Pharmacies have an edge in skin care that virtually no other retailer can boast: the presence of Pharmacy-Only and Pharmacist-Only products that draw customers into the community pharmacy sector.
And a better understanding of skin conditions and the products used to treat them could lead to a better-performing therapeutic skin care section.
Sydney pharmacist Nick Logan, proprietor of Artarmon’s Nick Logan Pharmacist Advice—one of Australia’s first forward pharmacies and the winner of Pharmacy of the Year in 2009—has done a lot of work in the dermatology area and says that eczema is a good case study.
“Corticosteroid phobia is a really big problem,” Logan says. “Unfortunately, most dispensing software still prompts you to add ‘sparingly’ to the directions, and so people think they’re being responsible adding ‘sparingly’ to the label.
“What they’re really doing is increasing the risk of non-adherence.
“Recently, there’s been lots and lots of studies clearly showing the safety of topical corticosteroids when used appropriately.”
He says Product Information leaflets which accompany the products state that they should be applied in a “thin film,” which “could be misconstrued as ‘sparingly’.”
Case study: eczema
Logan told the AJP that a step in the right direction would be to start quantifying the amount of topical corticosteroid consumers are directed to use; pharmacists can already start doing this, he says, and this level of advice can help the pharmacist begin to address the customer’s condition as a whole.
“Moving forward, I think at each step of the way, from the dermatologist to the GP to the pharmacist, we should be describing the dose of corticosteroid cream in fingertip units,” he says.
“Rather than saying, ‘put a little bit on,’ you can very clearly describe how much a fingertip unit will cover.
“The problem we have now is that people are guessing. You can imagine the variation in treatment when people are guessing how much to use, particularly when they’ve got in the back of their mind that applying the product to kids will thin their skin.”
Logan presented at the Dermatology Academy in June 2015 and says that in focus groups, he had one dermatologist confirm that he had only come across skin atrophy once – in a patient who had used diprosone on their groin twice a day for seven years.
“A bunch of the data I pulled for the Academy showed people using strong corticosteroids over large amounts of their body for six months continuously and showing no signs of skin atrophy.
“A few of the dermatologists I spoke to were trying to work out where this corticosteroid phobia came from and it seems to be mostly the neighbour over the back fence, but also a significant number of GPs and pharmacists.
“So the sooner we get out of the habit of warning people about topical corticosteroids in hushed tones, the more effectively people will be managing their eczema.”
Logan says that it behoves pharmacists to reassure their customers that corticosteroids are safe, and that by using an adequate amount they will experience improved health outcomes and improved quality of life.
“That’s not just for the individual with eczema, but can mean their whole family – instead of having a poor little kid scratching in the middle of the night waking everyone up, they can sleep because the itching is reduced,” he says.
“There’s several opportunities for us as pharmacists. We can reassure people, we can describe how much they should use – you should be able to tell them how long a 15g tube will last.”
He says that in an ideal world, patients and their families would receive an eczema action plan from their GP to handle flare-ups.
“You as a pharmacist can reinforce how to stick with that game plan,” Logan says.
A forgotten category
Therapeutic skin care is one of the “forgotten” categories in pharmacy, says industry analyst Bruce Annabel, and is an area where customers often self-diagnose.
“It gets mixed up with the general stuff and that’s where it’s reported in the Point of Sale systems; a lot of it’s heavily discounted and unfortunately there’s often not really a lot of knowledge in community pharmacy about therapeutic skin care at all,” he told the AJP.
“A lot of customers would probably go to the doctor about these things, others would self-diagnose and pick up something off the shelves which might not be the right product.
“This all comes under the heading of ‘minor ailments,’ where pharmacy has a significant opportunity to delight customers and give them reasons to come back.”
In the case of eczema, pharmacists should be able to give advice on caring for the skin by moisturising, says Logan – something all people prone to eczema should do.
“I think there’s room for pharmacists to become almost a moisturising coach for the family, so that they don’t drop the ball or get slack, but do it rigorously and effectively,” he says.
“There’s a lot of great products available to us over the counter. And we can do simple things like reminding people that if they moisturise right after the shower or the bath they trap moisture in their skin. If you moisturise only once a day, after the bath is the best time to do it.
“Don’t rub it on the skin, smooth it on, in the direction of hair growth so that you don’t encourage folliculitis from rubbing against hair. You’re not trying to irritate that skin but to moisturise it – the better moisturised the skin, the less the chance of an acute flare-up.
“Moisturising for eczema is a no-brainer,” says Logan. “And it’s a good opportunity for us because when pharmacists interact with their customers there’s invariably a bigger basket size, so the section becomes more commercially viable.
“Communication with your customer costs nothing and it’s easy.
“This applies to psoriasis as well as eczema, to the more obscure things: identifying rashes, especially on children. Every pharmacist would see a kid’s skin rash at least weekly, so having some level of differential diagnosis skill and knowing when to refer is important.”
Pharmacists can advise on common rashes such as molluscum as well, even when no treatment is necessary, he says – for example, that the problem usually self-resolves (albeit after some time in some cases) and that in the meantime, the child should try to avoid sharing baths and towels.
“Fungal is another one. When you’re talking about tinea of the body or the scalp there’s a lot of treatments and other things you could be doing.”
For more, see the March edition of AJP.