Dermatology under the spotlight

With a constant stream of innovations and new treatments in the dermatology pipeline, it is important that community pharmacists keep up to date. Here we highlight some of the latest advances with a focus on new guidelines and therapeutic agents

Learning objectives

After reading this feature you will be able to:

• Outline the latest advances in dermatology
• Explain recent NICE guidance on acne, eczema and wound management
• Appreciate the need for mental health support for those severely affected by acne.

Key Facts

• Skin conditions are one of the most common reasons patients see a GP
• There has been growing interest in the use of biologics for moderate to severe eczema
• Pharmacists can play an expanded role in all aspects of dermatology

Increase in consultations

Research shows that while GP consultation rates for skin conditions have increased, patients are less likely to return for a follow-up appointment.

Between 2006 and 2016, consultations for acne increased by 56 per cent1, while further research covering the period 2004-2013 found that, after an initial consultation for acne, two-thirds (66.1 per cent) of patients had no further consultations in the subsequent year.²

This was of particular concern, given that an oral antibiotic was prescribed for 24.9 per cent of patients, more than half of whom (60.1 per cent) had no further acne-related consultations in the following 90 days. While the authors were unable to explain their findings, they did suggest that longitudinal acne management may be sub-optimal in primary care.

Acne is a common skin condition that affects 95 per cent of people in England at some point. While most individuals will experience some acne in their teens and early 20s, around 3 per cent of the population have acne past the age of 35 years.

In June, NICE produced a new guideline (NG198) on the management of acne vulgaris (see p26 for treatment guidelines). Many recommendations are made but two areas in which pharmacists could offer advice to patients with acne relate to skincare and diet.

NICE suggests that for the purposes of washing, patients need only use a non-alkaline (i.e. skin pH neutral or slightly acidic) detergent twice daily. Furthermore, when acne patients require an emollient, sunscreen or even make-up, the advice is to choose a product labelled ‘oil-free’ or non-comedogenic.

Much has been made of the role of diet in acne, in particular the use of a low glycaemic index diet that avoids highly processed foods such as white bread, cakes or biscuits. While NICE recognised that such diets appear, at least from the available evidence, to produce some benefit in acne, a more relevant issue was that such diets led to weight loss. NICE felt that since eating disorders are common during adolescence, it was unable to recommend low glycaemic index diets, saying there is “not enough evidence to support specific diets for treating acne”.

Pharmacists can therefore counsel patients that diet is unlikely to have a huge impact on acne but should emphasise the importance of achieving a balanced diet nonetheless.

New acne therapies

The latest acne treatment to be introduced is clascoterone cream 1 per cent, a topical androgen receptor blocker. During puberty, androgens cause sebaceous gland hyperplasia with the result that more sebum is produced, making the skin appear greasy. Clascoterone competes with androgens, such as testosterone, for receptors in the skin, thereby reducing sebum production.

Clinical trial data published in April 2020 showed that clascoterone produced a significant reduction in both inflamed and non-inflamed lesions with a low incidence of side-effects.³ Clascoterone is currently only approved in the US but this is likely to change in the near future.

Acne and mental health

Mental health support for people who are severely affected by acne is recommended in the guidance from NICE on managing acne vulgaris.

Evidence suggests that any form of acne can cause a person to experience psychological distress and in some cases it can be a part of, or contribute to, a mental health disorder, says Dr Paul Chrisp, director of the Centre for Guidelines at NICE. 

“Acne affects most of us at some point in our lives and while it is usually limited to a few facial spots in our teenage years, for some people it is more severe and can impact on their self-esteem and mental health. Not everyone with acne will experience high levels of psychological distress, but it is important that we find ways to support those who do.

“With this new guideline it is our hope that people whose acne affects their everyday lives are offered the support they need to treat the condition, both physically and mentally.”

Eczema

Patients with eczema who experience an infected flare have been traditionally prescribed a topical steroid-antibiotic combination product. The rationale is that the secondary infection can be treated with the antibiotic, whereas the topical steroid will help to reduce any inflammation.

However, guidance issued by NICE in March 2021 (NG190) makes clear that not all flares are due to bacterial infection, even in the presence of typical signs of infection such as weeping and crusting. In other words, a patient’s eczematous areas can be colonised with bacteria but not clinically infected.

NICE recommends that clinicians do not routinely offer patients either a topical or systemic antibiotic for the management of a secondary bacterial infection unless the person is systemically unwell. This is especially relevant in light of the limited evidence base to support the use of combination products for infected eczema.

