SKINCARE: It’s not just skin deep

With rising waiting times, pharmacists are increasingly becoming the first port of call for patients suffering from a range of skin problems, writes Penelope Pratsou as she outlines her practical skincare tips…

Over the past two years, the Covid pandemic has resulted in a backlog of elective care within the NHS, with record numbers of patients on waiting lists across the UK. Despite efforts to catch up after the first wave, subsequent waves have put further strain on an already stretched NHS system.

This has had a tremendous impact on many patients waiting for routine dermatology appointments and, while every effort has been made to see patients with suspected serious skin cancers within two weeks, this target is not always achieved.

With rising waiting times, pharmacists are increasingly the first port of call for patients suffering with a broad range of skin problems. From acne and rosacea, eczema or psoriasis, to changing skin lesions or simple insect bites, pharmacists can give helpful advice, allowing some customers to find quick relief to their skin complaint in mild cases, while directing others to see their GP without delay.

Below is some practical advice that pharmacists can give to their customers with commonly encountered skin complaints.

Acne

Acne is a common skin condition that not only affects teenagers but adults too. It is estimated that up to 40 per cent of women continue to suffer with acne into their adult years. Acne has been linked to an increased incidence of depression, anxiety and even suicidal ideation.

Patients have reported feeling overlooked and often dismissed in their concerns by health care professionals.

Unfortunately, these issues have been further compounded by delays in being seen and treated due to the ongoing Covid pandemic. Pharmacists are well placed to help acne patients choose the right skincare. This should consist of lightweight products, such as gel or milky cleansers, with moisturisers in serum, lotion or light cream preparations. Some acne suitable products are further labelled as non-comedogenic.

Oil-based or occlusive preparations are best avoided. There are many good quality, non-comedogenic sun blocks suited to acne prone skin too.

Furthermore, there are several over-the-counter (OTC) preparations with active ingredients suitable in treating acne. Benzoyl peroxide and salicylic acid (found in washes and leave-on products) are important ingredients in the treatment of inflammatory acne with papules and pustules.

Glycolic acid is useful in providing gentle exfoliation while retinols can be beneficial in the prevention and treatment of comedonal acne. Other ingredients to look out for are tea tree oil and niacinamide.

Patients should be advised to keep their skincare simple, adding one active ingredient at a time to prevent skin irritation. While OTC treatments are useful for mild acne and the odd breakout, patients with persistent, moderate, severe, or scarring acne, should be signposted back to their GP or dermatologist for prescribed topical and oral medication.

Rosacea

Rosacea predominantly affects adults, with persistent redness and/or flushing, papules and pustules, stinging and burning of the skin, and sometimes ocular symptoms. The condition can be significant and debilitating for some, resulting in poor self-esteem, low mood and social isolation.

There are several potential environmental and lifestyle triggers, with sun exposure being a trigger in up to 90 per cent of rosacea sufferers. Patients should be advised to use a daily sunblock, with good UVA protection and SPF 30-50.

They should also be encouraged to explore and moderate other potential triggers such as alcohol, caffeine or spicy foods. Rosacea skin can be extremely sensitive, therefore less is more when it comes to skincare. Pharmacists should guide their rosacea customers to look for a gentle skin cleanser and facial moisturiser for sensitive or rosacea prone skin, with avoidance of fragranced and complex formulations.

Some OTC preparations contain active ingredients that are very useful for mild rosacea. Azelaic acid gel and niacinamide both have anti-inflammatory properties, though each ingredient should be added individually to prevent reactions. In ocular rosacea, patients often suffer with blepharitis and may benefit from eyelid hygiene wipes or advice on self-care measures.

Patients with more significant rosacea should be advised to speak to their GP about prescribed medications. This should include patients with seemingly mild rosacea who are struggling with their mood and self-image as a result.

