Dermatological Nursing, Volume:23. Issue: 3

DN British Dermatological Nursing Group

Autumn 2024 Volume: 23 Issue: 3

Atopic dermatitis An expert consensus on systemic treatment Chronic hand eczema Understanding the disease burden Eczema management A new treatment algorithm that includes fludroxycortide tape

The BDNG Members Journal delivered to you by Almirall has no input into the editorial content of the journal and their involvement is limited to a defined financial contribution.

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Contains promotional material for HCPs only.

KLISYRI® (tirbanibulin) is indicated for the field treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK, Olsen grade 1) of the face or scalp in adults.1

NOVEL MoA1,2

PROVEN EFFICACY2

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GENERALLY WELL-TOLERATED FIELD THERAPY2

STRENGTH FOR ACTINIC KERATOSIS, TOLERABILITY FOR PATIENTS1,2 KLISYRI®

(TIRBANIBULIN) PRESCRIBING INFORMATION

Please consult the Summary of Product Characteristics (SmPC) before prescribing. Klisyri 10 mg/g ointment Active Ingredient: Each gram of ointment contains 10 mg of tirbanibulin.

Each sachet contains 2.5 mg of tirbanibulin in 250 mg ointment. Excipients with known effects: Propylene glycol 890 mg/g ointment Indication: Klisyri is indicated for the field treatment of non-hyperkeratotic, non hypertrophic actinic keratosis (Olsen grade 1) of the face or scalp in adults. Dosage and Administration: Tirbanibulin ointment should be applied to the affected field on the face or scalp once daily for one treatment cycle of 5 consecutive days. A thin layer of ointment should be applied to cover the treatment field of up to 25cm2.

Consult SmPC and package leaflet for full method of administration. Contraindications, Precautions and Warnings: Contraindications: Hypersensitivity to the active substance or to any of the excipients listed in section 6.1 of SmPC. Precautions: Contact with the eyes should be avoided. Tirbanibulin ointment may cause eye irritation. In the event of accidental contact with the eyes, the eyes should be rinsed immediately with large amounts of water, and the patient should seek medical care as soon as possible. Tirbanibulin ointment must not be ingested. If accidental ingestion occurs, the patient should drink plenty of water and seek medical care. Tirbanibulin ointment should not be used on the inside of the nostrils, on the inside of the ears, or on the lips. Application of tirbanibulin ointment is not recommended until the skin is healed from treatment with any previous medicinal product, procedure or surgical treatment and should not be applied to open wounds or broken skin where the skin barrier is compromised. Local skin reactions in the treated area, may occur after topical application.

Treatment effect may not be adequately assessed until resolution of local skin reactions. Due to the nature of the disease, excessive exposure to sunlight (including sunlamps and tanning beds) should be avoided or minimised. Tirbanibulin ointment should be used with caution in immunocompromised patients. Changes in the appearance of actinic keratosis could suggest progression to invasive squamous cell carcinoma. Propylene glycol may cause skin irritation.

Consult SmPC and package leaflet for more information. Fertility, pregnancy and lactation: No human data on the effect of tirbanibulin ointment on fertility are available. Tirbanibulin

ointment is not recommended during pregnancy and in women of childbearing potential not using contraception. It is unknown whether tirbanibulin/metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded. Consult SmPC and package leaflet for more information. Adverse Reactions: Very common (≥1/10): Application site - erythema; exfoliation; scab; swelling; erosion. Common (≥1/100 to <1/10): Application site - pain, pruritus and vesicles. Consult SmPC and package leaflet for further information.

Legal Category: Ireland: POM Subject to prescription which may not be renewed (A). United Kingdom & Northern Ireland: POM Price: Ireland: Price to wholesaler United Kingdom & Northern Ireland: UK NHS Cost: £59.00 (excluding VAT). Marketing Authorisation Numbers: Ireland and Northern Ireland: EU/1/21/1558/001 Great Britain: PLGB 16973/0043 Marketing Authorisation Holder: Almirall, S.A., Ronda General Mitre, 151 08022 Barcelona, Spain Further information available from: Almirall Limited, Harman House, 1 George Street, Uxbridge, Middlesex, UB8 1QQ, UK. Date of First Issue: August 2021 Item code: IETIRBA-2100011

Complete information on where to find reportingforms and information for adverse events search MHRA Yellow Card in the Google Play or Apple App Store.

UK and UK(NI)-Adverse events should be reported. Reporting forms and information can be found at MHRA https:// yellowcard.mhra.gov.uk Adverse events should be also reported to Almirall Ltd. Tel. 0800 0087 399

IE-Adverse events should be reported. Reporting forms and information can be found at HPRA Website: www.hpra.ie.

Adverse events should be also reported to Almirall Ltd. Tel. +353 (0) 1431 9836

Reference: 1. KLISYRI® SmPC. Almirall. 2. Blauvelt A, et al. N Engl J Med. 2021;384(6):512-520.

almirallmed.co.uk IE-TIRBA-2100013 DOP: December 2021

Contents

British Dermatological Nursing Group

Autumn 2024 Volume: 23 Issue: 3

Editorial 6 An exciting future for Dermatological Nursing Jackie Tomlinson

8

The BACN Competencies and aims of the Education and Training Committee Anna Baker, Rachel Goddard

Position paper 11 Expert consensus on the systemic treatment of atopic dermatitis Hamish Hunter, Philip Laws, Agustin MartinClavijo, Louise Newell, Majid Sheikh, Richard Weller, Richard Woolf Clinical practice 16 An overview of the barriers and advances in hidradenitis suppurativa nursing intervention in Scotland Caitlin Thomson Clinical review 23 Eczema: A treatment algorithm incorporating fludroxycortide tape Nisa Aslam, Sangeeta Punjabi Clinical research 29 Discover the real burden of chronic hand eczema Anthony Bewley, Alia Ahmed, Angelika Razzaque, Margaret Kelman, Emily Goffin, Kate Barwise-Ennis, Shahil Lodhia Professional development 36 Conducting a literature review: Part 3 Laura Crosby Clinical review 39 Tirbanibulin for the management of actinic keratosis Rod Tucker Unit profile 43 Bed bug infestations: A growing problem Rod Tucker, Alexia Naylor

www.bdng.org.uk

BDNG meets 47 Research into mindfulness and skin disease Olivia Hughes, Rob Mair Ask the pharmacist 51 Could biologic therapy in atopic eczema halt the atopic march?

Rod Tucker

Sponsored by

Patient voice 54 Savannah’s story: Living with lamellar ichthyosis Georgia Butler Wellbeing for the workforce 58 How baking has improved my confidence and mental health Marlese Dinolan BDNG news 62 The first Burmese and skin-themed garden at the Chelsea Flower Show: The BDNG’s perspective Lucy Moorhead, Christopher E.M Griffiths, Su M. Lwin

67 71 72 74

BADBIR: Paediatric recruitment Tess McPherson Mind and Skin Workshop report Podcast update UKDCTN updates

78

Diary dates

80

Say hello to the BDNG’s new Member and International Liaison Lead Providing education opportunities nationwide, and preparing for the annual conference

82

Sponsored by

Dermatological Nursing 2024, Vol 23, No 3

3

DN

British Dermatological Nursing Group Editorial Jackie Tomlinson

Chair of the Editorial Board Dermatology Clinical Nurse Specialist, Addenbrooke’s Hospital, Cambridge University Hospitals Foundation Trust

Polly Buchanan

Clinical Editor Community Dermatology Nurse Specialist, NHS Fife pauline.buchanan2@nhs.scot

Rob Mair

Managing Editor Rob.Mair@pavpub.com

Lauren Nicolle

Deputy Editor Lauren.Nicolle@pavpub.com

Tony Pitt

Art Director Tony.Pitt@pavpub.com

Commercial Mark Freeman

Journal, Conference & Corporate Sponsorship Sales dnadvertising@bdng.org.uk 07957 404 831

Editorial board Mandy Aldwin

Michelle Ogundibo

Ichthyosis Support Group

Paediatric Dermatology Nurse Specialist, Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust

Tanya O. Bleiker Consultant Dermatologist, University Hospitals of Derby and Burton NHS Foundation Trust

Julie Brackenbury Aesthetic Nurse Practitioner, JB Cosmetic, Bath

Ivan Bristow Podiatrist and Associate Professor, Southampton

Sara Burr Senior Lecturer, Centre of Postgraduate Medicine and Public Health, University of Hertfordshire. Community Dermatology Specialist Nurse/Clinical Lead Community Skin Integrity Team, Norfolk Community Health and Care NHS Trust

Fiona Cowdell Professor of Nursing and Health Research, Faculty of Health, Education and Life Sciences, Birmingham City University

Senior Lecturer, Postgraduate Medicine, University of Hertfordshire and Dermatology Specialist Nurse, Dermatology Clinic Community Services, Cambridgeshire

Kathy Radley Senior Lecturer, School of Life and Medical Sciences, University of Hertfordshire and Dermatology Nurse Specialist, Dermatology Community Clinic Services, Cambridgeshire

Sue Rice Clinical Support Specialist, Huntleigh Healthcare

Alison Schofield Head of Education, Tissue Viability Nurse Consultant at NHS Pioneer Wound Healing and Lymphoedema centres

Reena Shah

Elfie Deprez

Senior Clinical Psychologist, Ickenham, Middlesex

PhD student and Psoriasis Nurse Specialist, University of Ghent, Belgium

Karen Stephen Lead Dermatology Nurse, NHS Tayside

Steven Ersser

Delia Sworm

Professor of Nursing and Dermatology Care and Head of Department of Nursing Science, Bournemouth University

Trainee Advanced Clinical Practitioner – Skin Cancers (Oncology), St Luke’s Cancer Centre, Royal Surrey NHS Foundation Trust

Mark Goodfield Consultant Dermatologist, Leeds Teaching Hospitals NHS Trust

Karina Jackson Nurse Consultant, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London

Teena Mackenzie Education and Development Lead, British Dermatological Nursing Group

Jodie Newman

Rod Tucker Community Pharmacist/Researcher with a Special Interest in Dermatology, East Yorkshire

Andrew Thompson Clinical Health Psychologist and Reader in Clinical Psychology, University of Sheffield

Carrie Wingfield Dermatology Nurse Consultant, Norfolk and Norwich University Hospital

Education Nurse, British Dermatological Nursing Group

dn

Dermatological Nursing is the official journal of the BDNG. To contact the BDNG, email: admin@bdng.org.uk or tel: 02892 793 981 Printed in Great Britain by Micropress, Reydon Business Park Fountain Way, Reydon, Southwold IP18 6SZ The BDNG logo and name are Registered Trademarks.

All registered rights apply.

4

Rebecca Penzer-Hick

Dermatological Nursing (ISSN 1477-3368) is published by the BDNG, 82 Antrim Street, Lisburn BT28 1AU Tel: 02892 793 981. www.bdng.org.uk All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means without the prior written permission of the BDNG. Opinions expressed in articles are those of the authors and do not necessarily reflect those of the BDNG or the editorial/advisory board. Advertisements have no influence on editorial content or presentation.

The advertisements in this journal are for a UK audience only.

Dermatological Nursing 2024, Vol 23, No 3

www.bdng.org.uk

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A proven, effective emollient1,2, that is preferred by patients3 and available in an added value, economy pack Doublebase Gel 1kg

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References: 1. Whitefield. M Clinical evaluation of Doublebase. A multi-centre GP study of 78 patients with dry skin conditions.

(Data on File). 2. Wynne A. et al. An effective, cosmetically acceptable, novel hydro-gel emollient for the management of dry skin conditions. Journal of Dermatological Treatment No. 2 June; 13:61-66. 3. Aslam. A Children’s preference in selecting an emollient of their choice. Br J Dermatol 2009; 161 (suppl.1): 116. 4. National Institute for Health and Care Excellence. Atopic eczema in under 12s: diagnosis and management. Clinical guideline [CG57] subsection 1.5.1.4. Published: 12 December 2007 Last updated: 02 March 2021. Available at: https://www.nice.org.uk/guidance/cg57 [Accessed 03/11/2022].

Doublebase™ Gel

Isopropyl myristate 15% w/w, liquid paraffin 15% w/w.

Uses: Highly moisturising and protective hydrating gel for dry skin conditions.

Directions: Adults, children and the elderly: Apply direct to dry skin as required.

Contra-indications, warnings, side-effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the rare event of a reaction stop treatment.

Instruct patients not to smoke or go near naked flames. Fabric (clothing, bedding, dressings etc) that has been in contact with this product burns more easily and is a potential fire hazard. Washing clothing and bedding may reduce product build-up but not totally remove it.

Package quantities, NHS prices and MA numbers: 100g tube £2.65, 500g pump dispenser £5.83, 1kg pump dispenser £10.98, PL00173/0183.

Legal category: P .

MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: May 2021.

‘Doublebase’ is a trademark.

Adverse events should be reported. Reporting forms and information can be found at 10mm yellowcard.mhra.gov.uk. Adverse events should also be reported to Dermal.

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Editorial

An exciting future for Dermatological Nursing Jackie Tomlinson

W

elcome to the Autumn issue.

No doubt you will have noticed a new design that was launched in the Spring. The eagle-eyed amongst you will see that the BDNG logo is reflected within the refresh of the design on the front cover and page layouts. I like to think that the design reflects growth and seasonality change.

Pavilion are the publishers for the journal, and Tony Pitt, Art Director, gave the editorial team a range of designs that encompassed images, typography, colours and sizes. The challenge was to narrow that down to agree a look and feel to strengthen the journal’s presence, image and message. Tony then tackled our comments to incorporate them without upsetting any established design conventions.

Over several meetings and out of all the various incantations, we decided to explore the design that linked the history and connection to BDNG the most. We loved the link with the logo, taking the flower and sunburst to create something that is unique to us.

Dermatological Nursing – or DN – is an amazing recourse that promotes clinical practice, research, development and the latest evidence undertaken by you. You are remarkable dermatology professionals sharing your work, knowledge and commitment to improve the lives of those living with skin disease.

After your article has undergone the peer review editorial process how do we publish? All publishing has its roots in print production and we are somewhat still at that point. Your content is laid out 6

in a template, saved as a print ready PDF electronic document that goes to the printer for a paper version. A PDF copy is then sent to BDNG head quarters and articles added to the website.

On the BDNG website you can find the DN archive organised by content headings and can find the article if you know what to look for. But what if you want to search a topic and/or are not a BDNG member?

Taking Dermatological Nursing into the digital age On a search – whether via Google or through a UK database – you may come across a DN article citation.

However, it is not fully accessible and you will be informed to contact your academic librarian. In theory, any academic librarian or individual could email the BDNG, who would then give that person access to the full article and email them the PDF file. That process takes time, and in reality, this does not happen that frequently. So, how can we make access better?

There is only so much you can do with a PDF file and we are at that limit.

Behind the scenes, the DN Editorial Board are working with Pavilion to achieve this goal. This will mean aligning the governance of the DN policies to conform with the recommendations for conduct, reporting and editing outlined by the National Library of Medicine.

Pavilion have undertaken a scoping exercise – ‘a deep dive’, if you will – into the journal, and we have a framework on what needs to be achieved prior to submission. It will take time and resource, which the BDNG has committed to support. We will be working through the criteria required to submit an initial application over the next year. We must be meticulous in our submission, as you cannot reapply again for a further two years. Our goal and aim will be to bring DN into the digital era and be accessible to a wider audience, meaning many more people will be able to learn about the amazing work you undertake.

“PubMed!” I hear some of your cheer?

The BDNG committee and the DN Editorial Board would like to move towards a free, full-text, archive for most of our journal articles. After all, it is dreamy when you click on a PubMed citation following a quick via Google search and open an article instantly.

As with all big jobs, there is a caveat, however. The journal will need to comply with the Medline policy on indexing electronic journals, and the word ‘electronic’ hits the nail on the head. DN is not currently an electronic journal and does not exist as HTML.

Dermatological Nursing 2024, Vol 23, No 3

Jackie Tomlinson is a Dermatology Clinical Nurse Specialist at Addenbrooke’s Hospital, Cambridge University Hospital’s Foundation Trust, and Chair of the Dermatological Nursing Editorial Board. www.bdng.org.uk

From young atopic eczema to elderly varicose eczema Dermol Cream knocks out Staph. and soothes very dry and itchy skin conditions • Rich hydrating emollient cream with antimicrobials and soap substitute • Preferred by the majority of patients to their previously used emollients for relief of itching, relief of dryness and cosmetic acceptability1

*

*Image used with permission of DermNet NZ www.dermnetnz.org. **Stock photo. Posed by model.

Dermol Cream ®

Benzalkonium chloride 0.1% w/w, chlorhexidine dihydrochloride 0.1% w/w, liquid paraffin 10% w/w, isopropyl myristate 10% w/w.

Uses: An antimicrobial emollient cream for the management of dry and pruritic skin conditions, especially eczema and dermatitis, and for use as a soap substitute.

Directions: Adults, children and the elderly: Apply direct to the dry skin or use as a soap substitute.

Contra-indications, warnings, side effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive (especially generalised allergic reaction) to any of the ingredients or if there is a possible history of allergic reaction to a chlorhexidine compound. In the unlikely event of a reaction, stop treatment. Local skin reactions are very rare (<1/10,000 based on spontaneous reporting). Reactions have been observed occasionally when used excessively as a leave-on application in the anogenital area. When breast-feeding, if use on the nipples is necessary, apply sparingly and after feeds. Take care to avoid

Proven activity against Staph. aureus including MRSA,2 FRSA,2 Mupirocin-resistant Staph. aureus,3 as well as, Pseudomonas aeruginosa,4 Streptococcus pyogenes5 and Malassezia furfur 6 when tested in vitro.

slipping in the shower or bath, when using as a soap substitute.

Keep away from the eyes.

Instruct patients not to smoke or go near naked flames.

Fabric (clothing, bedding, dressings etc) that has been in contact with this product burns more easily and is a potential fire hazard. Washing clothing and bedding may reduce product build-up but not totally remove it.

Package quantities, NHS prices and MA number: 100g tube £3.08, 500g pump dispenser £7.19, PL00173/0171.

Legal category: P .

MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR, UK. Date of preparation: June 2024.

‘Dermol’ is a registered trademark.

Adverse events should be reported. Reporting forms and information can be found at yellowcard.mhra.gov. uk. Adverse events should also be reported to Dermal.

References: 1. Data on File. Dermal Laboratories. January 2005; 2. Gallagher J. et al. Routine infection control using a proprietary range of combined antiseptic emollients and soap substitutes – their effectiveness against MRSA and FRSA. Poster presented at 18 th EADV Congress, October 2009, Berlin, Germany;

3. Gallagher J. and Rosher P. Topical antiseptic products – Antimicrobial activity against mupirocin resistant Staphylococcus aureus. Data presented at the 16 th Annual Maui Derm for Dermatologists, January 2020, Maui, USA; 4. Gallagher J. and Rosher P. Infected wounds – in vitro activity of topical antiseptic products against P. aeruginosa. Poster presented at the 23rd EADV Congress, October 2014, Amsterdam, The Netherlands; 5. Gallagher J. and Rosher P. Evaluation of the bactericidal activity of two antiseptic emollient formulations against Streptococcus pyogenes. Poster presented at the 73rd Annual Meeting of the American Academy of Dermatology, March 2015, San Francisco, USA; 6. Gallagher J. & Rosher P. In vitro antimicrobial activity of two topical antiseptic products against Malassezia furfur. Poster presented at the 10 th EADV Spring Symposium, May 2013, Cracow, Poland.

MRSA, Meticillin-resistant Staph aureus; FRSA, Fusidic acid-resistant Staph aureus.

www.dermal.co.uk

DEMPR138/JUN24

**

The BACN Competencies and aims of the Education and Training Committee Anna Baker, Rachel Goddard The British Association of Cosmetic Nurses (BACN) Competencies

By Anna Baker

An aesthetic nurse conducting medical aesthetic treatments is required to exercise a unique and multi-faceted clinical judgement and skillset, often in complex scenarios, which are unique to the medical aesthetic specialism. In light of this, an aesthetic nurse is required to demonstrate not only an awareness, but knowledge and accountability of the moral, ethical, clinical, and professional aspects of aesthetic practice, which includes developing a business acumen.

Nurses have been respected figures in medical aesthetic practice for decades and have significantly shaped and influenced the establishment and progression of the speciality of medical aesthetics. Aesthetic nursing can be regarded as a distinctive and specialist area of nursing practice that is rooted in core nursing principles and a commitment to a set of professional standards and competencies. The BACN Career and Competency framework is intended to be a tool to guide and facilitate best practice and professional development for nurses working in medical aesthetics. It may also be of

Anna Baker is Vice Chair of the BACN’s Education and Training Committee.

8

interest to the increasing number of nurses who are considering working within the speciality and wish to understand more about this discipline.

The framework recognises the specialist and continually evolving nature of aesthetic nursing and the importance of providing clear and consistent guidance to develop and maintain competence. In particular, the framework acknowledges that aesthetic nurses possess knowledge and skills at different levels of practice.The framework advocates the need to establish and maintain appropriate standards of education, training and practice to ensure nurses in aesthetic medicine possess the requisite knowledge, understanding and skills to provide professional and ethical treatment and care to patients, according to their level of competence.

The framework is not intended to be exhaustive or prescriptive, but rather a template to benchmark best practice and evaluate education, training and competence in aesthetic nursing.

The heritage of the BACN competency framework originates from 2005, and has had several extensive updates since, receiving RCN accreditation in 2013 and 2015 respectively. The role of the nurse in medical aesthetics evolved from partnerships between specialist nurses, plastic surgeons and dermatologists.

Initially, nurses were required to develop new skills related to skin resurfacing and dermal augmentation, which subsequently expanded to include other approaches, such botulinum toxin, laser skin treatment and skin rejuvenation.

I undertook the most recent extensive update of this competency framework, and this work is currently under way and close to completion. This updated framework has been undertaken at a

Dermatological Nursing 2024, Vol 23, No 3

critical time within the medical aesthetic sector, whereby standards of clinical practice, education and training are increasingly under scrutiny. The recent Department of Health & Social Care consultation on the proposed Licensing of Non-Surgical Cosmetic Procedures in England facilitated a timely impetus for BACN to gather evidence in support of medical professionals delivering aesthetic procedures.

The BACN Career and Competency framework was a key piece of evidence submitted in support of the medical approach, accountability and high standards of patient care. In addition, the revised levels of competency now include Advanced as the highest level of practice within aesthetic medicine, with each level of competency underpinned

by NMC standards in relation to treatment modalities. The BACN Education and Training committee are currently exploring several opportunities to accredit the framework with updates to be announced in due course.

The BACN Career and Competency Framework is designed to be read in conjunction and applied to practice with the BACN Code of Professional Conduct. This overarching document underpins many of the key principles of medical aesthetic practice, in light of the specialised and unique skillset which nurses possess. It should be understood that the professional code of conduct is intended to facilitate a continuing pathway of treatment, and serves to guide and facilitate best practice. The document offers comprehensive guidance, supported by contemporaneous references to current legislative and statutory guidance, which are continually reviewed and updated accordingly. www.bdng.org.uk

Guest Editorial XXXX

Outlining the aims of the BACN Education and Training Committee

By Rachel Goddard

The BACN education and training committee was re-established in November 2023. The committee and advisory panel consist of a group of experienced, driven aesthetic nurses who all have a shared passion for education and raising standards within the specialism. The committee meets bimonthly, and we had had a very proactive first six months, where we have been focused on getting several different projects off the ground.

One of our first tasks was to encourage the professional development of our non-prescribing members. The BACN offers a bursary of £500 towards the cost of the V300 non-medical prescribing module for those members wishing to attend university to study towards this qualification. We advise that our members should look to gain this qualification, as aesthetic treatments often require prescriptiononly medication such as botulinum toxin type A. Remote prescribing is not permitted in aesthetic practice and all patients must be seen face-to-face by the prescriber before a prescription is issued. The prescriber should be competent in the procedure they are prescribing for and be working within their scope of practice. With the current government consultation and changes to the licensing of non-surgical cosmetic procedures expected, now is the ideal time for our members to look to complete their Nurse Prescriber

Rachel Goddard is Chair of the BACN’s Education and Training Committee www.bdng.org.uk

“Other projects which are on-going include an induction pack for new members, prescribing updates and rolling out study groups across all regions” qualification. The bursary is available each year for a total of twelve nurses.

Since January this year, we have had five members apply and receive the bursary.

The education committee will continue to promote the bursary and the advantages of becoming a Nurse Prescriber to our members. By the end of the year, we hope to have granted all of the seven remaining bursaries.

The Education and Training Committee have arranged a presenting skills training day for BACN regional leaders. It is impor tant to invest in their professional development as they work on a voluntary basis to suppor t members in their area, arrange study days, plan informal coffee mornings and host regional meeting days focusing on education. The upcoming presenting skills training day will equip them with new skills and confidence when chairing meetings and speaking in front of an audience. As an association for nurses, we hope to encourage and see more nurses on stage presenting at our Spring Symposium and Autumn Conference.

Over the last few years, we have seen an increase in the number of BACN members studying at post-graduate level. Some of those nurses may wish to approach the BACN membership to recruit participants for research projects. The education and training committee are currently working on a checklist document which will make this process clear and transparent.

Anyone wishing to approach the BACN membership will need to provide the committee with their research proposal, participant information leaflet and a copy of the survey/ research questions. Once reviewed, written consent will then be given if appropriate. The researcher will then

be able to submit that letter as part of their university ethical approval process if required. With such measures in place, the committee will be aware of each research project using BACN members as participants and we can build a database of research in aesthetic medicine involving nurses.

Other projects which are on-going include an induction pack for new members, prescribing updates and rolling out study groups across all regions. The study groups were developed by one of the regional leaders and have proved to be a great success in that region so we now plan to ensure all regional groups can benefit from these educational sessions. We have also been updating the BACN website so members can read about the education and training committee, our current projects and access regular updates.

There is a lot of hard work taking place behind the scenes, such as meetings with the fantastic team at BDNG! With many changes on the horizon for those specialising in medical aesthetics, it is going to be a very busy time for the BACN education and training committee.

Register for the BDNG Dermatology for Aesthetic Nurse Conference, supported by the BACN, on 23 November 2024 here:

Dermatological Nursing 2024, Vol 23, No 3

9

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The entire Zeroderma® range is approved by the British Skin Foundation Prescribing Information Zerobase Emollient Cream. Manufacturer: Thornton & Ross Ltd, Linthwaite, Huddersfield, HD7 5QH, UK. Code # of Notified Body: N/A. Legal classification: Class I. Product name: Zerobase Emollient Cream. Ingredients: Purified Water, Liquid Paraffin 11% w/w, White Soft Paraffin, Cetostearyl Alcohol, Macrogol Cetostearyl Ether, Sodium Dihydrogen Phosphate, Chlorocresol, Phosphoric Acid. Indications: Zerobase Emollient Cream softens, moisturises and protects the skin, providing symptomatic relief for red, inflamed or dry skin. If you have eczema, the cream can also be applied before a bath to stop the skin drying further. It can be used as an alternative to soap. Adverse reactions: Zerobase contains cetostearyl alcohol and chlorocresol which may cause local skin reactions (e.g. contact dermatitis) or allergic reactions. Rarely, mild allergic reactions such as a skin rash may occur. If you notice any side effects; or your skin condition worsens, stop use and tell your doctor or pharmacist, they will tell you what to do.

Precautions: For external use only. Do not use if you or your child have an allergy to any of the ingredients listed. If the skin is badly cracked, infected or bleeding do not apply; seek medical advice before use. Avoid contact with the eyes. Use during pregnancy and breastfeeding is unlikely to have any ill effects when used as directed. If unsure, talk to your doctor or pharmacist. Do not use if tamper evident collar is broken or missing at first use (500g pack). Do not use if tube seal is broken or appears tampered with at first use (tubes). Fire hazard. Do not smoke or go near naked flames; clothing & bedding with this product dried on them can catch fire easily. Washing clothing and bedding may reduce product build-up but not totally remove it. If you accidentally swallow some see a doctor straight away. Take the pack with you to show which product you have swallowed. Use within three months of opening. Keep out of the sight and reach of children. Keep in the original carton (tube packs). Use by the date shown on the label (500g pack). Use by the date shown on the side of the carton (tube packs). Contra-indications: Hypersensitivity to any of the ingredients. Method of administration: Pumps: Prime the pump before first use by depressing fully until cream appears. If the pump stops working do not dismantle the pack. Re-start by covering the nozzle, then fully depress the pump several times to expel air. Adults, the elderly and children: Apply to the affected areas of skin as often as required. Smooth gently into the skin, following the direction of the hair growth.

Date of preparation: 14/11/2023.

Zerocream Emollient. Manufacturer: Thornton & Ross Ltd, Linthwaite, Huddersfield, HD7 5QH, UK. Code # of Notified Body: N/A. Legal classification: Class I. Product name: Zerocream Emollient. Ingredients: Purified Water, White Soft Paraffin 14.5% w/w, Liquid Paraffin 12.6% w/w, Cetyl Alcohol, Glyceryl Monostearate, Sodium Cetostearyl Sulfate, Lanolin, Citric Acid Monohydrate, Carbomer, Sodium Hydroxide, Sodium Methyl Hydroxybenzoate, Sodium Propyl Hydroxybenzoate, BHT. Indications: Zerocream Emollient is used for the relief of symptoms of flaking, dry skin, ichthyosis, dermatitis, the dry stage of eczema and dry cases of psoriasis. It can be used as an alternative to soap. Adverse reactions: Zerocream contains methyl and propyl parahydroxybenzoates, cetyl alcohol and lanolin which may cause local skin reactions (e.g. contact dermatitis) or allergic reactions which may not appear immediately. Rarely, mild allergic reactions such as a skin rash may occur. If you notice any side effects; or your skin condition worsens, stop use and tell your doctor or pharmacist, they will tell you what to do. Precautions: For external use only. Do not use if you or your child have an allergy to any of the ingredients listed. Avoid contact with the eyes. If the skin is badly cracked, infected or bleeding do not apply; seek medical advice before use. Use during pregnancy is unlikely to have any ill effects when used as directed. If unsure, talk to your doctor or pharmacist. Wash and dry hands before use. Do not use if tamper evident collar is broken or missing at first use.

