By Nat Jones, RPh, FAPC, PCCA Clinical Compounding Pharmacist

As colder weather descends in the fall and winter months, a few health challenges come with it. Because of the use of heating systems that dehumidify the air, we consequently dry our skin and mucous membranes, decreasing the functionality of our natural barriers to dermatological and respiratory conditions. This puts more stress on our immune systems. Some of the various common fall and winter health issues include viral infections (COVID-19, flu, common colds, sore throat (pharyngitis is most likely viral)) and a couple of unique dermatological problems as a result of mask-wearing. I will cover some compounding and nutritional suggestions for these problems in this article. There are additional commonly observed problems this time of year that involve poor indoor air quality, sedentary living, unhealthy eating habits and seasonal depression, to name a few, that are beyond the scope of this article. However, I will also provide some practical tips for keeping your pharmacy customers informed so that they can make healthy decisions, and I’ll point out a few additional resources you can look to if you want to learn more.

Preventive Measures for Common Fall & Winter Conditions

The potential of viral infections is certainly heightened during flu season. People are understandably concerned about exposure. While there is no guaranteed method of protection, many patients will be seeking advice for nutritional supplements to support their immune systems during this time of year. Common recommendations include vitamin D3, curcumin, antioxidants (buffered vitamin C, vitamin E, quercetin, epigallocatechin-3-O-gallate (EGCG)) and zinc.

EGCG, the major catechin component of green tea, has been shown to have antiviral activity by interfering with the viral membrane protein functions and inhibiting attachment.¹ Vitamin D3, quercetin and zinc have been shown to lower interleukin-6 levels,^2,3,4 which may therefore support a healthy immune response and help control inflammation.^5,6 Wellness Works offers all of these options and many more to pharmacies, which allows them to provide their patients professional-grade supplements.

Addressing Symptoms of Common Fall & Winter Conditions

In some upper respiratory infections or after endoscopic sinus surgery, patients may need nasal and sinus irrigation with formulations including ingredients such as antihistamines, corticosteroids and even leukotriene antagonists in combination for symptomatic relief. Nonsterile compounding options would include formulas made with our dispersion powder bases LoxaSperse ^® and XyliFos ^® . If the clinician suspects microbial involvement other than a virus (i.e., bacteria or fungi), they may request the addition of antibiotics such as aminoglycosides or fluoroquinolones, or antifungal ingredients such as itraconazole and even amphotericin B to these combinations. Many of these ingredients are not water soluble, and inclusion of LoxaSperse^® and XyliFos^® improve the solubilization and dispersion of these drugs.

Additionally, upper respiratory symptoms often include cough, but some patients don’t want or can’t have alcohol in their cough medicine. Formulations in SuspendIt ^® (our all-in-one base for oral suspensions that has a patented polymer complex) with the opioid cough suppressant hydrocodone in combination with guaifenesin and pseudoephedrine can serve a real need in these cases. Prescribers and pharmacists might also consider other compounded multi-ingredient formulas using decongestants, antihistamines and dextromethorphan for non-opioid options.

Nasal symptoms including rhinitis and congestion often associated with nasal polyps may be treated with combinations of mast cell stabilizer/antihistamines like azelastine and corticosteroids such as budesonide. Prescribers commonly request compounded formulations like this.

Something else to consider is an indirect complication of COVID-19 known as “maskne.” It is a new term describing acne caused by wearing masks. The current pandemic and the need to cover our mouths and noses has led us to an increase in dermatological problems for many people in various fields, especially those who work long hours wearing a mask. Dermatologists describe maskne as a variation of “acne mechanica,” which usually occurs when skin is pressed against heavy clothing or bulky protective gear. In other words, having to wear a mask for protection has created the perfect conditions for facial acne and other types of skin irritation. Some people are not getting comedones (the small bumps we think of as acne), so they technically do not have acne, but they are getting redness, inflammation and irritation caused by the effects of wearing a mask.

If the mask-wearing is truly causing comedones, then patients should try a regimen of washing the face twice with a gentle cleanser that removes dirt and oils but does not strip all of the natural barrier from the skin. Additionally, practitioners might consider prescribing a compounded formula based on age and severity of acne to possibly include tretinoin, clindamycin and/or niacinamide in either PCCA’s Clarifying^™ Base or WO6^® Anhydrous Topical Gel . Research has shown that niacinamide may decrease sebum production. ⁷ Using WO6 as the base will allow for longer BUDs. If mask-wearing is only causing irritation and not acne, prescribers might consider a compound containing ketotifen and possibly naltrexone in either Clarifying, WO6 or VersaBase^® Cream .

