Appendix A
Minor Ailment Service Level 1 Treatment Protocols
Patients with symptoms of the following conditions may be referred into this Service and
provided with advice and treatment. Accredited Pharmacists/Pharmacy support staff should
ensure that they are thoroughly familiar the protocols for these conditions before
providing any advice or treatment under the minor ailments Service.
Products should be used in line with product license. Guidance on each condition is listed
on the following pages although this guidance does not exceed your own clinical judgement.
Symptom / Condition
Cold and flu
Cough
Diarrhoea or vomiting
Fever
Management of Headlice
Pain
Sore throat
Vaginal thrush
Worms
Level 1 Treatment protocols
Page 1 of 10
COLD AND FLU
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Nasal congestion, sneezing, mild temperature, sore throat, general aches and pains are associated with
the common cold. Refer to other relevant protocols as appropriate.
--------------------------------------------------------------------------------------------------------------------------------Criteria for INCLUSION
Children or adults presenting with cold or flu-like symptoms
--------------------------------------------------------------------------------------------------------------------------------Criteria for EXCLUSION
 Patients under one year
 Concomitant rash that does not fade under pressing e.g. with glass
 Patient is breathless
 Light hurts the eyes
 It is painful to bend the neck
 Systemic decongestants (pseudoephedrine) should be avoided in patients taking MAOI inhibitors and
used with caution in patients with diabetes, hypertension, hyperthyroidism and ischaemic heart
disease
--------------------------------------------------------------------------------------------------------------------------------Action for excluded patients and non-complying patients
Referral to General Practitioner
--------------------------------------------------------------------------------------------------------------------------------Action for included patients
Advice
Simple analgesics to bring temperature down
Steam inhalation (with or without aromatic inhalant)
Maintain a good fluid intake
Encourage rest (if possible)
Warm soothing drinks
Common cold does not require antibiotics for effective treatment
Remind high risk patients of influenza vaccination programmes (over 65s, and those patients under 65
with CHD, respiratory disease or diabetes)
No improvement in symptoms after three days, consult GP
-----------------------------------------------------------------------------------------------------------Treatment
Paracetamol (tabs 500mg or suspension 120mg/5ml or 250mg/5ml)
--------------------------------------------------------------------------------------------------------------------------------Side Effects and Management
Very rare with paracetamol but rashes and blood disorders reported. If affected patient should stop
paracetamol immediately and contact their GP.
--------------------------------------------------------------------------------------------------------------------------------When and how to refer to GP
Conditional referral
Patients with other chronic illness e.g. heart, kidney or lung disease, those with reduced immunity or
patients living in long-stay institutions. These patients would benefit from influenza vaccination.
Consider Supply but patient should be advised to make an appointment to see a GP if:
New symptoms develop particularly in young children, the elderly or the infirm
Symptoms worsening
Patient becoming breathless
Painful to bend the neck or light hurts the eyes
Rapid referral:
Development of a rash that does not fade when you press a glass tumbler against the rash
Level 1 Treatment protocols
Page 2 of 10
COUGH
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Coughing arises as a defensive reflex mechanism
--------------------------------------------------------------------------------------------------------------------------------Criteria for INCLUSION
Troublesome cough requiring soothing
--------------------------------------------------------------------------------------------------------------------------------Criteria for EXCLUSION
Patients under one year
Cough of more than three weeks’ duration
Cough productive of blood-stained sputum
Asthmatics presenting with wheeze or reduced peak-flow
Family history of asthma
Difficulty breathing or shortness of breath
--------------------------------------------------------------------------------------------------------------------------------Action for excluded patients and non-complying patients
Referral to General Practitioner
--------------------------------------------------------------------------------------------------------------------------------Action for included patients
Advice only to be given, no medication.
Smoking status to be checked and advice given regarding cessation if appropriate.