Fire hazard. Do not smoke or go near naked flames; clothing & bedding with this product dried on them can catch fire easily. Washing clothing and bedding may reduce product build-up but not totally remove it. If you accidentally swallow some see a doctor straight away. Take the pack with you to show which product you have swallowed. Treated feet may be slippery. Take extra care when walking on smooth surfaces. Use within 12 months of opening. Keep out of the sight and reach of children. Keep in the original carton (tube packs). Do not use after expiry date shown on the side of the label (500g pack). Do not use after expiry date shown on the side of the carton (tube packs). Contra-indications: Hypersensitivity to any of the ingredients. Method of administration: Pumps: Prime the pump before first use by depressing fully until cream appears. If the pump stops working do not dismantle the pack. Re-start by covering the nozzle, then fully depress the pump several times to expel air. Adults, the elderly and children: Apply as required to the affected areas of skin, two or three times daily. Smooth gently into the skin, following the direction of hair growth. Date of preparation: 14/11/2023.

Zeroveen Emollient. Manufacturer: Thornton & Ross Ltd, Linthwaite, Huddersfield,

HD7 5QH, UK. Code # of Notified Body: N/A. Legal classification: Class I. Product name: Zeroveen Emollient. Ingredients: Purified Water, Glycerol 12.6% w/w, Liquid Paraffin 5% w/w, Isopropyl Palmitate, Distearyldimonium Chloride, Avena Sativa Kernal Flour, Cetyl Alcohol, Dimeticone, White Soft Paraffin, Benzyl Alcohol, Allantoin, Stearyl Alcohol, Microcrystalline Wax, Myristyl Alcohol, Sodium Chloride. Indications: Fragrance-free 2-in-1 moisturising cream and wash with natural oatmeal (avena sativa kernal flour) for use in the management of dry skin conditions as may be found in eczema, psoriasis, dermatitis, ichthyosis, elderly pruritus and other dry skin conditions.

Adverse reactions: Rarely, mild allergic reactions such as skin rash can occur. If you notice any side effects or the condition worsens while using the product, stop use and tell your doctor or pharmacist. They will tell you what to do. Zeroveen contains benzyl alcohol and cetyl, myristyl and stearyl alcohols which may cause local skin reactions (e.g. contact dermatitis) or allergic reactions which may not appear immediately. Precautions: Do not use if you or your child have an allergy to any of the ingredients listed. If the skin is badly cracked, infected or bleeding do not apply; seek medical advice before use. Avoid contact with the eyes. Use during pregnancy or breastfeeding is unlikely to have any ill effects when used as directed. If unsure, talk to your doctor or pharmacist. Wash and dry hands before use. Do not use if tube seal is broken or appears tampered with at first use (tubes). Fire hazard. Do not smoke or go near naked flames; clothing or bedding with this product dried on them can catch fire easily. Washing clothing and bedding may reduce product build-up but not totally remove it. Always replace the cap after use (tubes). If you accidentally swallow some see a doctor straight away. Take the pack with you to show which product you have swallowed. Treated feet may be slippery. Take extra care when walking on smooth surfaces. Keep out of sight and reach of children. Keep in the original carton (tubes). Do not use after expiry date shown on the side of the label (500g pack).

Do not use after expiry date shown on the side of the carton (tubes). Contra-indications: Hypersensitivity to any of the ingredients. Method of administration: Pumps: Prime the pump before first use by depressing fully until cream appears. If the pump stops working do not dismantle the pack. Re-start by covering the nozzle, then fully depress the pump several times to expel air. All packs: Apply cream to the skin. Adults, the elderly and children: Apply as required to the affected areas of skin. Smooth gently into the skin, following the direction of hair growth. Date of preparation: 14/11/2023.

Zerodouble Gel. Manufacturer: Thornton & Ross Ltd., Linthwaite, Huddersfield, HD7 5QH, UK. Code # of Notified Body: N/A. Legal classification: Class I. Product name: Zerodouble Gel. Ingredients: Purified Water, Isopropyl Myristate 15% w/w, Liquid Paraffin 15% w/w, Glycerol, Triethanolamine, Phenoxyethanol, C10-C30 Alkyl Acrylate Cross Copolymer, Sorbitan Laurate. Indications: Highly moisturising emollient gel for dry skin conditions, as may be found in eczema, psoriasis, dermatitis, ichthyosis, elderly pruritus, and other dry skin conditions. It can also be used as an alternative to soap. Adverse reactions: Rarely, mild reactions such as skin rash may occur, or allergic skin reactions on extremely sensitive skin. These effects tend to occur during the first few uses. If you notice any side effects, stop use and tell your doctor or pharmacist, they will tell you what to do. Precautions: For external use only. Do not use if you or your child have an allergy to any of the ingredients listed. If the skin is badly cracked, infected or bleeding do not apply; seek medical advice before use. Avoid contact with the eyes.

Use during pregnancy and breastfeeding is unlikely to have any ill effects when used as directed. The ingredients have been in widespread use for many years, without reports of problems. However, safety trials have not been conducted. If unsure, talk to your doctor or pharmacist. The ingredients in this product are not considered likely to affect or be affected by other medicines. Fire hazard. Do not smoke or go near naked flames; clothing & bedding with this product dried on them can catch fire easily. Washing clothing and bedding may reduce product build-up but not totally remove it. Check that the tube seal is not broken before first use (tubes). Do not use if tamper evident collar is broken or missing at first use (pump pack). If you accidentally swallow some, see a doctor straight away. Take this pack with you to show which product you have swallowed. Keep out of the sight and reach of children. Keep in the original carton (tubes). Use within 12 months of opening (100g tube & 500g pump pack). Use within 28 days of opening (20g tube).

Use by the expiry date shown on the side of the carton (tubes). Use by the expiry date shown on the side of the label (pump pack). The expiry date refers to the last day of that month. Contraindications: Hypersensitivity to any of the ingredients. Method of administration: Tubes: Unscrew the cap, check and remove the foil seal, then replace the cap. Pump pack: Prime the pump before first use by depressing fully until gel appears. If the pump stops working do not dismantle the pack. Re-start by covering the nozzle, then fully depress the pump several times to expel air. All: Apply the gel only to the skin. Make sure your hands are clean and dry before applying the gel. Adults,

Experts in dry skin conditions the elderly and children: Apply the gel to the affected area on a regular basis and as often as required. Smooth gently into the skin following the direction of the hair growth.

Alternatively apply as directed by your doctor or pharmacist. Zerodouble Gel may also be applied before washing or bathing in order to prevent further drying of the skin. Date of preparation: 14/11/2023.

Zeroderm Ointment. Manufacturer: Thornton & Ross Ltd, Linthwaite, Huddersfield, HD7 5QH, UK. Code # of Notified Body: N/A. Legal classification: Class I. Product name: Zeroderm Ointment. Ingredients: Liquid Paraffin 40% w/w, White Soft Paraffin 30% w/w, Cetearyl Alcohol, Polysorbate 60. Indications: Zeroderm Ointment is a rich emollient used to moisture and soften dry skin in eczema, dry cases of psoriasis and other dry skin conditions. It is suitable for all ages and may also be used as a skin cleanser or bath additive. Adverse reactions: The product contains cetearyl alcohol which may cause local skin reactions (e.g. contact dermatitis). If you notice any side effects, stop use and tell your doctor or pharmacist. They will tell you what to do. Precautions: For external use only. Do not use the ointment if you or your child have an allergy to any of the ingredients listed. If the skin is badly cracked, infected or bleeding do not apply; seek medical advice before use. Avoid contact with the eyes. Using Zeroderm Ointment during pregnancy and breastfeeding is unlikely to have any ill effects. If unsure, talk to your doctor or pharmacist. Baths and showers may become slippery. Take care not to slip.

Clean away any residues with household cleaner using warm water. Fire hazard. Do not smoke or go near naked flames; clothing & bedding with this product dried on them can catch fire easily. Washing clothing and bedding may reduce product build-up but not totally remove it. Do not use if tear-tab is broken or appears tampered with at first use. If you accidentally swallow some see a doctor straight away. Show this label or pack.

Use within 12 months of opening. Keep out of the sight and reach of children. Do not use after the expiry date. Contra-indications: Hypersensitivity to any of the ingredients.

Method of administration: Adults, the elderly and children: As an emollient: Apply to the affected area as often as required. Smooth gently into the skin, following the direction of the hair growth. As a bath additive: Melt about 4g (roughly a teaspoonful) of Zeroderm Ointment in hot water in a suitable container. Then add to the bath ensuring that the water has sufficiently cooled before getting in. As a soap substitute: Take a small amount of Zeroderm Ointment from the tub, lather it under warm water and use as required when washing or in the shower. Pat skin dry. Date of preparation: 14/11/2023.

Do not smoke or go near naked flames – risk of severe burns. Fabric (clothing, bedding, dressings etc) that has been in contact with this product burns more easily and is a serious fire hazard. Washing clothing and bedding may reduce product build-up but not totally remove it.

Medical advice should be sought before use of emollients if the skin is broken, badly cracked, infected or bleeding.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Thornton and Ross Limited by emailing thorntonross@medinformation. co.uk or by calling 01484 848164.

Zeroderma, Zerobase, Zerocream, Zeroveen, Zerodouble and Zeroderm are registered trade marks of Thornton & Ross Ltd.

References: 1. IQVIA RXA Unit Sales ending March 2024. 2. Thornton & Ross, data on file. 3. NICE, Which emollient product should I prescribe? Available at: https://cks.nice. org.uk/topics/eczema-atopic/prescribing-information/emollients/#choice-of-product accessed August 2024.

STADA UK, Thornton & Ross Ltd., The Globe (3rd floor), Bridge Street, Slaithwaite, Huddersfield, HD7 5JN Telephone: +44 (0)1484 500283 www.zeroderma.co.uk

UK-ZERO-303(1) | August 2024.

Expert consensus on the systemic treatment of atopic dermatitis Hamish Hunter, Philip Laws, Agustin Martin-Clavijo, Louise Newell, Majid Sheikh, Richard Weller, Richard Woolf Introduction This consensus contains the personal views of the authors. Any information not derived from the consensus discussion has been referenced accordingly.

Atopic dermatitis (AD) is a chronic, systemic, inflammatory skin condition, affecting 5-10% of UK adults.1,2 Approximately 30% of patients with AD are reported to have moderate to severe disease.3 Moderate to severe AD can be holistically defined as disease which fails to respond to maximum topical therapy (including topical corticosteroids and topical calcineurin inhibitors) and has a

significant impact on the physical, psychological, and social wellbeing of the patient.

Until recently, the treatment landscape was limited to topical and conventional systemic therapies and phototherapy, which do not target specific disease pathways.2 Topical therapies, whilst integral to AD skincare, are onerous to apply and by definition, lack efficacy as monotherapy for moderate to severe AD. Conventional standard systemic therapies (methotrexate, azathioprine, ciclosporin and mycophenolate mofetil), of which ciclosporin is the only licensed treatment, are effective for some patients, however, many suffer from tolerability

Summary: This position paper centres on recommendations from UK dermatology experts on the treatment of atopic dermatitis in the UK, including prescribing decisions in the new treatment landscape of atopic dermatitis. It then provides consensus on how the UK healthcare system should evolve treatment recommendations going forward, providing suggestions for prescribing systemics, biologics and JAKs in different patients.

Abstract: Background: Atopic dermatitis (AD) is a chronic, systemic, inflammatory skin condition.

In recent years, with increased understanding of the pathophysiology of AD, more disease-specific therapy options have become available. Objectives: This article presents recommendations developed by an expert panel of UK dermatologists on treatment choice, sequencing and bridging (overlapping conventional systemics with targeted therapies), in the new AD treatment landscape with newly approved biologics and Janus kinase inhibitors (JAKs). This manuscript also includes evaluation of the definition of moderate to severe disease. Method: These recommendations were generated after a detailed evaluation of the clinical trial data for dupilumab, tralokinumab, baricitinib, upadacitinib and abrocitinib. Insights were gathered using medCrowd, a digital advisory board technology. Results: A consensus opinion was developed by the authors discussing next steps in the evolving management of AD. Conclusion: The data shows that earlier intervention may reduce the risk of chronic disease status and optimise treatment response, thereby improving quality of life and reducing disease burden on the individual.

Citation: Hunter H, Laws P, MartinClavijo A, Newell L, Sheikh M, Weller R, Woolf R. Expert consensus on the systemic treatment of atopic dermatitis. Dermatological Nursing 2024. 23(3):11-14.

Keywords: Atopic dermatitis, Biologics, JAK inhibitors, Treatment choice, Consensus

Author info: Dr Hamish Hunter MRCP (Derm), PHD, Northern Care Alliance NHS Foundation Trust. Philip Laws MBChB, Leeds Teaching Hospital NHS Trust. Agustin Martin-Clavijo LMS, PhD, MRCP, University Hospital Birmingham NHS Foundation Trust. Louise Newell MB ChB (Hons) MRCP (Derm), University Hospital Bristol and Weston NHS Trust. Majid Sheikh BSc (Hons), Leo Pharma UK. Richard Weller FRCP(Ed), University of Edinburgh Division of Medical and Radiological Sciences. Richard Woolf MBChB and PhD, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK. www.bdng.org.uk

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issues.3 In recent years, with the increased understanding of AD pathophysiology, more disease-specific therapeutic options have become available.2 These include biologics: dupilumab (an anti–interleukin (IL)-4Rα antibody), tralokinumab (anti-IL-13 antibody) and JAK: baricitinib (JAK 1, 2 and 3) upadacitinib (JAK 1) and abrocitinib (JAK 1).2,4 What is already known about this topic? l National Institute for Health and Care Excellence (NICE) and Scottish Medicines Consortium (SMC) preclude the use of biologics or JAK for first-line treatment. l Guidelines state that at least one conventional systemic must be tried or standard therapy contraindicated before moving to a biologic or JAK. l There is limited real-world data on most biologics and JAK, with the exception of dupilumab.

What does this study add? l A consensus opinion in light of new therapies being approved for use in AD. l Suggestions for how to switch between new therapies. l Holistic definition of treatment failure. l Consensus on next steps required in the AD field.

Methodology Six expert dermatologists were selected to co-author this manuscript due to their expertise in AD (Table 1). Insights were gathered via a text-based asynchronous digital advisory board which was carried out on medCrowd, a dedicated healthcare communications platform. Before initiating the advisory board, the dermatologists were presented with one summary of all indicated therapies and conventional systemics, as well as clinical study summaries for dupilumab, tralokinumab, baricitinib, upadacitinib and abrocitinib. The studies which were included in these

summaries were chosen by searching for all pivotal phase 3 trials in AD. The experts were initially asked an open-ended question to highlight the topics that they wished the consensus piece to cover. The five topics which were deemed most important by the experts were then selected and organised into five conversations with more specific questions. These conversations were then posed to the experts over the course of two months, with one conversation being posted to medCrowd every oneto-two weeks and left open for experts to respond to asynchronously. Insights from the group phase conversations were summarised and discussed in a Teams meeting and follow-up questions asked to ensure full comprehension and clarity on final statements. Finally, the group of authors was asked to come up with a consensus opinion on the current landscape of AD and recommendations going forward. This consensus opinion was then discussed and confirmed via email after the Teams meeting.

Results and discussion Treatment decisions: conventional systemics

Choice of drug is influenced by many factors including coexisting conditions, comorbidities, pregnancy, drug interactions, lifestyle factors, route of administration and licensing issues. Clinicians should take these factors into account when prescribing, but ultimately should have autonomy for treatment decisions, acknowledging that every patient is unique and will have a different clinical need.

Clinicians feel comfortable using conventional systemics given their proven track record and known side effect profile. Moreover, they are easy to access with no Bluteq/ NICE criteria to satisfy. Ciclosporin is the only treatment licensed for moderate to severe AD. Ciclosporin is

Declaration of interest Hamish Hunter has received grant funding from AbbVie, Janssen, Merck Serono and Pfizer. He has received honoraria and/ or consultancy fees and/or travel bursaries from AbbVie, Almirall, DICE Therapeutics, Eli Lilly, Galderma, Janssen, La RochePosay, Leo, Novartis, Pfizer, Regeneron, Sanofi Genzyme, UCB and UNION Therapeutics. He has acted as an investigator for AbbVie, Almirall, Bayer Pharmaceuticals, DICE Therapeutics, Eli Lilly, Evelo Biosciences Inc., Janssen, Leo, Novartis, ONO Pharmaceutical Co. Ltd., Sanofi Genzyme, UCB and UNION Therapeutics.

Philip Laws has received honoraria and/or grants as an investigator, speaker, and/or advisory board member for AbbVie, Almirall, Actelion, Celgene, Janssen, Lilly, Sanofi, Leo, UCB and Novartis.

Agustin Martin-Clavijo has received honoraria as a speaker, scientific advisor and steering committee member and has attended conferences by AI Nexus, Almirall, BMS, Leo and Novartis.

Louise Newell has received honoraria and/or participated in advisory boards for Almirall, Leo and Sanofi.

Majid Sheikh is an employee of LEO Pharma.

Richard Weller has received honoraria as a speaker and consultant for Almirall, Eli Lilly, Galderma and Sanofi.

Richard Woolf has acted as an investigator in clinical trials for Abbvie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galderma, Janssen, Leo Pharma, Novartis, Pfizer and Sanofi. He has received honoraria from and done consultancy work for Abbvie, Leo Pharma, Novartis, Sanofi and UCB as well as honoraria from NICE as a clinical expert.

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favoured in patients with urticaria or urticated eczema and is also relatively favoured in pregnancy, however it may cause hypertension which can increase the risk of pre-eclampsia. Ciclosporin is rarely used in patients with hypertension, renal impairment, hyperlipidaemia or gout and is not suitable for obese patients with fatty livers and/ or renal impairment. Methotrexate is another commonly used systemic treatment but should not be used in patients with raised P3NP or non-alcoholic steatohepatitis (NASH) and should be used cautiously in those with liver comorbidities (especially in those patients with high alcohol intake). Methotrexate is also contraindicated in pregnancy for six months after stopping treatment.

It is also important to take patient infection status into account when choosing a treatment. Screening for human immunodeficiency virus (HIV), hepatitis B and C, varicella zoster virus (VZV) and herpes simplex virus (HSV) are recommended.

Choice of agent: biologics or JAKs

In the UK, NICE mandates using conventional systemic therapies as first-line treatment. Since the introduction of biologics and JAKs, patients can progress to biologic or JAK therapy following one failed systemic. The authors agreed that if cost was not a factor, the newer treatments should be available as a first-line option due to their superior evidence base when compared to conventional systemics.

NICE and SMC guidance positions JAKs alongside biologics as this allows the healthcare professional (HCP) and patient to come to a joint decision about the best treatment option. Positioning of biologics vs JAKs depends on a variety of HCP and patient factors. JAKs may be more suitable for patients with needle phobia and higher risk of eye side effects, as well as those requiring rapid response.

Biologics may be more suitable for elderly patients, patients with significant atopic disease (such as asthma), patients with significant COVID risk and those who are immunosuppressed. HCPs may feel more comfortable with prescribing biologics due to more real-world experience and the fact that they are a more targeted treatment with good efficacy and a favourable side effect profile.

Whilst there is sometimes a clear choice between JAKs and biologics due to patient factors, there is still no overall consensus on what order to prescribe JAKs and biologics in most AD patients.

Lack of response

Treatment failure lacks an agreed definition and depends on the goals and expectations of the patient and clinician.

In clinical trials, treatment failure is usually defined as not achieving the primary end point (usually a pre-defined IGA or EASI score). However, whilst NICE defines treatment failure as EASI 50 and DLQI>4 improvement, in practice, the definition of treatment failure is more holistic, depending on the patient’s expectations and the physician.

Some measures of treatment failure that are commonly

www.bdng.org.uk

used in practice are qualitative evidence of no response or poor response, failure to reach EASI 75, or treatment results not meeting patient expectations.

When considering whether a treatment has failed and whether to switch treatments, it is important to look for other related factors which may explain why the disease is not controlled (e.g. lack of adherence or allergens that may be causing dermatological symptoms). If all other factors are addressed and there is still a lack of response, then HCPs must consider whether to augment or switch therapies.

Treatment failure is dealt with differently depending on the treatment in use. If the patient fails on a conventional systemic, physicians should discuss dupilumab or tralokinumab, as well as alternative targeted treatments depending on patient choice. If the patient fails on a biologic, physicians should consider JAKs or revisit untried conventional systemics. If a patient fails on a JAK, physicians should consider alternative JAKs, biologics or revisit untried conventional systemics.

Treatment switching

When changing treatments, care must be taken to ensure a safe and effective switch. This includes factoring in a washout period if necessary, to avoid drug interactions, bridge (overlap) treatments, and avoid disease flare whilst establishing efficacy.

When switching treatment, therapies are not routinely bridged if the risk of disease flare is low, however, if the risk is significant, treatment bridging may be important. In some instances, ciclosporin or methotrexate may be used alongside other treatments whilst establishing efficacy.

Immunosuppressants are also used when transitioning some patients from conventional systemics to dupilumab, or from ciclosporin to methotrexate. A short course of prednisolone may also be used when initiating methotrexate treatment. In some instances, there may be reasoning to co-prescribe treatments for longer periods of time. In many cases, topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI) may be co-prescribed with systemic treatments, and dupilumab may be coprescribed alongside methotrexate, although this is off license and uncommon.

There is currently less experience in switching from JAKs to biologics and vice versa, so the decision to do so would be based on clinical need. Physicians should consider switching from a biologic to a JAK due to primary or secondary failure, or if the patient is suffering from unacceptable side effects including eye symptoms. A washout period of four to six weeks would be recommended, but if disease control is a concern, a washout period of two weeks could be considered. Physicians should take into account that JAKs require more frequent blood monitoring than biologics. Physicians should consider switching from a JAK Dermatological Nursing 2024, Vol 23, No 3

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to a biologic due to primary or secondary failure, or if the patient has unacceptable side effects or is developing comorbidities. A washout period of three to five days is recommended to avoid drug interactions.

Treatment breaks

Treatment breaks can be considered if the eczema is well controlled whist on therapy and remains quiescent or mild while off therapy. This decision would generally be made in conjunction with the patient. In treatments where it is within license, it would be recommended to reduce dosing frequency before taking a treatment break, but if the patient is in remission or has minimal disease and wants to consider stopping therapy, treatment breaks could be considered. This would usually be after at least 12 months of treatment.

There are some risks of taking treatment breaks. Firstly, the longevity of effect and likelihood of relapse after stopping long-term AD treatment is unknown. Secondly, it is possible that taking treatment breaks may minimise the likelihood of inducing deep remission. Additionally, when using a start-stop approach, there is a risk of not recapturing disease control when reinitiating treatment. A proportion of patients with severe disease are unlikely to become disease free and intermittent therapy is rarely indicated. In the subset of patients that experience prolonged remission, dose reduction or treatment withdrawal may be an option.

Conclusion Consensus opinion

AD and its associated disease burden is often underappreciated, under-treated and under-resourced in both primary and secondary care. This is despite its higher profile due to recent therapeutic advances. A lack of experience in treating AD means that individuals may not be provided with prompt, optimal therapy. This includes all elements of the pathway from topical treatment to novel therapies.

Recent therapeutic advances suggest we should be aiming for higher response rates earlier on in the treatment pathway. As such, patients suitable for systemic therapies should be recognised and referred promptly. Earlier intervention may reduce the risk of chronic disease status and optimise treatment response, thereby improving quality of life and reducing disease burden on the individual.

Acknowledgements Funding: This manuscript was created and funded by LEO Pharma.

Advisory Board/Medical Writing/Editorial Assistance: Advisory board support, medical writing and editorial assistance were provided by Francesca Pullan, MChem, Pavandeep Bilkhu, MSc, and Soufiane Taleb, MBiol, from medDigital, funded by LEO Pharma.

Authorship: All named authors take responsibility for the integrity of the work as a whole and have given their approval for this version to be published.

We would also like to acknowledge Dr Joyce Leman, Consultant Dermatologist (previous employee of LEO Pharma) for her support in initiating this manuscript.

References 1. Cork MJ, Danby SG, Ogg GS. Atopic dermatitis epidemiology and unmet need in the United Kingdom. J Dermatolog Treat 2020.

31(8):801-809 2. Moyle M, Cevikbas F, Harden JL and Guttman-Yassky E. Understanding the immune landscape in atopic dermatitis: The era of biologics and emerging therapeutic approaches. Exp Dermatol 20I9. 28(7):756-768 3. Silverwood RJ, Mansfield KE, Mulick A et al. Atopic eczema in adulthood and mortality: UK population-based cohort study, 19982016. J Allergy Clin Immunol. 2021 May; 147(5): 1753-1763 4. Cartron AM, Nguyen TH, Roh YS, Kwatra MM and Kwatra SG. Janus kinase inhibitors for atopic dermatitis: a promising treatment modality. Clin Exp Dermatol 2021. 46(5):820-824.

Table 1. Information about the authors Participant

Years of experience

Hamish Hunter

12

Philip Laws

10

Agustin Martin-Clavijo Louise Newell

14 10

Richard Weller Richard Woolf

25 12

14

Specialty area Consultant dermatologist, clinical and research specialist in the management of eczema.

Co-lead of a medical dermatology service and clinical trial investigator focusing on psoriasis, eczema and lupus.

Consultant dermatologist and dermatology research lead.

Consultant adult and paediatric dermatologist, lead for the adult and paediatric complex eczema services.

Clinical and research specialist in eczema.

Clinical and research specialist in eczema, steering committee member on AD registry and author on local and regional AD guidelines.

Dermatological Nursing 2024, Vol 23, No 3

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An overview of the barriers and advances in hidradenitis suppurativa nursing intervention in Scotland Caitlin Thomson Introduction Hidradenitis suppurativa (HS) or acne inversa is a chronic, inflammatory condition involving apocrine glands of the skin. The skin surrounding the apocrine glands forms painful abscesses and cysts, causing sinus tract formation and severe scarring.1 Common sites include the axillae, groin, perineum, buttocks and sub-mammary region, but it can occur anywhere on the body. The lesions can be painful, exceedingly persistent and disfiguring. It is thought that approximately 1-4% of the population are affected by this distressing, incurable condition.2 There is a higher prevalence in women than men,3 and research has found high incidence in African American populations in comparison to that of Hispanic, Latino and Caucasian individuals, suggestive of a genetic aetiology in some cases.4 Smoking and obesity are the most named risk factors associated with the condition, but it is important to remember that a non-smoker with a healthy BMI score can still be affected by the condition.5

Diagnostic delay and its impact HS remains vastly misunderstood and the problem appears to begin with receiving a timely diagnosis. Patients with HS reported an average delay of seven years before

an accurate diagnosis, with reviews by three separate physicians prior to a correct diagnosis.6 Since HS is a progressive scarring condition, seven years can cause irreversible damage to the skin. Initially, these statistics appear startling; however, the study does have limitations.

The reasoning for this delay is not disclosed and does not consider external patient factors (for example, the time the patient waits to go to their general practitioner). That being said, we cannot ignore this delay nor deny the abundance of literature surrounding diagnostic delays.

Unfortunately, the difficulty in obtaining a diagnosis in primary care and a timely referral to specialist services compounds the problem. The Scottish Government announced in a report in 2021 that NHS outpatient services had seen a 41% decrease in activity since March 2020.7 In time, this has had significant delays to the care and treatment of many dermatological conditions, including HS. A cause of the diagnostic delay is unarguably due to a lack of funding for research. Minimal funding efforts into researching a condition and its possible treatments and/ or cures limits our understanding of the aetiology and disease course. In the USA, where approximately 98 out of 100,000 people are affected by HS,8 a study in 2019 found

Abstract: This article looks at the care pathway in Scotland for patients with hidradenitis suppurativa. It will consider the challenges for diagnosis, assessment and management in primary care, as well as secondary care referral, and explores the need for appropriate psychological support for patients. It will also look at the role of the dermatological nurse within this pathway.

Author info: Caitlin Thomson is a dermatology nurse working within NHS Fife, Scotland.

She has three years dermatology nursing experience and four years previous experience in medical and surgical settings including orthopaedics, general medicine and gastroenterology.

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Keywords: Hidradenitis suppurativa, Acne inversa, Management, Treatment, Psychological support Citation: Thomson C. An overview of the barriers and advances in hidradenitis suppurativa nursing intervention in Scotland.

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that 4,443 funding grants had been awarded into psoriasis research, whereas only nine grants had been awarded to research into HS.9 Lack of research can result in crucial treatments being missed or never having the opportunity to be explored. Understandably, psoriasis is a more prevalent condition; however, it is unfair to compare them due to their number of affected individuals. It also does not invalidate the symptoms or suffering associated with HS. It seems almost inhumane to deny someone treatment based on a lack of evidence.

Primary care nursing assessment and management Primary care facilities such as GP practices are usually where a HS diagnosis takes place and initial treatment is started. The Primary Care Dermatology Society (PCDS) has a set of guidelines available to primary care health professionals in the UK to aid first-line treatment of HS symptoms. These guidelines offer practical advice in terms of managing the condition with topical and oral preparations (e.g. antiseptic washes for use on skin and oral antibiotics to treat active disease).10 The PCDS does offer some guidance on wound care, but overall, there is limited guidance available for managing wounds. In addition, flexural areas on the body can be difficult to treat, and standard shaped dressings are not always helpful.

It can therefore make dressing selection difficult, especially if dressings have excessive absorbency properties for high exudate sites. It is thought that people with HS can change wound dressings up to three times daily, and more during flare-ups.11 A study on HS wound dressings in 2022 found greater patient satisfaction, pain reduction and lack of negative emotions due to access to HS-specific dressings.12 Therefore, dressing of HS-associated wounds is an important aspect of care to manage flare-ups and preserve skin integrity.

HS patients should also be offered regular consultations to help preserve their mental wellbeing and reduce the likelihood of engaging with psychology services and causing longstanding psychological issues. Therefore, psychologically aimed questionnaires should be given to patients to ensure professionals have documented evidence of their thoughts and feelings. A questionnaire tool commonly used in practice is the Dermatology Quality of Life Index (DLQI). First developed in the 1990s and subsequently updated, the DLQI tool is a simple 10-question analysis for understanding the psychological impact of skin disease on an individual.13 This, among other questionnaires, can be used in both primary and secondary care and does not need specialist training to initiate or interpret.

