A recent meeting of dermatology specialist pharmacists showed that changes are afoot and independent-prescriber pharmacists could be poised to take on the management of a number of long-term skin diseases.
For many years, a small number of pharmacists have had an interest in patients with dermatological diseases but this has not been seen as a headline item and has not been embraced with the same enthusiasm as, for example, case-finding for people with atrial fibrillation or management of high blood pressure. Neither has it been an area that pharmacy bodies have pushed forward in a consistent way.
However, a large number of pharmacists expressed an interest in forming a group and a meeting was held recently. Several things were immediately evident: first, there was a high level of enthusiasm and expertise among the pharmacists, rather than just passing interest and curiosity; second, the dermatology landscape has changed – numerous monoclonal antibodies and other new drugs are now being developed for use in skin diseases; and third, consultant physicians were welcoming the prospect of working alongside prescribing pharmacists as members of the wider dermatology team.
It is interesting to reflect on how some of these things have come about. Some years ago, dermatology pharmacists tended to develop an interest in the area because they recognised a clinical need and an opportunity to improve the effectiveness of medicines’ use.
No-one who has worked in a dermatology clinic could fail to be moved by the plight of patients with bags of poorly-labelled, barely-used creams and inadequately-controlled skin disease. In the modern era, there have been a number of important developments in drug treatment for inflammatory skin diseases – starting with the introduction of topical corticosteroids and going on to include calcipotriol, topical calcineurin inhibitors pimecrolimus and tacrolimus and topical retinoids/retinoid-like drugs for acne.
Arguably, using topical treatments effectively for relapsing/remitting skin diseases is as critical as using inhaler therapy correctly for asthma and yet it never seemed to excite the same enthusiasm. Now, it looks as if the growth in the numbers of pharmacists working in GP practices could put this right.
Healthcare needs
There is no shortage of work in this area. The Health Care Needs Assessment published by the Centre of Evidence-Based Dermatology in 2009 showed that the need was considerable: about 24% of the population in England and Wales visited their GP with a skin problem in one year and it was estimated that about 54% of the UK population experiences a skin condition in a given 12-month period. Moreover, skin diseases have a profound impact on quality of life and psychosocial wellbeing.
The quality-of-life impairment can be at least as great as that seen in life-threatening conditions such as cancers. This can translate into inability to function well at school, at work and in home life. Finally, skin disease, especially dermatitis affecting the hands, can cause disability, loss of productivity and loss of earnings. Although this needs assessment was undertaken more than 10 years ago, there is little reason to suppose that things have changed much since then.
Dermatology medicines
The demand for support for effective use of dermatological medicines remains strong. For example, steroid-phobia – often fuelled by scare stories in the tabloid press – continues to hamper effective use of topical corticosteroids. Sadly, misunderstandings about the safe and effective use of topical corticosteroids are still widespread amongst the public and healthcare professionals.
The arrival of monoclonal antibodies for treatment of psoriasis and, more recently, for atopic eczema has changed the prescribing landscape markedly. The first taste of this scale of change came about 25 years ago when the immunomodulator ciclosporin was introduced for psoriasis. Well-informed patients were quick to seize the initiative and ask for ciclosporin and wave goodbye to the coal tar ointments and dithranol products that compounded the misery of psoriasis.
Furthermore, dermatology suddenly went from being a low-cost prescribing backwater to being a high-cost budget item. As understanding of the molecular basis of inflammatory skin diseases continues to grow, so too does the number of drugs. Some described this as a ‘tsunami of new drugs’. These include monoclonal antibodies that target specific cytokines and small molecules such as Janus kinase (JAK) inhibitors and histamine 4 (H4) receptor blockers. How much more of an impact can be expected as these drugs take their place in the dermatology formulary?
One useful spin-off already has been the input from pharmacists with expertise in high-cost drug management. Many of these have been able to draw on experiences with rheumatology drugs and home-care services to help prescribers and patients navigate the complex framework of contracts and services to ensure that patients receive timely treatment and appropriate support. This is a group that brings a different but valuable perspective to the mix.
Prescribing pharmacists
Finally, perhaps the most uplifting feature of the meeting was the collegial approach of consultant dermatologists. They welcomed the input that pharmacists could make and recognised their breadth of knowledge about medicines. Critically, they distinguished between the expertise of the dermatology specialist nurse and that of the dermatology specialist pharmacist. Both are needed as they bring different skills and knowledge to the table.
Describing the need for effective chronic disease management in this area, one said that this now needed “redesign of pathways to use everyone’s strengths”. It is of interest that other ideas have also been proposed, for example, that pharmacist prescribers might become involved in the use of liquid nitrogen, management of leg ulcers and even diagnostics.
It should be stressed that these were not recommendations but examples of the types of discussions that are starting as others start to work out what pharmacists can contribute to the care of people with dermatological diseases. It was suggested that pharmacists should “define clearly the role that [they] want and what can be offered”.
The General Pharmaceutical Council (GPhC) acknowledges the need for sufficient numbers of independent prescribing pharmacists (IPs) to support service delivery. To this end it has proposed changes that will result in all trainees becoming prescribers at the point of registration. Currently there are 11,698 IPs in Great Britain, accounting for just under 20% of pharmacists registered with the GPhC.
Organising any meeting at the present time can be a difficult exercise and the organisers of the specialist dermatology pharmacists’ meeting deserve to be roundly congratulated on their achievement. What emerged loud and clear is that this is an area where effective use of medicines can benefit greatly from the input of pharmaceutical expertise.
Pharmacists could find themselves pushing at an open door. Moreover, the number and type of medicines used is going to grow spectacularly in the next few years. A number of pioneers have led the way and now is the time to build on their experience and make ‘dermatology pharmacy’ as familiar as ‘respiratory pharmacy’ or ‘cardiology pharmacy’.
Dermatology pharmacy has come of age at last!