Eczema

Patients with eczema have a defective skin barrier which can allow irritants and allergens in and not retain enough moisture, with subsequent excessive dryness and inflammation. Eczema sufferers should be advised to follow a simple approach, consisting of:

1. An eczema-specific soap substitute +/- bath emollient.
2. A suitable bland emollient, made for eczema-prone skin, at least twice daily. Fragranced and complex formulations should be avoided due to the risk of irritation and allergy.
3. Episodic use of an anti-inflammatory treatment such as a topical corticosteroid during flare ups. Mild and moderately potent corticosteroids can be obtained OTC if appropriate.

Patients with eczema can experience flare ups if they run out of their prescribed treatments and it would be worthwhile ensuring they have repeat prescriptions in place. Furthermore, pharmacists could take the opportunity to educate patients on appropriate amounts of steroid to be used, via the fingertip unit application measure, or direct them to suitable resources such as https://patient.info/treatment-medication/steroids/fingertip-units-for-topical-steroids.

Psoriasis

Patients with psoriasis suffering with scaly patches should be advised to use topical emollients twice daily as these can soften any scales and allow their prescribed treatments to penetrate more easily.

Several therapeutic shampoos, containing salicylic acid and coal tar, can be obtained OTC. This may also be an opportunity to give lifestyle advice which can result in psoriasis improvement and reduction of cardiovascular risk, such moderating alcohol intake, weight reduction if overweight and smoking cessation.

Skin cancers

GP surgeries are continuing to offer a hybrid model of remote and face-to-face consultations beyond the pandemic. While this is convenient for many and works extremely well for some conditions, it may not be suitable for others. One such example is skin lesions, which can be difficult to photograph by the affected individual, and may require dermoscopic views to formally diagnose. There has unfortunately been an increase in cases of delayed skin cancer presentations since March 2020.

Patients with skin lesions may opt to speak to a pharmacist and should be strongly encouraged to see their GP in cases of:

1. Change in the size, shape or colour of a pre-existing mole or symptoms such as itching, soreness or bleeding. Any new and changing pigmented lesion should also be reviewed. Educational posters alerting patients to the signs of melanoma could be positioned in the pharmacy. https://www.skinhealthinfo.org.uk/wp-content/uploads/2020/10/ABCDE-A4-border-2016.pdf
2. A new and persistent skin lump that may or may not be growing, becoming painful, bleeding, or scabbing as this could be a sign of a non-melanoma skin cancer (NMSC). NMSC represents at 85% of skin cancers in the UK, with squamous cell carcinoma requiring urgent referral and treatment. https://www.skinhealthinfo.org.uk/wp-content/uploads/2020/10/NON-MELANOMA-SIGNS-A4-2016.pdf

Patients with sun damage or previous skin cancers may need advice on sunblock and pharmacy staff can assist in choosing a suitable one with SPF of at least 30, with high UVA protection and regular reapplication every 2 hours. Further advice can be given on wearing protective clothing with a hat and long sleeves and keeping in the shade between the hours of 11-3.

New skin rash

Some people may find it easier to pop in to speak to a pharmacist for advice if they suddenly develop a new rash. Depending on the site and extent of the rash, sensible advice would include discontinuation of cosmetics or other possible irritants and allergens to affected area, the use of a soap substitute and liberal use of topical emollient creams.

In case of an extensive eruption, it may be worthwhile scrutinising the patient’s medication list to ensure no new medication has been added to precipitate the rash, as it may need to be discontinued pending a GP review. Patients with widespread rashes should be advised to speak to their GP without delay. Oral antihistamines can be tried, though response may be variable.

Other skin complaints

Most insect bites can be dealt with without seeing a doctor. Customers could use soothing emollients, topical corticosteroids such as hydrocortisone 1% or clobetasol cream, and oral antihistamines for a few days.

Rashes such as athlete’s foot and intertrigo can be addressed with appropriate OTC anti-yeast and antifungal preparations. Viral warts can be dealt with salicylic acid and OTC cryotherapy.

Dr Penelope Pratsou is a consultant dermatologist and spokesperson at British Skin Foundation.