One of the most important things to remember is allowing the patient to tell their story and share their experiences. It can be a useful way of understanding what treatment pathways may be appropriate for them and therefore increase compliance with treatment plans. www.bdng.org.uk

Mild-to-moderate HS can be managed in primary care settings, however a referral to dermatology outpatient care should be considered for specialist intervention such as methotrexate, dapsone, biologic therapies, or possibly surgical intervention.

Challenges in secondary care: Medical and surgical management In Scotland, patients with HS follow a treatment pathway as set out by the Scottish Government and associated NHS health boards. Treatment can also be given under guidelines by the Scottish Intercollegiate Guidelines Network (SIGN) (specific to Scotland) or the National Institute for Health and Care Excellence (NICE). Currently, there is no available guidance on HS treatment and management within SIGN. NICE has published guidance on the use of adalimumab in “moderate to severe” HS.14 This tends to be the treatment of choice when systemic medication such as dapsone and methotrexate have failed.

Adalimumab is usually initiated by a specialist to ensure appropriate monitoring (for example, a dermatology consultant or advanced nurse practitioner). Although a relatively successful treatment, the time it takes to reach this point can be very disheartening for HS patients.

“Dressing of HS-associated wounds is an important aspect of care to manage flare-ups and preserve skin integrity” In some instances, patients may be referred for surgical intervention for drainage of abscesses and removal of damaged skin when medical intervention does not provide symptomatic relief. However, as with any intervention, surgery comes with risks. One risk associated with surgical input is increased risk of infection. A report by Health Protection Scotland which audits the infection rates in hospitals in Scotland highlighted that over 65% of people who acquired it by a bacterium called staphylococcus aureus were acquired in a clinical setting.15 In addition, the prevalence of coronavirus is still a factor to be considered, with 966 positive Covid-19 cases in Scotland submitted on 15 October 2023, and 256 of these cases resulting in hospital admission.16 This statistic is representative of cases reported; there may have been many more unreported positive cases. The prevalence of infection can warrant the need for antibiotic treatment and therefore possibly prolong hospital admission, depending on the severity.

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This can increase the cost to the NHS and result in additional stress for the patient and their family. In this instance, the risk of peri-surgical complications, coupled with the prevalence of HS, is a factor worth considering.

Additionally, the estimated average cost to the NHS per surgery is approximately £2,402.17 Given the inability to cure HS via surgical intervention, the practitioner must consider whether this is the most appropriate course of action. It may be suitable for short-term treatment such as drainage of cysts or abscesses that arise, but several NHS health boards heavily discourage surgical intervention as a treatment route for this reason.

In a positive advance for HS treatment, guidelines for the use of secukinumab as a viable treatment option for treating moderate to severe HS were approved by the Scottish Medicines Consortium (SMC).18 This is a promising step forward to expanding HS treatment, and many patients who are failing to control their condition on current therapies will hopefully benefit from this new treatment.

Psychological assessment and support Psychological support tends to be viewed as an additional treatment aim, but should we be looking to manage the psychosocial impact of the disease as we do the physical symptoms?

In a study of psychiatry and HS, nearly 30% of more than 600 participants had psychological co-morbidities19 as well as an increased risk of suicide and depression compared to the general public.20 This figure emphasises that the associated psychosocial symptoms of HS can be very serious. In addition, as many as 40% of patients with HS can experience sexual dysfunction and reluctance to connect with sexual partners, contributing to distressing psychological symptoms such as anxiety and depression.21 A fear or reluctance to connect with sexual partners can be an exceedingly painful experience, which many find difficult to come to terms with and resolve. This is another significant life adjustment someone with a HS diagnosis may have to face. Ongoing mental health symptoms and even suicide risk are very serious and should not be taken lightly when dealing with chronic health conditions.

Conversations around psychological symptoms should be explored in appointments and the patient should feel supported to openly share their thoughts and feelings in a safe, judgement-free environment. It can be difficult for patients to discuss their psychological symptoms, but it can be equally hard for the practitioner to broach the subject of mental wellbeing and even suicide.

Compassionate nursing care The above evidence emphasises how severely some patients’ psychological wellbeing can be impacted when living with HS, leaving them feeling vulnerable and expressing poor self-esteem and quality of life. HS is regarded as the most impactful condition on quality of 18

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“One of the most important things to remember is allowing the patient to tell their story and share their experiences” life among dermatological conditions.22 This is where we need to look at our practice as healthcare practitioners, in particular, the way we deliver our interventions and consultations.

Compassionate care is a highly sought after aspect of modern-day nursing. In Scotland, Healthcare Improvement Scotland (HIS) published their Excellence in Care framework, a tool for healthcare practitioners which envisions providing person-centred care across the country.23 This guide states that compassion is important when delivering care to service users due to the positive impact it has on healthcare interventions.

Although the publication provides a clear approach to positive nursing care, it would seem there are still dissatisfied patient groups. In a study of patient perceptions of care, 31.6% of patients described their nursing consultation as lacking in satisfactory knowledge and instruction from the practitioner, with 11.5% stating they did not think their practitioner had a ‘caring attitude’.24 Thus, making improvements to the way in which we practice is highly sought after. After all, the Nursing and Midwifery Council (NMC) expect nurses to treat patients with compassion, as highlighted in the NMC Code of Conduct.25 With that in mind, we must regularly selfevaluate our practice as agreed when we became part of the NMC register for professional nursing practice and renew our registrations through a process known as revalidation. This can be achieved through regular auditing of nursing consultations using the Care and Relational Empathy (CARE) measure which evidences the empathetic response from a clinician in a patient's treatment journey.26 Increasingly, dermatology nursing innovations and interventions are the mainstay of long-term management for chronic inflammatory skin conditions. Much like primary care, nurses are usually the first point of contact for patients. Along with practical interventions, such as systemic blood monitoring and providing topical treatments, they can go through logical problem-solving in terms of wound dressings, clothing, diet and exercise, not to mention signposting patients on to further support or specialists such as weight management services and external support groups. Nurses are also on hand to aid with psychological symptoms associated with HS, with the ability to listen to patient concerns and aid them in living their best possible life. Dermatology nurses www.bdng.org.uk

Clinical practice

are usually highly trained in the aetiology and effects of the condition, and can offer high quality education for the patient, explain the rationale behind treatments and interventions, and share management tips on what has helped other patients. Dermatology nurses are usually the first to hear about new HS management options and can advise patients on what is becoming available, as well as involving patients in clinical trials to test new medications and other interventions.

While we are highly educated in the condition, it is exceptionally hard as a healthcare practitioner to signpost a person with HS towards condition-specific support groups or charities within the UK. The USA has many organisations, such as the HS Foundation, Hope for HS and HSConnect.

Regarding HS history, aetiology and clinical presentation, UK-based individuals may find some benefit from these sites, however UK-specific organisations need to be in operation to support patients.

“HS is regarded as the most impactful condition on quality of life among dermatological conditions” Due to this support gap, patients are taking it upon themselves to form informal groups via social networking sites and personal blogs. Of course, websites such as the British Association of Dermatologists and the British Skin Foundation have information on HS, but there is no condition-specific outlet for HS patients to support each other openly. Without a space for discussion, it can be incredibly isolating. It can also entice patients into a false sense of security. It is undeniable American healthcare is far more advanced in some matters compared to the UK, and therefore treatment and management may vary greatly from NHS-approved therapies. This can be incredibly disappointing knowing more effective treatments or management options are available based on a geographical advantage.

Multi-disciplinary team collaboration and the future perspective on HS Although it is clear we understand a lot about the prevalence and aetiology of HS, there is still more work to be done. A recent literature review found a vast increase in the available research and publications on HS from 2008-2018.27 The information available includes a variety of research including, randomised controlled trials, surveys and case studies. This is a huge advance in HS knowledge and understanding, and gives practitioners and patients hope that HS management is improving. www.bdng.org.uk

The review used only one search database and nonEnglish language articles were excluded from the research, limiting the analysis. Consequently, there could be much more data available in different languages to support other areas of the population. With an increased number of recent resources available for clinicians, there is room for improved nursing interventions, which in turn can result in better patient experiences and outcomes. In addition, with resources being more available in the public domain, it can result in better patient education and possibly more effective self-management behaviours for people living with HS.

Conclusion This article has provided an overview of HS, management strategies (including nursing interventions) and holistic approaches to care and assessment. HS treatments and management have made positive advances over the years.

The recent unveiling of new ground-breaking medical biological medication is a much-welcomed option by many patients across the world. However, as dermatology healthcare practitioners, we know that more research needs to be done to manage the condition effectively and safely. We also need to consider strategies for earlier diagnosis and ways to incorporate holistic approaches to assessment and care.

The wider healthcare team across primary, secondary and tertiary care services can be involved in optimising care through appropriate assessment, timely referral and evidenced-based treatments. This will aim to reduce known complications such as recurrent severe infections and scarring, and psychosocial impact and recognise co-morbidities more quickly. If more practitioners are aware and knowledgeable about HS, treatment pathways and holistic nursing interventions, we may be able to provide better care and education for the patient. There is a profound lack of psychosocial support for those affected by HS within the NHS. Advances in dermatology nursing and practices have seen nurse-led clinics be developed to support the ongoing management and screening of persons living with a long-term condition. This is something very relevant for HS management as early screening for comorbidities and monitoring of advanced treatments is vital and represents a major nursing contribution.

The prognosis may at times appear bleak for some, but hopefully with dermatology nursing innovation and service development for new treatments, the future will be bright for patients with HS in Scotland and beyond.

References 1. Hidradenitis Suppurativa (HS). NHS.uk. 2022. Available at: https://www.nhs.uk/conditions/hidradenitis-suppurativa/ [last accessed April 2024] 2. Guy’s and St Thomas’ NHS Foundation Trust. Available at: https://guysandstthomas.nhs.uk [last accessed April 2024]

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“Dermatology nurses are usually first to hear about new HS management options and can advise patients on what is becoming available” 3. Hidradenitis Suppurativa – Patient Information Leaflet. British Association of Dermatologists 2021. Available at: https://cdn.bad. org.uk/uploads/2021/11/15153002/Hidradenitis-suppurativa-PILMay-2021.pdf [Last accessed April 2024] 4. Sachdeva M, Shah M, Alavi A. Race-Specific Prevalence of Hidradenitis Suppurativa. Journal of Cutaneous Medicine and Surgery 2021. 25(2):177-187 5. Nicolle L. Optimising hidradenitis suppurativa care: A multiprofessional consensus statement. 2022. HS consensus statement.

Available at: https://bdng.org.uk/wp-content/uploads/2022/09/DNSeptember-2022-Supplement-HS.pdf [last accessed April 2024] 6. Saunte, DM, Boer J, Stratigos A. et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol 2015.

173: 1546-1549 7. NHS Recovery Plan 2021-2026. Scottish Government 2021. Available at: https://www.gov.scot/binaries/content/ documents/govscot/publications/strategy-plan/2021/08/nhsrecovery-plan/documents/nhs-recovery-plan-2021-2026/nhsrecovery-plan-2021-2026/govscot%3Adocument/nhs-recoveryplan-20212026.pdf [last accessed April 2024] 8. Garg A, Kirby JS, Lavian J, Lin G, Strunk A. Sex- and AgeAdjusted Population Analysis of Prevalence Estimates for Hidradenitis Suppurativa in the United States. JAMA Dermatol 2017.

153(8):760-764 9. Naik HB, Lowes MA. A Call to Accelerate Hidradenitis Suppurativa Research and Improve Care-Moving Beyond Burden.

JAMA Dermatol 2019. 155(9):1005-1006 10. Moloney S, Fitzgerald D, Roshan D, Gethin G. Impact of hidradenitis suppurativa-specific wound dressing system on patient quality of life and dressing-related pain: pilot study. Journal of Wound Care 2022. 31(11):898-906 11. Hidradenitis Suppurativa. Primary Care Dermatology Society 2021. Available at: https://www.pcds.org.uk/clinical-guidance/ hidradenitis-suppurativa [last accessed April 2024] 12. Theakston C, Henderson N, Skedgel C. The Burden of Hidradenitis Suppurativa on Patients, the NHS and Society: Estimates and Recommendations. Office of Health Economics Contract Research Report 2023. Available at: https://www.ohe.org/ publications/es [last accessed April 2024] 13. Finlay A, Khan, G. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clinical and Experimental Dermatology 1994. 19: 210-216 14. Adalimumab for treating moderate to severe hidradenitis suppurativa [TA392]. NICE 2016. Available at: https://www.nice.org. uk/guidance/ta392 [last accessed April 2024]

bacteraemia and Surgical Site Infection in Scotland Health Protection Scotland 2019. Available at: https://hpspubsrepo.blob. core.windows.net/hps-website/nss/2866/documents/2_2019-1001SAB-CDI-EColi-SSI-Infections-Q2-2019-Report.pdf [last accessed April 2024] 16. Viral respiratory diseases (including influenza and COVID-19) surveillance in Scotland. Public Health Scotland 2023.

Available at: https://publichealthscotland.scot/publications/viralrespiratory-diseases-including-influenza-and-covid-19-in-scotlandsurveillance-report/viral-respiratory-diseases-including-influenzaand-covid-19-in-scotland-surveillance-report-4-april-2024/ [last accessed April 2024] 17. Secukinumab for treating moderate to severe Hidradenitis Suppurativa. Draft Guidance Consultation 2023. National Institute for Health and Care Excellence: London; 2023. Available at: https:// www.nice.org.uk/guidance/gid-ta11095/documents/674.uk [last accessed April 2024] 18. Secukinumab (Cosentyx). Scottish Medicines Consortium.

Healthcare Improvement Scotland 2024. Available at: https://www. scottishmedicines.org.uk/media/8106/secukinumab-cosentyx-finaljan-2024-for-website.pdfv [last accessed April 2024] 19. Holgersen N, Nielsen VW, Ring HC, Rosenø NA, Egeberg A, Thyssen J P et al. Psychiatric co-morbidity in patients with hidradenitis suppurativa: A cross-sectional study of clinical characteristics and burden of disease. Journal of the European Academy of Dermatology and Venereology 2023. 2(4):994-1004 20. Thorlacius L, Cohen AD, Gislason GH, Gregor J, Egeberg, A. Increased Suicide Risk in Patients with Hidradenitis Suppurativa.

Journal of Investigative Dermatology 2018. 138:52-7 21. Seetan K, Al-Zubi M, Al-Omari R. Sexual Dysfunction in Patients with Hidradenitis Suppurativa: A Systematic Review and Meta-Analysis. Journal of Clinical and Aesthetic Dermatology 2021.

14(8):61-65 22. Touhouche A, Chaput B, Rouquet R, Montastier E, Caron P, Gall Y et al. Integrated multidisciplinary approach to hidradenitis suppurativa in clinical practice, International Journal of Women’s Dermatology 2022. 6(3):164-168 23. Excellence in Care Framework. Healthcare Improvement Scotland. Available at: https://www.healthcareimprovementscotland. org/our_worl/patientsafety Published 2022. [last accessed April 2024] 24. Samina M, Gj Q, Tabish S, Samiya M, Riyaz R. Patient’s Perception of Nursing Care at a Large Teaching Hospital in India.

International Journal of Health Sciences 2008 2(2):92-100 25. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing & Midwifery Council 2018. Available at: http://www.nmc.org.uk/globalassets/ sitedocuments/nmc-publications/revised-new-nmc-code.pdf [last accessed April 2024].

26. Mercer SW. The CARE Measure. Available at: https:// caremeasure.stir.ac.uk/#:~:text=The%20Consultation%20 and%20Relational%20Empathy,to%20complete%20 patient%2Dcompleted%20questionnaire [last accessed April 2024] 27. Savage K T, Gonzalez Brant E, Flood K S, Salian, P, Porter M L, Kimball A B. Publication trends in Hidradenitis Suppurativa from 2008 to 2018. Journal of the European Academy of Dermatology and Venereology 2020. 34:1885-9.

15. Quarterly epidemiological data on Clostridioides difficile infection, Escherichia coli bacteraemia, Staphylococcus aureus

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Eczema: A treatment algorithm incorporating fludroxycortide tape Nisa Aslam, Sangeeta Punjabi Introduction Management of eczema is often challenging. Not only can eczema cause severe physical symptoms in terms of flares, but it is also associated with mental health issues such as depression, low self-esteem and lack of confidence.1 The treatment of eczema often requires a multi-factorial approach.

1. Firstly, address dry skin: It is managed in a stepwise manner with emollient therapy used as the foundation of care along with advice to avoid irritants.

2. Secondly, address the inflammation: Topical steroids will almost always be needed, with the strength used dependent on the severity of the condition and the response to treatment. Use of topical calcineurin inhibitors (e.g. tacrolimus) in severe, recalcitrant cases and referral to secondary care may occasionally be needed.

3. Thirdly, if infection is present, then this will need to be addressed accordingly.

The key rescue treatment for acute flares involves timely prescribing of topical steroids, as they can effectively and rapidly tackle flares. Topical steroids are available in a range of formulations including creams, ointments, liquids and steroid impregnated tape.

Steroid tape is an effective, easy to use, safe and patientfriendly formulation for select specific areas of high impact and functionality in eczema and should be encouraged where appropriate.

In the UK, the commercially available formulation is fludroxycortide impregnated tape (4 micrograms per sq. cm; fludroxycortide tape is a prescription-only medicine.

For Prescribing Information and Adverse Events Reporting, please see: https://www.typharm.com/wp-content/ uploads/2020/06/PI-Fludroxycortide-Tape.pdf), which represents a potent steroid.

It is licensed in the UK for recalcitrant chronic dermatoses such as eczema and psoriasis. Whilst fludroxycortide tape has been available in the UK for several decades, it is not used as much as steroid creams and ointments, often due to lack of awareness and knowledge by healthcare professionals. Fludroxycortide tape offers improved patient choice and potentially better adherence to topical steroid treatment regimes, especially in high impact functional areas such as hands and feet as well as chronic disabling prurigo lesions.

This review paper describes a simplified treatment algorithm for the management of eczema, including how fludroxycortide tape fits within the stepped approach to the management of eczema in keeping with guidelines.

Patients often struggle to find a topical steroid regime that they are happy with. This may compromise management, exacerbating both physical and emotional symptoms.

Summary: This review paper describes a simplified treatment algorithm for the management of eczema, including how fludroxycortide tape fits within the stepped approach to the management of eczema in keeping with guidelines.

Author info: Dr Nisa Aslam is a GP with 15 years of experience working in the NHS with a special interest in dermatology. Dr Sangeeta Punjabi is the Clinical Lead Dermatology Consultant at London North West Hospitals NHS Trust. www.bdng.org.uk

Keywords: Atopic eczema, Fludroxycortide tape, Treatment, Treatment algorithm Citation: Aslam N, Punjabi S. Eczema: A treatment algorithm incorporating fludroxycortide tape. Dermatological Nursing 2024. 23(3):23-26.

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Eczema Eczema (also known as dermatitis) is a non-contagious, inflammatory dry skin condition that may affect people from early infancy to old age. Eczema affects 11-20 percent of children and five to 10 percent of adults in the UK,2 and the lifetime prevalence is increasing in both adults and children.

Approximately 70-90 percent of eczema cases develop before the age of five years, and usually before 12 months of age. About 30 percent of people first develop symptoms as adults.2 The condition is twice as likely to be severe if it presents before 12 months of age.

If one or both parents have a history of atopic eczema, their child has an approximately 60 percent chance of developing it.

The trajectory of symptoms varies. There are usually periods when symptoms improve followed by periods when they get worse (flares). Flares may occur as often as two to three times a month.3 The skin is often unbearably itchy and during a flare the lesions may be erythmatous, pruritic and lichenified. The distribution and presentation of an eczematous flare can be influenced depending on the anatomical site affected, the person’s age, gender, duration and whether there is an infection present. Excoriation may also be present in some cases.

The distribution of the rash varies with the patient’s age. Infants tend to have widely distributed, dry, scaly, and erythematous patches with small excoriations. They also tend to have lesions on their face, especially the cheeks. With age, the rash becomes more localised; areas affected include the extensor surfaces such as the wrists, elbows, ankles, and knees. School-aged children tend to follow the pattern seen in adults: the involvement of the flexural surfaces usually affects the anticubital and popliteal fosse.4

“It is best to avoid any eczema triggers, such as allergens and irritants that can be found in products such as soaps, detergents or household cleaners” Patients with eczema require optimal daily skin management, as well as timely management of flares.

Skin dryness Dryness of the skin is inherent in eczema and is due to the lack of formation of natural moisturising factors in atopic skin. Best practice advice is to use emollients, moisturisers and emollient soaps and bath preparations liberally and frequently. A daily emollient bath should be recommended. An annual review of emollient use is also important. In addition, it is best to avoid any eczema triggers, such as allergens and irritants that can be found in

products such as soaps, detergents or household cleaners. Hard water can also be an irritant which should be considered in the context of baths and showers. Education is also key for the patient and carer(s) as it is essential to maintain the health of the skin and reduce the risk of flares.

Inflammation Topical corticosteroids are essential for eczema flares and are safe and effective when used correctly. All patients with eczema should be provided with a management plan. A treatment algorithm for eczema is shown in Algorithm 1 (Figure 1) and may be used

Figure 1. Algorithm 1: Eczema treatment algorithm Daily baths/moisturisers/ emollients

Acute exacerbation

Mild infection

Identify and treat cause

Severe infection Hospital ref

Mild/Moderate topical steroid ointment. Review 2-3 weekly: Response & S/E of topical steroid

Topical steroids such as fludroxycortide tape (select cases) + systemic antibiotics

Response Poor

Partial

Good

Management of eczema: treatment algorithms and best pathways

Refer to hospital

Check compliance Infection/Tachyphylaxis Step up potency Diagnosis?/allergic

If recurrent flares, face/body Calcineurin – 4-6 weeks until clearance

Management of eczema requires a three-pronged approach: addressing skin dryness, inflammation and infection.

Long term maintenance for more severe eczema: Calcieurin can be used twice weekly for up to 1 year

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as an aide‑memoire for the healthcare professional and as the basis of a management plan for the patient.

Different potencies of steroid formulations (cream, ointment, gel, tape) are chosen according to severity (mild, moderate, severe) and site of involvement as this is crucial for eczema management. It is important to explain to the patient how to apply topical steroids using methods such as fingertip units or the glistening technique, or even how to cut the tape to size and use only over the affected areas.

Infection Infection (bacterial, fungal or viral) is an important consideration as treatment will not be effective unless this is addressed. Systemic antibiotics may be needed if the skin is infected and a non-sedating antihistamine (e.g. cetirizine or loratadine) if there is severe itch. Topical treatments such as antiseptics and anti-fungals may be prescribed as required.

Prompt treatment with anti-viral medication is required in the case of eczema herpeticum; a rare but serious complication of eczema which manifests as a painful, itchy rash with blisters.

Monitoring and reviewing topical steroid treatment should be conducted by the patient (with the health professional informed as necessary according to the care plan).

If treatment response is good, topical steroid treatment should be continued.

In all cases, application of the steroid should be continued for 48 hours after the flare has subsided. If there is a partial response, patient adherence should be checked and stepping up the potency of the steroid should be considered.

If treatment response is poor, hospital referral may be needed.

Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are effective for more severe eczema that is unresponsive to conventional therapy, but they are not recommended first line for eczema of any severity.

Topical pimecrolimus is licensed for

www.bdng.org.uk

the short-term treatment of mild to moderate atopic eczema for twice daily application.5 Tacrolimus is licensed for short term twice daily topical use in the treatment of moderate to severe atopic eczema.6 For prevention of flares in moderate to severe eczema and for patients in whom initial treatment with tacrolimus has been effective, twice weekly application may be prescribed. These preparations should be initiated by physicians (including general practitioners) with a special interest and experience in dermatology or experienced dermatology nurses with a non-medical prescriber (NMP) qualification. Chronic treatment may be continued for a year and should be reviewed two to three times each year.

In cases of chronic lichenified eczema (see Figure 2) emollients form the basis of therapy, stepped up in case of a flare with a potent topical steroid, zinc oxide paste bandages, fludroxycortide tape or Comfifast garments. For patients with recurrent flares, a topical calcineurin inhibitor should be applied to the face and body as required for four to six weeks until the flare subsides. For longer term maintenance of chronic eczema, a topical calcineurin inhibitor may be prescribed twice weekly for up to a year.5,6

The place of fludroxycortide tape in eczema management Fludroxycortide tape is a flexible, versatile and waterproof prescription-only steroid tape. This tape has several advantages over other steroid formulations, including ease of application and non-invasive nature, which are important for both children and adults in maintaining as normal routine as possible. It is applied by cutting the adhesive material to the size and shape of the skin area to be treated with minimal overlap on the surrounding skin. Patients can shower as normal with the tape applied, then pat dry. Patients can also apply their everyday make-up over the tape too.

The tape should be changed every 12‑24 hours.

The tape is highly flexible, which makes it easy to apply to different body sites. It adheres well to affected skin, particularly where the skin is dry. Due to the adhesive and flexible nature of the tape, it can be used on, but is not limited to, joints such as elbows, knees, and fingertips.

The tape also offers the potential to maintain a continuous level of steroid concentration. This might help to control the inflammation which is central to skin conditions such as eczema and psoriasis.

Figure 2. Treatment Algorithm 2 Chronic lichenified eczema Baths/Moisturisers/Emollients Potent topical steroid for 2 weeks Zinc oxide paste bandages or Fludroxycortide Tape Comfifast garments

Maintenance: If recurrent flares, Calcineurin – Body/face 4 to 6 weeks until clearance

Review: 2-3 times monthly: Long term maintenance for more severe eczema. Calcieurin can be used twice weekly for up to 1 year

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Clinincal review

“With the use of topical corticosteroids, or with products such as fludroxycortide tape, eczema can become manageable” The unique properties of fludroxycortide tape, such as being waterproof and that it can be cut to any size or shape (due to its roll presentation), ensures it is a distinct alternative for the treatment of skin conditions such as eczema.

Evidence of benefit of tape over other topical steroids Several studies have shown the benefits of topical steroid tape over cream.

The original study in 1966 compared flurandrenolone (fludroxycortide) tape with flurandrenolone cream in combination with plastic film in 10 patients with psoriasis.7 In all 10 patients, clinical improvement began within a few days and was apparent at the end of the first week with both formulations.

The tape was equal or superior to the cream applied with a covering film in eight patients. All 10 patients preferred the tape to the cream on the basis of convenience and ease of application.7 The tape protected lesions from scratching and mechanical irritation from belts and clothing. Most patients tolerated a 20-hour application without adverse effects.

Similar results have been found with the tape compared with creams and ointments in other inflammatory skin conditions.8

The role of occlusion Fludroxycoride tape shares the same mechanisms of action as other topical steroids (i.e. anti-inflammatory and immunosuppressive) agents which are important in eczema treatment.

However, a key mechanism of action of fludroxycortide tape formulation is occlusion.7 This is a dermatological technique that covers or encloses the skin to create a moisturerich environment. It enhances the absorption of steroids and reduces

26

the need for stronger steroids, thereby minimising the risk of side effects. Evidence also shows that the vasoconstrictive effect of topical steroids is enhanced by occlusion. It helps retain moisture, blocks entry of irritants, allergens and microbes, and promotes healing by creating a physical barrier against scratching.8

The role of nurses in eczema management Everyone has an important role in helping to manage eczema. Nurses working in general practice often have the responsibility of providing ongoing clinical management of this cohort of patients. Their key responsibilities include: l Offering support and guidance and reiterating on self-help measures l Advising how to use the finger tip unit or skin glistening technique for topical applications and how to cut and apply tape if required l Offer clinical reviews to monitor compliance l Act as a point of contact and improve patient self-confidence and reassurance.

Conclusion When managing eczema, it is well accepted that utilising a stepped approach can promote a positive patient outcome. With the use of topical corticosteroids, or with products such as fludroxycortide tape, eczema can become manageable. Using the right treatment at the right time can significantly impact patient experience and disease management as it is will be tailored to the affected individual.

Declaration of interest This article has been sponsored

by Typharm. The opinions, as well as the presented treatment pathways are those of the authors.

allowing for timely treatment with the best formulation. Topical steroids are a key part of treatment but awareness of the place of fludroxycortide tape is limited. Evidence from studies shows the superior acceptability of steroid tape due to ease of application, better adherence and localisation to the affected area of skin, inconspicuous appearance, controlled medication release and improved absorption due to occlusion and protection from mechanical irritation from scratching and clothing.

References 1. Jafferany M, Pastolero P. Psychiatric and Psychological Impact of Chronic Skin Disease.

The primary care companion for CNS disorders 2018. 20(2).

2. NICE. Eczema – atopic. Updated July 2024. Available at: https://cks.nice.org.uk/topics/ eczema-atopic/ [last accessed August 2024] 3. NHS. Symptoms. Atopic eczema. Updated November 2023 Available at: https://www.nhs. uk/conditions/atopic-eczema/symptoms/ [last accessed August 2024] 4. Nemeth V, Siyad H, Evans J. Eczema. 2024.

Available at: https://www.ncbi.nlm.nih.gov/ books/NBK538209/ [last accessed August 2024] 5. British National Formulary/NICE. Pimecrolimus. Available at: https://bnf.nice.org. uk/drugs/pimecrolimus/ [last accessed August 2024] 6. British National Formulary/NICE. Tacrolimus. Available at: https://bnf.nice.org.uk/ drugs/tacrolimus/ [last accessed August 2024] 7. Weiner M. Flurandrenolone tape. A new preparation for occlusive therapy. Journal of Investigative Dermatology 1966. 47:63-6 8. Burr S. Fludroxycortide tape: a versatile and well tolerated treatment option. .

Dermatological Nursing 2021. 20:23-6.

Management of eczema requires a stepped approach and the algorithms presented in this review can make a huge contribution to patient care

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Continual delivery of steroid treatment for hypertrophic scars & keloids PREVIOUSLY CALLED HAELAN TAPE

Recommended by The British Association of Aesthetic Plastic Surgeons as a simple steroid treatment for scars & keloids1

Fludroxycortide 4 micrograms per square centimetre Tape effectively treats inflammatory dermatoses and it can be cut to any size or shape.

