One area for which there is a considerable demand in primary care for advice and support is dermatology and some evidence suggests that many people with skin problems manage their condition through self-care.
Eczema (or atopic dermatitis) is a common, inflammatory skin condition characterised by red, dry, itchy skin. Those with eczema can experience acute worsening of their condition, which are referred to as flares. During flares the skin becomes red which can sometimes weep, become blistered, crusted and thickened.
The symptoms of this skin disorder can range from mild to severe, and all forms of eczema can have a significant impact on the quality of life for the person with eczema, caregivers and their loved ones. Eczema can have a significant impact on a person’s quality of life. It is important for all community pharmacists and their teams to refresh your knowledge of the condition’s symptoms, treatments and self-care advice in this learning article so you can pass on expert knowledge to customers.
Eczema affects approximately 1 in 5 children and 1 in 12 adults in Ireland. While the exact cause of eczema is not known, certain factors are thought to be important in its development, these include an inherited (genetic) predisposition to have a weakened skin barrier, as well as altered inflammatory and allergy responses.
Atopic eczema can run in families and frequently occurs alongside other atopic conditions, including hayfever and asthma. Although there is no cure for eczema yet, treatment are available to manage the condition.
Eczema is recognisable by the presence of red, dry, itchy skin, which can sometimes weep, become blistered, crusted and thickened. However, the appearance of eczema, and the locations of the body affected, can vary greatly depending on the age of the person.
Irritants and allergens
Atopic eczema can be triggered or aggravated by exposure to a number of environmental irritants or allergens. Common irritants include soap, bubble bath, shampoo, laundry detergents, fragrances, clothing that feels ‘itchy’ next to the skin (e.g. wool), changes in temperature, or allergens like animal dander, the house dust mite or pollen, but sometimes no cause can be identified.
Emotional stress can aggravate eczema. Finding ways to reduce stress may lessen the frequency and, hopefully, the intensity of the flare-ups. Whilst stress is associated with flares of atopic eczema, it is not yet fully understood.
Atopic skin is more vulnerable to infection and infection is often associated with a worsening of eczema. Advise customers to seek medical attention if skin becomes:
• Wet or weepy, with yellow/ brownish crusts
• Very sore, with clusters of painful itchy blisters, particularly if there has been contact with someone who has a cold sore.
Dry skin occurs when the epidermis does not hold on to sufficient moisture, so skin can feel tight, rough, flaky and itchy. A number of things can contribute to its development, for example; too frequent bathing, use of harsh drying soaps, the ageing process (the production of natural oils in the skin slows as we age, and sun damage is cumulative so a lifetime of sun exposure and sun damage can result in thinner skin that doesn’t retain moisture so well), or certain conditions such as eczema or psoriasis.
The average skincare category accounts for 5% of total OTC shelf space. It is important this space works hard for you and the range stocked provides maximum return in terms of profitability as well as offering customers the right range of specialist skincare treatments to meet their needs.
People suffering from dry skin, shouldn’t use harsh, alcohol-based products as these can irritate skin and dry it out. People who have oily skin should avoid oil-based products and choose water-based ones instead. A good moisturiser is not necessarily an expensive one. Deciding what is best for skin depends on ingredients. There are various ingredients that provide different functions including:
• Ceramides. Ceramides help the skin hold water and soothe dry skin. Synthetic ceramides may mimic the natural substances in the outermost layer of skin that help keep moisture in.
• Dimethicone and glycerin. These draw water to the skin and keep it there.
• Hyaluronic acid. Like ceramides, hyaluronic acid helps skin hold water.
• Lanolin, mineral oil, and petroleum jelly (petrolatum). These help skin hold on to water absorbed during bathing.
Psoriasis is a common, noncontagious, long-term, immunemediated inflammatory disease in which there is an increase in the rate at which skin cells are produced and shed from the skin.
Psoriasis affects at least 100 million people worldwide, including upwards of 73,000 people in Ireland, suggesting a prevalence of close to 2% of the Irish population. It is estimated that around 9000 people in Ireland have severe psoriasis.
Psoriasis is a condition which tends to run in families. Several different genes have been identified but the exact way in which the disorder moves from generation to generation has not yet been established. What is known is that both the immune system and genetics are important in its development. So although the potential to develop psoriasis is genetically inherited, it is by no means certain that it will ever occur.
Triggers for this abnormal immune reaction can include physical injuries or infections (in particular, a streptococcal throat infection), certain medicines, and emotional stress. Psoriasis varies in severity from person to person and can vary in severity in the same person at different times.
Red, scaly patches (also called plaques or lesions) with sharply defined edges, that occur most commonly on both elbows, both knees, the scalp, under arms, under breasts, natal cleft (groove between the buttocks) and genitalia, or at the site of an injury
• If the scales are gently scraped off, a number of small, bleeding points can be seen underneath
• Nail changes – loosened, thickened or pitted nails (pits are small dents/ice pick like depressions on the surface of the nails) People who have psoriasis are at risk of developing psoriatic arthritis, which commonly affects the joints of the fingers, toes and spine. Psoriasis is associated with a slightly higher risk of diabetes, high blood pressure, high cholesterol, cardiovascular disease (angina, heart attack, stroke), and obesity. There is also a strong association between psoriasis and depression.
Some symptoms that may be associated with psoriatic arthritis include;
• Joint pain, especially with redness, swelling, and tenderness
• Pain in the heel(s) or tennis elbow
• A finger or toe that was completely swollen (sausage shaped) and painful for no apparent reason
• Morning stiffness/pain in the back that improves with movement
Those presenting into the pharmacy who suffer from psoriasis and exhibit any of these symptoms, should be referred to their local GP for follow-up.
Role of Pharmacy
In general practice, chronic disease consultations and medication reviews are increasingly being conducted by clinical pharmacists. Many pharmacists working in general practice come from community pharmacy backgrounds, and will therefore already have experience in supporting patients to manage their eczema.
Before recommending any product, pharmacists should determine whether self-treatment is appropriate and refer patients to seek further medical evaluation when warranted, especially if signs of skin infection are present.
Patients under the age of 2 years should always be referred to their primary health care provider for appropriate treatment. To avoid allergic reactions, patients with allergies to skin care products and cosmetics should be advised to use hypoallergenic products.