--------------------------------------------------------------------------------------------------------------------------------Recommended Treatments, Route and Legal status. Frequency of administration and maximum
dosage
N/A
--------------------------------------------------------------------------------------------------------------------------------When and how to refer to GP
Conditional referral:
 If cough and other symptoms persist beyond one week the patient should consult the GP;
Rapid referral:
 Constant chest pain or chest pain on normal inspiration
 Difficulty breathing
 Green or rusty sputum
 If pain related to exertion
Level 1 Treatment protocols
Page 3 of 10
DIARRHOEA & VOMITING
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Diarrhoea Increased frequency and fluidity of defecation
Vomiting Forcible ejection of contents of stomach
---------------------------------------------------------------------------------------------------------------------------------Criteria
for INCLUSION
Patients experiencing the above symptoms
---------------------------------------------------------------------------------------------------------------------------------Criteria
for EXCLUSION
 Children under the age of 1 year
 Pregnant women
 Patients with chronic diarrhoea problems
 Vomiting not improving after 1 day
 Diarrhoea not improving after 5 days, especially following return from tropical or developing country.
---------------------------------------------------------------------------------------------------------------------------------Action
for excluded patients and non-complying patients
Referral to General Practitioner
---------------------------------------------------------------------------------------------------------------------------------Action
for included patients
Advice
Patient should have adequate fluid replacement for 24 – 48 hours until the symptom resolves
Fast for 24hours with clear fluids only
Sip fluids
Light diet for first few days
Diarrhoea not improving after 5 days, especially following return from tropical or developing country.
These patients will be advised to collect a specimen bottle from the surgery for stool culture and to make
an appointment to see the doctor when the results are available.
------------------------------------------------------------------------------------------------------Treatment
Loperamide caps x 12
Dioralyte sachets x 6
Criteria
Loperamide for adults and children over 12 years
---------------------------------------------------------------------------------------------------------------------------------Side
effects and their management
Loperamide can cause abdominal pain and bloating
---------------------------------------------------------------------------------------------------------------------------------When
and how to refer to GP
Conditional referral
If symptoms persist beyond 48 hours, consult the GP
Consider Supply but patient should be advised to make an appointment to see a GP if:
Patients taking medication with recognised diarrhoea effect
Rapid referral:
Adults, where symptoms have lasted more than 5 days
Children, where symptoms have lasted more than 48 hours or who look ill or dehydrated
Pregnancy
Level 1 Treatment protocols
Page 4 of 10
FEVER
-----------------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Feeling of hotness in the body and temperature in excess of the normal (over 38C /100.4F. Symptoms
may include flushing and feeling sweaty.
---------------------------------------------------------------------------------------------------------------------------------------Criteria for INCLUSION
Child or adult presenting with feeling of hotness, flushing or feeling sweaty.
---------------------------------------------------------------------------------------------------------------------------------------Criteria for EXCLUSION
 Babies <3 months
 Severe headache or continuous vomiting
 Shortness of breath or difficulty in breathing
 Concomitant rash that does fade on pressing, e.g. with glass
 Ibuprofen C/I in patients with hypersensitivity to aspirin or other NSAID, during pregnancy and
breast-feeding, and in coagulation defects
 NSAIDs should not be given to patients with active peptic ulceration
 Worsening of asthma symptoms with NSAID previously
 Aspirin C/I if under 16 yrs of age, breast-feeding, GI ulceration, haemophilia or history of
hypersensitivity to aspirin or other NSAID.
---------------------------------------------------------------------------------------------------------------------------------------Action for excluded patients and non-complying patients
Referral to General Practitioner
---------------------------------------------------------------------------------------------------------------------------------------Action for included patients
Advice
 Use regular analgesic to reduce the temperature
 Increase fluid intake
 Wear light clothing
 Make sure that the room temperature is not too warm
 Tepid sponging
 Encourage rest (if possible)
----------------------------------------------------------------------------------------------------Treatment
Paracetamol (tabs 500mg or suspension 120mg/5ml or 250mg/5ml)
Ibuprofen (tabs 200mg or suspension 100mg/5ml)
-----------------------------------------------------------------------------------------------------------------------------------------Side Effects and Management
Very rare with paracetamol but rashes and blood disorders reported. If affected patients should stop
paracetamol immediately and contact their GP.