Scan the QR code to view the application video.

Alternatively visit typharm.com or call 01603 722480 for more information Typharm Limited, 14D Wendover Road, Rackheath Industrial Estate, Norwich, NR13 6LH

Including hand eczema and finger tip fissures2

Waterproof protection once in place

Can be cut to size for scar site

For both children and adults

Job code: 1/FT/12/2407/1010. Date of Preparation: July 2024.

Reference: 1. Scars & Keloids. BAAPS. Available at https://baaps.org.uk/patients/procedures/16/scars_and_keloids [Last Accessed January 2023].

2. Layton A. Reviewing th e use of Fludroxycortide tape (Haelan Tape) in Dermatology Practice. Typharm Dermatology.

FLUDROXYCORTIDE TAPE PRESCRIBING INFORMATION: Fludroxycortide 4 micrograms per square centimetre Tape See full Summary of Product Characteristics (SmPC) before prescribing. Presentation: Transparent, plastic surgical tape impregnated with 4 micrograms fludroxycortide per square centimetre. Indications: Adjunctive therapy for chronic, localised, recalcitrant dermatoses that may respond to topical corticosteroids and particularly dry, scaling lesions. Posology and Method of Administration: Adults and the Elderly: For application to the skin, which should be clean, dry, and shorn of hair. In most instances the tape need only remain in place for 12 out of 24 hours. The tape is cut so as to cover the lesion and a quarter inch margin of normal skin. Corners should be rounded off. After removing the lining paper, the tape is applied to the centre of the lesion with gentle pressure and worked to the edges, avoiding excessive tension of the skin. If longer strips of tape are to be applied, the lining paper should be removed progressively. Paediatric population: Courses should be limited to five days and tight coverings should not be used. If irritation or infection develops, remove tape, and consult a physician. Fludroxycortide Tape is waterproof. Cosmetics may be applied over the tape. Contraindications: Chicken pox; vaccinia; tuberculosis of the skin; hypersensitivity to any of the components; facial rosacea, acne vulgaris, perioral dermatitis, perianal and genital pruritus; dermatoses in infancy including eczema, dermatitic napkin eruption, bacterial (impetigo), viral (herpes simplex) and fungal (candida or dermatophyte) infections. Warnings and Precautions: Not advocated for acute and weeping dermatoses. Local and systemic toxicity of medium and high potency topical corticosteroids is common, especially following long-term continuous use, continued use on large areas of damaged skin, flexures and with polythene occlusion. Systemic absorption of topical corticosteroids has produced reversible hypothalamic-pituitary-adrenal (HPA) axis suppression.

Long-term continuous therapy should be avoided in all patients irrespective of age. Application under occlusion should be restricted to dermatoses in very limited areas. If used on the face, courses should be limited to five days and occlusion should not be used. In the presence of skin infections, the use of an appropriate antifungal or antibacterial agent should be instituted. Long term continuous or inappropriate use of topical steroids can result in the development of rebound flares after stopping treatment (topical steroid withdrawal syndrome). A severe form of rebound flare can develop which takes the form of a dermatitis with intense redness, stinging and burning that can spread beyond the initial treatment area. It is more likely to occur when delicate skin sites such as the face and flexures are treated. Should there be a reoccurrence of the condition within days to weeks after successful

treatment a withdrawal reaction should be suspected. Reapplication should be with caution and specialist advise is recommended in these cases or other treatment options should be considered. For children, administration of topical corticosteroids should be limited to the least amount compatible with an effective therapeutic regimen. Children may absorb proportionally larger amounts of topical corticosteroids and thus may be more susceptible to systemic toxicity. Pregnancy and Lactation: Use in pregnancy only when there is no safer alternative and when the disease itself carries risks for mother and child. Caution should be exercised when topical corticosteroids are administered to nursing mothers. Undesirable Effects: The following local adverse reactions may occur with the use of occlusive dressings: burning, itching, irritation, dryness, folliculitis, hypertrichosis, acne form eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, maceration of the skin, secondary infection, skin atrophy, miliaria, striae and thinning and dilatations of superficial blood vessels producing telangiectasia. Transient HPA axis suppression. Cushing’s syndrome. Hyperglycaemia.

Glycosuria. Adrenal suppression in children may occur. Infected skin lesions, viral, bacterial, or fungal may be substantially exacerbated by topical steroid therapy. Wound healing is significantly retarded.

Local hypersensitivity reactions. Stop treatment immediately if hypersensitivity occurs. Withdrawal reactions - redness of the skin which may extend to areas beyond the initial affected area, burning or stinging sensation, itch, skin peeling, oozing pustules. Precautions for Storage: Store in a dry place, below 25oC. Pack Size and Price: Polypropylene dispenser and silica gel desiccant sachet in a polypropylene container, with a polyethylene lid, packed in a cardboard box, containing 20cm or 50cm of translucent, polythene adhesive film, 7.5cm wide, protected by a removable paper liner.

7.5cm x 20cm £19.49. 7.5cm x 50cm £28.95. Legal Category: POM Marketing Authorisation Number: PL 00551/0014 Marketing Authorisation Holder: Typharm Ltd., Unit 1, 39 Mahoney Green, Rackheath, Norwich NR13 6JY. Tel: 01603 722480, Fax: 01603 263804. Date of Revision of Text: January 2023

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Typharm Limited on 02037 694160.

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Discover the real burden of chronic hand eczema Anthony Bewley, Alia Ahmed, Angelika Razzaque, Margaret Kelman, Emily Goffin, Kate Barwise-Ennis, Shahil Lodhia

W

e often take our hands for granted, failing to realise their health can impact and influence our own wellbeing. Despite the importance of our hands, chronic hand eczema (CHE) can be under-appreciated when compared to other skin conditions, and its impact – which can sometimes be hidden – has historically been overlooked. There is a need for more insight into the patient experience of CHE so that the care and support received can be optimised.

Eczema on the hands is hard to handle Hand eczema has a one-year prevalence of approximately 9% in the general population and a lifetime prevalence of around 14%.1,2 CHE is a multifactorial, inflammatory skin disease that presents on the hands and wrists.3,4 It is defined as hand eczema that lasts for more than three months, or relapses twice or more per year.3

“I’m frightened of doing things. I don’t want to touch that new object in case it’s going to set me off. I have fear and worry every time I go out, is the food going to be different from what I’m used to and set off the eczema?”

CHE Patient

Disclaimer This article has been developed and funded by LEO Pharma UK/IE. The research was initiated, funded, and written by LEO Pharma UK. Allergy UK and UK healthcare professionals reviewed and contributed to the research and report. Allergy UK is working in collaboration with LEO Pharma to share the outputs of this report to improve healthcare support for people living with chronic hand eczema.

While CHE patients most commonly experience itching and pain,3,4 they may also experience a wide range of symptoms that can fluctuate and flare up over time. These recurring flares are often in response to exogenous triggers that can be difficult for CHE patients to avoid.3 Our hands are indispenable for washing, cleaning, cooking and a variety of other everyday tasks. However, their constant use means they are frequently exposed to various irritants (e.g. water, hand soap/sanitiser, detergents), allergens and microbes which can make the condition worse.2,5,6,7 What’s more, the fact that the hands are highly visible makes it hard for patients to hide their CHE.

Summary: This report presents the findings of research looking at the burden of chronic hand eczema.

The research considered five different aspects of daily life to gauge the impact of the condition: the physical experience and unavoidable triggers, the psychosocial impact, quality of life and relationships, the occupational burden and the patient’s experience of engaging with the healthcare system.

Citation: Bewley A, Ahmed A, Razzaque A, Kelman M. Goffin E, Barwise-Ennis K , Lodhia S. Discover the real burden of chronic hand eczema.

Dermatological Nursing 2024.

23(3):29-34. www.bdng.org.uk

Keywords: Hand eczema Chronic hand eczema Burden of disease Patient care

Author info: Professor Anthony Bewley is a Consultant Dermatologist at Barts Health NHS Trust. Dr Alia Ahmed is a Consultant Dermatologist at Frimley and Barts Health NHS Trusts. Dr Angelika Razzaque is a General Practitioner with an extended role in Dermatology at One Health Lewisham and King’s College Hospital NHS Foundation Trust. Margaret Kelman is a Specialist Allergy Nurse at Allergy UK. Emily Goffin MSc BSc, Kate Barwise-Ennis BSc, Shahil Lodhia MPharm at LEO Pharma, UK. Dermatological Nursing 2024, Vol 23, No 3

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Clinical research

In comparison with eczema that affects other anatomical regions, hand eczema presents with additional, unique challenges, often heightening it’s impact.

Introducing the CHE Patient Impact Report In partnership with Allergy UK and a multi-disciplinary taskforce of healthcare experts comprising Professor Anthony Bewley, Dr Alia Ahmed, Dr Angelika Razzaque and Margaret Kelman, LEO Pharma conducted research to understand the hidden experiences, specific challenges and unmet needs of patients living with CHE.

Research design Recruitment criteria and demographics for the research

LEO Pharma carried out five in-depth interviews with CHE patients in the UK together with an online survey of 152 further patients with CHE to understand their views across five key areas: physical experience and unavoidable triggers, psychosocial impact, quality of life and relationships, occupational burden and their experience of engaging with the healthcare system.

The insights gathered have been compiled into a report to highlight the burden of living with CHE and to equip healthcare professionals with knowledge when providing care and support to this patient community.

Key findings from the CHE Patient Impact Report Physical experience and unavoidable triggers

When was the last time you didn’t use your hands to do something?

Our hands do so much for us, from greeting others to washing up, they are a fundamental part of our everyday lives.

The report found three out of four CHE patients strongly agree that having eczema on the hands is harder than the rest of the body because they’re in constant use.8

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Figure 1 Infographic

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A common theme reported by the survey respondents was the impact CHE had on being able to perform housework (73%).8 Itch was confirmed as the most common symptom of CHE together with dry/chapped and cracking skin.8 Around half of patients experience itchy or dry/chapped skin every or most days.8 When asked to score the extent to which itch from hand eczema impacts their life, CHE patients rated a mean 7.2 out of 10, with pain/burning rated 6.2 out of 10 (on a scale of 0-10, 0=not at all, 10=significant impact).8

“It’s like a drug addict when they’re itching to like get their next fix, I’m itching to itch.

They’re itching to get their next fix. I’m itching to get rid of itch. They want to get rid of that like desperation for drugs, and I’m trying to get rid of the desperation to itch.”

– Patient with CHE Psychosocial impact

Our hands are a vital part of our identity and how we see ourselves.

Together with the face, we’re more likely to show the world our hands than any other part of our body. Given they are highly visible, it is very difficult to hide hand eczema from people around us.

In total, 67% of patients stated they feel that people stare at their hand eczema and 82% of patients feel uncomfortable or embarrassed when people look at their hand eczema.8 As a result, nearly three quarters (71%) of CHE patients admitted they try to hide their hand eczema as much as they can.8

“Makes me so insecure and self-conscious, as if people think I have a disease or I’m disgusting. I feel ashamed.” – Patient with CHE

www.bdng.org.uk

Figure 2 View on having eczema on hands compared to other areas of the body As well as withdrawal from activities, 60% of patients with CHE reported feeling anxious or stressed due to their hand eczema and over half (55%) said they have felt angry and resentful of their hand eczema.8

Did you know?

Anxiety or stress and eczema can become a vicious cycle. Not only can stress trigger eczema flares, but dealing with eczema can cause stress and make eczema worse.9,10 Despite half of CHE patients having experienced anxiety or anger due to

their condition, only 14% have been asked about the emotional impact by any healthcare professional.8

“The psychological impacts reported reflect the deep level of frustration experienced by people with CHE. Adapting behaviours and lifestyle choices to live with CHE has an overwhelming effect and leads to feelings of psychological distress and anger.”

– Dr Alia Ahmed

Figure 3 What patients experienced Dermatological Nursing 2024, Vol 23, No 3

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Quality of life and relationships

We often use our hands without even thinking. We only start to appreciate their value when something goes wrong.

That’s why we find impairment of the hands can cause a big hindrance on our lives. Over three quarters (76%) of survey respondents acknowledged hand eczema has had a moderate to high impact on their overall quality of life, with 89% of patients sharing that it negatively impacts their quality of life at least most months.8 Our hands are fundamental to how we interact with others. So, when we don’t have full use of them, it can negatively affect our interpersonal relationships.

Results from the survey showed that seven out of 10 CHE patients believe that their CHE has some impact on their existing relationships or ability to build new ones.8 The effect that CHE has on personal relationships is further explored in the survey findings, which tell us that 59% of patients have experienced people avoiding touching their hands because of their hand eczema, and 56% say their hand eczema has prevented them from touching loved ones (e.g., children, partner, parents) as much as they’d like.8

Figure 4 Hand eczema and existing relationships CHE can impact a patient’s ability to work, particularly in occupations that involve prolonged wet work or harmful skin exposure. In fact, 72% of CHE patients stated that they currently experience some impact on their work or education due to their CHE.8 Tradespeople, healthcare professionals, service industry workers and those in

education reported the greatest impact of CHE on their performance.8 The socioeconomic impact of hand eczema can be substantial,3 which might be due to things like difficulty focusing (47%), tasks taking longer than they should (28%), sick leave (27%) and loss of productivity (20%).8

“I can’t bath my little boy regularly because of my hands and I feel really guilty as I feel like a bad mum. It also means that I get anxious about housework as my partner has to do more than me.”

– Patient with CHE Nearly half of patients (49%) with CHE say they feel undesirable or unattractive due to their hand eczema and experience low self-esteem.8 Occupational burden

The hands are our primary tool for completing workplace tasks, whether writing, typing, handling products or operating heavy machinery. So, imagine how frustrating it must be if simply gripping a pen or grasping a hammer is difficult to do.

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Figure 5 CHE and work

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“Very draining, certain jobs and tasks I cannot do, no money due to unemployment or being unemployable. I have to wear gloves most of the time.”

– Patient with CHE Patient healthcare experience

Despite the impact that CHE has on daily life, survey results revealed that patients experience symptoms for a median of eight years prior to seeing a healthcare professional for the first time.8 The most reported reason for this delay was because patients didn’t think that their CHE was severe enough, with 41% only seeking help when they felt unable to manage their hand eczema by themselves anymore.8 Even after patients have sought help, 66% said they are still worried they will never gain control of their hand eczema.8 In addition, over half (56%) of CHE patients would like education for healthcare professionals around the unique challenges of hand eczema versus general eczema and two in three agreed they would like to get more support from their healthcare professional to control their hand eczema.8 We hope this report shines a light on the hidden impact of CHE and sparks a conversation that will enhance care for patients.

“Patients are telling us quite clearly that we as healthcare professionals are not prioritising the effective management of CHE highly enough. The finding that the median time of eight years for patients with CHE to access help is shocking.”

– Professor Anthony Bewley Further information about CHE CHE is an umbrella term for several subtypes

CHE is a heterogeneous disease with varying morphologic features.3 It can www.bdng.org.uk

Figure 6 CHE and the healthcare experience be divided into several etiological and clinical subtypes.3 However, classifying CHE into these subtypes can be challenging. For example, an individual may exhibit more than one etiological or clinical subtype, the disease can evolve over time, and there is no reliable connection between the clinical presentation and the underlying cause.3,4,11 Whatever the morphology or subtype, it is important to think: Could it be CHE, and could the condition be a big burden for your patients to carry?

CHE can be self-perpetuating irrespective of subtype

While each etiological subtype has a unique immune signature, there are some shared aspects of pathophysiology across subtypes.

The pathophysiology of CHE is characterised by skin barrier dysfunction and inflammation.5,6,7 The breakdown of the skin barrier itself can lead to an inflammatory response.5,6,7 In addition, the impaired skin barrier allows for the penetration of allergens, irritants and microbes which can also trigger an immune response and further inflammation.5,6,7 Regardless of subtype, hand eczema can persist in patients even after initial triggers (i.e. allergens or irritants), have been removed from their environment.12 This vicious cycle of hand eczema occurs because damage to the skin barrier and the inflammatory processes can continue independent of the initial trigger.12 Without appropriate and timely management, the condition can

become chronic, significantly affecting the patient’s quality of life.12

The way forward: Consider how you can lighten the load for CHE patients CHE poses additional, unique challenges versus eczema on other parts of the body.8 Findings from the CHE Patient Impact Report highlight that the condition has a significant physical and emotional impact across many aspects of life. The results identify an opportunity for a strengthened approach to supporting patients.

Equipped with enhanced knowledge of the CHE patient experience from this report, we can help alleviate some of the burden that patients face day in, day out, ensuring their concerns are heard and addressed effectively.

“We need to reflect on the patient experience on accessing healthcare and their frustration and disappointment with the lack of knowledge about the condition and its impact on patients’ physical and mental health.

“Not being asked routinely in consultations how it is impacting on their professional life or their relationships may lead to disengagement with healthcare providers in general.”

– Dr Angelika Razzaque

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Scan the QR code to download the full report from the LEO Pharma UK/IE website, for more insights and experiences from people living with CHE..

“Despite half of CHE patients having experienced anxiety or anger due to their condition, only 14% have been asked about the emotional impact by any healthcare professional” first step for informing discussions about improving or expanding their support.

“The feedback generated from this survey is extremely compelling and serves only to further compound what individuals with CHE have been trying to tell us for years: that CHE has a huge impact on a person’s ability to carry out simple everyday tasks, affecting all areas of their lives including their social, emotional and psychological wellbeing. For many people living with CHE this is not being addressed by their healthcare provider. This report demonstrates from its findings that there is a need to review how patients with CHE are managed to ensure they receive optimum care for their condition.”

– Margaret Kelman When you spot the burden of CHE becoming too heavy for a patient to handle, take the chance to champion their needs and advocate for improved outcomes with their dermatologist or wider multi-disciplinary team.

Remember, the weight can be so much heavier than it appears. Go beyond the physical and make sure you’re asking patients about the impact hand eczema is having on their mental health and day-to-day lives.

A quality-of-life tool might be useful to quantify how CHE is holding your patients back and could be a good 34

Declarations This is a non-promotional article written and funded by LEO Pharma UK with review and input from a taskforce of four UK healthcare professionals, Professor A Bewley, Dr A Ahmed and Dr A Razzaque and a representative from the charity Allergy UK, Margaret Kelman. All taskforce members received consultancy fees from LEO Pharma for their involvement within the Chronic Hand Eczema Taskforce which included contribution into the development of the research, the report and development of this article. The authors declare no conflict of interest related to this project.

To discuss the patient impact of CHE and to receive more information about the disease, contact the medical team at LEO Pharma (medical-info. uk@leo-pharma.com).

References 1 Quaade AS, Wang X, Sølberg JBK, McCauley BD, Thyssen JP, Becker C, et al.

Inflammatory plasma signature of chronic hand eczema: Associations with aetiological and clinical subtypes. J Eur Acad Dermatol Venereol 2024. 38:1101–1111 2 Quaade AS, Simonsen AB, Halling AS, Thyssen JP, Johansen JD. Prevalence, incidence, and severity of hand eczema in the general population - A systematic review and metaanalysis. Contact Dermatitis 2021. 84(6):361374

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3 Thyssen JP, Schuttelaar MLA, Alfonso JH, et al. Guidelines for diagnosis, prevention, and treatment of hand eczema. Contact Dermatitis 2022. 86(5):357-378 4 Grant L, Seiding Larsen L, Burrows K, Belsito DV, Weisshaar E, Diepgen T et al.

Development of a Conceptual Model of Chronic Hand Eczema (CHE) Based on Qualitative Interviews with Patients and Expert Dermatologists. Adv Ther 2020.

37(2):692-706 5 Lee GR, Maarouf M, Hendricks AK, Lee DE, Shi VY. Current and emerging therapies for hand eczema. Dermatol Ther 2019.

32(3):e12840 6 Tauber M, Bérard E, Lourari S, Questel E, Redoules D, Paul C et al. Latent class analysis categorizes chronic hand eczema patients according to skin barrier impairment. J Eur Acad Dermatol Venereol 2020. 34(7):15291535 7 Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J, Lane ME, Moustafa M et al. Epidermal barrier dysfunction in atopic dermatitis. J Invest Dermatol 2009.

129(8):1892-908 8

DOF DERM-001 June 2024

9 Japundžić I, Lugović-Mihić L, Košćec Bjelajac A, Macan J, Novak-Hlebar I, Buljan M et al. Psychological Stress and Hand Eczema in Physicians and Dentists: A Comparison Based on Surgical Work. Behav Sci (Basel) 2023.

13(5):379.

10 Hafsia M, Kacem I, Maalel EO, Maoua M, Brahem A, Aroui H, et al. Relationship between hand eczema severity and occupational stress: A cross-sectional study.

Dermatol. Res. Pract 2019 11 Diepgen TL, Andersen KE, Chosidow O, Coenraads PJ, Elsner P, English J et al.

Guidelines for diagnosis, prevention and treatment of hand eczema--short version.

J Dtsch Dermatol Ges 2015. 13(1):77-85 12 Agner T, Elsner P. Hand eczema: epidemiology, prognosis and prevention. J Eur Acad Dermatol Venereol 2020. 34 Suppl 1:4-12.

MAT-74445 August 2024 www.bdng.org.uk

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AKLIEF®▼(trifarotene) An antibiotic free treatment option Aklief is a topical retinoid indicated for the cutaneous treatment of moderate acne vulgaris of the face and/or trunk in patients from 12 years of age and older when many comedones, papules and pustules are present5 Aklief is contraindicated during pregnancy or for women planning a pregnancy

Aklief 50 microgram/g cream - Prescribing Information (United Kingdom)

Please refer to SmPC before prescribing. Presentation: Aklief is presented in a multidose container with airless pump containing 75g of cream. One gram of cream contains 50 micrograms of trifarotene. Indications: Aklief is indicated for the cutaneous treatment of Acne Vulgaris of the face and/or the trunk in patients from 12 years of age and older, when many comedones, papules and pustules are present. Dosage and Method of administration: Dosage: Apply a thin layer of Aklief cream to the affected areas of the face and/or trunk once a day, in the evening, on clean and dry skin. It is recommended that the physician assesses the continued improvement of the patient after three months of treatment. Special populations: Paediatric population and Elderly patients. The safety and efficacy of Aklief in children below 12 years old and in geriatric patients aged 65 years and above have not been established.

Renal and hepatic impairment. Aklief has not been studied in patients with renal and hepatic impairment. Method of administration: For cutaneous use only. Before using the pump for the first time, prime it by pressing down several times until a small amount of medicine is dispensed (up to 10 times maximum). The pump is now ready to use.

Apply a thin layer of Aklief cream once a day, to the following affected areas, in the evening, on clean and dry skin: • forehead, nose, chin and right and left cheeks – one pump actuation should be enough. • upper trunk (i.e. reachable upper back, shoulders and chest) – two pump actuations should be enough • one additional pump actuation may be used for middle and lower back if acne is present. Patients should be instructed to avoid contact with the eyes, eyelids, lips and mucous membranes and to wash their hands after applying the medicinal product. Contraindications: • Pregnancy • Women planning a pregnancy • Hypersensitivity to the active substance or to any of the excipients.

Precautions and Warnings: To mitigate the risk of erythema, scaling, dryness, and stinging/burning, patients should be instructed to use a moisturizer from the initiation of treatment (while allowing sufficient time before and after the application of Aklief cream to allow the skin to dry), and, if appropriate, reduce the frequency of application of Aklief cream, or suspend use temporarily. If severe reactions persist the treatment may be discontinued. The product should not be applied to cuts, abrasions, eczematous or sunburned skin. As with other retinoids, use of “waxing” as a depilatory method should be avoided on skin treated with Aklief. If a reaction suggesting sensitivity to any component of the formula occurs, use should be discontinued. Caution should be exercised if cosmetics or acne medications with desquamative, irritant or drying effects are concomitantly used with the medicinal product, as they may produce additive irritant effects. Aklief should not come into contact with the eyes, eyelids, lips, or mucous membranes. If the product enters the eye, wash immediately and abundantly with lukewarm water. Excessive exposure to sunlight, including sunlamps or phototherapy should be avoided during the treatment. Use of a broad-spectrum, waterresistant sunscreen with a Sun Protection Factor (SPF) of 30 or higher and protective clothing over treated areas is recommended when exposure cannot be avoided. This product contains propylene glycol (E1520) that may cause skin irritation. Aklief also contains 50 mg alcohol (ethanol) in each gram which is equivalent to 5% w/w. It may cause burning sensation on damaged skin. Pregnancy, Breast-feeding and Fertility: Orally administered retinoids have been associated with congenital abnormalities. When used in accordance with the prescribing information,

topically administered retinoids are generally assumed to result into low systemic exposure due to minimal dermal absorption. However, there could be individual factors (e.g. damaged skin barrier, excessive use) that contribute to an increased systemic exposure. Pregnancy: Aklief is contraindicated during pregnancy or in women planning a pregnancy. If the product is used during pregnancy, or if the patient becomes pregnant while taking this drug, treatment should be discontinued. Breast-feeding: A risk to the suckling child cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Aklief therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman. To avoid the risk of ingestion by, and/or contact exposure of, an infant, nursing women should not apply trifarotene cream to the chest or breast area. Fertility: No human fertility studies were conducted with Aklief. After oral administration of trifarotene to dogs, findings of Germ cell degeneration were observed. Effects on ability to drive and use machines: Aklief has no or negligible influence on the ability to drive and use machines. Undesirable Effects: The most “commonly” reported adverse reactions (occurring in ≥1/100 to <1/10 patients) of application site irritation, application site pruritus and sunburn (see table below) occurred in 1.2% to 6.5% of patients treated with Aklief cream in clinical studies.

Table of “commonly” reported adverse reactions of patients treated with Aklief cream in clinical studies System Organ Class Adverse reactions General disorders and administration site conditions Application site irritation, Application site pruritus Injury, poisoning and procedural complications Sunburn Prescribers should consult the Summary of Product Characteristics (SmPC) in relation to the uncommon (≥1/1,000 to <1/100) and rarely occurring (≥1/10,000 to <1/1,000) adverse reactions as reported in these studies. Packaging Quantities and Cost: 1 x 75g multidose container with airless pump; £ 27.75 excluding VAT. Marketing Authorisation Number: PL 10590/0071. Legal Category: POM. Marketing Authorisation Holder: Galderma (UK) Limited, Evergreen House North, Grafton Place, London, NW1 2DX, United Kingdom. Further information is available from: Galderma (UK) Ltd, Evergreen House North, Grafton Place, London, NW1 2DX, United Kingdom.

Telephone: +44 (0)300 3035674. Date of Revision: July 2023.

Adverse events should be reported.

Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

Adverse events should also be reported to Galderma (UK) Ltd: E-mail: medinfo.uk@galderma.com Tel: +44 (0)300 3035674

References: 1. Kasser M et al. J Cosmet Dermatol. 2020;00:1–6. 2. Stein Gold L et al. Dermatol Ther (Heidelb) 2021;11:661–664 3. Blume-Peytavi U et al. JEADV 2020, 34, 166–173. 4. Bell K et al. Annals of Pharmacotherapy 2021;55(1) 111–116 5. Aklief Summary of Product Charactistics. Available at: https://www.medicines.org.uk/emc/product/13881/smpc#gref. Accessed: Aug 2024 GB-AFC-2400074 I Aug 2024

Conducting a literature review: Part 3 Laura Crosby

I

n the second article in this series, we looked at how to combine search terms using a PICO (Population, Intervention, Control and Outcome) table and where to search for the best quality literature. In this article, we will consider how to narrow down our search results so that we are using the highest quality evidence in relation to our question.

As in the previous article we will be using the following research question: Is laser treatment effective in the treatment of acne scarring in young adults?

When carrying out a literature review, the aim is to have a high level of sensitivity and then to have a high level of specificity by excluding literature that does not answer our question.1 This means conducting a wide literature search to result in a high level of sensitivity before excluding articles to give a more specific search result. This can be done, in part, by using exclusion criteria during the literature search. However, this strategy would increase the risk of missing relevant literature. Consequently, many articles are excluded using criteria applied after the initial literature search.

Our PICO literature search resulted in 278 studies being identified. To identify the best quality evidence with which to answer our research question, we need to exclude studies which do not answer our question.

For a published systematic review, it is good practice to use a table to show how many studies have been excluded and why.2 One way of doing this is to use a PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)

flow diagram.3 This flow diagram shows the number of included and excluded studies and the reasons for their exclusions. This process also helps us as researchers to focus our attention on the most relevant studies.

Using the literature search we have carried out, inclusion and exclusion criteria may be presented in the following way: An initial search of the databases returned 278 articles, which seemed initially relevant. Once duplicates were removed, this number was reduced to 159. A total of 93 records remained once the titles had been screened. These exclusions were due to the title of the paper clearly stating that the paper was looking at a condition, a treatment or a population that is not relevant to the question.

Following a review of the abstracts, a further 90 articles were excluded; 74 of these were discounted because of the study design or type of evidence. There were a small number of reviews and retrospective studies, but most of the exclusions based on evidence type were because the paper was reporting on a study that had no control. Whilst the initial search did not specify a placebo-controlled trial, this design would give the best quality evidence.

Screening of the abstracts identified that a placebo controlled randomised controlled trial (RCT) had been found, as well as a systematic review that included the placebo-controlled trial. Therefore, it was possible to discount studies that did not include a placebo control.

All these studies had a comparator arm, but acne scarring can improve with time so a placebo control would be crucial in assessing efficacy of any treatment. Eleven studies either did not consider acne scarring in the

Summary: This is the third in a series of articles which aims to explain how to carry out a literature review, critically appraise the findings and how to apply these findings to practice. This article will focus on narrowing down search results to identify the highest quality evidence.

Author info: Laura Crosby is a Clinical Nurse Specialist, Medical Dermatology, at University Hospitals Bristol and Weston NHS Foundation Trust.

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Keywords: Literature review, Evidence, Evidence-based practice, Professional development Citation: Crosby L. Conducting a literature review: Part three. Dermatological Nursing 2024. 23(3):36-37. www.bdng.org.uk

Professional development

not focus specifically on the age group that forms part of the PICO question, but this is still the highest quality evidence for this question. This paper states the age ranges of the participants in the included studies, if available, and includes the specified age group, even if it doesn’t exclude other age groups.

