeatedly asking for thrush treatment.
“And recurrent thrush is of concern for anyone – why are they getting it? It shouldn’t really be recurring. It’s important to refer onto a doctor, as in some cases the infection may not be caused by the usual candida but another type of fungal infection entirely; in a case like that you’d need to have it diagnosed via a swab.”
Recurrent thrush can also be a symptom of undiagnosed diabetes; and likewise, people with a diabetes diagnosis may continue to be more prone to thrush, particularly if their condition is not well controlled.
“Diabetes is so complicated and it can be so overwhelming when someone’s been first diagnosed that they don’t receive the support they need,” Hagidimitriou says. “Some have never even heard of a diabetes educator.”
She says there is a strong role for pharmacists in talking to people with diabetes about self care, and helping prevent thrush, whether oral or vaginal.
High sugar levels provide a better environment for candida albicans to grow, and damaged skin also promotes its growth.
“Then there’s nipple thrush, which is quite common with new mums, and often the baby will get oral thrush,” Hagidimitriou says. “These are all opportunities for counselling, as is talking to women who are on oral contraceptives, and talking to people who are on some asthma medications about maybe using a spacer and washing out their mouth after using the puffer.”
Prevention of thrush infections remains important, in part due to the development of drug resistance.
A 2016 study reviewed the literature on natural products and sources of new antifungal drugs to treat candida albicans and found that the search for new drugs is promising, with a long list of natural substances showing activity against the yeast infection.
“Investigations must be pursued not only to found more new anti-Candida compounds from plants and organisms but also to [carry] out details on molecules from already known anti-Candida compounds and to more elucidate mechanisms of action,” the authors concluded.
In the meantime, Hagidimitriou recommends probiotics.
“These exist to take alongside antibiotics, which we recommend for women if they’re prone to thrush – they’re a yeast that competes against the candida that can become overgrown otherwise.”
Fungal infections may seem relatively innocuous, but globally, nearly 1.5 million people die from them each year—more people than malaria, breast cancer or tuberculosis.
In mid-2016 scientists from Aberdeen presented research at the “Killer Fungus” exhibit of the Royal Society’s Summer Science Exhibition, which represented research from 12 UK universities who lead the world in research into fungal infections.
Professor Neil Gow, world expert in fungal research at the University of Aberdeen, led the Killer Fungus exhibit and said that serious, life-threatening fungal infections are “more common than people realise”.
“At the moment we have no fungal vaccines and a relatively limited number of antifungal drugs for treating serious fungal infections,” he says.
“There is a pressing need to develop new treatments. We also need to get better at diagnosing fungal infections.
“At the moment we’re not very good at making these diagnoses early enough to save patients with life threatening infections.”
Some fungal infections can also cause respiratory problems or severe allergies and fungal infections in the eye also lead to hundreds of thousands of cases of blindness per year globally.
Serious fungal infections can carry higher risks, including death. People who have suffered a trauma (such as an accident which has resulted in an infected wound) and people with weak immune systems (for example those being treated with chemotherapy, by stem cell or bone marrow transplantation or suffering from HIV-AIDS) may be more vulnerable to the risk of serious infection.
In the UK alone it is estimated that about 14,000 people may suffer from a serious fungal infection each year.