Around three-quarters of people with a skin condition treat it themselves, and there is a huge opportunity for pharmacies to get more involved.

Each year around 54 per cent of the UK population is affected by skin disease, according to the King’s Fund report on dermatology services. Of these, some 13 million people will see their GP, with 5.5 per cent referred to a specialist. Some 69 per cent of people with skin conditions will manage them with self-care measures and so, as the King’s Fund report states, “there are significant opportunities to improve and support better self-care and selfmanagement including medication adherence. In particular, increasing the use of pharmacies for advice and follow-up.”

The report also highlights concerns around low levels of patient adherence to dermatological treatment. One study found that reduced compliance occurs in 34 to 45 per cent of patients and therefore “pharmacists could play a valuable role in helping people to self-care for minor conditions as well as providing advice on more specialist medications to help improve adherence.”

What’s more, skin conditions represent big business for pharmacy, with OTC dermatological products accounting for 17 per cent of sales, putting them on a par with the cough and cold remedies sector and second only to the pain relief category. Some 10 skin conditions – including eczema, psoriasis and acne – account for 80 per cent of dermatology consultations in general practice and up to 23 per cent of requests for advice from pharmacy staff. So there are plenty of reasons to help patients and make the most of this category.

Eczema

Eczema is among the most common skin conditions – one in five children and one in 12 adults are affected.

Spot the signs

Eczema in infants often begins on the face, elbows and knees. Later, eczema may develop on the neck, hands, inner arms and behind the knees. Skin becomes itchy, scaly and rough, with thickening and cracking in places, and has a tendency to become red and inflamed. Skin can also look weepy and swollen.

Treatment options

There is a stepped approach to eczema treatment, with emollients being the mainstay. Evidence shows that the more they are used, the less topical steroids – such as hydrocortisone – are needed. These are often required if there is a flare up.

“For compliance, it’s essential the patient likes the emollient that they use, and they may need to try out several first. Find out what they’ve already used,” says consultant dermatologist Dr Susan Mayou at the Cadogan Clinic.

Dry skin is one of the main symptoms of eczema. It reduces the skin’s barrier function, allowing irritants and allergens to penetrate the skin and trigger further eczema symptoms or cause it to worsen. Regular, daily use of emollients will help control dry skin. These also soothe and relieve itching and produce an oily layer over the skin’s surface to trap moisture.

There are several forms of emollient and it’s important to understand their differences. “I usually start with the least greasy and work up through cream and ointment as needed,” says Dr Mayou. The different options include:

• Lotions: contain more water and less fat than creams and spread easily, but are less effective on very dry skin
• Creams: non-greasy and contain a mix of fat and water. Creams are easily spread on sore skin, but some contain preservatives which can cause sensitivity
• Ointments: don’t contain water so there’s no need for preservatives, but the formulas can be greasy. Ointments are ideal for very dry, thickened areas of skin or sensitive skin, as well as for use at night. Ointments shouldn’t be used on weeping eczema
• Bath oils: advise customers to avoid bubble bath and soap, as these are drying and potentially irritating. Instead, emollient bath oils lock in the moisture absorbed by the skin during bathing. Some bath oils are fully dispersing and others are semidispersing, leaving more or less oil on the skin. They can also be used in the shower instead of soap or body wash.

Emollients require careful application to achieve the best results. Pharmacy teams can offer customers this advice:

• Apply two to four times daily, using a generous amount
• They can be used in combination with topical steroids. Leave 30-60 minutes between the treatments to avoid a diluting effect
• Apply gently in the direction of hair growth and don’t rub in
• Always apply after bathing
• Choose a pump dispenser where possible or use a clean spatula for pots of emollient
• Add an emollient bath oil to warm, rather than hot water. Skin should be patted dry after bathing.

If a customer is suffering from an eczema flare-up, Dr Mayou advises that the following should be kept in mind:

• Go up the scale with emollients, moving to a greasier one
• Increase the potency of the steroid cream, or begin using one
• If a steroid is needed for longer than seven days, see a GP.

Self care tips

• Use cotton clothing and bedding to reduce itching
• Cut labels out of clothing
• Use non-biological washing powder
• Keep nails short to prevent scratching
• Keep bedrooms cool at night
• Cotton mittens or sleep suits with mittens reduce children’s night-time scratching
• Regular vacuuming and damp dusting reduces dust mites, which are a common eczema trigger
• Keep pets out of bedrooms.

Psoriasis

Psoriasis is an auto-immune condition which affects around three per cent of the population. “Genetic factors are important – 30 per cent of people with psoriasis have a relative who suffers,” says Dr Emma Wedgeworth, consultant dermatologist and British Skin Foundation spokesperson. “Triggers include bacterial (streptococcal) infection, some medication, including lithium, areas of injury to the skin and also stress.”