Screening

Identification

Identification of studies via databases and registers

Records identified from*: Databases (n = 278)

Records screened (n = 159)

Records excluded** (n = 156)

Records screened (n = 159)

Records excluded** (n = 156)

Reports assessed for eligibility (n = 3)

Included

Records removed before screening: Duplicate records removed (n = 118) Records marked as ineligible by automation tools (n = 0) Records removed for other reasons (n = 0)

The ages of participants ranged from 18-65 with skin type II, III, IV and V. The results were not separated by age range, and therefore it is not possible to identify any impact that age may have on the outcomes. There were no eligible papers that specifically focused on the target age group. This paper also considers other treatment interventions than those identified for this literature search. However, this still provides the most robust evidence for the question identified.

Having selected the most relevant piece of evidence to answer our clinical question, we now need to critically appraise this in order to establish what answer it gives to our research question and how reliable and applicable this answer is to our clinical practice. We will work through a critical appraisal in the next article in this series.

Reports excluded: Methodology not RCT (n = 1) Findings included in included study (n = 1)

Studies included in review (n = 1)

References 1. Nordenstrom J. Evidence-Based Medicine on Sherlock Holmes’ Footsteps. Oxford: Blackwell Publishing 2007.

Figure 1 Identification of studies population or did not consider laser as the intervention. A further five had populations that focused on specific ethnic groups, that might give results which are not transferrable to other populations.

is a systematic review which considers all of the relevant and most up to date evidence and no additional good quality evidence was found. Consequently, only one study was selected for critical appraisal in this example.

One article was excluded because it did not have a clearly focused question and included retrospective studies, case series and case reports. One article was not chosen as this study was included in Hay et al.4 and consequently this research could be considered alongside other potentially relevant studies.

Whilst it is good practice to consider all studies which provide good quality, relevant research, in this example there

The article chosen for review is Hay AR, Shalaby K, Zaher H, Hafez V, Chi CC, Dimitri S, Nabhan AF, & Layton AM. (2016). Interventions for acne scars. The Cochrane database of systematic reviews, 4(4).

www.bdng.org.uk

Hay et al.4 was chosen as this study has a clear question around the efficacy of laser for treating acne scars.

Unfortunately, this systematic review did

2. Lefebvre C, Glanville J, Briscoe S, Featherstone R, Littlewood A, Metzendorf M-I, Noel-Storr A, Paynter R, Rader T, Thomas J, Wieland LS. Chapter 4: Searching for and selecting studies. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated October 2023). Cochrane, 2023.

Available at: www.training.cochrane.org/ handbook [last accessed July 2024] 3. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.

The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021. 372(71).

4. Hay AR, Shalaby K, Zaher H, Hafez V, Chi CC, Dimitri S, Nabhan AF, Layton AM. Interventions for acne scars. The Cochrane Database of Systematic Reviews 2016. 4(4).

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EFFACLAR DUO+M No. 1 Dermatologist recommended moisturiser for use as a mono and adjunctive therapy Combats the drying effects of commonly prescribed acne treatments and helps to maintain efficacy post BPO KEY ACTIVES Aqua Posae Filiformis PhylobiomaTM NEW! Salicylic Acid Niacinamide Piroctone Olamine LHA ProceradTM FOR USE AS A...

MONOTHERAPY

Imperfections by >50% in 28 days1,2 POST-TREATMENT

Months anti-relapse efficacy post BPO3 ADJUNCTIVE THERAPY

To commonly prescribed treatments including BPO4

Study of 73 Consultant Dermatologists Jan-April 2023.

*

Clinical study, 15 patients, 2/day, Half-face Effaclar, Half-face placebo. Lesion count at D28 & D56. 2Clinical study, 45 patients, 1/day Effaclar & Effaclar foaming gel 2/day, 4 weeks.

3 Clinical study, 25 subjects with effaclar duo(+) after BPO 1/day, 3 months. 4Clinical study, 64 patients in 3 groups: Effaclar, BPO, Effaclar in combination with BPO, 56 days.

1

Tirbanibulin for the management of actinic keratosis Rod Tucker

A

ctinic keratoses (singular: keratosis) represent benign, intra-epithelial neoplasms that arise on chronically sun-exposed areas of the skin.1 Clinically, AKs present as irregularly shaped, hyperkeratotic lesions. These lesions can be either flesh-coloured, yellow or erythematous and appear on the face, scalp, backs of the arms and the dorsal aspects of the hands and feet. Actinic keratoses are generally considered to be a marker of cumulative exposure to sunlight and are therefore more likely to occur in older adults. However, a recent systematic review and meta-analysis of 65 studies found that the point prevalence in patients over 60 years of age was 19% (ranging from 10 to 30%) but only slightly less at 15% (9 to 21%) in patients under 60 years of age.2

diclofenac gel 3% and imiquimod. The latter is available in two strengths: 3.75% and 5% treatment. The 3.75% cream is applied daily for two treatment cycles of two weeks, separated by a two-week interval. In contrast, the 5% cream is applied only three times per week (although not on consecutive days) and left in contact with the skin for at least eight hours. Assessments are then made after a fourweek, treatment-free period.

AKs are also deemed to be premalignant lesions with the potential for transformation into a squamous cell carcinoma (SCC). While some research indicates that the rate of malignant conversion for a single lesion is less than one in 1,000,3 other data suggests that the rate can be as high as 20%.4 While it is difficult to predict which AKs will undergo transformation, the risk is elevated as the number of individual lesions increase. For instance, it has been estimated that in patients with more than 20 AKs, there is a 26% probability of conversion to an SCC.5 Rather than single, isolated lesions, multiple AKs, many of which are not visible, can also develop and become confluent in areas of sun-damaged skin. This is referred to as an area of field cancerisation (FC), where the skin is characterised by a rough texture, telangiectasia, atrophy and pigmentation disorders.6 Since the FC area contains a large number of AKs and with a higher attendant risk for malignant transformation, treatment is recommended for patients.7

Tirbanibulin

In the UK, there are currently three topical agents for field-directed actinic keratosis therapy: 5-fluorouracil;

The latest addition to clinician’s armamentarium is tirbanibulin. The drug boasts a unique mode of action and the duration of treatment is only a few days. So, does this novel therapeutic agent represent a major advance in the treatment of AKs? In 2020, the FDA approved tirbanibulin for use as a field-directed treatment in the management of nonhyperkeratotic, non-hypertrophic actinic keratosis.

A similar approval by the EMA followed in 2021. However, tirbanibulin is not a new molecule and has previously been explored as an oral anti-cancer agent.8 This work revealed that the drug had a dual mode of action, involving both an anti-proliferative and anti-tumour action.

The anti-proliferative action arises due to the action on tubulin. Within cells, tubulin undergoes polymerisation to create microtubules, which are part of a cell’s cytoskeleton and contribute to various cell processes such as protein transport, cell migration and division.

Tirbanibulin inhibits tubulin polymerisation, therefore disrupting cell proliferation. This action leads to apoptosis (i.e., programmed cell death) and ultimately a lower level of inflammation. What’s more, the binding to tubulin is reversible and this is postulated to account for the drug’s observed lower degree of toxicity, because less reversible

Summary: With a unique mode of action, does tirbanibulin offer any advantages over current treatments available for the management of actinic keratoses?

Keywords: Actinic keratosis, Tirbanibulin, Clinical evidence, Study

Author info: Rod Tucker is a pharmacist with a special interest in dermatology, and a member of the Dermatological Nursing editorial board

Citation: Tucker R. Tirbanibulin for the management of actinic keratosis. Dermatological Nursing 2024. 23(3):39-41.

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Clinical review

Clinical evidence Early studies

The initial phase 1 and phase 2 trial data used a 1% tirbanibulin ointment and were published in the same article.11 These studies enrolled patients with AKs covering a skin area of either 25cm2 or 100cm2. The phase 1 trial focused on AKs only affecting the forearm, whereas in the phase 2 trial, participants had AKs on either the face or scalp. In both trials, tirbanibulin was applied once daily for three or five consecutive days, with an approximate dose of either 50 or 200mg/day.

Assessments were based on the proportion of patients who had either 100% or at least a 75% reduction in AK counts in the treated area. These were designated as a complete (i.e., 100%) or partial (i.e., 75%) clearance of AKs on days 45 (phase 1) or day 57 (phase 2). The details of the trials are described in Table 1.

Table 1. Summary of phase 1 and 2 study details At least 75% Phase 1 trial 100% clearance clearance (n = 30) N (%) at day 45 N (%) at day 45 Cohort 1: 50 mg daily for 3 days (25 cm2) Cohort 2: 200 mg daily for 3 days (100 cm2) Cohort 3: 50 mg daily for 3 days (25 cm2) Cohort 2: 200 mg daily for 5 days (100 cm2)

1 (25)

2 (50)

0

3 (30)

4 (50)

5 (63)

1 (12.5)

4 (50)

Phase 2 trial (n = 168)

100% clearance (%) at day 57

Cohort 1: 50 mg daily over 25 cm2 for five days Cohort 2: 50 mg daily over 25 cm2 for three days

43

At least 75% clearance (%) at day 57 56

32

52

Adverse effects were generally mild and transient in nature, and included localised erythema, flaking/scaling, pruritus and pain. Plasma levels of tirbanibulin were either low or undetectable.

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Phase 3 trials

Following the success of the phase 1 and 2 trials, two identical, randomised, double-blind, placebo-controlled trials were published as a single paper in 2021.12 A total of 702 patients (351 per trial) with AKs on the face or scalp were randomised to either tirbanibulin 1% ointment or placebo.

Both treatments were applied over a 25cm2 area of skin with between four and eight lesions for five consecutive days. As with the earlier trials, the primary efficacy outcome was the percentage of patients achieving a complete clearance of lesions in the treatment area at day 57. The secondary efficacy outcome was, as with the phase 1 and 2 trials, partial clearance.

The mean age of participants in both trials ranged from 69.1 to 70.2 years with the proportion of male subjects ranging from 84 to 89%. The majority (69 to 81%) had a Fitzpatrick skin type of either I or II, and a median number of six actinic keratosis lesions. Overall, between 44 and 51% of participants had a history of skin cancer.

The findings for complete and partial clearance of AKs are shown in Figures 1 and 2 respectively. % complete clearance of actinic keratosis

compounds are associated with a higher toxicity.9 The second action of tirbanibulin involves interruption of Src signalling. Src is a non-receptor tyrosine kinase which has an important role in cellular growth. Moreover, it has been shown that Src expression and activity are increased in AKs and SCCs, suggesting that it may play a role in the development of keratinocyte cancer.10 By preventing Src signalling within cells, tirbanibulin reduces cancer cell migration and survival.

60 50

54 44

40 30 20

13 5

10 0

Tirbanibulin Trial 1

Placebo Trial 2

Figure 1 Proportion of patients achieving complete clearance of their AKs In trial 1, a similar proportion of patients in both tirbanibulin and placebo (33 vs 32%) experienced adverse events. These proportions were slightly higher (38 vs 39%) albeit similar in trial 2. Overall, the pooled complete clearance rate was 49.3% and the pooled partial clearance rate was 72.2%.

Maintenance of treatment response

After completion of the trial, 174 participants assigned to tirbanibulin with complete clearance of their lesions were followed up for a period of 12 months. Among these individuals, 124 developed one or more lesions

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% partial clearance of actinic keratosis

Clinical review

80 70

shorter treatment regimen and a lower incidence of adverse effects indicates that tirbanibulin is an effective and well-tolerated field-directed therapy for patients with actinic keratoses.

76

68

60

References

50 40 30

16

20

20

10 0

Trial 1 Tirbanibulin

Trial 2 Placebo

Figure 2 Proportion of patients achieving a partial reduction in the number of AK lesions

within the original area of treated skin. The Kaplan-Meier estimate of sustained complete clearance was 27%.

Place in therapy NICE has yet to provide an appraisal of tirbanibulin, although both the Scottish and Welsh authorities have approved the drug for use in their respective countries.

Just where tirbanibulin might fit within treatment ladder of field-directed therapies remains unclear. However, the likely cost-effectiveness of the drug, at least for use in Scotland, was recently examined.

Using a decision-tree approach, researchers calculated the costs and benefits of different treatment strategies for AK on either the face or scalp over a one-year period. Their analysis concluded that tirbanibulin would generate cost savings compared to diclofenac and imiquimod 5% and 5-fluorouracil.13 The real-world value of tirbanibulin has also been recently examined in a study of 38 patients with 228 AKs. The results showed that tirbanibulin gave rise to complete clearance in 51% of lesions and partial clearance in 73% of lesions.14 Moreover, in 2022, the American Academy of Dermatology updated its recommendations on the treatment of AKs to include the use of tirbanibulin.15

Conclusion Tirbanibulin represents a first-in-class, dual action field-directed therapy for non-hyperkeratotic, nonhypertrophic actinic keratosis. Although complete clearance rates with tirbanibulin are comparable to other currently available therapies, both adherence and patient satisfaction are higher with shorter treatment regimens in patients with AKs.16 The combination of a www.bdng.org.uk

1 Marques E CT. Actinic keratosis: StatPearls Publishing 2023.

Available at: https://www.ncbi.nlm.nih.gov/books/NBK557401/ [last accessed July 2023] 2 George CD, Lee T, Hollestein LM, Asgari MM, Nijsten T. Global epidemiology of actinic keratosis in the general population: a systematic review and meta-analysis. Br J Dermatol 2024.

190(4):465-76 3 Marks RRG, Selwood TS. Malignant transformation of solar keratosis to squamous cell carcinoma. Lancet 1988. 1:975-797 4 Eisen DB, Asgari MM, Bennett DD, Connolly SM, Dellavalle RP, Freeman EE, et al. Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol 2021. 85(4):e209-e33 5 Ratushny V, Gober MD, Hick R, Ridky TW, Seykora JT. From keratinocyte to cancer: the pathogenesis and modeling of cutaneous squamous cell carcinoma. J Clin Invest 2012. 122(2):46472 6 Nart IF CR, Dirschka T et al. Defining the actinic keratosis field: a literature review and discussion. J Eur Acad Dermatol Venereol 2018. 32(4):544-63 7 de Berker D, McGregor JM, Mohd Mustapa MF, Exton LS, Hughes BR. British Association of Dermatologists’ guidelines for the care of patients with actinic keratosis 2017. Br J Dermatol 2017.

176(1):20-43 8 Liu T, Hu W, Dalton HJ, Choi HJ, Huang J, Kang Y, et al. Targeting SRC and tubulin in mucinous ovarian carcinoma. Clin Cancer Res 2013. 19(23):6532-43 9 Niu L,Yang J,Yan W,Yu Y, Zheng Y,Ye H, et al. Reversible binding of the anticancer drug KXO1 (tirbanibulin) to the colchicine-binding site of beta-tubulin explains KXO1’s low clinical toxicity. J Biol Chem 2019. 294(48):18099-108 10 Serrels B, Serrels A, Mason SM, Baldeschi C, Ashton GH, Canel M, et al. A novel Src kinase inhibitor reduces tumour formation in a skin carcinogenesis model. Carcinogenesis 2009. 30(2):249-57 11 Kempers S, DuBois J, Forman S, Poon A, Cutler E, Wang H, et al. Tirbanibulin Ointment 1% as a Novel Treatment for Actinic Keratosis: Phase 1 and 2 Results. J Drugs Dermatol 2020.

19(11):1093-100 12 Blauvelt A, Kempers S, Lain E, Schlesinger T, Tyring S, Forman S, et al. Phase 3 Trials of Tirbanibulin Ointment for Actinic Keratosis. N Engl J Med 2021. 384(6):512-20 13 Dymond A, Green W, Edwards M, Pont MAL, Gupta G. Economic Evaluation of Tirbanibulin for the Treatment of Actinic Keratosis in Scotland. Pharmacoecon Open 2023. 7(3):443-54 14 Li Pomi F, Vaccaro M, Pallio G, Rottura M, Irrera N, Borgia F. Tirbanibulin 1% Ointment for Actinic Keratosis: Results from a RealLife Study. Medicina (Kaunas) 2024. 60(2) 15 Eisen DB, Dellavalle RP, Frazer-Green L, Schlesinger TE, Shive M, Wu PA. Focused update: Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol 2022. 87(2):373-4 e5 16 Grada A, Feldman SR, Bragazzi NL, Damiani G. Patientreported outcomes of topical therapies in actinic keratosis: A systematic review. Dermatol Ther 2021. 34(2):e14833.

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Methyl aminolevulinate

ONAL

olevulinate

DAYLIGHT

on your AK marks Convenient Actinic Keratoses (AK) treatment session, Methyl aminolevulinate

! e n o d … t e get s Think PDT first for treating AK; think METVIX as a first option for proven clinical outcomes1–3

METVIX® is indicated in adults (≥18 years) for the treatment of: Thin or non-hyperkeratotic and non-pigmented actinic keratoses on the face and scalp · Superficial and/or nodular basal cell carcinoma (BCC) only when unsuitable for other available therapies due to possible treatment related morbidity and poor cosmetic outcome; such as lesions on the mid-face or ears, lesions on severely sun damaged skin, large lesions, or recurrent lesions · Squamous cell carcinoma (SCC) in situ (Bowen’s disease) when surgical excision is considered less appropriate1

PI Metvix 160 mg/g cream Prescribing Information (UK & IRE)

Presentation: Cream containing 160mg/g of methyl aminolevulinate (as hydrochloride). Indications: Treatment in adults over 18 years of thin or non-hyperkeratotic and non-pigmented actinic keratoses (AK) on the face and scalp.

Only for treatment of superficial and/or nodular basal cell carcinoma (BCC) unsuitable for other available therapies due to possible treatment related morbidity and poor cosmetic outcome; such as lesions on the mid-face or ears, lesions on severely sun damaged skin, large lesions, or recurrent lesions.Treatment of squamous cell carcinoma in situ (Bowen´s disease) when surgical excision is considered less appropriate. Dosage and administration: Please refer to summary of product characteristics before use.Treatment of AK lesions and/or field cancerization, BCC and Bowen’s disease using red-light lamp: For treatment of AK, one session of photodynamic therapy should be administered.

Treated lesions should be evaluated after three months and if there has been an incomplete response, a second treatment may be given. For treatment of BCC and Bowen’s disease, two sessions should be administered with an interval of one week between sessions. Before applying Metvix cream, the surface of AK and superficial BCC lesions should be prepared to remove scales and crusts and roughen the surface of the lesions. Exposed tumour material should be removed gently without any attempt to excise beyond the tumour margins. Using a spatula, apply the cream (about 1mm thick) to the lesion area (for field cancerization, up to 20 cm², approximately) and approximately 5-10mm of the surrounding area. Cover the treated area with an occlusive dressing for 3 hours. Remove dressing and clean with saline. Immediately after cleaning the lesions, illuminate the treatment area with a red-light source (must be CE-marked), either with a narrow spectrum around 630 nm and light dose of approximately 37 J/cm² or a broader and continuous spectrum in a range between 570-670 nm with a light dose of 75 J/cm2. Healthy, untreated skin surrounding the lesions does not need to be protected during illumination. Multiple lesions may be treated during the same treatment session. Lesion response should be assessed after three months, and it is recommended to confirm the response of BCC and Bowen’s disease lesions by histological biopsy. AK and BCC lesion sites that show incomplete response may be retreated if desired. Treatment of AK lesions and/or field cancerization with natural daylight: Daylight treatment may be used to treat mild to moderate AK lesions. One treatment should be given.

Treatment lesions should be evaluated after three months and if there is incomplete response, a second treatment may be given. Daylight treatment can be used if the temperature conditions are suitable to stay comfortably outdoors for 2 hours. If the weather is rainy, or is likely to become so, daylight treatment should not be used. A sunscreen should be applied. Once sunscreen has dried, scales and crusts should be removed from the lesion(s) or field of cancerization and the skin surface roughened before applying a thin layer of Metvix to the treatment areas. No occlusion is necessary. Patients should go outside after Metvix application or, at the latest, 30 minutes later in order to avoid excessive protoporphyrin IX accumulation which would lead to greater pain on light exposure. In order to minimize pain and ensure maximum efficacy the patient should then stay outdoors for 2 continuous hours in full daylight and avoid going indoors. On sunny days, should the patient feel uncomfortable in direct sunlight, shelter in the shade may be taken. Following the 2-hour exposure period, Metvix should be washed off. Multiple lesions may be treated during the same treatment session. Treatment of AK lesions and/or field cancerization using artificial daylight device (CE-marked): Scales and crusts should be removed, and the skin surface roughened before applying a thin layer of Metvix to the areas to be treated. Occlusion is not necessary. Sunscreen is not needed, as patients are not exposed to ultraviolet light. Lesion should be exposed to artificial daylight after Metvix application or, at the latest, 30 minutes later in order to avoid excessive protoporphyrin IX accumulation which would lead to greater pain on light exposure. In order to minimize pain and ensure maximum efficacy, the patient should be exposed to artificial daylight for 2 continuous hours in a comfortable position. Following the 2-hour exposure period, Metvix should be washed off. The devices should have a continuous light spectrum of 400-750 nm and an illuminance greater than 12,000 lux at the lesion surface. Healthy, untreated skin surrounding the lesions does not need to be protected during illumination. Multiple lesions may be treated during the same treatment session. Lesion responses should be assessed after three months, and at this response evaluation, lesion sites showing incomplete response may be retreated.

Contraindications: Hypersensitivity to the active or excipients, including arachis oil or peanut or soya. Morpheaform basal cell carcinoma. Porphyria. Precautions and Warnings: Photodynamic therapy, when using red light or an artificial daylight lamp, should only be administered in the presence of a health care professional trained in the use of photodynamic therapy with Metvix. When using daylight treatment, a sunscreen should be applied to all areas exposed to daylight, prior to lesion preparation. Sunscreen used should offer adequate protection (SPF30 or higher) and must not include physical filters (e.g. titanium dioxide, zinc oxide, iron oxide). Only sunscreens with chemical filters should be used with daylight treatment. Not recommended during pregnancy. Only limited experience is available in relation to the treatment of actinic keratosis and/or Bowen’s disease amongst transplant patients on concomitant

immunosuppressive therapy. A close monitoring of these patients, with re-treatment if necessary is recommended in this population.There is no experience in treating Bowens disease in patients with a history of arsenic exposure.There is no experience of treating pigmented or highly infiltrating lesions with Metvix cream. Thick (hyperkeratotic) actinic keratoses should not be treated with Metvix. Methyl aminolevulinate may cause sensitization by skin contact resulting in angioedema, application site eczema or allergic contact dermatitis. The excipient cetostearyl alcohol may cause local skin reactions (e.g. contact dermatitis), methyl and propyl parahydroxybenzoate (E218, E216) may cause allergic reactions (possibly delayed). Any UV-therapy should be discontinued before treatment. As a general precaution, sun exposure on the treated lesion sites and surrounding skin has to be avoided for a couple of days following treatment.

Direct eye contact with Metvix cream should be avoided. Metvix cream should not be applied to the eyelids and mucous membranes. Pain during illumination with red light may induce increased blood pressure. Measure blood pressure in patients prior to treatment with red light. If severe pain occurs during treatment, the blood pressure should be checked. In case of severe hypertension, the illumination with red light should be interrupted in addition to taking appropriate symptomatic measures. Conventional Photodynamic Therapy (PDT) with a red-light lamp may be a precipitating factor for transient global amnesia in very rare instances. If signs of confusion or disorientation are observed, PDT must be discontinued immediately Pregnancy and lactation: There is no or limited data from the use of methyl aminolevulinate in pregnant women. Metvix is not recommended during pregnancy and in women of childbearing potential not using contraception. It is unknown whether methyl aminolevulinate /metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue/abstain from Metvix therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman. Undesirable effects: Metvix with red light in AK, BCC and Bowen’s disease: Approximately 60% of patients experience reactions localised to the treatment site that are attributable to toxic effects of the photodynamic therapy (phototoxicity) or to preparation of the lesion.The most frequent symptoms are painful and burning skin sensation typically beginning during illumination or soon after and lasting for a few hours with resolving on the day of treatment.The symptoms are usually of mild or moderate severity and rarely require early termination of illumination. The most frequent signs of phototoxicity are erythema and scab.

The majority are of mild or moderate severity and persist for 1-2 weeks or occasionally longer. Repeated treatment with Metvix is associated with reduced frequency and severity of local phototoxic reactions.The incidence of adverse reactions in a clinical trial population of 932 patients receiving the standard treatment regimen with red light and from post marketing surveillance are as follows. Very common (≥1/10): pain of skin, skin burning sensation, scab, erythema; common (≥1/100, <1/10): skin infection, skin ulcer, skin oedema, skin swelling, blister, skin haemorrhage, pruritus, skin exfoliation, skin warm, paraesthesia, headache, application site discharge, feeling hot; uncommon (≥1/1000, ≤1/100): fatigue, eye swelling, eye pain, wound haemorrhage, nausea, urticaria, rash, skin irritation, photosensitivity reaction, skin hypopigmentation, skin hyperpigmentation, heat rash, skin discomfort; not known: transient global amnesia (including confusional state and disorientation), eyelid oedema, hypertension, angioedema, face oedema (swelling face), application site eczema, allergic contact dermatitis, rash pustular (application site pustule). Metvix with daylight in AK: No new local adverse reactions were reported in the two phase III Metvix daylight studies compared to the already known local adverse reactions with Metvix red light. In the two Phase III studies, including a total of 231 patients, local related adverse events were reported less frequently on Metvix DL-PDT than on c-PDT treated sides (45.0% and 60.1% of subjects, respectively). Prescribers should consult the summary of product characteristics in relation to other side effects. MA Numbers: PL 10590/0048 (UK) & PA22743/010/001 (Ireland).

Packaging Quantities and Cost: Tube of 2 gram, UK - £171.50 (NHS), Ireland - €227.00. Legal Category: POM. Marketing Authorisation Holder: UK: Galderma (UK) Limited, Galderma (UK) Limited, Evergreen House North, Grafton Place, London, NW1 2DX, United Kingdom,Tel: +44 (0)300 3035674; IE: Galderma International S.A.S.,Tour Europlaza, La Défense 4, 20 Avenue André Prothin, 92927, France. Date of Revision: October 2022.

Adverse events should be reported.

For the UK: Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.

For Ireland: Suspected adverse events can be reported via HPRA Pharmacovigilance, Website: www.hpra.ie; Adverse events should also be reported to Galderma (UK) Ltd. E-mail: Medinfo.uk@galderma.com; Tel: +44 (0)300 3035674

References: 1. Metvix Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/6777. Accessed Aug 2024.

2. Rubel DM, et al. Br J Dermatol 2014;171(5):1164–71. 3. Lacour JP, et al. J Eur Acad Dermatol Venereol 2015;29(12):2342–8.

GB-MVR-2400007 I Aug 2024

Bed bug infestations: A growing problem Rod Tucker, Alexia Naylor

D

ealing with bed bug infestations can be stressful.

Fortunately though, help is at hand. The Bed Bug Foundation (BBF), a not-for-profit organisation, seeks to increase homeowner and business awareness of the parasite and how to manage infestations when they arise.

Alexia Naylor has been the business manager of the BBF since 2017. A biologist by training, she spent many years as a teacher before being drawn into the world of bed bugs in 2015, working alongside her husband Richard in their company Cimex Store. Richard, who undertook a PhD on bed bugs, established Cimex Store in 2011 in response to a global rise in bed bugs, which created a demand for live bed bug specimens for research. Today, Cimex Store cultures tens of thousands of bed bugs for product testing, and works with a wide range of inventors, manufacturers and academic institutions to evaluate bug bed management products. The company even has two laboratory-like test bedrooms for testing products in a realistic bed bug environment.

Bed bugs and their hosts What exactly are bed bugs and how do they survive?

As Alexia describes, bed bugs are “hematophagous [blood-feeding] parasites, which are a bit like a wingless mosquito”. She adds that “adult bed bugs are similar in size, shape and colour to an apple seed, but the nymphs can be as small as a grain of brown sugar.” Bed bugs go through five nymphal stages before reaching maturity, with the whole process taking about six weeks. At each stage the developing nymph requires a single blood meal from a warm-blooded host. Bed bugs are mainly active at night. Foraging is triggered by elevated carbon dioxide

and body heat from the host. After feeding, the bug looks for somewhere to hide close to the feeding site.

Although the term bed bug is used because of the current association with beds, according to Alexia, the original hosts for bed bugs are bats. Bed bugs belong to the family Cimicidae, which is comprised of around 100 species, most of which feed on bats and a few species of cave-nesting birds. All members of the group are flightless and live off the host, which means that they rely on hosts species that consistently return to the same locations to sleep. Humans are similar to bats in this respect. It is believed that bed bugs made the transition from bats to humans around 20,000 years ago, when humans still lived in caves alongside bat populations.

As humans moved out of caves and began to build huts, the bugs simply followed.

“Bed bugs go through five nymphal stages before reaching maturity, with the whole process taking about six weeks” Current trends According to data from Rentokil, the UK is facing what they describe as ‘a significant rise in bed bug infestations’, with a 65 per cent increase from 2022 to 2023. Media reports in Autumn of 2023 suggested that outbreaks originating

Summary: With a recent increase in media reports about bed bugs in the UK and France, Alexia Naylor from the Bed Bug Foundation spoke with Rod Tucker about how to identify and minimise the risk of a bed bug infestation at home.

Keywords: Bed bugs, Infestation, Insecticide, Bites

Author info: Rod Tucker is a pharmacist with a special interest in dermatology, and a member of the Dermatological Nursing editorial board. Alexia Naylor is the business manager of the Bed Bug Foundation.

Citation: Tucker R, Naylor A. Bed bug infestations: A growing problem. Dermatological Nursing 2024. 23(3):43-45.

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in Paris were spreading to London and beyond. So, is it time to panic?

Bed bug numbers have been increasing steadily since the late 90s, but they were temporarily knocked back during the COVID-19 pandemic as a result of the social distancing rules and travel restrictions. The recent spike reported

by Rentokil is probably just bed bug numbers bouncing back to their prepandemic levels now that people are free to move around again.

The narrative presented by the media regarding bed bugs spreading from Paris was very misleading. In reality, bed bugs have been well-established in every major city for many years. There is no evidence that bed bug numbers have suddenly increased in the UK as a result of outbreaks in France.