Ibuprofen – refer to C/I listed in exclusion criteria. Side effects include GI irritation, hypersensitivity
reactions (rashes, bronchospasm or angiooedema), fluid retention (caution in patients with heart failure,
hypertension and in patients with oedema for any other reason. If side effects occur advise patient to
stop ibuprofen and contact their GP or pharmacist.
Aspirin – Side –effects include GI irritation, bronchospasm and skin reactions in some patients – stop
aspirin use and consult GP or pharmacist.
---------------------------------------------------------------------------------------------------------------------------------------When and how to refer to GP
Conditional referral
General aches and pain, sore throat, sneezing or runny nose – probably a viral infection
Earache (refer to management of earache protocol)
Diarrhoea (refer to management of acute diarrhoea protocol)
Tender swellings around jaw and neck – probably swollen glands (analgesic + plenty of cool drinks)
Consider Supply but patient should be advised to make an appointment to see a GP if:
Patient is difficult to wake, not keeping fluids down or light hurts the eyes
Fever has lasted more than 5 days
Difficulty in breathing
Patient has recently travelled abroad
Severe headache or continuous vomiting
New symptoms develop or existing symptoms worsen
Rapid referral:
Concomitant rash that does not fade on pressing, e.g. with glass
Level 1 Treatment protocols
Page 5 of 10
MANAGEMENT OF
HEADLICE
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
An infection by the head louse (Pediculus humanus capitis). A person must have a living, moving louse to
be infected. Head lice can only be transmitted by direct, prolonged, head to head contact between
individuals. Nits are the empty egg cases that stick to hair and do not indicate a current infection.
--------------------------------------------------------------------------------------------------------------------------------Criteria for INCLUSION
Children or adults presenting with evidence of a living, moving louse seen on the scalp (most reliable
method is detection combing). Children under 1 yr can be treated at the pharmacist’s discretion (medical
supervision for children under 6 months).
All family members should be checked for head lice. Only those found to have a live, moving louse should
be considered for treatment
--------------------------------------------------------------------------------------------------------------------------------Criteria for EXCLUSION
 Family/siblings of patient, who are not proven to be infested (note: infestation is not indicated by the
presence of nits [hatched and empty egg shells])
 Children under the age of six months
--------------------------------------------------------------------------------------------------------------------------------Action for excluded patients and non-complying patients
Referral to General Practitioner
--------------------------------------------------------------------------------------------------------------------------------Action for included patients
Advice
 Broad comb, then wet comb well conditioned hair to remove dead lice and eggs
 Regular detection combing as treatment will not prevent re-infection from classmates
 Remove all adult lice before return to school
 Continue combing for two weeks
 Check all members of family (including grandparents etc. if contact)
 If live lice still present, consult health visitor or pharmacist to check technique
 Hair should be allowed to dry naturally – avoid flames. Do not use hair dryers
 Check pillow and collars for little black specks (lice droppings) and shed lice skins
 Encourage patient or parent to contact close relatives and friends to ensure detection and treatment
of further confirmed cases.
-----------------------------------------------------------------------------------------------------------Treatment
Wet Combing - an alternative to chemical application using a ‘Bug-busting kit’
Requires mechanical removal of head lice by meticulous combing with a detection comb
(for at least 30 minutes at a time) over the whole scalp, at four days intervals, for a
minimum of two weeks.
Use any conditioner.
--------------------------------------------------------------------------------------------------------------------------------Side effects and their management
Side effects are experienced rarely
--------------------------------------------------------------------------------------------------------------------------------When and how to refer to GP
Refer to GP if combing has failed and further treatment with liquid head lice lotions is required to
halt infestation.
Level 1 Treatment protocols
Page 6 of 10
PAIN
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Pain is a subjective experience, the nature and location of which may vary considerably.
