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Can nurses improve outcomes for patients with skin disease?

Thomas F Poyner
MB BS FRCP(Lond) FRCP(Glasg) MRCGP DPD
GP
Stockton-on-Tees
Founder member
Primary Care Dermatology Society
E:thomas.poyner@gp-a81002.northy.nhs.uk

Skin disease is common and most cases can be treated in the community. Those who cannot be treated in primary care will in the future often be dealt with in intermediate care, leaving secondary care for the small number of severe or difficult cases. With this expansion and change of delivery of care, nurses are going to be playing an increasing role in advising and prescribing.

Improving compliance
One can make a diagnosis, prescribe appropriately, yet fail to have the desired outcome. Most therapies are available in primary care and are just waiting to be used appropriately. We need to make best use of resources and the unit cost of the drug is only part of the equation. Frequently it's not the efficacy of the therapy that is wrong, it's that the treatment was never given a chance. The patient had little idea of how to apply it and what to expect. We need not only to prescribe appropriate medication, but also to give advice and provide practical demonstrations. Supplementing advice with patient information leaflets is invaluable. The leaflets can be personalised by writing on them advice specific for that individual.

Patients want therapies to be effective, and first impressions are important. Patients like to see quick results and a rapid speed of action improves compliance. The presentation of a medication and its cosmetic acceptability are important. Side-effects such as irritation or stinging can reduce compliance.

Skin diseases in primary care
Common skin complaints presenting in primary care are eczema, acne, psoriasis and superficial infections.

Eczema
When treating eczema (see Figure 1a) one wants to use topical steroids to bring the rash under control, then use emollients to maintain the epidermal barrier. Topical steroids reduce inflammation and the more potent the steroid the more effective they are. However, the more potent the steroid the greater the risk of side-effects such as thinning of the skin and stretch marks. Topical steroids are an invaluable treatment but patients often have a phobia about them. This can be overcome by giving advice on their correct usage.

[[NIP07_fig1_57]]

The simplest way is to advise patients to start with a mild topical steroid such as hydrocortisone. If the rash does not respond one can increase to a moderate potency steroid, eg, Eumovate (Glaxo Wellcome). For adults with rashes on the trunk and limbs that do not respond, one can then try a potent steroid, eg, Betnovate (Glaxo Wellcome). One should take extra care with steroids when treating the face, flexures or at any site on children.

How much steroid should one apply, what does sparingly mean?  The finger tip unit can be used as practical guide. One fingertip unit equals the amount of ointment squeezed from a standard 5mm diameter nozzle from the distal-crease to the tip of the adult index finger.(1) Two fingertip units are equal to 1g of medication. One can then apply the rule of hand to measure the surface area of a rash and how much steroid is required. One uses the flat of an adult hand with the fingers together as a rough measuring tool. Four hand units are covered by two fingertip units and require 1g of cream or ointment.(2)

Prescribing the correct formulation of a topical preparation makes a difference  Creams have a higher water content and spread easily. Ointments are greasier, tend to form an occlusive film over the rash and are more effective. One tends to use a cream on a moist rash or area. So in the flexures or an acute weeping eczema one would use a cream. One prescribes creams for the face as this is more cosmetically acceptable. On chronic scaly rash on the trunk and limbs one would use an ointment, as they are more occlusive and tend to be more effective.

Emollient use  Patients should be encouraged to use complete emollient therapy (this should include an emollient, bath emollient and soap substitute). The emollient needs to be applied frequently and prescribed in adequate quantities, eg, 500g. The emollient is applied as dabs which are then joined up by a careful downward stroking action. While emollients differ in efficacy, the best emollient is the one the patient will use. Soap is irritant and needs to be replaced by a soap substitute with the addition of a bath emollient when bathing.

Continuous emollient therapy should remain the cornerstone of eczema management and it is important for patients to be aware that this therapy be adopted not only during periods of "flare" or exacerbation but on an unremitting basis. A forthcoming paper advising on best practice management for emollient usage is aimed at further improving day-to-day management of eczema.(3)

The nurse needs to know the patient's domestic circumstances when advising on therapy and recommending emollients or daily cleansing routines. The emollient most suited to the patient's lifestyle is the one that will help improve compliance whilst education will aid the understanding of their condition. The ABC Programme is supported by the National Eczema Society, and accredited by the British Skin Foundation. It is an educational initiative which aims to deliver accurate, practical information to patients and health professionals on how to manage eczema and other dry skin conditions. The ABC programme advocates the following three-step strategy:
A    Avoid soap.
B    Benefit from emollients.
C    Control inflammation.