Keeping out of sight As Alexia explains, “Bed bugs hide in the cracks and crevices around the bed, come out to feed and then hide again very quickly.” Contact time with the host is minimal, as bed bugs only feed for a few minutes about once a week. Most people experience a delayed reaction to bed bug bites, and around a third of people don’t react at all, so it can sometimes take months for people to realise they have an infestation.

For those that do react, the bites have a characteristic presentation. Bed bugs only bite exposed skin and never push under clothes or bedding. They typically feed without walking on the skin, as this would make them easier to detect, so bites tend to occur in lines where the clothing or bedding meets the exposed skin. Bites on the neck, shoulders and upper arms are most common. Bites to the feet and ankles only occur when the host sleeps with their feet protruding from the covers.

However, there are many other causes of bite-like skin reactions that are not due to bed bugs, so before embarking on any control measures, it is always important to establish whether bed bugs really are the cause. Alexia notes that other house dwelling insects, such as carpet beetle larvae, can cause skin 44

“There is no evidence that bed bug numbers have suddenly increased in the UK as a result of outbreaks in France” irritation and a reaction that resembles bed bug bites. There are also bacterial and fungal skin infections that can sometimes look similar.

Where to look For those who believe they may have a bed bug infestation, Alexia recommends they start by conducting a careful visual inspection. As the name suggests, bed bugs tend to hide in the bed structure, seeking out cracks and crevices that offer some physical protection. Where people spend a lot of time sitting on sofas and armchairs, these may also get infested.

Start by removing the bedding and other soft furnishings. Inspect any seams, pleats, pockets and other features that may be hiding a bug, and then put these to one side. Lift the mattress off the bed and check along the piping and around any grab handles, as bugs will sometimes squeeze up against these.

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Frame beds are normally easier to inspect than divan beds, because bed bugs will often hide inside the bed base, where they are difficult to find. In this case it may be necessary to turn the bed on its side and remove the woven fabric from the underside so that the internal structure is visible.

With a good torch, inspect all the cracks and crevices, countersunk screw holes and features around the headboard.

While bed bugs are good at hiding, they are also very messy, leaving inky black faecal spots on the bedding and bed frame. Developing bed bugs also leave behind cast skins (exuvia) as they grow.

These pale brown, papery structures can be found littering the areas where the bugs are hiding.

For anybody who finds an insect and needs help with the identification, the BBF offers a free insect identification service, the details of which can be found on their website. Of the

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Unit profile

specimens and photographs that the BBF receives each year, only around 20% are bed bugs, so it is worth checking if you are not certain.

Sniffing out an infestation Bed bugs hide together in clusters and locate each other by emitting aggregation pheromones, which help them to find their way back to their harbourages after feeding. Dogs can be trained to recognise this distinctive odour, allowing them to sniff out exactly where the bugs are hiding.

Alexia describes how part of the work of the Foundation has been to provide an annual certification for bed bug detection dog teams. Currently, she says there are “about 75 teams across Europe that are certified with us and it’s growing a lot, particularly in France.”

Detection dogs can quickly screen rooms or apartments with minimal disturbance. This can help pest managers identify where control measures should be focused and subsequently confirm when the eradication has been successful.

Eradicating an infestation Although chemical insecticides are still widely used, Alexia points to evidence of increasing resistance to these compounds, forcing pest managers to implement other control measures.

Different pest managers employ different strategies. Heat treatments are

effective, but they are time-consuming and therefore expensive. This option would normally be employed in more severe infestations that have spread to multiple rooms. Steam is very effective, as long as the pest manager takes the time to thoroughly treat all infested areas. Some steam machines have now been specifically developed for bed bug control.

Desiccant dusts, like diatomaceous earth and amorphous silica dioxide, can be applied to the cracks and crevices where bed bugs tend to hide. These dusts have a physical mode of action, drying out the insects. While they can be slow to take effect, they do provide long lasting residual protection. This can be particularly helpful in multiple occupancy buildings where reinfestation from neighbouring rooms or apartments is likely.

immediately. Carefully inspect all the seams, flaps and pockets, which could potentially be hiding a stow-away.

For those living in apartment buildings where bed bugs could be arriving from neighbouring rooms or apartments, it can be helpful to isolate the bed from the room by placing dishes under the bed legs and moving the bed slightly away from the wall. If bed bugs can’t reach the bed to feed, they can’t reproduce and will eventually die. Metal frame beds are much less susceptible to bed bugs than divan and wooden beds because bed bugs can’t climb the smooth, metal legs.

Mattress and bed base encasements can help by eliminating potential bed bug harbourages, making it easier to check the bed structure for signs of bugs in the future.

Preventative measures

Further information

There are several simple strategies that can be adopted to reduce the chances of a bed bug infestation in your home.

When travelling, keep your bags off the floor and away from the bed. If there is a luggage stand, use it. Hard shell suitcases offer fewer hiding places for bed bugs than rucksacks and soft bags.

The Bed Bug Foundation website contains a huge amount of information and self-help advice on identifying and eradicating bed bugs: https:// bedbugfoundation.org

If you believe you have been exposed to bed bugs while travelling, take care when unpacking. Either unpack outside or in the bathtub and wash your clothes

The Topical Dermatology Magazine Rash Talk® is a Registered Trade Mark of Derma UK Limited

The Bed Bug Foundation also has a separate site for those wishing to engage the services of a certified bed bug detection dog team in their area: https:// bbf-k9.org

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This promotional meeting is being funded and organised by medac Pharma and is intended for UK Healthcare Professionals only.

Methotrexate in Focus

SAVE THE DATE

Topics to include: The role of SC MTX in Psoriasis

Blood monitoring requirements

How to educate patients on SC MTX use

Common Questions in clinic

Monday 11th November 2024 11.30 - 16.30 Leonardo Birmingham

Shared Care with primary care

Speakers:

Teena Mackenzie

Dr Tom King

Nurse Consultant, Royal Berkshire NHS Foundation Trust

Consultant Dermatologist, Sheffield Teaching Hospitals

Emma Button

Emmanuel Toni

Dermatology Clinical Nurse Specialist, Kingston Hospital NHS Foundation Trust

Nurse Practitioner Dermatology, PhD Research, Centre for Appearance Research, UWE Bristol

To register your attendance, scan the QR code or visit: https://bdng.org.uk/methotrexate-in-focus/ Metoject® PEN is indicated for moderate to severe psoriasis in adult patients who are candidates for systemic therapy, and severe psoriatic arthritis in adults (https://www.medicines.org.uk/emc/search?q=metoject#gref. Last Accessed: August 2024).

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to medac drug safety at: drugsafety@medac.de

Prescribing Information - Please refer to the Summary of Product Characteristics Hypersensitivity to methotrexate or any of the excipients; severe liver impairment; (SmPC) before prescribing. alcohol abuse; severe renal impairment (creatinine clearance < 30 ml/min); preexisting blood dyscrasias (bone marrow hypoplasia, leukopenia, thrombocytopenia, Metoject® PEN (methotrexate) 7.5 mg / 10 mg / 12.5 mg / 15 mg / 17.5 mg / 20 significant anaemia); serious, acute or chronic infections such as tuberculosis, HIV, mg / 22.5 mg/ 25 mg/ 27.5 mg / 30 mg solution for injection in pre-filled pen other immunodeficiency syndromes; ulcers of the oral cavity and known active gastrointestinal ulcer disease; pregnancy, breastfeeding; concurrent vaccination Qualitative and quantitative composition: 1 pre-filled pen with 0.15 ml (0.20 ml; with live vaccines. Special warnings and precautions for use: In the treatment 0.25 ml; 0.30 ml; 0.35 ml; 0.40 ml; 0.45 ml; 0.50 ml; 0.55 ml; 0.60 ml) contains of rheumatoid arthritis, juvenile idiopathic arthritis, psoriasis and psoriatic arthritis, 7.5 mg (10 mg; 12.5 mg; 15 mg; 17.5 mg; 20 mg; 22.5 mg; 25 mg; 27.5 mg; 30 and Crohn’s disease, Metoject PEN (methotrexate) must only be used once a week. mg) methotrexate. Excipients: NaCl, NaOH, HCl, water for injections. Therapeutic Dosage errors in the use can result in serious adverse reactions, including death. indications: Active rheumatoid arthritis in adult patients; polyarthritic forms of Undesirable effects: Most serious adverse reactions of methotrexate include bone severe, active juvenile idiopathic arthritis, when the response to nonsteroidal anti- marrow suppression, pulmonary toxicity, hepatotoxicity, renal toxicity, neurotoxicity, inflammatory drugs (NSAIDs) has been inadequate; moderate to severe psoriasis in thromboembolic events, anaphylactic shock and Stevens-Johnson syndrome. Most adult patients who are candidates for systemic therapy, and severe psoriatic arthritis frequently (very common) observed adverse reactions of methotrexate include in adults; mild to moderate Crohn’s disease either alone or in combination with gastrointestinal disorders e.g. stomatitis, dyspepsia, abdominal pain, nausea, loss corticosteroids in adult patients refractory or intolerant to thiopurines. Posology of appetite and abnormal liver function tests e.g. increased ALAT, ASAT, bilirubin, and method of administration: Should only be prescribed by physicians who are alkaline phosphatase. Other frequently (common) occurring adverse reactions are familiar with the various characteristics of the medicinal product and its mode of leukopenia, anaemia, thrombopenia, headache, tiredness, drowsiness, pneumonia, action. Patients must be educated to use the proper injection technique. The first interstitial alveolitis/pneumonitis often associated with eosinophilia, oral ulcers, injection of Metoject PEN should be performed under direct medical supervision. diarrhoea, exanthema, erythema and pruritus. Effects: Pharyngitis, infection Adults, rheumatoid arthritis: The recommended initial dose is 7.5 mg of Metoject (incl. reactivation of inactive chronic infection), sepsis, conjunctivitis. Lymphoma. once weekly, administered subcutaneously. Depending on the individual activity of Leukopenia, anaemia, thrombopenia, pancytopenia, agranulocytosis, severe the disease and tolerability, the dose may be increased gradually by 2.5 mg per courses of bone marrow depression, lymphoproliferative disorders, eosinophilia. week. A weekly dose of 25 mg should in general not be exceeded. Polyarthritic Allergic reactions, anaphylactic shock, hypogammaglobulinaemia. Precipitation of forms of juvenile idiopathic arthritis: The recommended dose is 10-15 mg/m2 diabetes mellitus. Depression, confusion, mood alterations. Headache, tiredness, body surface area (BSA)/once weekly, administered subcutaneously. In therapy- drowsiness, dizziness, pain, muscular asthenia or paraesthesia/ hypoaesthesia, refractory cases the weekly dosage may be increased up to 20 mg/m2 BSA/once changes in sense of taste (metallic taste), convulsions, meningism, acute aseptic weekly. Use in children < 3 years of age is not recommended as insufficient data meningitis, paralysis, encephalopathy/ leukoencephalopathy. Visual disturbances, on efficacy and safety is available for this population. Psoriasis vulgaris, psoriatic impaired vision, retinopathy. Pericarditis, pericardial effusion, pericardial arthritis: Test dose of 5 – 10 mg should be administered parenterally, one week tamponade. Hypotension, thromboembolic events. Pneumonia, interstitial alveolitis/ prior to therapy to detect idiosyncratic adverse reactions. The recommended initial pneumonitis often associated with eosinophilia. Symptoms indicating potentially dose is 7.5 mg of methotrexate once weekly, administered subcutaneously. The severe lung injury (interstitial pneumonitis) are: dry, not productive cough, short of dose is to be increased gradually but should not, in general, exceed a weekly breath and fever, pulmonary fibrosis, Pneumocystis jirovecii pneumonia, shortness dose of 25 mg of methotrexate. Crohn’s disease: Induction treatment: 25 mg/ of breath and bronchial asthma, pleural effusion, epistaxis, pulmonary alveolar week administered subcutaneously. Response to treatment can be expected after haemorrhage. Stomatitis, dyspepsia, nausea, loss of appetite, abdominal pain, approximately 8 -12 weeks. Maintenance treatment: 15 mg/week. Elderly: Dose oral ulcers, diarrhoea, gastrointestinal ulcers and bleeding, enteritis, vomiting, reduction should be considered due to reduced liver and kidney function as well as pancreatitis, gingivitis, haematemesis, haematorrhea, toxic megacolon. Abnormal lower folate reserves. If changing the oral to parenteral administration a reduction liver function tests (increased ALAT, ASAT, alkaline phosphatase and bilirubin), of dose may be required due to the variable bioavailability. Contraindications: cirrhosis, fibrosis and fatty degeneration of the liver, decrease in serum albumin, medac code: medacuk 139/08/2024 Date of Preparation: August 2024

acute hepatitis, hepatic failure. Exanthema, erythema, pruritus, photosensitisation, loss of hair, increase in rheumatic nodules, skin ulcer, herpes zoster, vasculitis, herpetiform eruptions of the skin, urticarial, increased pigmentation, acne, petechiae, ecchymosis, allergic vasculitis, Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell’s syndrome), increased pigmentary changes of the nails, acute paronychia, furunculosis, telangiectasia, skin exfoliation/ dermatitis exfoliative. Arthralgia, myalgia, osteoporosis, stress fracture, osteonecrosis of jaw (secondary to lymphoproliferative disorders). Inflammation and ulceration of the urinary bladder, renal impairment, disturbed micturition, renal failure, oliguria, anuria, electrolyte disturbances, proteinuria. Inflammation and ulceration of the vagina, loss of libido, impotence, gynaecomastia, oligospermia, impaired menstruation, vaginal discharge. Fever, wound-healing impairment, asthenia, injection site necrosis, oedema. Subcutaneous application of methotrexate is locally well tolerated. Only mild local skin reactions (such as burning sensations, erythema, swelling, discolouration, pruritus, severe itching, pain) were observed, decreasing during therapy. Overdose: Calcium folinate is the specific antidote for neutralising the toxic undesirable effects of methotrexate.

Basic NHS price: 7.5 mg/0.15 ml single pen 10 mg/0.20 ml single pen 12.5 mg/0.25 ml single pen 15 mg/0.30 ml single pen 17.5 mg/0.35 ml single pen 20 mg/0.40 ml single pen 22.5 mg/0.45 ml single pen 25 mg/0.50 ml single pen 27.5 mg/0.55 ml single pen 30 mg/0.60 ml single pen

£12.87 £13.26 £14.35 £14.41 £15.25 £15.56 £16.11 £16.13 £16.50 £16.56

Legal classification: POM Marketing authorisation holder: medac GmbH, Theaterstr. 6, 22880 Wedel, Germany.

Product information in the UK: medac Pharma, Scion House, Stirling University Innovation Park, Stirling, FK9 4NF. T:01786 458086, F:01786 458032. info@medacpharma.co.uk Marketing authorisation number: PL 11587/0076 - 0085 Date of revision of text: 09.2023 Website: www.metoject.co.uk

Research into mindfulness and skin disease Olivia Hughes, Rob Mair in how people cope with skin conditions.1 Some of the responses we had to an online survey, which was part of that work, gave us insight into the wide-ranging psychological burden that’s often experienced by people with a range of different skin diseases. That work really showed me that I wasn’t the only one that had struggled with a skin condition, and that made me quite passionate about pursuing this research further and really focusing on psychodermatology.

I then went on to do a Master’s in Clinical Psychology and Mental Health at Swansea University, and my dissertation investigated anger and its impact on psoriasis.2 I interviewed people from a range of different backgrounds about their skin condition and what it had been like for them, and it was a privilege, really, to hear their stories and experiences of living with the same disease as me.

Rob Mair: Can you start by telling me a little bit about your background and research, and how you became interested in looking at skin disease and wellbeing?

Olivia Hughes: I’ve always had an interest in skin conditions, and that’s mostly come from my own experience of having psoriasis since childhood. I’ve also always been interested in mental health as well, and that pushed me to pursue psychology.

I completed an undergraduate degree in Counselling Studies and Psychology at the University of Wales, Trinity St David, and with my supervisors, I wrote my dissertation looking at stigma and gender differences

So, when the opportunity arose to do a PhD on skin conditions at the School of Psychology in Cardiff University with Professor Andrew Thompson, Professor Katherine Shelton, and Dr. Helen Penny [Aneurin Bevan University Health Board], I was keen to apply.

Throughout my doctoral studies, I’ve been able to draw on my experience of living with psoriasis, and also use this to contribute to research. I’m involved with the Welsh charity Skin Care Cymru, I’m a Patient Associate Editor for the British Journal of Dermatology, and I’m a Patient Representative on the British Association of Dermatologists Biologic and Immunomodulators Register [BADBIR] steering committee. Having the dual role of dermatology patient and researcher has enhanced my ability to conduct research by showing me first-hand the importance of involving experts by experience, which is something we tried to incorporate into my PhD.

Summary: In this article, Dr Olivia Hughes talks to Dermatological Nursing about her doctoral work investigating mindfulness, mental health and skin disease.

Keywords: Mindfulness, Psychology, Skin disease, Burden of disease

Author info: Dr Olivia Hughes is a Research Associate at the School of Psychology at the University of Cardiff.

Citation: Hughes O, Mair R. Research into mindfulness and skin disease.

Dermatological Nursing 2024.

23(3):47-50.

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RM: And what was your PhD about?

OH: My PhD specifically focused on the potential role of mindfulness for supporting families affected by skin conditions. Mindfulness is an approach that involves acting with awareness and learning to be more present in the moment, and it consists of doing things like breathing exercises and meditation to achieve that. It is being increasingly used within a range of different healthcare settings, including dermatology.

What we wanted to do with my PhD was find out what the support needs are for families and how we could meet that need with something like mindfulness.

We aimed to incorporate expert by experience views when trying to look at whether mindfulness could be a promising intervention for reducing stress and stress in children and parents affected by skin conditions.

The work was comprised of several components. I carried out a systematic review to look at the existing literature and see where mindfulness had been used previously to support children and their parents.3 What that showed us was, although the approach had been applied to children with a range of different physical health condition conditions, there were a lack of interventions for families as a whole, and particularly for children affected by skin disease.

To try and understand the specific issues faced by these families, and to understand what they wanted from a support resource, I held interviews with children and their parents with conditions including eczema, vitiligo, psoriasis and ichthyosis, and we found that families would be open, potentially, to practicing mindfulness techniques.4 But we also found that there was a specific need for mindfulness interventions that could fit into people’s daily care routines. Often, these people had quite intensive routines of skincare needs which needed to be upheld. So, as part of this, we interviewed healthcare professionals, which included dermatologists, dermatology nurses, psychologists and psychiatrists, to get their views on using mindfulness with families.5 They really highlighted the need for the increased provision of psychological support for children and their parents, and they gave anecdotes about how mindfulness could be therapeutic for families. They also suggested that parents could benefit from receiving additional support to reduce stress within the family unit, as much of the focus can be on the child with skin condition, even though the parents can be affected as well.

All of this work ultimately led to the delivery of an online group-based mindfulness intervention to parents of children with common and rare skin conditions with funding from the Ichthyosis Support Group.6 Also, the findings from my PhD suggest that mindfulness could be a promising approach, reducing stress and improving the quality of life of parents 48

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and the family unit caring for children with skin conditions.

More research is needed though.

RM: It’s interesting that you mention that wider burden to the family, because in our Patient Voice articles we can really see that, especially when it’s the parents writing about their child’s experiences.

But it’s rare in those articles for the parents to say, ‘this is the support we received, and this is how it helped’. The focus is often always solely on the child.

But I get the impression that parents would really value that extra help and targeted support.

OH: There is an unmet need there, I think. Much of the focus is on the child with the condition, but parents are the primary caregivers, and they oversee treatment routines.

They take the children to their appointments and there are a lot of additional considerations – and that extends to siblings as well, who are also living within the household with a child with a chronic condition. It really affects more than the child, it affects the whole family.

RM: Mindfulness has really grown as a concept over this past decade or so, but it’s really exciting to see how people are looking at the application of it, and this seems like a prime example.

OH: One of the main researchers in mindfulness literature is Jon Kabat-Zinn, and one of the early studies carried out in 1998 was with people with psoriasis. Kabat Zinn and colleagues found that the rates of clearance of psoriasis for patients undergoing light therapy including UVB and PUVA was increased in patients who engaged in meditation alongside treatment.7 So, I think mindfulness is a really promising approach for people, particularly with inflammatory skin conditions where the condition itself is affected by stress. Targeting stress levels with an approach like mindfulness could really be beneficial for people with those types of conditions, because it helps train the mind to change how situations are appraised, so you can alter your reaction to stress to some extent. It is a really interesting line of research, particularly when it is applied to something like dermatology. As well as this, there has been some more recent research funded by The Psoriasis and Psoriatic Arthritis Alliance [PAPAA] looking at mindful parenting to support parents caring for children with psoriasis and eczema.8 RM: On the family point, I think it’s easy to forget how much time parents might spend on this. It’s everything from appointments to the treatment, which might be three or four times a day, wrapping wounds or applying bandages. So they’ve already got all of this stuff to contend with – for the nurses to then say, ‘well, research is telling us that mindfulness could be really important’, but for the parents, they might just hear that there’s something else they need to fit into their day…

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BDNG meets

OH: That’s one of the difficult things with any intervention.

You have to make sure that it has relevance to people’s lives. One of the themes that emerged in the research I carried out as part of my PhD was that parents want something that can fit into their existing routines. I think that was a really important finding, because it’s something that needs to be considered going forward. When we’re now thinking of developing support resources that are going to be usable by the target population, we have to consider this if we want it to be useable. It has to designed around the needs of families, it needs to accessible, and it needs to be something that can be easily undertaken by parents.

RM: One of the papers that you’ve published was on the healthcare professional’s view, so what did you find?

OH: So, the study highlighted how children with skin conditions can experience a range of emotions, from low mood through to things like clinical levels of distress or depression and anxiety. And parents, too, can experience a negative psychological impact from having to provide care to the child with a chronic health condition; they might experience things like sadness, worry and there can be a lot of uncertainty as well, but many of the skin conditions are chronic, and this is why it was felt that parents could be an important target for an intervention.

The healthcare professionals I interviewed felt that psychological support was essential in dermatology, as well as having open discussions with patients surrounding their mental health and how they cope with their skin condition. And in some cases, mindfulness had been delivered to paediatric patients, as well as other approaches. So, for example, psychologists had used techniques including cognitive behavioural therapy or acceptance and commitment therapy.

However, what was really clear was there were several barriers for the provision of specialist psychological services across England and Wales, and access to these services can vary massively depending on location within the UK. And this is what I think is really important to say. This is where the role of a dermatology nurse was so important and goes beyond really treating physical symptoms. Their role extends to supporting the psychological wellbeing of children, because nurses are often a point of contact for many paediatric patients, sometimes for several years, as they progress through paediatric care to adult services.

Many of the dermatology nurses I’ve met throughout the entirety of my PhD, have all been dedicated to ensuring their patients are supported. And I think it takes a whole team of multidisciplinary specialists to provide holistic care for children with skin conditions, and nurses really play a crucial part in that. I thoroughly enjoyed working with nursing colleagues, and I think www.bdng.org.uk

what’s been most clear is how valued nurses are in dermatology, so not just in managing the condition but in supporting the whole family.

RM: That idea of continuity of care is probably really important, not just for the patient, but for the wider family, too. I guess it can be overlooked, but that relationship is probably provides a sense of structure.

OH: Yes. And that came through in my research. Nurses were very valued, both from the healthcare professionals I spoke to and from the children. It was across the board.

RM: So how have things changed since you finished your PhD? How do you take all this learning and implement change?

OH: Since I completed my PhD, I’ve been lucky enough to be working on a project funded by DEBRA UK with Professor Andrew Thompson and Dr Faith Martin, developing and testing a self-help toolkit to support the psychological wellbeing of parents of children with epidermolysis bullosa (EB). EB is a rare blistering skin condition, and having a child with EB can impact the whole family. It’s well known that there’s a lack of psychological support for people with a range of different skin conditions, so we’re aiming to create a resource that can be easily accessed and used by parents to reduce levels of stress.

To inform the design of the toolkit and guide our research, we’re involving expert stakeholders, which includes parents and children with EB and healthcare professionals such as dermatology nurses, dermatologists and psychologists on a steering group. We’ll also be holding focus groups, and really our work and the content of the toolkit will be informed by expert clinicians, parents as well as the literature base, and this will likely incorporate mindfulness and self-compassion, depending on feedback from our expert steering group.

If you are a dermatology nurse with experience working clinically with children and families affected by EB, please consider taking part in a focus group funded by DEBRA UK: https://www.debra.org.uk/cardiff-mentalhealth-toolkit. For more information, email: HughesOA@cardiff.ac.uk References: 1. Hughes O, Hutchings PB, Phelps C. Stigma, social appearance anxiety and coping in men and women living with skin conditions: A mixed methods analysis. Skin Health and Disease 2021. 2(4):1-11 2. Hughes O, Hunter R. Understanding the Experiences of Anger in the Onset and Progression of Psoriasis: A Thematic Analysis. Skin Health and Disease 2022. 2(4)e111 3. Hughes O, Shelton KH, Penny H, Thompson AR. Living with Physical Health Conditions: A Systematic Review of MindfulnessDermatological Nursing 2024, Vol 23, No 3

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based Interventions for Children, Adolescents, and their Parents.

Journal of Pediatric Psychology 2023. 48(4):396-413

Conditions: A Single Group Cases Series. Behavioural and Cognitive Psychotherapy 2024. (In-press)

4. Hughes O, Shelton KH, Penny H, Thompson AR. Parent and child experience of skin conditions: Relevance for the provision of mindfulness-based interventions. British Journal of Dermatology 2022.

188(4):514-523

7. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley TG et al. Influence of a mindfulness meditationbased stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA).

Psychosomatic Medicine 1998. 60(5):625-632

5. Hughes O, Shelton KH, Thompson AR. Healthcare Professionals’ Views on Psychological Support for Children and Families Affected by Skin Conditions: A Qualitative Study. Skin Health and Disease 2024. e376 6. Hughes O, Shelton KH, Penny H, Thompson AR. ‘Living in the Present’ Mindfulness Intervention for Parents of Children with Skin

8. Heapy C, Norman P, Emerson LM, Murphy R, Bögels S, Thompson AR. Mindful parenting intervention for parents of children with skin conditions: a single group experimental cases series. Behavioural and cognitive psychotherapy 2022.

50(5):462-480.

Aspire’s 2024 webinar series Sophie Williams

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very year, as part of our corporate sponsorship with the BDNG, Aspire Pharma run a series of webinars educating members on a variety of dermatology topics with expert speakers from the industry. In previous years we have worked with healthcare professionals such as Ivan Bristow and Timothy Cunliffe on dermatology topics from podiatry to skin cancer. Past webinars have received great feedback, so we are excited to bring you a fresh 2024 series.

This year, Aspire are taking a different approach with our new series ‘Walking in Your Patient’s Shoes’. The three-part series will be hosted by the amazing Dermatology Nurse Consultant Paula Oliver, and will discuss three skin conditions: the commonly seen eczema and psoriasis, and the lesser seen ichthyosis.

Each hour-long webinar will consist of a 30-minute education on the topic, a

Summary: An overview of Aspire’s 2024 webinar series 50

15-minute interview between Paula and a patient with the skin condition, and a 15-minute Q&A with Paula to close.

The interview aims to encourage healthcare professionals to see the condition from their patient’s point of view, as the questions from Paula will touch on the impact of the condition on the patient’s life as well as the support they have received.

The closing Q&A is an opportunity for you to ask Paula any questions you have about the skin condition and hear her expert advice.

We hope that these webinars will not only further educate or remind delegates of the clinical presentations and treatments of the conditions themselves, but bring light to the impact that these conditions have on the everyday lives of those who have them.

If you missed last year’s webinars, don’t worry, you can watch them on demand by scanning the QR code.

This new series will take place across three months, starting with the eczema webinar on Wednesday 25 September, followed by the ichthyosis webinar in October and closing with the psoriasis webinar in November. Keep an eye on your emails and the BDNG newsletter for the sign-up links so you don’t miss out.

Author info: Sophie Williams is Brand Associate at Aspire

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These webinars are funded by Aspire Pharma

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Could biologic therapy in atopic eczema halt the atopic march?

Rod Tucker, a pharmacist with a special interest in dermatology, answers more questions submitted by DN readers.

If you have a burning question that you’d like answered in a future issue, please email it to susan. maguire@bdng.org.uk entitling your email: Ask the Pharmacist.

T

he term ‘atopy’ comes from the Greek word atopia, which means ‘different’ or ‘out of place’. The first clinical manifestation of atopy is atopic eczema (AE), which globally affects 0.96 to 22.6% of children1 and between 2.1 and 4.9% of adults.2 In fact, AE normally first presents during infancy and 95% of those affected will experience an onset of symptoms before five years of age.3 Once an individual has developed AE, longitudinal studies have suggested that this subsequently leads to the development of other atopic diseases such as asthma and aeroallergen sensitisation, which is a major cause of allergic rhinitis.4 This onward trajectory has been referred to as the atopic march.

Moreover, support for this sequence of events comes from systematic reviews which reveal a high prevalence of both co-morbidities in those with AE. For example, one review identified an asthma point prevalence of 25.7% in patients with AE.5 Similarly, among patients with AE, the point prevalence of allergic rhinitis has been found to be 40.5%.6 But, as well as allergic diseases, it has also become increasingly clear that

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having AE is associated with an increased risk of a number of other co-morbidities including autoimmune diseases (e.g., alopecia areata), cardiovascular diseases such as hypertension, and even some forms of cancer.7

How common is the atopic march?