Spot the signs

It is characterised by dull red, sharply defined, scaly plaques, especially on the elbows, knees, scalp and lower back. These are not usually itchy and vary in size from a few millimetres to several centimetres in diameter. Patients will need to see a GP and, if their symptoms are severe, may be referred to a dermatologist.

Treatment options

Emollients are an important part of treatment for psoriasis and make the skin more comfortable, reducing the amount of scales. Topical treatments such as vitamin D derivatives, coal tar preparations, topical steroids, dithranol, vitamin A derivatives and calcineurin inhibitors may also be recommended by a GP. If there is thick scaling, it may be necessary to use de-scaling agents – such as five per cent salicylic acid in yellow soft paraffin – before using a topical treatment.

Psychological impact

It’s common for people with psoriasis to experience psychological effects. Some dermatology departments have psychologists working within the team or a GP can refer patients for help. “Just acknowledging that psoriasis can be difficult to live with is helpful. Often people don’t get asked how they feel about their condition, so it can be a relief if someone does,” says Dr Wedgeworth.

The Psoriasis Association has online forums, where people can get extra help and exchange tips with fellow sufferers.

Dry skin

Dry skin affects people of all ages, but is more common in young children and the elderly. Factors that can cause dryness include seasonal changes – especially cold, dry weather – hot water, central heating and chemical ingredients in soaps and detergents.

Spot the signs

Dry skin is characterised by patches of rough, flaky and sensitive skin. It may just be in certain areas such as the cheeks, hands, lips, elbows and knees, or it may be widespread.

Treatment options

Emollient use is key to managing dry skin. Suggest customers:

• Apply an emollient daily. Avoid those with perfume or colourants and always apply after bathing. Test a new emollient on a small patch of skin first to check for irritation
• Avoid soaps and bubble baths as these can dry the skin out. Use a soap substitute and an emollient bath oil
• Moisturise hands and lips regularly.

Dr Wedgeworth also advises:

• Be aware of your skin type and personalise skincare accordingly
• Take action as soon as you see patches of dry skin so it doesn’t lead to itching or worsening of the condition
• Use gentle products and avoid harsh detergents
• Avoid fragranced, foaming or sodium lauryl sulphate-containing products.

Acne

While almost every teenager has a few spots from time to time, around 15 per cent have acne that requires treatment. In most cases it clears up by their early 20s, but it can last longer. Hormonal changes are thought to be the main trigger for acne, which is why it is most common in adolescence, but also while pregnant or when starting or stopping the contraceptive pill.

Spot the signs

Acne is most commonly seen on the face, upper back and chest and there are several types of spots. These include: blackheads, whiteheads, papules (small red bumps), pustules (red bumps with a white tip in the centre), nodules (large, hard lumps under the skin’s surface) and cysts (large pus-filled lumps that look similar to boils and carry the greatest risk of scarring).

Treatment options

Antibiotics are frequently used to treat severe cases of acne, but for mild to moderate cases, topical treatments are available OTC. “It’s far better to try to control acne using non-antibiotic topical preparations which will help to prevent flare-ups,” says Dr George Moncrieff, chair of the Dermatology Council for England and member of the executive committee of the Primary Care Dermatology Society.

“I advise all acne patients (unless pregnant) to use a topical retinoid [vitamin A cream] as this really helps control acne,” says Dr Moncrieff. Benzoyl peroxide is also highly effective as it has an antibacterial effect and promotes shedding of the skin. “Azelaic acid is useful for mild acne as it’s less irritant to skin, but has a fairly weak effect. Salicylic acid treatments are also useful as they have a gentle peel effect,” Dr Moncrieff adds. He also suggests:

• Give treatment several weeks to take full effect. A topical retinoid doesn’t treat today’s spots, but prevents next week’s
• Treat all areas of skin ever affected, not just the visible spots
• Rinse hands well after using benzoyl peroxide, which will bleach towels and clothing
• Use sunscreen, as photosensitivity can be a problem when using retinoids. Apply retinoids at night and use benzoyl peroxide during the day to minimise effects
• If a topical irritates skin, don’t give up immediately. Build tolerance slowly by applying just for 30 minutes and then washing off, at first. Slowly increase the time and frequency until it can be left on overnight
• Don’t pick spots as this will cause scarring.

A sensitive topic

Many patients will feel embarrassed talking about their acne, so be prepared for this. “Questionnaires can be a good starting point for patients. Be sensitive in your approach and acknowledge how upsetting or difficult the condition can be. Give them time and a private space to talk openly about it,” says Dr Moncrieff. “Try ‘often patients feel really embarrassed by their acne....’ or ‘tell me how you feel about your spots’ as an opener.”

It’s important to recognise that acne can have a profound psychological effect on some patients, especially teenagers. “If you think your patient is depressed or stressed because of their acne, refer them to their GP. Some teens can become suicidally depressed and you should alert their GP if you suspect this,” advises Dr Moncrieff.