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To the Patients and Providers we serve,
With the recent closing of Restore Health Pharmacy, we would like you to know that we are equipped and staffed to quickly meet your compounded prescription needs. MD Custom Rx was the first pharmacy in Wisconsin to be accredited by the Pharmacy Compounding Accreditation Board and continues to be a leader in providing customized medicine. Please contact us today - we are here to help.
Sincerely,
Dan and Monica Zatarski, PharmDs, Owners
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Nail Psoriasis and Onychomycosis
Nail health can be a mirror of overall health. For example, Muehrcke's lines (horizontal bands of nail discoloration) are typically caused by low serum albumin. Nail clubbing, which develops over years, is associated with low oxygen in the blood and has been described in patients suffering from severe gastrointestinal disorders, cardiovascular disease, and immune dysfunction. Koilonychia, a spoon-like depression of the nail bed, may indicate hypochromic anemia or other disruptions of iron absorption. Beau's lines, indentations that run across the nail, can be a sign of trauma but can also be a sign of zinc deficiency. Finally, nail pitting, scaling, and thickening is common to psoriasis involving the nails and can accompany onychomycosis, or fungal infection of the nail.
In nail conditions such as nail psoriasis and onychomycosis, topical medications can help reduce the signs of nail structure damage.
Psoriatic nail disease generally occurs in patients with cutaneous psoriasis; however, it can rarely (5%) be seen in the absence of clinically evident psoriasis of the skin. Nail psoriasis can be treated using compounded topical agents and treatment may include an antifungal component since nail psoriasis and fungal nail infections are often comorbid conditions. Medications typically found in compounded nail psoriasis therapy include fluorouracil, glucocorticoids and/or vitamin D3 analogues. These agents can be compounded into creams, ointments, and gels. A study which included 48 patients, tested the efficacy of a preparation containing calcipotriol and clobetasol propionate in the treatment of nail psoriasis. After a year of treatment, nail thickness was reduced by 81.2% and 72.5% in finger and toe nails, respectively.
In the case of recalcitrant onychomycosis, a multi-drug approach to treatment has been studied and used with success. Compounded preparations can include a potent antifungal agent paired with other agents and applied directly to the nail. One study looked at the effects of combining butenafine, a potent antimitotic fungicidal, with tea tree oil, known to have antiseptic and antifungal properties, in a cream base for the treatment of onychomycosis. In this study, 60 patients were randomized to treatment with a compounded topical agent or placebo. After 16 weeks of therapy, 80% of patients in the treatment group were cured compared to zero patients in the placebo group. Another study looked at a combination of fluconazole, along with the emollient urea, compounded into a nail lacquer. In this study of 70 patients, treatment was well tolerated and had an 82.8% cure rate.
Topical preparations are the preferred route of treatment of nail disorders due to the relatively toxic effects of systemic therapy. Since treatment can be prolonged, oral regimens may require regular side effect monitoring and may even interact with other oral medications; elderly patients with comorbidities are particularly at risk for experiencing adverse effects and drug interactions from oral therapy. Generally, it's important to use a combination of medications to promote healing and prevent nail disorder relapse.
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Novel Scar Therapies
Emerging scar therapies can help treat and prevent painful, unsightly scars. At the surface, a wound from trauma or surgery may leave a scar that is raised and discolored; at a deeper level, blood vessel and nerve damage can result in associated pain and itching. Therefore, the best therapies involve a multi-prong approach to help smooth and lighten the physical appearance of the scar, while controlling or eliminating associated discomfort. Individually compounded scar therapy preparations may contain caffeine; vitamin A; avocado, coconut, and other tree oils; and medications including corticosteroids, antihistamines, as well as other agents such as verapamil that promote healing. Verapamil exhibits anti-proliferative properties that reduce collagen deposits and promotes scar tissue breakdown by increasing collagenase production. Another often used drug is pentoxifylline. In vitro, pentoxifylline inhibits the production of collagen; topical application improves blood flow and elasticity of scar tissue. Other agents used in scar therapy include: imiquimod 5% (immune-response modifier and Toll-like receptor (TLR) agonist), hyaluronic acid (corporal lubricant), and tranilast (suppresses collagen synthesis by fibroblasts). With so many options available, the key is to work closely our compounding pharmacist to find the preparation that will work best for your patient's skin type, scar location, and stage of healing. Medications may be compounded into a cream, ointment, or gel base. Several studies show the benefits of a silicone gel base in the treatment of scars. The mechanism by which silicone aids in scar healing is not well understood. One possible role is the creation of a physical barrier to prevent water loss through damaged scar tissue. It is thought that promoting hydration and proper temperature and oxygen transmission creates an environment conducive to healing. In one study, a total of 36 post-operative patients applied silicone gel twice daily resulting in statistically significant improvements in scar height, pain, pigmentation, pliability, pruritus and vascularity. Taking an individualized approach to treating scars with compounded topical scar therapy can be an important adjunct in the treatment of wounds and scars. References:
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Topical Medications for Sports Injuries in Youth
Adolescents, aged 13-15, account for the majority of sports injuries in youth. Tailoring treatment to the patient's age and life style is important in order to promote prompt healing and decrease the chances of repeat injury.
There are several things to consider when treating pain stemming from a sports injury in a pediatric patient. For example, codeine, previously a mainstay in the treatment of pain, may not be the best choice, especially for children and adolescents. Codeine's analgesic effects are due to its metabolism or conversion to morphine in the body via the cytochrome P450 enzyme system. In this age group, this system is not fully developed and thus high doses and blood levels of codeine or morphine don't always correlate with analgesic effects. Another class of drugs used to treat pain in youth is NSAIDS. Drugs in this class (i.e., ibuprofen, ketoprofen) are effective oral analgesics, but their dosing frequency and timing may not be ideal for a busy school-aged patient. Oral NSAIDs should be administered with meals to avoid stomach upset, however, children's eating habits and meal times aren't always predictable. Studies, including a large meta-analysis, have described the advantages of topical vs. oral NSAID therapy. These include high tissue levels of medication at the site of injury, with minimized systemic side effects, such as stomach upset and drowsiness. Odorless and easy-to-apply creams or gels can be compounded using the most appropriate types of medications based on the individual's specific needs. The use of compounded topical therapy can play an important role in getting adolescents back in the game! References:
We compound customized medications to meet specific needs.
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