Kathy Oxtoby looks at common skincare conditions that are often distressing to sufferers…
 

Since the pandemic, with its limits on face-to-face GP consultations, pharmacies are more likely to be the first place that patients go with concerns about skin conditions. And with many people self-treating, there is a plenty of opportunity for pharmacists to advise on how best to manage and treat them.

Here we look at common skin problems, the signs and symptoms, and how pharmacists can support patients with these often-distressing conditions.

Acne
Acne is a common condition that affects most people at some point. Usually starting in puberty, acne can range from a few spots to a more severe problem that may cause scarring and reduce self-confidence.2 There are several types of spots caused by acne, including blackheads, white heads, papules, pustules, nodules and cysts.1

To help manage acne patients should cleanse their skin and remove make-up with a gentle cleanser and water, or an oil-free soap substitute.2 If dry skin is a problem, they can use a fragrance-free water-based emollient.1

Treatment for acne depends on its severity. It can take several months of treatment before symptoms improve.1 For mild to moderate acne, an over-the-counter cream or gel containing benzoyl peroxide, salicylic acid or nicotinamide can be used.

Patients are advised not to squeeze spots, as this can make them worse and cause permanent scarring. They should avoid oil-based make-up, skincare and sun care products, and instead use water-based non-comedogenic products, which are less likely to block pores.2

Carianne Stokes, superintendent pharmacist for independent pharmacy chain Poolearth in Plymouth, advises patients to avoid over-cleansing. “There’s an assumption acne is related to poor personal hygiene – it’s not at all, and over cleansing skin can make the condition worse,” she says.

If patients find that OTC medication doesn’t work, if they have severe acne symptoms, or their condition is distressing them, they should be referred to their GP to discuss their options.

Ruth Giles, the brand manager for Care at Thornton & Ross, said: “Before pharmacist teams recommend products to patients, they should ask about treatments they have already tried or if they are currently taking any medication. 
 
“Medicines can sometimes be the trigger of acne and so, pharmacy staff should ensure they can rule out current treatments to determine possible causes and provide effective product recommendations.
 
“Good skin care and hygiene is key but it’s important to remember this is not always the main cause of acne. There are washes and soaps that contain antiseptic agents, such as chlorhexidine, which help to degrease skin and reduce the amount of skin bacteria. Oil-based make-up can exacerbate acne, so it is best to recommend that customers wear water-based products and ensure that they are removed thoroughly at the end of the day.” 
 

Cold sores
Cold sores are caused by a virus – herpes simplex - which stays with people for life. They can be triggered by changes in the weather, stress or illness.

Cold sores start with a tingle, and often recur in the same place around the lips, cheeks or nose.. Over the next 48 hours small, fluid filled blisters can appear. They then burst and crust over into a scab.3

To help manage cold sores NICE says practitioners should advise patients to avoid trigger factors, if possible, and to reduce the risk of transmission to other people.4 It recommends the use of sunscreen or sunblock lip balm for people with current infections triggered by sunlight.

Antiviral creams containing aciclovir can be recommended to treat cold sores over the counter. Treatments are most effective when applied at the initial prodromal stage and will shorten the period of infection. Topical analgesics, mouthwash, and lip barrier preparations are not routinely recommended, but some people may find them helpful. Patches which cover and protect cold sores while they heal, can be used. Patients can also use a greasy moisturising cream, like petroleum jelly, on the skin.5

Patients should not kiss anyone when they have cold sores as they are contagious. They should wash their hands with soap and water before and after applying cream, and not rub cream in the cold sore but dab it on instead3.