Helping Your Patients Make Healthy Decisions

Prevention starts with the knowledge your patients need to make good decisions for their health, so it might be helpful to share practical tips for cold and flu season. Pharmacists may want to consider adding public service messaging to their websites and on-hold messaging for their phone systems that can possibly include variations of these messages:

• Get immunized, especially if you or your loved ones are at risk; wash your hands; and cover your mouth when you cough or sneeze
• Stay active, maintain a healthy diet and be sure to get enough sleep each night
• Don’t wait for winter health problems. Get proactive and take your supplements to help support your immune system
• Talk to our pharmacist when you experience symptoms. You don’t have to wait for your symptoms to get “bad enough” before seeking advice or treatment

Where You Can Learn More

We have more information and related resources available for helping your community stay healthy during the colder months of the year. You can read these articles on The PCCA Blog:

• “ What is ‘maskne,’ and what can we do about it? ”
• “ Compounding Opportunities for Winter ”

PCCA members can also find our extensive document Commonly Requested Compounding Ideas and Products for Patients During the Winter & Flu Season (PCCA Document #97852) on our Members-Only Website. It has many commonly requested formula examples, including some that are related to what I have covered above.

PCCA members can hear Nat talk more about compounding ideas for fall and winter in our October 2020 Marketing & Sales Power Hour recording on PCCA Play

Nat Jones, RPh, FAPC, graduated from the Virginia Commonwealth University, Medical College of Virginia’s School of Pharmacy in 1979. In 2014, after 20 years of owning a compounding pharmacy, he joined PCCA’s staff. Nat has given continuing education lectures at medical professional seminars and webinars on numerous topics, including general compounding, wound care, pain management, nutrition, otolaryngology, women’s health, sexual dysfunction, insulin resistance, hormone replacement therapy, neurotransmitter imbalance and dermatology. He has published many articles and case studies in magazines and professional journals along with an open-access ebook titled Advances in Psoriasis with Avid Science. Since 2016, Nat has served on the Texas State Palliative Care Interdisciplinary Advisory Council.

References

1. Kaihatsu, K., Yamabe, M., & Ebara, Y. (2018). Antiviral mechanism of action of epigallocatechin-3-O-gallate and its fatty acid esters. Molecules, 23(10). https://doi.org/10.3390/molecules23102475

2. De Haes, P. Garmyn, M., Degreef, H., Vantieghem, K., Bouillon, R., & Segaert, S. 1,25-dihydroxyvitamin D3 inhibits ultraviolet B-induced apoptosis, Jun kinase activation, and interleukin-6 production in primary human keratinocytes. Journal of Cellular Biochemistry, 89 (4), 663–673. https://doi.org/10.1002/jcb.10540

3. Mlcek, J., Jurikova, T., Skrovankova, S., & Sochor, J. (2016). Quercetin and its anti-allergic immune response. Molecules, 21(5). https://doi.org/10.3390/molecules21050623

4. Hatakeyama, D., Kozawa, O., Otsuka, T., Shibata, T., & Uematsu, T. (2002). Zinc suppresses IL-6 synthesis by prostaglandin F2alpha in osteoblasts: Inhibition of phospholipase C and phospholipase D. Journal of Cellular Biochemistry, 85(3), 621–628. https://doi.org/10.1002/jcb.10166

5. Tanaka, T., Narazaki, M., & Kishimoto, T. (2014). IL-6 in inflammation, immunity, and disease. Cold Spring Harbor Perspectives in Biology, 6(10). https://dx.doi.org/10.1101%2Fcshperspect.a016295

6. Aziz, M., Fatima, R., & Assaly, R. (2020). Elevated interleukin-6 and severe COVID-19: A meta-analysis. Journal of Medical Virology, 92(11), 2283–2285. https://doi.org/10.1002/jmv.25948

7. Draelos, Z. D., Matsubara, A., & Smiles, K. (2006). The effect of 2% niacinamide on facial sebum production. Journal of Cosmetic and Laser Therapy, 8(2), 96–101. https://doi.org/10.1080/14764170600717704

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.