Despite a widespread recognition and acceptance of the atopic march, not all patients go on to the develop other atopic diseases. In fact, some studies have questioned the extent to which this progression occurs. For instance, one cohort study of 9,801 children with an 11-year follow-up observed how less than 7% of children followed a trajectory resembling the atopic march.8 Furthermore, in a recent analysis, researchers discovered that while AE, wheeze and rhinitis are not mutually exclusive, there did not appear to be a typical sequence of symptom progression as defined by the atopic march.9

barrier is fixed, allergens are less likely to penetrate the skin and cause immune sensitisation and subsequently, allergic diseases. While there is no evidence to suggest that this is an effective strategy, one small pilot trial using an emollient containing ceramides (which are reduced in eczematous skin) did observe trend towards a lower incidence of food sensitisation after six and 12 months.10 Another approach, this time using topical pimecrolimus, was also unsuccessful, finding no significant difference in the proportion of children affected by asthma, food allergies or allergic rhinitis.11

Halting the atopic march

Although oral antihistamines play a minor role in AE, a trial from 2001 looked a whether cetirizine, given for 18 months, could prevent the onset of asthma in children with AE. While during the 18-month period of follow-up, the incidence of asthma was no different between the two groups, after 36 months, children assigned to cetirizine, and with either grass pollen or house dust mite (HDM) allergies, were significantly less likely to develop asthma.12 Finally, oral immunotherapy directed against HDM has also been examined. Again, using a randomised trial, children less than one year of age, at a high risk of atopy (since both parents were atopic), received an HDM extract twice daily for 12 months. While the cumulative sensitivity to any of the tested allergens was significantly reduced in those receiving the HDM extract, there was, surprisingly, no difference in the sensitivity to HDM or the subsequent development of atopic diseases.13

Since a prominent feature of AE is a defective skin barrier, one approach is to correct this defect. The logic of this approach is that once the defective

With biological therapy now being increasingly used to treat more severe cases of AE, could such treatment terminate the atopic march?

Nevertheless, where the atopic march does occur, halting its progression would be of enormous benefit to patients.

After all, both asthma and allergic rhinitis are incurable and often require life-long therapy. Therefore, any intervention that thwarts the advance of these conditions would significantly reduce the disease burden upon patients and have a significant impact on the associated healthcare expenditure for both diseases.

But what is the most effective therapeutic approach to stopping this progression?

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Ask the Pharmacist

Biologics and the atopic march Physiologically, AE is characterised by an allergen-specific type-2 inflammatory response. This response involves a whole series of events, including the release of interleukins (IL-4, IL-13, IL-33) and ultimately, the release of IgE antibodies. In fact, a higher level of IgE antibodies is strongly associated with the development of AE.14 Since biologics target these interleukins, which play a fundamental role in the initiation of an allergic response, could this mark a more effective target for altering the atopic trajectory? Early evidence is positive as shown in a 2023 metaanalysis. Researchers included 12 clinical trials to assess whether using dupilumab might reduce the risk of developing new allergies in paediatric patients with AE. Their analysis revealed that the drug reduced the risk of new or worsening of allergies by 34%. What’s more, this effect was not reversed once treatment was discontinued.15 The most recent analysis was a retrospective study based on information retrieved from a US database. A total of 4,384 patients (2,192 patients in each cohort) were included. Par ticipants were equally matched, based on factors such as age, gender and prior therapies and placed into one of two groups: a dupilumab or conventionally treated group. These individuals were followed and researchers compared the atopic march progression in the two groups. Over a three-year period, the incidence of atopic march progression was reduced by 32% in the dupilumab group. Additionally, the incidence of asthma and allergic rhinitis were reduced by 40% and 31% respectively for those treated with dupilumab.16 Delving deeper into the results, it also became clear that there was a

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reduced risk of asthma symptoms and prescriptions for inhalers in the dupilumab group.

profiles of eczema, wheeze, and rhinitis: two population-based birth cohort studies. PLoS Med 2014. 11(10):e1001748

Although this was a retrospective study and therefore could not infer causality, it hints at dupilumab being a potentially atopic march-modifying drug. While these early findings are encouraging, we need to remain cautious until the emergence of data confirming a similar effect from other biologics used in the treatment of paediatric atopic eczema.

10. Lowe A, Su JC, Allen K J et al. A randomized trial of a barrier lipid replacement strategy for the prevention of atopic dermatitis and allergic sensitization: the PEBBLES pilot study. Br J Dermatol 2018.

178(1):e19-e21

References 1. Bylund S, Kobyletzki LB, Svalstedt M, Svensson A. Prevalence and Incidence of Atopic Dermatitis: A Systematic Review. Acta Derm Venereol 2020. 100(12):adv00160 2. Wollenberg A, Barbarot S, Bieber T, Christen-Zaech S, Deleuran M, Fink-Wagner A, et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I. J Eur Acad Dermatol Venereol 2018. 32(5):657-82 3.Thomsen S. Epidemiology and natural history of atopic diseases. Eur Clin Respir J 2015. 2 4. Rhodes HL TP, Sporik R et al. A birth cohort study of subjects at risk of atopy: twenty-twoyear follow-up of wheeze and atopic status.

Am J Respir Crit Care Med 2002. 165:176-80 5. Ravnborg N, Ambikaibalan D, Agnihotri G, Price S, Rastogi S, Patel KR, et al. Prevalence of asthma in patients with atopic dermatitis: A systematic review and meta-analysis. J Am Acad Dermatol 2021. 84(2):471-8 6. Knudgaard MH, Andreasen TH, Ravnborg N, Bieber T, Silverberg JI, Egeberg A, et al.

Rhinitis prevalence and association with atopic dermatitis: A systematic review and metaanalysis. Ann Allergy Asthma Immunol 2021.

127(1):49-56 7. Thyssen JP, Halling AS, Schmid-Grendelmeier P, Guttman-Yassky E, Silverberg JI. Comorbidities of atopic dermatitis-what does the evidence say? J Allergy Clin Immunol 2023.

151(5):1155-62 8. Belgrave DC, Granell R, Simpson A, Guiver J, Bishop C, Buchan I, et al. Developmental

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9. Haider S, Fontanella S, Ullah A, Turner S, Simpson A, Roberts G, et al. Evolution of Eczema, Wheeze, and Rhinitis from Infancy to Early Adulthood: Four Birth Cohort Studies. Am J Respir Crit Care Med 2022.

206(8):950-60

11. Schneider L, Hanifin J, Boguniewicz M, Eichenfield LF, Spergel JM, Dakovic R, et al.

Study of the Atopic March: Development of Atopic Comorbidities. Pediatr Dermatol 2016.

33(4):388-98 12. Warner JO, ETAC Study Group Early Treatment of the Atopic Child. A doubleblinded, randomized, placebo-controlled trial of cetirizine in preventing the onset of asthma in children with atopic dermatitis: 18 months’ treatment and 18 months’ posttreatment follow-up. J Allergy Clin Immunol 2001.

108(6):929-37 13. Zolkipli ZRG, Cornelius V et al.

Randomized controlled trial of primary prevention of atopy using house dust mite allergen oral immunotherapy in early childhood. J Allergy Clin Immunol 2015.

136(6):1541-7 14. Fukiwake N FN, Takeoka H et al.

Association factors for atopic dermatitis in nursery school children in Ishigaki islands Kyushu University Ishigaki Atopic Dermatitis Study (KIDS). Eur J Dermatol 2008. 18:571-4 15. Geba GP, Li D, Xu M, Mohammadi K, Attre R, Ardeleanu M, et al. Attenuating the atopic march: Meta-analysis of the dupilumab atopic dermatitis database for incident allergic events.

J Allergy Clin Immunol 2023. 151(3):756-66 16. Lin TL, Fan YH, Fan KS, Juan CK, Chen YJ, Wu CY. Reduced atopic march risk in pediatric atopic dermatitis patients prescribed dupilumab versus conventional immunomodulatory therapy: A populationbased cohort study. J Am Acad Dermatol 2024. 10.

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PHA R

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EPIMAX Eyelid Ointment

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CONSUMERS’ CHOICE

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Soothe, hydrate and comfort dry skin around the delicate eye area For sensitive, irritated eyelids or for those with eyelid eczema

Helps to relieve eyelids that are: Dry Itchy Flaky

Visit epimax.co.uk to find out more EPIMAX® Eyelid Ointment is available for patients to buy OTC and online EPIMAX® Eyelid Ointment Product Information Presentation: Ointment in 4g tube Main ingredients: Yellow soft paraffin 80%, liquid paraffin 10% and wool fat (lanolin) 10%. Indications: Soothing moisturiser for dry, itchy, red, and flaky eyelids. Method of use: Apply to the eyelid skin as frequently as required. Warnings: For external use only. Avoid contact with eyes. If product does accidentally come in to contact with eyes, rinse well with water and seek medical advice. Do not use if allergic to any of the ingredients. This product contains lanolin, which may cause local skin reactions or allergic reactions. Seek medical advice before use if the skin is broken, infected, or bleeding; or after use if any undesirable effects are experienced, or if accidentally swallowed.

No special precautions during pregnancy or breast-feeding. Contraindications: Patients with known hypersensitivity to any ingredient. Product classification: Class I Medical Devices. Cost: RRP: £9.95 NHS List Price: £2.35 Legal Manufacturer: Aspire Pharma Ltd, Unit 4, Rotherbrook Court, Bedford Road, Petersfield, Hampshire, GU32 3QG, UK. Date reviewed: March 2023 Version number: 10104511504 v 2.0

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Aspire Pharma Ltd on 01730 231148.

Please advise your patients to always read the label 10104512167 v 1.0 January 2024

Savannah’s story: Living with lamellar ichthyosis Georgia Butler Savannah’s birth Savannah arrived safely into the world after a textbook pregnancy in the early hours of a Wednesday morning in September 2022. We had been eagerly awaiting her arrival for nine months and could not believe she was finally here!

After a few moments spent cuddling her, a midwife noticed a small blister on her cheek and went to find a doctor. The doctor came along, looked at Savannah and said she needed to go to the neonatal unit. We weren’t sure what was going on and were a bit all over the place with our emotions.

Soon the doctor returned and asked us if there were any skin conditions in our family and if we were related – we answered no to both questions. We were told Savannah may have a skin condition but were not told anything beyond that.

When we next saw Savannah later that morning, she had a very obvious layer of shiny skin, which we learnt to be called a collodion membrane, after we received a piece of paper stating, ‘collodion baby’. Despite being asleep, her eyes were open.

The nurses explained she was having hourly eye drops to keep her eyes moist and regular full body moisturises to help her skin. She was in an incubator in high humidity too.

The advice from GOSH was to continue as is, and gradually reduce humidity in the incubator to see how her skin coped. She coped well!

The doctors began their rounds, and it was explained to us that apart from what they are currently doing, the doctors did not know what to do next and were waiting on advice from Great Ormond Street Hospital (GOSH).

Ichthyosis is very rare – Savannah is around one in 200,000 – and so local doctors and consultants did not have much knowledge on the condition. Although we understand this, it left us feeling very alone, isolated and we struggled to see light at the end of the tunnel. She also did not pass her newborn hearing screening, which was another worrying blow.

Luckily, Savannah also fed well, and a week after she was born we were allowed to take her home. I was convinced as we walked out of the hospital that someone would say there has been a mistake and she needed to come back.

I was so excited to get home, and for us to spend the first night together as a family. We got home and took her for a tour! That week in hospital felt so much longer, and to be home was such a relief. I don’t think I could have coped staying there much longer, still so in the dark about her health, but I didn’t want to leave her either.

Summary: Our little girl, Savannah, was born with lamellar ichthyosis (ick-thee-o-sis), which is a genetic dry skin condition. In this article, we tell our story of learning to live with the condition.

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Her eye drops and moisturising continued, and we were advised to bring her back if she showed any signs of skin infections or if she wasn’t feeding well.

Two weeks later, we were in London at Great Ormond Street, having battled a rush hour train journey with a newborn. www.bdng.org.uk

Patient voice

This is the first time we heard the word ‘ichthyosis’. It was a relief to have spoken to someone knowledgeable on Savannah’s condition, although I couldn’t bring myself to Google anything just yet. But, for the first time since she was born, now surrounded by experts, I had a feeling that everything might just about be okay – that light at the end of the tunnel was beginning to appear. Although we were told there is currently no cure for ichthyosis and it is simply a process of managing the condition, I felt positive that we had someone knowledgeable looking after us.

A few months later, Savannah’s genetic testing confirmed that she had TGM1 gene mutation, which causes ichthyosis.

Savannah’s ichthyosis is a recessive condition, which means you need mutated copies from both parents to have the condition. Dan and I have one mutated copy of the TGM1 gene each, so we do not have the condition but have passed it on to Savannah without even knowing we had it.

This means there is a 25% chance our baby would have ichthyosis, 50% chance they would be a carrier (like us) and 25% chance they would be unaffected.

Appointments Time went on, and we attended lots of appointments.

Ophthalmology was one, to check her eyes were developing as they should and were not too dry from her inability to close them. Audiology was another, as Savannah did not pass her newborn hearing screening and people with ichthyosis can suffer with blocked ears. We still have regular appointments with these departments, along with Dermatology and Ear, Nose and Throat (ENT).

As with all new babies, we had appointments with health visitors and doctors throughout the first few months of Savannah’s life for check-ups, vaccinations etc. Every time, I had to explain Savannah’s condition to them, as they had not seen or heard of it before.

Life now Savannah is coming up to two years of age now. The time has gone so quickly, and my little 6lb baby is no www.bdng.org.uk

longer a baby. She is an independent, funny, happy and headstrong toddler.

We still provide just as much care to Savannah as when she was a newborn – long baths, moisturising, eye drops and attending regular appointments. This will continue throughout her childhood, and as she grows, she will continue to need our guidance until she is old enough to make her own decisions and do her own research.

I have no doubt she will go through a phase where she doesn’t want her eye drops or moisturising, but we will have to push through it and guide and encourage her to continue these necessary tasks. Along with guidance directly to Savannah, we will also need to guide her nursery and school on her care and pick up any issues we may face with them. I am worried that her school will not provide the care she needs, but I will be keeping a close eye on this when the day comes. Currently, Savannah attends nursery one day a week and is getting on brilliantly. I purposely picked the nursery as it is a small, independent one.

Savannah is our first baby, and her having ichthyosis has almost become ‘normal’ to us. This is the only experience of parenthood we have, and it still gets me sometimes that other people don’t have to moisturise their babies multiple times a day, or have to give their baby a bath every morning and that they don’t have lots of appointments to attend.

I giggle to myself sometimes, because once upon a time I was an expert on lipsticks and eyelashes, now I’m an expert on the best nappies and ichthyosis!

Ichthyosis Support Group We are really fortunate to have become members of the Ichthyosis Support Group (ISG), a UK-based charity supporting those affected by ichthyosis. We were first told about this charity by our consultant dermatologist at GOSH; she suggested we join as members and look at the masses of useful information on their website. I didn’t Dermatological Nursing 2024, Vol 23, No 3

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do this until Savannah was about six months old, as I was struggling with her diagnosis. However, as soon as I looked at the website and joined as a member, I wish I had done it sooner. We attended a family conference run by the ISG just before Savannah’s first birthday, and to meet other people with ichthyosis and other parents who had been through what we had been through was refreshing. We had such a great time, and decided before we had even left that we would be attending the next one. We hope Savannah will make some friends through ISG and always have someone she can talk to who understands.

The support we receive from Savannah’s dermatologist is great, but what we receive from the ISG is invaluable. It is run by people with or affected by ichthyosis, for those with or affected by ichthyosis. Not only is there plenty of easily accessible and useful information on their website, but I know that there is always an ambassador or another member just an email or text message away that will offer me advice or support when I need it – someone who has been through exactly what I am asking about and can offer personalised advice.

Thanks to the ISG, we have been put in contact with a few families of children with ichthyosis similar to Savannah’s age, and we have a group chat run by an ambassador where we share our frustrations, product recommendations and cute photos. This has helped us feel so much less alone.

We wouldn’t find that anywhere else, and this is what makes the ISG so unique.

Visual differences Savannah’s skin can vary throughout the year. At all times, it is dry, but on a humid day, we find we need to moisturise her a little less. When we have been inside an airconditioned building, her skin really dries out and we must moisturise her a lot.

Her scalp is probably the area we struggle with most, and we are always trying new things. Fortunately, her hair has begun growing really well and I hope this continues.

On her forehead, she often has dry patches that appear brown. This is common with lamellar ichthyosis. I do find that people can sometimes stare at her. Children are curious, and sometimes ask questions which I absolutely welcome and answer in a way they can understand.

However, I do get frustrated with grown adults staring.

I try not to react or take notice, but I often find myself scowling back at them. Many times, we have been asked if she has eczema followed by a suggestion of how to improve it, and we attempt to politely interrupt and explain that she does not have eczema.

I am hopeful that as Savannah grows, I can encourage her to be confident and explain her skin condition to her friends.

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Dermatological Nursing 2024, Vol 23, No 3

The future Ichthyosis is currently not curable, but there are companies working on topical creams which contain the TGM1 gene, so fingers crossed for this soon.

Ichthyosis comes with many implications, such as the risk of overheating, dehydration and increased chance of infections. This is something we keep a close eye on now with Savannah and will continue throughout her childhood.

As parents, we will continue to advocate for her and for the wider ichthyosis community.

As an adult, Savannah is likely to have her own questions about her skin condition and I hope she can continue to have knowledgeable people around her to answer those.

The support she needs will continue into adulthood, it will just be in different forms.

Savannah is the light of our lives, and brings us incredible amounts of joy every day. We wouldn’t change our precious girl for the world and are so excited to continue watching her grow.

My motto for a family day out is ‘as long as we leave the house with a tub of emollient and a pack of eye drops, all will be fine!’

Navigating life with ichthyosis wasn’t easy at first, but we have just about got the hang of it now. I wish I could go back to September 2022 and tell myself that everything would be okay and to simply enjoy my newborn.

For more information: Ichthyosis Support Group www.ichthyosis.org.uk 0800 368 9621 isg@ichthyosis.org.uk

www.bdng.org.uk

Available from Alliance and Phoenix

Itchy?

PIP

127-2541

Price

£49.201

Scratchy?

Treatment of human sarcoptic scabies.

Treatment is justified when the diagnosis of scabies has been established clinically and/or by parasitological examination. Without formal diagnosis treatment is not justified in case of pruritus.2 Official guidelines should be taken into consideration.

The dose,2 as determined by the patient’s weight, is as follows:

BODY WEIGHT (kg)

DOSE (number of 3 mg tablets)

15 to 24

One

25 to 35

Two

36 to 50

Three

51 to 65

Four

66 to 79

Five

≥80

Six

References: 1. BNF. Available at: https://bnf.nice.org.uk/drugs/ivermectin/medicinal-forms/ (Accessed August 2024).

2. Ivermectin 3mg Summary of Product Characteristics.

Ivermectin 3 mg Tablets Prescribing Information: Scabies indication Please consult the Summary of Product Characteristics (SmPC) before prescribing Presentation: Each round white tablet contains 3 mg of ivermectin. Indication: Treatment of human sarcoptic scabies. Treatment is justified when the diagnosis of scabies has been established clinically and/or by parasitological examination.

Without formal diagnosis treatment is not justified in case of pruritus. Dosage and administration: A single oral dose to provide ivermectin at 200 mcg/kg body weight.

Common scabies: Recovery will be considered as definite only after 4 weeks of the treatment. Persistence of pruritus or scraping lesions does not justify a second treatment before 4 weeks. Administration of a second dose within 2 weeks after the initial dose should only be considered: a) when new specific lesions occur, b) when the parasitologic examination is positive at this date. Profuse and crusting scabies: In these heavily infected forms, a second dose within 8 to 15 days of ivermectin and/or concomitant topical therapy may be necessary to obtain recovery. Paediatric population. Safety in paediatric patients weighing less than 15 kg of body weight has not been established. Elderly patients. Treatment of an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Method of administration: One single oral dose taken with water on an empty stomach. The dose may be taken at any time of the day, but no food should be taken within two hours before or after administration. In children less than 6 years of age and weighing at least 15kg, tablets should be crushed before swallowing. Note for patients treated for scabies: Contact persons should undergo a medical examination as soon as possible and if necessary should be given prompt antiscabies treatment.

Hygienic measures to prevent reinfection should be taken into account and official recommendations regarding cleaning of clothing and bedding should be closely

EXE-I/IPR-IVE-1531 August 2024

followed. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Special warnings and precautions for use: For information on special warnings, precautions and interactions in indications other than scabies treatment please refer to SmPC. Pregnancy and lactation: Ivermectin should only be used in pregnancy when strictly indicated. Ivermectin may only be given to breastfeeding mothers if the expected benefit outweighs the potential risk to the infant. Undesirable effects: Transient hypereosinophilia, liver dysfunction including acute hepatitis, increased liver enzymes, hyperbilirubinemia and haematuria have been reported.

Very rarely, toxic epidermal necrolysis and Stevens-Johnson syndrome have also been reported. In patients with scabies, transient exacerbation of pruritus may be observed at the start of treatment. Please refer to SmPC for full details. Legal category: POM. Presentation and cost: 4 x 3 mg tablets £49.20; Marketing authorisation number: PL 23218/0227. Further information is available from Exeltis UK Limited, Two Snowhill, 7th Floor, Birmingham, B4 6GA. Date of last revision: January 2024 Job Number: EXE-E/IPR-IVE-1232.

Adverse events should be reported. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Exeltis UK Limited on 01494 411775 or by email to uk.medinfo@exeltis.com

How baking has improved my confidence and mental health Marlese Dinolan

B

aking has been my stress reliever and go to activity when I am feeling low for some years. Growing up, I was not interested in cooking or baking. I always thought that baking was for those with creative minds and patience, but with enough practice, anyone can do it.

I remember coming home from work one day feeling low, homesick and stressed out. I wanted to do something to distract me from how I was feeling. I knew there must be something I could do with my spare time to help me unwind and relax, and that’s when I found baking.

At first, I was more worried about the mess I would create and all the tidying up afterwards, rather than the outcome of my hard work. Getting familiar with all the baking terminology was another struggle as English is my second language. However, with perseverance and support from my family, I became more confident.

“My mother-in-law taught me a lot of the basic skills and was a huge source of encouragement” My mother-in-law taught me a lot of the basic skills and was a huge source of encouragement; she taught me not to feel too discouraged when something went wrong.

Visiting my mother-in-law, I was always greeted by lovely baking smells as soon as I walked in through the door.

I remember when I first met her, she baked a lovely looking Victoria sponge cake. I was amazed how she was able to make such an amazing cake and prepare a three-course meal at the same time.

“Not everyone is born a baker, it’s all about trial and error”

The first recipe I tackled myself was banana muffins.

Apart from weighing scales and measuring utensils, I didn’t have any baking equipment in the house. The first attempt wasn’t perfect, but it was edible and didn’t give anyone an upset stomach!

This spurred me on to do some more baking and try new recipes. With good feedback, I became more confident, and gradually, the recipes got more complex.

I not only became more of a confident baker but also felt I was getting more confident in the kitchen as a whole.

Eventually, I built up the courage to enter a baking competition run by the hospital where I worked, and I won! I was so pleased with myself, especially beating one of our dermatology consultants who was famous for his

Summary: Everyone adopts different methods to relax and unwind while they are away from work. For Marlese, baking has proven itself to be a great stress and anxiety reliever, and she encourages others to try it out and reap the benefits.

58

Dermatological Nursing 2024, Vol 23, No 3

Author info: Marlese Dinolan is a Dermatology Clinical Nurse Specialist at the Royal Berkshire Hospital, Reading. www.bdng.org.uk

Wellbeing for the Workforce

very tasty lemon cake. The feedback I got from the judges was encouraging and it boosted my confidence even more.

I was asked if I would be interested in joining the Great British Bake Off, which was the best compliment I have ever received. I won a trophy baking spoon and a medal.

I then enrolled on a cake decorating class in London to improve my skills. Cake decorating has been and still is my biggest bugbear and an area I’m trying to improve in.

However, looking back on how I felt before I started baking, I know pushing myself outside my comfort zone is good for me.

Most of the cakes I have baked have received good feedback, and I am now trying more complex recipes.

Thankfully, my family has gifted me most of the baking utensils I need to encourage me to do more challenging bakes – but I think it’s their subtle way of saying ‘Keep feeding us!’

“Baking has helped me look at life more positively” Baking has helped me develop my confidence and significantly improved my mental health. I used to attend cognitive behavioural therapy (CBT) and talking therapy to help me with my mental health, but now, I find I can manage my mental health better and I’m more aware when it starts to deteriorate. My work colleagues have benefited too, as every time I try a new recipe, I bring it to work for them to try.

I believe that since I started baking, it has helped me looked at life more positively. Stress is part of our daily life, it’s how we deal with it and cope with it that is key. I can say baking has saved me when I was feeling low. I hope after reading this you will consider baking as a hobby or a way to relax when away from work.

This QR code will take you to my bake-off winning recipe.

Call for Papers E

ach year, the Dermatological Nursing Editorial Board actively seeks and encourages colleagues to write up their work and publish. As Clinical Editor, I support this and would like to highlight this call for papers.

l Is there a particular clinical area that interests you and you wish to share? l Do you have a medical or nursing colleague who would like to write for publication?

l Are you interested in having your work published? l Have you completed some work or project which enhances knowledge, skills or dermatology nursing? l Do you have a patient case study that would be of interest to our readership? l Have you recently completed an audit that has informed practice development or service delivery? l Have you recently completed a dissertation or a literature review?

Support and advice is available to guide you through the writing process, so please, do not hesitate to contact myself, Jackie, Rob or any member of the Editorial Board for advice. (Email addresses are listed in the journal).

www.bdng.org.uk

If so, please consider submitting a paper to Dermatological Nursing.

Polly Buchanan Clinical Editor, BDNG Dermatological Nursing journal Dermatological Nursing 2024, Vol 23, No 3

59

+1treated million patients globally across

For your eligible patients with moderate to severe plaque psoriasis (PsO) and concomitant psoriatic arthritis (PsA)1,2

indications and counting*3

Efficacy that

GOES FURTHER

†4

than just

SKIN CLEARANCE

‡5

Cosentyx has a consistent safety profile with over 8 years’ experience across indications1,2 The most frequently reported adverse reactions are URTIs (17.1%) (most frequently nasopharyngitis, rhinitis)1,2 Therapeutic indications Cosentyx®️ (secukinumab) is indicated for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy, and for the treatment of active psoriatic arthritis in adult patients, alone or in combination with methotrexate, when the response to previous DMARD therapy has been inadequate.

Please refer to the Summary of Product Characteristics for the complete list of therapeutic indications.1,2

Cosentyx is intended for use under the guidance and supervision of a physician experienced in the diagnosis and treatment of conditions for which Cosentyx is indicated.

This promotional material has been created and funded by Novartis for UK healthcare professionals only. Please see SmPC for full product information before prescribing. The images do not depict real patients. For illustrative purposes only. Prescribing Information can be found on the next page. *Refers to people who have been prescribed Cosentyx for any indication since launch. This is an estimated number at December 2022.3 GOES FURTHER = FUTURE 5 was a randomised, double blind, placebo-controlled, multicentre, 2-year, phase 3 study in patients with PsA (N=996). Subjects were stratified by prior anti-TNF use (naïve or inadequate response), and randomised to receive Cosentyx 300 mg, 150 mg or placebo. At 104 weeks, the proportion of patients with no radiographic progression (change from baseline in vdH-mTSS ≤0.5) receiving Cosentyx 300 mg (n=222) was 89.5%.4

†

SKIN CLEARANCE = STEPIn was a randomised, open-label, multicentre study in adults with new onset (≤12 months) moderate to severe PsO (N=160). Subjects were randomised to receive Cosentyx 300 mg or nb-UVB phototherapy for 52 weeks. The primary endpoint was to demonstrate that early treatment with secukinumab 300 mg is superior to nb-UVB in patients with respect to the proportion of patients achieving a ≥90% improvement in PASI (PASI 90 response) at Week 52, which was met (PASI 90 response: 91.1% [70/77] vs 42.3% [32/76] for Cosentyx 300 mg vs nb-UVB phototherapy, respectively; p<0.0001). PASI 100, an exploratory endpoint, was achieved in 68.8% of patients receiving Cosentyx 300 mg vs 22.4% (p<0.0001) of patients receiving nb-UVB phototherapy at Week 52.5

‡

DMARD, disease-modifying anti-rheumatic drugs; nb-UVB, narrow-band ultraviolet B; PASI, Psoriasis Area and Severity Index; PsA, psoriatic arthritis; PsO, plaque psoriasis; TNF, tumour necrosis factor; URTI, upper respiratory tract infection; vdH-mTSS, van der Heijde-modified total Sharp score.

References: 1. Cosentyx (secukinumab) GB Summary of Product Characteristics. Available at: https://www.medicines.org.uk/emc/product/11973/smpc (Accessed November 2023); 2. Cosentyx (secukinumab) NI Summary of Product Characteristics. Available at: https://www.emcmedicines.com/en-gb/northernireland/medicine?id=627fbcd7-1ca5-458c-9841-9103cb457911&type=smpc (Accessed November 2023); 3. Novartis Data on File. Secukinumab (Sec008). February 2023; 4. Mease PJ et al. RMD Open 2021;7(2):e001600; 5. Iversen L et al. J Eur Acad Dermatol Venereol 2023;37(5):1004–1016.

Adverse Event Reporting Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Novartis via uk.patientsafety@novartis.com or online through the pharmacovigilance intake (PVI) tool at www.novartis.com/report. If you have a question about the product, please contact Medical Information on 01276 698370 or by email at medinfo.uk@novartis.com.

UK | November 2023 | 311350 © 2023 Novartis Pharmaceuticals UK Ltd.

Cosentyx® (secukinumab) Great Britain Prescribing Information.

Please refer to the Summary of Product Characteristics (SmPC) before prescribing.