Patients should see their GP if their cold sore has not started to heal within 10 days, if the cold sore is very large or painful, or they have a weakened immune system.3

Shingles
Shingles is a painful blistering rash caused by the reactivation of the chickenpox virus.6Before the blisters appear, the first obvious symptom is a constant dull, tingling, aching or burning pain or sensation in the area where the virus is reactivating. The rash usually appears a day or two after the onset of pain, and a fever and/or a headache may develop.6

People with shingles can spread the condition to those who have not had chickenpox before. They are infectious from the point of the first blister until the blisters crust over (approximately seven days).6

NICE advises patients wear loose-fitting clothes to reduce irritation and to cover lesions that are not under clothes while the rash is still weeping. Patients should avoid work or school if the rash is weeping and cannot be covered.7

Antiviral drugs, such as acyclovir tablets may shorten the duration, but work best if given within the first three days (72 hours) of onset of the outbreak. It is therefore important to get an early diagnosis from a GP as soon as shingles is suspected.6

If symptoms are not too severe, “shingles can be managed with an over-the-counter analgesic, plenty of rest and fluids”, says Ms Stokes.
Patients should avoid contact with people who have not had chickenpox, particularly pregnant women, immunocompromised people, and babies younger than one month of age. They should also avoid sharing clothes and towels.7

Shingles affecting the face may spread to the eyes, leading to inflammation and ulceration, and later to scarring, which if untreated could lead to vision problems or blindness. Patients should seek urgent advice from an ophthalmologist.6

Postherpetic neuralgia - the pain caused by shingles - may persist long after the rash has cleared, particularly in older people. Patients should be referred to their GP to advise on the best treatment.6

For patients with dermatological issues generally, Ms Stokes says it is important for pharmacists to remember there is “a massive need to be able to access advice. And if pharmacists don’t know the answers there and then, they need to signpost patients to evidence based, reliable sources of information.”
 

No known cure…
Some skin conditions have no known cure. Rosacea, for example, is a chronic condition which tends to affect the cheeks, forehead, chin and nose. Typical signs include persistent redness caused by dilated blood vessels, small bumps and pus-filled spots similar to acne.8

There are a variety of triggers that patients can avoid, including alcohol, exercise, high and low temperatures, hot drinks, spicy foods and stress.8

Rosacea can be sun sensitive so wearing a high factor sunscreen may help, while green coloured creams can help to cover redness. For severe cases, patients can ask their GP for a prescription treatment.

Vitiligo is a long-term condition where pale white patches develop on the skin.9 Patients are advised to protect their exposed skin with clothing, and wear a hat that protects the face, neck and ears, and a pair of UV protective sunglasses.10

People experiencing anxiety, depression and low self-esteem because of vitiligo are advised to see their doctor, who will be able to recommend sources of self-help or referral to psychological services if needed.10
 

Signposting support
Acne Support: http://www.acnesupport.org.uk/
British Association of Dermatologists: https://www.bad.org.uk/
British Skincare Foundation: www.britishskinfoundation.org.uk
NHS Health A-Z https://www.nhs.uk/conditions/
Shingles Support Society: https://shinglessupport.org.uk/
The Vitiligo Society: www.vitiligosociety.org

References

1 NHS (2019) Overview. Acne. https://www.nhs.uk/conditions/acne/
2 British Association of Dermatologists (BAD) (2020) Patient Information Leaflet. Acne. https://www.bad.org.uk/shared/get-file.ashx?id=65&itemtype=document
3 NHS (2020) Cold sores. https://www.nhs.uk/conditions/cold-sores/
4 NICE (2021) Herpes Simplex – oral. https://cks.nice.org.uk/topics/herpes-simplex-oral/
5 BAD (2019) Patient Information Leaflet. Herpes Simplex. https://www.bad.org.uk/shared/get-file.ashx?id=208&itemtype=document
6 BAD Shingles (herpes zoster) (2020) https://www.bad.org.uk/shared/get-file.ashx?id=128&itemtype=document
7 NICE (2021) How should I manage a person with shingles? https://cks.nice.org.uk/topics/shingles/management/management/
8 BAD (2018) Patient Information Leaflet. Rosacea. https://www.bad.org.uk/shared/get-file.ashx?id=229&itemtype=document
9 NHS. (2019) Overview. Vitiligo. https://www.nhs.uk/conditions/vitiligo/
10 BAD (2021) Patient Information Leaflet. Vitiligo. https://www.bad.org.uk/shared/get-file.ashx?id=137&itemtype=document