---------------------------------------------------------------------------------------------------------------------------------Criteria
for INCLUSION
Patients requiring relief or pain / fever associated with upper respiratory tract infections and dental
problems
---------------------------------------------------------------------------------------------------------------------------------Criteria
for EXCLUSION
Children under the age of 3 months
Recurrent or severe pain
---------------------------------------------------------------------------------------------------------------------------------Action
for excluded patients and non-complying patients
Referral to General Practitioner
--------------------------------------------------------------------------------------------------------------------------------Action for included patients
Advice
Enquire about concurrent analgesic usage
Paracetamol daily dose – other products containing Paracetamol
Other NSAIDs – prescribed or OTC
Rest, warming, cooling or changing position, may obtain relief from pain. Patients should be advised to
avoid any aggravating factors
Pharmacists should be aware of the National Institute for Clinical Excellence guidance on Feverish
Children and can advise on alternating ibuprofen with paracetamol if neither work individually
NB. Overuse of analgesics can cause headaches
-----------------------------------------------------------------------------------------------------------Treatment
Paracetamol (tabs 500mg or suspension 120mg/5ml or 250mg/5ml)
Ibuprofen (tabs 200mg or suspension 100mg/5ml)
---------------------------------------------------------------------------------------------------------------------------------Side
Effects and Management
Side effects are rare with occasional use of Paracetamol
Ibuprofen should be taken after food to avoid GI side effects.
---------------------------------------------------------------------------------------------------------------------------------
Level 1 Treatment protocols
Page 7 of 10
SORE THROAT
-------------------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Painful, inflamed throat which makes swallowing difficult. Most sore throats are caused by viruses and
symptoms can take 2-7 days to clear after they start
-------------------------------------------------------------------------------------------------------------------------------------------Criteria for INCLUSION
 Children or adults presenting with symptoms of acute, uncomplicated sore throat.
-------------------------------------------------------------------------------------------------------------------------------------------Criteria for EXCLUSION
 Patients under one year
 Presence of tender lumps below the ear or at the jaw angle
 Severe difficulty in swallowing
 Five or more episodes of sore throat in the last 12 months causing serious disruption of daily life
 Suspicion of more serious disorder e.g. leukaemia, drug induced neutropenia
 Aspirin C/I if under 16 yrs of age, breast-feeding, GI ulceration, haemophilia or history of
hypersensitivity to aspirin or other NSAID.
 Symptoms not improved after 5 days
-------------------------------------------------------------------------------------------------------------------------------------------Action for excluded patients
Referral to General Practitioner
Can consider supply where the pharmacist considers this appropriate providing there is no delay in
seeking further treatment (see below)
-------------------------------------------------------------------------------------------------------------------------------------------Action for included patients
Advice
Maintain good fluid intake
Eat soft foods or warm soup
Encourage rest (if possible)
Avoid a smoky environment - smoking status to be checked and advice given regarding cessation if
appropriate.
Regular pain relief
Advise on natural course of sore throat i.e. can take several days for symptoms to subside
PIL
Patients >16 years gargle with soluble aspirin
Patients <16 years analgesia
-----------------------------------------------------------------------------------------------------------Treatment
Soluble aspirin 300mg (over 16s only)
Ibuprofen tabs 200mg tabs
Ibuprofen suspension 100mg/5ml SF
Paracetamol susp 120mg/5ml or 250mg/5ml
-------------------------------------------------------------------------------------------------------------------------------------------Side Effects and Management
Very rare with paracetamol but rashes and blood disorders reported. If affected patient should stop
paracetamol immediately and contact their GP.
Aspirin and ibuprofen – refer to C/I listed in exclusion criteria. Side effects include GI irritation,
hypersensitivity reactions (rashes, bronchospasm or angioedema), fluid retention (caution in patients with
heart failure, hypertension and in patients with oedema for any other reason. If side effects occur advise
patient to stop aspirin or ibuprofen and to contact their GP or pharmacist.
-------------------------------------------------------------------------------------------------------------------------------------------When and how to refer to GP
Conditional referral
If symptoms persist more than one week
If tonsils are dotted with white or yellowish spots – possible tonsillitis or pharyngitis – is the treatment any different?
Medical advice.
