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The role of nurses in the treatment of skin conditions

Thomas F Poyner
MB BS FRCP MRCGP DRCOG DPD
GP
Stockton-on-Tees
Founder member
Primary Care Dermatology Society

Skin disease is not a trivial complaint - it is a condition that can have a major impact on the lives of patients in the community.

For example, eczema on visible sites causes embarrassment, whilst the rash on the trunk and limbs produces scratching and results in sleep disturbance. The impact of skin disease on the quality of life of patients seen in primary care is significant and comparable with that of patients seen in secondary care.(1)

Eczema most common
The most common skin complaint in primary care is eczema, and the most frequent consultation is for a child with atopic eczema.(2) Whilst most children's eczema improves by puberty, for a minority it continues on into adult life. In the elderly, itchy dry skin is a common and distressing problem.

The vast majority of patients with atopic eczema can be treated in the community. Their rash is mild and they respond to topical therapy. Treating eczema requires a whole range of medication, usually including a topical steroid, an emollient, a bath emollient and a soap substitute. Most of the treatments available in secondary care are also available in primary care.

Use of topical steroids
Topical steroids offer an effective and cosmetically acceptable therapy that can be used to bring eczema under control. The natural history of eczema involves a cycle of exacerbation and remission. Topical steroids can be a tremendously effective intervention; however, their use is often limited by "steroid phobia".
 
It is important for patients to understand that topical steroids come in four potencies: mild, moderately potent, potent and very potent. The risks from steroids are related to:

  • Potency of the steroid.
  • Site of application.
  • Age of the patient.
  • Duration of use.

If used appropriately, topical steroids can provide an effective means of bringing eczema under control.

Emollient therapy
Patients with eczema do not want to be treated any differently from anyone else. However, soap is an irritant and vigorous drying irritates the skin. While bathing may be beneficial in reducing bacterial colonisation, the soap and drying can have a negative effect. Washing and bathing can therefore be a problem for patients with eczema.
 
Using bath emollients and soap substitutes can make washing and bathing a more beneficial and pleasurable experience. Emollients soothe and smooth the skin, as well as maintain the skin's barrier function. They can also reduce the frequency and severity of eczema flare-ups, which may decrease the need for steroid therapy.

Patients need to be introduced to the concept of complete emollient therapy, which should include:

  • An emollient.
  • A bath emollient.
  • A soap substitute.

Emollients have to be applied frequently to large areas, hence they need to be prescribed in large quantities (eg, 500g). There is also tremendous personal variation in which emollients a patient finds cosmetically acceptable and will use. It is therefore important to find a complete emollient therapy pack for each patient that is both effective and acceptable to them.

Eczema treatments may be available from the primary care team on prescription or over the counter from the community pharmacy. However, patients need help to be able to help themselves. If they are only given the medication with no explanation of its benefits or advice on how to use it, compliance is usually poor.

Government initiatives
The UK has a long history of research in dermatology. However, over recent years, it has lagged behind the rest of Europe in the provision of services for patients with skin disease. Deficiencies have been highlighted by the reports of the All Party Parliamentary Group on Skin and the Associate Parliamentary Group on Skin.(3,4)

"Action on Dermatology" is a government initiative aimed at developing and expanding the provision of dermatological services through a series of pilot schemes across the UK. It is part of a wider project to help address the increasing demand on outpatient clinics and to reduce waiting lists. A common theme is to develop the role of nurse specialists in the provision of skin services,(5) including the expansion of nurse-led clinics.

Nurse-led care
The traditional barriers between primary and secondary care are breaking down, and the concept of an integrated team is coming to the fore.

It has been suggested that dermatological services should be targeted to treat conditions where the greatest benefits will be achieved locally, such as eczema, psoriasis and leg ulcers.(6) Nurses can give practical demonstrations of therapies and support and advise patients. Practice nurses with dermatological training could also be involved in the provision of care for patients with skin disease.(7)

Advice can be passed on at a face-to-face consultation. This will need to be reinforced and supplemented with written information, an example of which is the ABC leaflet. This provides information and guidelines for patients on the management of eczema and dry skin conditions. It is accredited by the British Skin Foundation and supported by the National Eczema Society, a UK charity dedicated to helping people with eczema, dermatitis and sensitive skin.

Leaflets can also be personalised by writing individualised advice for each patient.

Some practices and dermatology departments build up libraries of videos that can then be lent out to patients and their carers.
The internet offers a wealth of information that can be accessed both in the surgery and at home. The National Eczema Society can be a tremendous resource for both patients and healthcare professionals. The Primary Care Dermatology Society has also developed guidelines on the management of atopic eczema in primary care.

For best practice in eczema, see Clinical Evidence or access its website.(8)

Conclusion
The therapies and expertise are available - we now need to educate our patients about the benefits of treatment and how to manage their condition.

Only by providing such support and advice along with medication can we hope to have successful outcomes.

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References

  1. Harlow D, Poyner T, Finlay AY et al. Impaired quality of life of adults with skin disease in primary care. Br J Dermatol 2000;143:979-82.
  2. OPCS Morbidity Statistics. General Practice Fourth National Study. 1991-1992:54-5.
  3. All Party Parliamentary Group on Skin. Enquiry into the training of healthcare professionals who come into contact with skin diseases. London; July 1998.
  4. Associate Parliamentary Group on Skin. Report on the enquiry into skin diseases in elderly people. London: November 2000.
  5. All Party Parliamentary Group on Skin. An investigation into the adequacy of service provision and treatments for patients with skin diseases in the UK. London; March 1997.
  6. Dermatology Care Working Group. Assessment of best practice for dermatology services in primary care. April 2001.
  7. Kernick D, Cox A, Powell R et al. A cost consequence study of the impact of a dermatology-trained nurse on the quality of life of primary care patients with eczema and psoriasis. Br J Gen Pract 2000;50:555-8.
  8. Skin disorders. Clin Evidence 2001;5.

Resources
National Eczema Society
T:020 7281 3553
W:www.eczema.org
Primary Care Dermatology Society Guidelines
W:www.eguidelines.co.uk
Clinical Evidence (best practice in eczema)
W:www.clinicalevidence.org
British Dermatology Nursing Group
T:020 7383 0266

Further reading
For more information and copies of the ABC guidelines on managing dry skin and eczema, please contact: Janine Raine IntraMed Middlesex House 34 Cleveland Street London W1T 4JE