However, NICE does advocate patients are reviewed and that treatment might be necessary in cases where symptoms rapidly worsen. This latest advice points towards a limited justification for the use of steroid-antimicrobial preparations in patients with infected eczema.

Biologic therapy

There has also been growing interest in the use of biologics in patients with moderate to severe eczema. This therapeutic approach began in 2018 with the approval of the monoclonal antibody, dupilumab, which targets the signalling of two interleukins, IL-4 and IL-13 – key inflammatory mediators in eczema.

Pharmaceutical companies have invested much time and money into the development of similar molecules and one that has attracted a good deal of attention is tralokinumab, which specifically binds to IL-13 and therefore prevents interaction with its receptor and the subsequent inflammatory signalling.

The drug is given as a subcutaneous injection every other week. The results of two randomised, double-blind trials, which were published in 2021, reported that 25 and 33 per cent of patients receiving tralokinumab achieved a 75 per cent improvement in their eczema after 16 weeks.4 These improvements were largely maintained when the study continued for 12 months.

NICE is in the process of reviewing the data and will hopefully provide guidance by the end of this year.

Oral treatments

While subcutaneous biologic treatments are effective in eczema, a far more convenient option for patients is an oral treatment. One novel class of therapies now being used in eczema is the Janus kinase (JAK) inhibitors.

Once a ligand such as an interleukin binds with its cell surface receptor, it activates the Janus kinase pathway – an intercellular signalling system that ultimately leads to the activation of various genes and, in eczema, the production of inflammatory mediators.

The drug baricitinib, which was originally licensed for use in rheumatoid arthritis, works by inhibiting the JAK intercellular messaging pathway, thus preventing activation of inflammatory mediators.

Baricitinib is licensed for the treatment of patients with moderate to severe eczema at a dose of 4mg daily, although this is reduced to 2mg in those over 75 years of age.

A second JAK inhibitor, upadacitinib, while currently only licensed for rheumatoid and psoriatic arthritis and ankylosing spondylitis, has been shown to be effective in eczema. In a recent Lancet study5, the achievement of a 75 per cent improvement in eczema severity occurred in 70 per cent of patients given upadacitinib 15mg and 80 per cent of those prescribed the 30mg dose. It is likely that upadacitinib will receive a licence for the treatment of eczema in the near future.

Psoriasis

Psoriasis, which affects around 3 per cent of the UK population, is due to an abnormal, increased rate of production of the keratinocyte cells in the skin, leading to the formation of raised, visible plaques, typically on the elbows and knees.

Fortunately, the majority of patients with psoriasis have mild to moderate disease, which can be easily managed with topical therapies. However, for an unfortunate minority, the disease becomes more widespread making topical treatment inappropriate.

Over the past 15 years, and starting with etanercept, biologics have revolutionised the management of moderate to severe psoriasis. As researchers gained a better understanding of the pathophysiology of the condition, newer and more effective treatments have emerged that specifically target the different interleukins involved in the development of psoriasis.

For example, interleukin-17 (IL-17) is now recognised as an important agent in the inflammatory process, although researchers have identified that it is not a single entity but has several subtypes (e.g. IL-17A through to IL-17F).

The latest biologic to be studied is bimekizumab, which targets both IL-17A and IL-17F. In a clinical study published in April 2021, bimekizumab was tested against secukinumab, which only blocks IL-17A.6 The results showed that after 16 weeks of either therapy, 61 per cent of those given bimekizumab achieved complete clearance of their psoriasis compared to only 49 per cent of those using secukinumab.

When the drug was continued for 48 weeks, 67 per cent of bimekizumab patients were still free of their psoriasis, compared to 46 per cent of those on secukinumab. These results suggest that bimekizumab, by blocking two different interleukins, is an important new addition to the treatment of patients with severe psoriasis.

There is also a new topical treatment on the horizon, a combination of halobetasol, which is a corticosteroid, and the retinoid tazarotene. Topical steroids are widely used in psoriasis for their anti-inflammatory effect, whereas a topical retinoid normalises the increased and abnormal proliferation of keratinocytes in the skin.

The combination product has been approved by the FDA in the US and a 2020 study revealed that after eight weeks of treatment, up to 45.3 per cent of patients using the combination treatment achieved the outcome of clear or nearly clear skin.7 Not currently available in the UK, approval by the FDA suggests that the manufacturer is likely to approach the UK and European regulators in the near future.

Impetigo

Guidance from NICE (NG153) now recommends that, where suitable, localised impetigo should be initially managed with hydrogen peroxide 1% cream. This represents an important development, as hydrogen peroxide is an antiseptic rather than an antibiotic and therefore avoids the potential for antibiotic resistance.