Patients on immunosuppressants, oral steroids, drugs causing bone marrow suppression
Patient having reported five or more episodes of sore throat
Swelling of neck glands – common with sore throats
Consider Supply but patient should be advised to make an appointment to see a GP if:
Prolonged throat soreness, difficulty in swallowing or voice hoarseness
If new symptoms develop (could also contact pharmacist or NHS Direct)
Rapid referral:
Patient unable to swallow own saliva – call 999 or NHS Direct
Level 1 Treatment protocols
Page 8 of 10
VAGINAL THRUSH
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Vaginal candidiasis (Thrush)
---------------------------------------------------------------------------------------------------------------------------------Criteria
for INCLUSION
Occuring in adult females with a previous diagnosis of Thrush who are confident it is a recurrence of the
same condition.
---------------------------------------------------------------------------------------------------------------------------------Criteria
for EXCLUSION
 Patients under 16 years
 Patients over 60 years
 Patients unsure if it is Thrush
 Recurrent (more than 2 episodes in 6 months)
 No previous diagnosis by GP
 Pregnancy
---------------------------------------------------------------------------------------------------------------------------------Action
for excluded patients and non-complying patients
Referral to General Practitioner
---------------------------------------------------------------------------------------------------------------------------------Action
for included patients
Advice
Make aware sexual partners should be treated concurrently
Advise if symptoms do not resolve within 7 days to make an appointment to see a GP
Avoid irritants e.g. bath additives
Make aware of problems with vaginal deodorants, scented soap etc.
---------------------------------------------------------------------------------------------------Treatment
Clotrimazole pessary 500mg with clotrimazole cream if needed for external symptoms
Fluconazole capsule 150mg
---------------------------------------------------------------------------------------------------------------------------------Side
Effects and their Management
Sensitivity to Imadazoles
Drug Interactions
Pharmacist should consider interactions, for example with anti-coagulants, some antihistamines,
tranquillisers, statins etc.
---------------------------------------------------------------------------------------------------------------------------------When
and how to refer to GP
Conditional referral
On 3rd occurrence
Consider Supply but patient should be advised to make an appointment to see a GP if:
Post-menopausal women
Rapid referral:
Presence of loin pain
Fever
If blood present in discharge
Level 1 Treatment protocols
Page 9 of 10
WORMS
--------------------------------------------------------------------------------------------------------------------------------Definition/Criteria
Threadworm infection
--------------------------------------------------------------------------------------------------------------------------------Criteria for INCLUSION
Patients with intense perianal or perivaginal night time itching who can confirm a threadworm infection.
---------------------------------------------------------------------------------------------------------------------------------Criteria
for EXCLUSION
 Patients under 2 years
 Pregnancy
 Breastfeeding
 Recent return from tropical/developing country
---------------------------------------------------------------------------------------------------------------------------------Action
for excluded patients and non-complying patients
Non-drug therapy (hygiene measures)
---------------------------------------------------------------------------------------------------------------------------------Action
for included patients
Advice
 Family members should be treated simultaneously
 For 14 days after treatment hygiene measures should be taken which include:
o Wear underpants at night;
o Have a bath or wash around the anus (back passage) each morning immediately on rising;
o Change and wash underwear, nightwear and bed linen (if possible) each day;
o Keep fingernails short;
o Wash hands and scrub under the nails first thing every morning, after using the toilet or changing
nappies, and before eating or preparing food;
o Vaccum all carpets and clean bathroom surfaces daily;
 For Mebendazole – a second dose may be required after 2-3 weeks if re-infection occurs
-----------------------------------------------------------------------------------------------------------Treatment
Mebendazole tabs 100mg
---------------------------------------------------------------------------------------------------------------------------------Side
Effects and their Management
Side effects are rare but transient abdominal pain or diarrhoea may occur.
Very occasionally there may be hypersensitivity reactions.
---------------------------------------------------------------------------------------------------------------------------------When
and how to refer to GP
Conditional referral
Pregnant women and breastfeeding mothers who have failed to eradicate after 6 weeks of hygiene
measures.
Consider Supply but patient should be advised to make an appointment to see a GP if:
If there is a risk of a secondary infection due to intense scratching of the perianal skin
In persistent or heavy cases of infection where patient has suffered loss of appetite, weight loss, insomnia
and irritability
If recently returned from tropical/developing country
Level 1 Treatment protocols
Page 10 of 10