Psoriasis (Figure 1b)
Patients often decide not to treat their psoriasis. This is because they find the time and messiness of treatment unacceptable. Even the odour of a preparation can make it unacceptable to patients. Patients find vitamin D analogues both efficacious and cosmetically acceptable; however, to achieve the best results they need to apply them thickly, up to three times thicker than a topical steroid. The vitamin D analogue should be applied to the plaque and practical demonstrations improve compliance. When treating the scalp one wants therapies suited to a hairy area. Shampoos and applications are ideal. Only those with severe scalp disease will want to put the effort into applying an ointment to the scalp.

Acne
Acne causes a lot of distress to teenagers and they need to feel their acne is taken seriously. They are often embarrassed and are looking for a cure. Myths such as diet playing a role are humbug. Patients need to understand that if they comply with regular therapy their acne will improve and over time resolve. Benzoyl peroxide or a topical antibiotic will treat inflamed lesions. A topical retinoid-like drug, eg, adapalene, will treat microcomedones which are a precursor of new lesions.

Superficial infections
Impetigo is usually due to Staphylococcus aureus and occasionally due to Streptococcus pyogenes. Taking a swab can confirm the diagnosis and detect bacterial resistance. Small areas respond to topical antibiotics, eg, fusidic acid or mupirocin. More extensive involvement requires a course of oral antibiotics, eg, flucloxacillin or erythromycin. To prevent the spread of infection the patient and family should be given appropriate advice. The patient should use their own towel, sponge/face cloth and soap. Following advice from the nurse patients can make an informed decision on whether they wish to treat cold sores (herpes simplex infections) using over-the-counter preparations.

While it is reasonable to treat tinea pedis (athlete's foot) on empirical grounds, for other ringworm infections it is good practice to confirm the diagnosis by taking samples for mycology. A fungal infection, eg, tinea corporis (ringworm on the body) can appear similar to eczema. The nurse can take mycological samples, eg, scrapings from the skin and clippings from the nails. Results of microscopy are available in days although culture takes three weeks. Having positive microscopy increases the chances of having correctly diagnosed the rash and thus a greater chance of a cure. Diagnostic uncertainty and inappropriate prescribing of antifungals leads to scenarios such as "this rash hasn't responded to either topical steroids or an antifungal, please advise"!

Scabies is increasing, not because of drug resistance, but because of failure to correctly apply treatment and not treating the whole family. The nurse can advise on topical treatments for head lice and on the use of physical measures (shampoo, nit combing). Less reliance on insecticides may reduce the incidence of drug resistance.

Summary
The vast majority of dermatological diagnostic aids and treatments are available in primary care. Increased nursing input could lead to more accurate diagnosis of skin conditions within primary care, improved concordance, better outcomes and increased patient satisfaction. The difficulty is not with nurses, they overwhelmingly express interest and enthusiasm for dermatology; what is needed is more education, training and funding for those who want to help bring dermatology into the community.

Refernces

  1. Long CC, Finlay AY. The fingertip unit: a new practical measure. Clin Exp Dermatol 1991;16:444-7.
  2. Long CC, et al. The rule of hand. Arch Dermatol 1992;328:1129-30.
  3. Holden C, et al. Advised best practice for the use of emollients in eczema and other dry skin conditions. J Dermatol Treatments In press. 2002.

Resources
The ABC Programme.
Access practice materials or order samples from
T:08707 800 777
E:abc_dove@uk.sudler.com
W:www.abc-dove.co.uk
British Association of Dermatologists (including British Dermatology Nursing Group)
W:www.bad.org.uk
National Eczema Society
W:www.eczema.org
The Primary Care Dermatology Society guidelines
W:www.eguidelines.co.uk
NICE
Referral advice for acne, atopic eczema in children and psoriasis:
W:www.nice.nhs.uk
Acne Support Group
W:www.m2w3.com/ace
W:www.stopspots.org
The Psoriasis Association
T:01604 711129