Skincare Survey

Aston University is undertaking a study to understand the key aspects of skincare from a community pharmacy perspective. An online survey should take around 10 minutes to complete. Contact Dr Ian Maidment at: i.maidment@aston.ac.uk.

Wound management

A wound product was approved by NICE in February 2021 (NICE MTG 55). Leukomed Sorbact has a novel antibacterial mode of action for which it is impossible to develop any form of resistance. The active agent, dialkylcarbamoyl chloride (DACC), is chemically hydrophobic in nature and coated over the surface of a dressing.

Since bacteria and fungi have hydrophobic surfaces, they are physically attracted to, and bind with, DACC. This binding does not cause lysis (breakdown) of the organisms, which might release bacterial inflammatory mediators into a wound. The intact micro-organisms are removed once the dressings are changed. NICE has approved Leukomed Sorbact for use after closure of caesarean section wounds and those associated with vascular surgery.

FIRST PERSON: Pharmacists can Make a difference in dermatology

Community pharmacies could become a cornerstone of dermatology if we invest and upskill ourselves and our teams. We could make a massive difference to patients and their long-term outcomes. 

“For a start there aren’t enough dermatologists and there appears to be a massive backlog of things which patients haven’t wanted ‘to bother the doctor about’. Last week, for example, I saw a lady who had had a lesion on her nose for a year. After taking a history I examined the lesion with a dermatoscope, was able to identify a basal cell carcinoma (BCC) and make a referral to the GP asking for the patient to be referred to the hospital for treatment.

I could do this because in January I took the plunge and did an independent prescribing course. Since Covid
I have been seeing a huge increase in patients presenting with skin problems. Like most pharmacists I had muddled through with a combination of antihistamines, emollients and steroids, but didn’t necessarily feel confident. So I decided to turn a weakness into a strength by ‘specialising’ (probably too grand a word: ‘focusing’ might be more accurate) on dermatology. The more I thought about it, the more it seemed like the right decision.

One of our pharmacies has a reasonably sized skincare business and this would help not only me but the whole business to focus on trying to do one thing really well.

There was virtually nothing in my IP course on dermatology itself, but my Designated Medical Practitioner (DMP) is a consultant dermatologist and has helped me to network with colleagues locally who have been invaluable in their advice and support.

There is no reason why more pharmacists could not be trained in dermatoscopy. With adequate safeguards a service could be designed that would improve patient access and reduce the pressure on general practice and secondary care. This could be designed either as part of a commissioned service or it could be a private service.

Boots has previously piloted a successful mole check service, which could be expanded to all contractors and help to cut the number of preventable deaths from melanoma, which are amongst the highest in the UK down here in the south-west.

One thing that I have picked up from my DMP is that rashes are hard! When someone says, “it’s just a simple rash”, don’t believe them. It is important to take a thorough and accurate history, as well as undertaking a physical examination – one reason why I don’t think we can do this free of charge.

Patients are increasingly prepared to pay to see a private GP or a consultant because what they want ultimately is access to treatment. As an IP, I will be able to help them get earlier access to treatment because there is no three-week waiting list to see me.

Great patient response

I am really surprised about how much I have enjoyed the dermatology and how well the patients have responded to it. It is amazing how quickly word of mouth spreads and I’ve had people turning up at the pharmacy wanting to talk about their skin because I’d managed to help their friend or neighbour. It is also professionally rewarding to help make a difference to someone’s life.

One man I saw had a recurrent reaction to sunlight going back more than 15 years, and it was only by taking the time to talk to him that I was able to point to a diagnosis of polymorphic light eruption and give him advice on how to manage it.

We also shouldn’t forget the really important link between skin and mental health (see panel on opposite page). Helping to normalise treatments and intervene appropriately earlier in disease progression could help young people with acne, say, to reduce harmful scarring or the impact on their self-esteem that this can cause.

The next stage in my dermatology journey is a post- graduate diploma. I never thought I’d say that because I was dead set against doing a diploma after I finished my pre-reg (many moons ago). We’ve also got some exciting plans to build technology into our service as there are a plethora of useful apps and kit that could help us to really improve patient care in the area of skin problems.”

References

1. Dermatology Nursing 2020; 19(1): 30-40
2. British Journal of Dermatology 2017; 176(1):107-115
3. JAMA Dermatol 2020; 156(6):621-630
4. British Journal of Dermatology 2021; 184(3):437
5. Lancet 2021; 397:2151
6. New England Journal of Medicine 2021; 385;142
7. Clin Cosmet Investig Dermatol 2020; 13:391