Indications: Treatment of: moderate to severe plaque psoriasis in adults, children and adolescents from the age of 6 years who are candidates for systemic therapy; active psoriatic arthritis in adults (alone or in combination with methotrexate) who have responded inadequately to disease-modifying anti-rheumatic drug therapy; active ankylosing spondylitis in adults who have responded inadequately to conventional therapy; active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) evidence in adults who have responded inadequately to non-steroidal antiinflammatory drugs; active enthesitis-related arthritis and juvenile psoriatic arthritis in patients 6 years and older (alone or in combination with methotrexate) whose disease has responded inadequately to, or who cannot tolerate, conventional therapy; active moderate to severe hidradenitis suppurativa (acne inversa) in adults with an inadequate response to conventional systemic HS therapy. Presentations: Cosentyx 75 mg solution for injection in pre-filled syringe; Cosentyx 150 mg solution for injection in pre-filled syringe; Cosentyx 150 mg solution for injection in pre-filled pen; Cosentyx 300 mg solution for injection in prefilled pen. Dosage & Administration: Administered by subcutaneous injection at weeks 0, 1, 2, 3 and 4, followed by monthly maintenance dosing. Consider discontinuation if no response after 16 weeks of treatment. Each 75 mg dose is given as one injection of 75 mg. Each 150 mg dose is given as one injection of 150 mg. Each 300 mg dose is given as two injections of 150 mg or one injection of 300 mg. If possible avoid areas of the skin showing psoriasis. Plaque Psoriasis: Adult recommended dose is 300 mg. Based on clinical response, a maintenance dose of 300 mg every 2 weeks may provide additional benefit for patients with a body weight of 90 kg or higher. Adolescents and children from the age of 6 years: if weight ≥ 50 kg, recommended dose is 150 mg (may be increased to 300 mg as some patients may derive additional benefit from the higher dose). If weight < 50 kg, recommended dose is 75 mg. Psoriatic Arthritis: For patients with concomitant moderate to severe plaque psoriasis see adult plaque psoriasis recommendation. For patients who are anti-TNFα inadequate responders, the recommended dose is 300 mg, 150 mg in other patients. Can be increased to 300 mg based on clinical response.

Ankylosing Spondylitis: Recommended dose 150 mg. Can be increased to 300 mg based on clinical response. nr-axSpA: Recommended dose 150 mg. Enthesitis-related arthritis and juvenile psoriatic arthritis: From the age of 6 years, if weight ≥ 50 kg, recommended dose is 150 mg. If weight < 50 kg, recommended dose is 75 mg. Hidradenitis suppurativa: Recommended dose is 300 mg monthly. Based on clinical response, the

Cosentyx® (secukinumab) Northern Ireland Prescribing Information.

Please refer to the Summary of Product Characteristics (SmPC) before prescribing.

Indications: Treatment of: moderate to severe plaque psoriasis in adults, children and adolescents from the age of 6 years who are candidates for systemic therapy; active psoriatic arthritis in adults (alone or in combination with methotrexate) who have responded inadequately to disease-modifying anti-rheumatic drug therapy; active ankylosing spondylitis in adults who have responded inadequately to conventional therapy; active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) evidence in adults who have responded inadequately to non-steroidal antiinflammatory drugs; active enthesitis-related arthritis and juvenile psoriatic arthritis in patients 6 years and older (alone or in combination with methotrexate) whose disease has responded inadequately to, or who cannot tolerate, conventional therapy; active moderate to severe hidradenitis suppurativa (acne inversa) in adults with an inadequate response to conventional systemic HS therapy. Presentations: Cosentyx 150 mg solution for injection in pre-filled pen; Cosentyx 300 mg solution for injection in pre-filled pen. Dosage & Administration: Administered by subcutaneous injection at weeks 0, 1, 2, 3 and 4, followed by monthly maintenance dosing. Consider discontinuation if no response after 16 weeks of treatment. Each 150 mg dose is given as one injection of 150 mg. Each 300 mg dose is given as two injections of 150 mg or one injection of 300 mg. If possible avoid areas of the skin showing psoriasis.

Plaque Psoriasis: Adult recommended dose is 300 mg monthly. Based on clinical response, a maintenance dose of 300 mg every 2 weeks may provide additional benefit for patients with a body weight of 90 kg or higher. Adolescents and children from the age of 6 years: if weight ≥ 50 kg, recommended dose is 150 mg (may be increased to 300 mg as some patients may derive additional benefit from the higher dose). If weight < 50 kg, recommended dose is 75 mg. However, 150mg solution for injection in pre-filled pen is not indicated for administration of this dose and no suitable alternative formulation is available. Psoriatic Arthritis: For patients with concomitant moderate to severe plaque psoriasis see adult plaque psoriasis recommendation. For patients who are anti-TNFα inadequate responders, the recommended dose is 300 mg, 150 mg in other patients. Can be increased to 300 mg based on clinical response. Ankylosing Spondylitis: Recommended dose 150 mg. Can be increased to 300 mg based on clinical response. nraxSpA: Recommended dose 150 mg. Enthesitis-related arthritis and juvenile psoriatic arthritis: From the age of 6 years, if weight ≥ 50 kg, recommended dose is 150 mg. If weight < 50 kg, recommended dose is 75 mg. However, 150mg solution for injection in pre-filled pen is not

maintenance dose can be increased to 300 mg every 2 weeks.

Contraindications: Hypersensitivity to the active substance or excipients. Clinically important, active infection. Warnings & Precautions: Infections: Potential to increase risk of infections; serious infections have been observed. Caution in patients with chronic infection or history of recurrent infection. Advise patients to seek medical advice if signs/symptoms of infection occur. Monitor patients with serious infection closely and do not administer Cosentyx until the infection resolves. Non-serious mucocutaneous candida infections were more frequently reported for secukinumab in the psoriasis clinical studies.

Should not be given to patients with active tuberculosis (TB). Consider anti-tuberculosis therapy before starting Cosentyx in patients with latent TB. Inflammatory bowel disease (including Crohn’s disease and ulcerative colitis): New cases or exacerbations of inflammatory bowel disease have been reported with secukinumab. Secukinumab, is not recommended in patients with inflammatory bowel disease. If a patient develops signs and symptoms of inflammatory bowel disease or experiences an exacerbation of pre-existing inflammatory bowel disease, secukinumab should be discontinued and appropriate medical management should be initiated.

Hypersensitivity reactions: Rare cases of anaphylactic reactions have been observed. If an anaphylactic or serious allergic reactions occur, discontinue immediately and initiate appropriate therapy. Vaccinations: Do not give live vaccines concurrently with Cosentyx; inactivated or nonlive vaccinations may be given. Paediatric patients should receive all age appropriate immunisations before treatment with Cosentyx. LatexSensitive Individuals: The removable needle cap of the 75mg and 150 mg pre-filled syringe and 150mg pre-filled pen contains a derivative of natural rubber latex. Concomitant immunosuppressive therapy: Combination with immunosuppressants, including biologics, or phototherapy has not been evaluated in psoriasis studies. Cosentyx was given concomitantly with methotrexate, sulfasalazine and/or corticosteroids in arthritis studies. Caution when considering concomitant use of other immunosuppressants. Interactions: Live vaccines should not be given concurrently with secukinumab. No interaction between Cosentyx and midazolam (CYP3A4 substrate) seen in adult psoriasis study. No interaction between Cosentyx and methotrexate and/or corticosteroids seen in arthritis studies. Fertility, pregnancy and lactation: Women of childbearing potential: Use an effective method of contraception during and for at least 20 weeks after treatment.

Pregnancy: Preferably avoid use of Cosentyx in pregnancy. Breast feeding: It is not known if secukinumab is excreted in human breast milk.

A clinical decision should be made on continuation of breast feeding during Cosentyx treatment (and up to 20 weeks after discontinuation) based on benefit of breast feeding to the child and benefit of Cosentyx therapy to the woman. Fertility: Effect on human fertility not evaluated.

Adverse Reactions: Very Common (≥1/10): Upper respiratory tract infection. Common (≥1/100 to <1/10): Oral herpes, headache, rhinorrhoea, diarrhoea, nausea, fatigue.

Uncommon

(≥1/1,000 to <1/100): Oral candidiasis, lower respiratory tract infections, neutropenia, inflammatory bowel disease. Rare (≥1/10,000 to <1/1,000): anaphylactic reactions, exfoliative dermatitis (psoriasis patients), hypersensitivity vasculitis. Not known: Mucosal and cutaneous candidiasis (including oesophageal candidiasis). Infections: Most infections were non-serious and mild to moderate upper respiratory tract infections, e.g. nasopharyngitis, and did not necessitate treatment discontinuation. There was an increase in mucosal and cutaneous (including oesophageal) candidiasis, but cases were mild or moderate in severity, non-serious, responsive to standard treatment and did not necessitate treatment discontinuation. Serious infections occurred in a small proportion of patients (0.015 serious infections reported per patient year of follow up). Neutropenia: Neutropenia was more frequent with secukinumab than placebo, but most cases were mild, transient and reversible. Rare cases of neutropenia CTCAE Grade 4 were reported.

Hypersensitivity reactions: Urticaria and rare cases of anaphylactic reactions were seen. Immunogenicity: Less than 1% of patients treated with Cosentyx developed antibodies to secukinumab up to 52 weeks of treatment. Other Adverse Effects: The list of adverse events is not exhaustive, please consult the SmPC for a detailed listing of all adverse events before prescribing. Legal Category: POM. MA Number & List Price: PLGB 00101/1205 – 75 mg pre-filled syringe x 1 - £304.70; PLGB 00101/1029 - 150 mg pre-filled pen x2 £1,218.78; PLGB 00101/1030 - 150 mg pre-filled syringe x2 £1,218.78; PLGB 00101/1198 – 300 mg pre-filled pen x 1 £1218.78. PI Last Revised: June 2023. Full prescribing information, (SmPC) is available from: Novartis Pharmaceuticals UK Limited, 2nd Floor, The WestWorks Building, White City Place, 195 Wood Lane, London, W12 7FQ. Telephone: (01276) 692255.

indicated for administration of this dose and no suitable alternative formulation is available. Hidradenitis suppurativa: Recommended dose is 300 mg monthly. Based on clinical response, the maintenance dose can be increased to 300 mg every 2 weeks. Contraindications: Hypersensitivity to the active substance or excipients. Clinically important, active infection. Warnings & Precautions: Infections: Potential to increase risk of infections; serious infections have been observed.

Caution in patients with chronic infection or history of recurrent infection.

Advise patients to seek medical advice if signs/symptoms of infection occur. Monitor patients with serious infection closely and do not administer Cosentyx until the infection resolves. Non-serious mucocutaneous candida infections were more frequently reported for secukinumab than placebo in the psoriasis clinical studies. Should not be given to patients with active tuberculosis (TB). Consider anti-tuberculosis therapy before starting Cosentyx in patients with latent TB. Inflammatory bowel disease (including Crohn’s disease and ulcerative colitis): New cases or exacerbations of inflammatory bowel disease have been reported with secukinumab. Secukinumab, is not recommended in patients with inflammatory bowel disease. If a patient develops signs and symptoms of inflammatory bowel disease or experiences an exacerbation of pre-existing inflammatory bowel disease, secukinumab should be discontinued and appropriate medical management should be initiated.

Hypersensitivity reactions: Rare cases of anaphylactic reactions have been observed. If an anaphylactic or serious allergic reactions occur, discontinue immediately and initiate appropriate therapy. Vaccinations: Do not give live vaccines concurrently with Cosentyx; inactivated or nonlive vaccinations may be given. Paediatric patients should receive all age appropriate immunisations before treatment with Cosentyx. LatexSensitive Individuals: The removable needle cap of the 150mg pre-filled pen contains a derivative of natural rubber latex. Concomitant immunosuppressive therapy: Combination with immunosuppressants, including biologics, or phototherapy has not been evaluated in psoriasis studies. Cosentyx was given concomitantly with methotrexate, sulfasalazine and/or corticosteroids in arthritis studies. Caution when considering concomitant use of other immunosuppressants.

Interactions: Live vaccines should not be given concurrently with secukinumab. No interaction between Cosentyx and midazolam (CYP3A4 substrate) seen in adult psoriasis study. No interaction between Cosentyx and methotrexate and/or corticosteroids seen in arthritis studies.

Fertility, pregnancy and lactation: Women of childbearing potential: Use an effective method of contraception during and for at least 20 weeks after treatment. Pregnancy: Preferably avoid use of Cosentyx in pregnancy. Breast feeding: It is not known if secukinumab is excreted in human breast milk. A clinical decision should be made on continuation of breast feeding during Cosentyx treatment (and up to 20 weeks after discontinuation) based on benefit of breast feeding to the child and benefit of Cosentyx therapy to the woman. Fertility: Effect on human fertility not evaluated. Adverse Reactions: Very Common (≥1/10): Upper

respiratory tract infection. Common (≥1/100 to <1/10): Oral herpes, headache, rhinorrhoea, diarrhoea, nausea, fatigue. Uncommon (>1/1,000 to <1/100): Oral candidiasis, lower respiratory tract infections, neutropenia, inflammatory bowel disease. Rare (≥1/10,000 to <1/1,000): anaphylactic reactions, exfoliative dermatitis (psoriasis patients), hypersensitivity vasculitis. Not known: Mucosal and cutaneous candidiasis (including oesophageal candidiasis). Infections: Most infections were non-serious and mild to moderate upper respiratory tract infections, e.g. nasopharyngitis, and did not necessitate treatment discontinuation. There was an increase in mucosal and cutaneous (including oesophageal) candidiasis, but cases were mild or moderate in severity, non-serious, responsive to standard treatment and did not necessitate treatment discontinuation. Serious infections occurred in a small proportion of patients (0.015 serious infections reported per patient year of follow up). Neutropenia: Neutropenia was more frequent with secukinumab than placebo, but most cases were mild, transient and reversible. Rare cases of neutropenia CTCAE Grade 4 were reported.

Hypersensitivity reactions: Urticaria and rare cases of anaphylactic reactions were seen. Immunogenicity: Less than 1% of patients treated with Cosentyx developed antibodies to secukinumab up to 52 weeks of treatment. Other Adverse Effects: The list of adverse events is not exhaustive, please consult the SmPC for a detailed listing of all adverse events before prescribing. Legal Category: POM. MA Number & List Price: EU/1/14/980/005 - 150 mg pre-filled pen x2 £1,218.78; EU/1/14/980/010 – 300 mg pre-filled pen x 1 £1218.78. PI Last Revised: May 2023. Full prescribing information, (SmPC) is available from: Novartis Pharmaceuticals UK Limited, 2nd Floor, The WestWorks Building, White City Place, 195 Wood Lane, London, W12 7FQ. Telephone: (01276) 692255.

UK | 290802 | June 2023

Adverse Event Reporting: Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Novartis via uk.patientsafety@novartis.com or online through the pharmacovigilance intake (PVI) tool at www.novartis.com/report.

If you have a question about the product, please contact Medical Information on 01276 698370 or by email at medinfo.uk@novartis.com

UK | 284832 | May 2023

Adverse Event Reporting: Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Novartis via uk.patientsafety@novartis.com or online through the pharmacovigilance intake (PVI) tool at www.novartis.com/report If you have a question about the product, please contact Medical Information on 01276 698370 or by email at medinfo.uk@novartis.com

The first Burmese and skinthemed garden at the Chelsea Flower Show: The BDNG’s perspective Lucy Moorhead, Christopher E.M Griffiths, Su M. Lwin

W

e have previously shared with readers the longstanding collaboration between the Burma Skincare Initiative (BSI) and BDNG in Dermatological Nursing articles and the plan to showcase the work of the BSI at this year’s Royal Horticultural Society (RHS) Chelsea Flower Show.1,2,3

As a recap, Myanmar (also known as Burma) is a country of over 54 million people, located in Southeast Asia. The country has been under military dictatorship since its independence from the British in 1948 which has led to a systematic disinvestment in healthcare and education, resulting in minimal provision of skincare throughout the country. There are only three dermatology centres, and, since the military coup in 2021, there are less than 50 dermatologists and dermatology trainees serving the entire population in Myanmar – a country that is almost three times the size of the UK. The BSI, a registered charity in England and Wales: no.

1187197, was founded by Dr Su Lwin and Professor Chris Griffiths in 2019 with an overall vision to provide equitable access to quality and sustainable skincare for the people of Myanmar.4 Since its inception, the charity held the first, and only, international dermatology conference in Myanmar in February 2020. Four members of the BDNG travelled to the country to teach on the first day of the conference, which was fully dedicated to dermatology nurses who had travelled from all parts of the country to attend.

The inaugural BSI conference was a historical milestone

Summary: This article updates the reader on the work of the Burma Skincare Initiative (BSI) and its continued collaboration with the British Dermatological Nursing Group (BDNG). In May 2024, the BSI with support from the BDNG, exhibited a garden at the prestigious Royal Horticultural Society (RHS) Chelsea Flower Show. This article provides a report and a reflection on the show.

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A Burmese dancer performing on the press day.

Author info: Lucy Moorhead, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK Christopher E.M Griffiths, Department of Dermatology, King’s College Hospital, King’s College London, London, UK. Centre for Dermatology Research, University of Manchester, Manchester UK Su M. Lwin, St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK www.bdng.org.uk

BDNG News

The BSI Spirit of Partnership Garden at the RHS Chelsea Flower Show. as the first educational meeting for dermatological nurses in Myanmar.2 Furthermore, trainee dermatologists from Myanmar were supported to travel to Europe for conferences, and research studies planned on diseases such as mycetoma – a debilitating deep fungal infection seen in rural agricultural communities – and on the diagnosis of immunobullous diseases, such as pemphigus, which are common in the country.

Tragically, Myanmar experienced a military coup as well as the COVID pandemic following the conference in 2020. These unprecedented events have decimated the already fragile healthcare system in the country. In the face of adversity, the BSI has continued to support and promote dermatology in both Myanmar and other strife-ridden areas. One output from the work of the BSI has been the development of one-page protocols on diagnosis and management of common skin diseases for non-dermatologist healthcare workers (https:// www.burmaskincare.org/en/clinical-services) as part the BSI’s Essential Emergency Skincare (EES) programme.2 These protocols have been used in other conflict zones, including Ukraine. The BDNG has further supported the EES initiative by developing a short video on scabies and how to apply permethrin correctly (https://www. burmaskincare.org/en/headlines/videos-and-podcasts), as well as participating in online teaching for frontline healthcare workers. www.bdng.org.uk

“As one of the sponsors, we were able to have two nurses visit the show each day to help promote the garden and its aims” Growing a sanctuary garden With the aim of raising public awareness about the importance of skin disease and sustainable global health partnerships in its management, the BSI was successful in submitting a sanctuary garden design by Helen Olney: “The Burma Skincare Initiative Spirit of Partnership Garden” at the 2024 RHS Chelsea Flower Show. There were 30 gardens on show at Chelsea, including seven sanctuary gardens. The sanctuary gardens are the mediumsized show gardens measuring 12m x 7m, with a focus on contemporary design to showcase the restorative power of gardening.

The BDNG saw this as a unique opportunity to help raise the profile of the group to a completely new audience and were delighted to be asked to sponsor the garden alongside Sanofi, No. 7 Beauty Company, Almirall, Dermatological Nursing 2024, Vol 23, No 3

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DEBRA, the Devonshire Clinic and Skin Health Alliance.

In-kind support was also provided by the Royal College of Physicians, the International League of Dermatological Societies, Consultant Connect and Lahpet Burmese restaurant in London.

As one of the sponsors, we were able to have two nurses visit the show each day to help promote the garden and its aims, as well as experience the delights of Chelsea firsthand. We invited BDNG members to apply via our e-newsletter and names were pulled from a hat. Members of the BDNG executive were also invited to attend.

We were delighted with the response and that so many members applied.

In the weeks leading up to RHS Chelsea 2024, it was riveting to follow the build up to the show on social media.

Having seen the plans from the outset, it was exciting to see the garden unfold, first as the main structures were built in Sussex and then the final build in Chelsea. There were only 15 days to turn a patch of ground measuring 12x7m into the garden you see in the pictures. Helen Olney, the garden designer, was joined by Ross Conquest and his team at Conquest Creative Spaces, Sussex, and Richard Clegg, a drystone wall builder from Yorkshire, to bring the garden to life. The media company Ten Stories, based in Cumbria, also supported the project throughout the week of the show with PR and social media support and training before the event.

The first day of the show is a designated press and VIP day.

The day dawned in glorious sunshine. First thoughts on seeing the garden was how much detail had been included in such a small space. Talking to Helen, Ross and the team,

The authors of the article with Helen Olney, garden designer and Andrew Fisher-Tomlin, Founder of the London College of Garden Design. we learnt how the stupa, the traditional dome-shaped Buddhist shrine, had to be transported from Sussex to Chelsea in three pieces (it weighed four tons); how the beautiful magnolia tree (Porcelain Dove) had to be kept neither too warm nor too cold prior to the show so as not to bloom too early. Fortuitously, its first flower opened on the first day of the judging. Perfect timing!

“We are delighted to inform you that the garden exceeded all expectations” One of my favourite details was to learn that the wood for the stilt house floor and boardwalk is reclaimed greenheart wood from a dismantled 18th century jetty that had stood in the River Thames; imagine the stories it could tell. All the plants included in the garden grew both in the UK and Myanmar and, as described in the previous article,3 were chosen to represent the diversity of the people and the landscapes of the country as well as the striking “dermatological bark” on some of the trees such as Acer davidii or snake bark maple, resembling ichthyosis.

The past BDNG president Rebecca Penzer-Hick with current president Lisa McGovern and Lucy Moorhead.

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On the first morning of the show, we were given a briefing on the plants and the symbolism of the garden, from the sanctuary of the stilt house to the sinuous shape of the

www.bdng.org.uk

BDNG News

stone bench representing “la” – the 28th letter of the Burmese alphabet, which in a sentence means “coming together”. We encouraged members of the public and VIPs passing by to visit the garden and hear the story behind it. Upon learning they were speaking to a nurse, visitors shared their own experiences of healthcare and gratitude to the nursing profession alongside first impressions of the garden. This was as far removed from the day job as one gets, and initial trepidation was quickly replaced by enthusiasm, seeing how positively visitors reacted to the garden and to the aims of the BSI whilst realising what a unique experience this was, unlikely to be repeated.

During the first day, celebrities such as Bruno Tonioli, Paul Hollywood and Lord David Cameron passed by and learnt about the garden. Although King Charles did not pay a visit, the Princess Royal – Princess Anne – visited with her husband, Vice-Admiral Sir Tim Laurence, later in the week.

Garden awards Awards for the garden are presented on the second day.

We are delighted to inform you that the garden exceeded all expectations. Gardens are awarded gold, silver-gilt, silver or bronze. In the previous article, we described how this garden represented many of the Chelsea’s firsts: Helen Olney’s first garden design as someone not yet in the profession, the first garden themed around skin health and skin disease, and the first Burmese garden – so imagine everyone’s surprise that the garden was awarded a gold medal and the best sanctuary garden. A phenomenal achievement for all involved!

For the remainder of the week, there were nurse representatives at the garden each day. Over 20 nurses had the opportunity to attend the show and promote the garden alongside a dedicated team including junior doctors and professors of dermatology. All those attending were given a brief and had QR Codes to distribute information regarding the garden.

Feedback was overwhelmingly positive on all things aside from the weather – which was British and changeable to say the least – or was it the Burmese monsoon, suitably summoned for the Burmese garden? Emmanuel Toni described the garden as “Abuzz with people wanting to know more about the garden and the charity”; Karen Stephens felt “Proud to represent the garden on behalf of the BDNG”, whilst Kate Mayers reported “A lot of interest in her work as a clinical nurse specialist in skin cancer” and “Meeting so many lovely people, whilst experiencing a global horticultural event encompassing dermatology and skin care”. Lynne Skrine noted that “Conversations regarding the texture of plants led on to discussions around dermatological nursing”. Throughout the week, there was also a visit from previous BDNG president – Rebecca Penzer-Hick – who supported the initial sponsorship, and current President – Lisa McGovern – who has continued Rebecca’s support. www.bdng.org.uk

Ross Conquest from Conquest Spaces and Helen Olney holding their certificates for gold medal and best sanctuary garden The end of the Chelsea Flower Show came too soon but the good news is that the garden will live on as it will be rebuilt with some minor adjustments at its legacy site at Dulwich College, London – the alma mater of Professor Chris Griffiths. The BSI Garden at Dulwich will continue to tell the story of the BSI, lived experience of skin disease and the importance of partnerships in its management whilst educating pupils and the public about nature, sustainability and of course, Myanmar. We hope to announce the opportunities for how the BDNG will continue its involvement with the garden in the near future.

To keep the BSI growing from strength to strength, the charity needs your support more than ever.

Join us. Fund us. Work with us. www.burmaskincare.org References: 1. Moorhead, L Griffiths CEM, Lwin SM. The Burma Skincare Initiative – A BDNG collaboration: our progress so far.

Dermatological Nursing. 2021. 20(4) 2. Griffiths CEM, Lwin SM. Immediate global support is needed for Myanmar. British Journal of Dermatology. 2021. DOI: 10.1111/ bjd.20385 3. Moorhead, L Griffiths CEM, Lwin SM. Burma Skincare Initiative Spirit of Partnership Garden. Dermatological Nursing. 2024. 23(1) 4. Htet KZ, Griffiths CEM, Lwin SM, Essential emergency skincare: a global health dermatology innovation for Myanmar and beyond, British Journal of Dermatology. 2023. 189(6):760-763.

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Fight infected dermatoses

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FOR SKIN IRRITATED BY INFECTED DERMATOSES Fight infected dermatoses with the POWER OF 3.

Recommend Nystaform HC Cream – now available and ready to prescribe Reference: 1. Perspectus Global; omnibus survey of 1,000 adults; July 2023. Job code: 1/NYS/12/2404/970. Date of preparation: April 2024. Abridged Prescribing Information Nystaform HC Cream. See Nystaform HC Cream Summary of Product Characteristics (SmPC) prior to prescribing. Presentation: Cream containing nystatin (100,000 I.U./g), chlorhexidine hydrochloride (1.0% w/w) and hydrocortisone (0.5% w/w) for topical administration. Indications: Treatment of infected dermatoses where fungal (particularly monilial) and/or bacterial infections are present. Posology and Method of Administration: Adults and children: For topical application only. Apply to the infected area 2-3 times daily.

Treatment should be for a maximum of 7 days. If the condition does not improve within seven days, return to doctor. Contraindications: Known sensitivity to the active substances, especially those with a history of chlorhexidine-related allergic reactions. Tuberculous lesions of the skin. Special Warnings and Precautions for Use: For external use only. Avoid contact with the eyes. If sensitivity occurs or if new infection appears, discontinue use and institute alternative therapy. Cetostearyl alcohol may cause local skin reactions (e.g. contact dermatitis). Chlorhexidine is known to induce hypersensitivity, including generalised allergic reactions and anaphylactic shock. Should not be administered to anyone with a potential history of an allergic reaction to a chlorhexidine-containing compound. In infants, long-term continuous topical steroid therapy should be avoided. Adrenal suppression can occur when extensive areas are treated, particularly under occlusion. Long term continuous or inappropriate use of topical steroids can result in the development of rebound flares after stopping treatment (topical steroid withdrawal syndrome). A severe form of rebound flare can develop which takes the form of a dermatitis with intense redness, stinging and burning that can spread beyond the initial treatment area. It is more likely to occur when delicate skin sites such as the face and flexures are treated. Should there be a reoccurrence of the condition within days to weeks after successful treatment a withdrawal reaction should be suspected. Reapplication should be with caution and specialist advise is recommended in these cases or other treatment options should be considered. Pregnancy and Lactation: Nystatin and corticosteroids should be administered with caution during the early months of pregnancy and its use requires that the anticipated benefits outweigh the possible risks. Undesirable Effects: Skin disorders: Allergic skin reactions such as dermatitis, pruritus, erythema, eczema, rash, urticaria, skin irritation and blisters. Immune disorders: Hypersensitivity including anaphylactic shock. Withdrawal reactions - redness of the skin which may extend to areas beyond the initial affected area, burning or stinging sensation, itch, skin peeling, oozing pustules. Precautions for Storage: Store below 25oC. Pack Size and Price: 30 g aluminium tubes with screw caps, £9.66. Legal Category: POM. Marketing Authorisation Number: PL 00551/0019. Marketing Authorisation Holder: Typharm Limited, Unit 1, 39 Mahoney Green, Rackheath, Norwich, NR13 6JY. Tel: 01603 722480, Fax: 01603 263804. Date of Revision of Text: January 2023. Adverse events should be reported.

Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Typharm Limited on 02037 694160. *Nystatin 100,000 I.U./g

BADBIR: Paediatric recruitment Tess McPherson

P

soriasis is not uncommon in children: one third of adult patients start their psoriasis journey in childhood and 10 percent of patients with chronic plaque psoriasis present before the age of 10. Psoriasis can have a huge impact on many aspects of life in these age groups and is known to have long term life impact.

BADBIR (established in 2007) has included recruitment of children (under 16) since 2015.

The inclusion of children and young people in this database, and monitoring the use of medications, efficacy and short and longer-term safety is vital for various reasons.

Children are not little adults and there are many important differences across age, including lifestyle, co-morbidities (and potential future co-morbidities), immunology, infection exposure and psychological impact. Additionally, exposure times are going to be longer in younger patients, and potentially high lifetime exposure (due to the chronic nature of the disease) may result in a different safety profile than those seen in adults, potentially risking higher incidents of malignancies and infections.

Data has shown previously variable management of paediatric patients and poor monitoring of medications in this age group.1,2 Over the past decade, the treatment options are fast-expanding and we need better guidance on what to use, when and how. Many treatments

“Children are not little adults and there are many important differences across age” remain unlicensed in children but remain important first-line medications (for example methotrexate). New(er) medications including biologics are now licenced in children (since 2009) based on trials which are showing excellent efficacy and short-term safety. They remain expensive and without longterm data; in particular in younger age groups. There remains a real need, even more vital than in adults, for real world data, longer term follow-up and health economics for all medications.

Recently we have started some work to examine the paediatric patients registered on the BADBIR database.3 There are 132 patients who were under the age of 18 years at registration in March 2021. A total of 90 (55.6%) patients are registered in the biologic cohort and 72 (44.4%) in the conventional cohort. The mean age was 16.1 years (65% female, 45% male) and mean psoriasis area severity (PASI) at registration was 15.2. The most common treatment at registration was adalimumab (52%). Others include Ustekinumab (27%); etanercept (20%) representing licensed biologics at the time. Since 2021 IL17/secukinumab has also now been licensed for this

Author info: Dr Tess McPherson is a Consultant Dermatologist at Oxford University Hospitals and a member of the British Society for Paediatric and Adolescent Dermatology (BSPAD). www.bdng.org.uk

age group. In the conventional cohort, the mean age was 13.4 years (61% female, 49% male) and mean PASI at registration was 17.6. The most common therapies prescribed at registration were methotrexate (29) and ciclosporin (34), acitretin (7), fumaric acid esters (2).

Our ongoing work will include descriptive analyses of other patient characteristics such as patient reported outcomes, body mass index and comorbidities. We will also analyse data on the development of any adverse effects of systemic therapy.

Registries such as BADBIR highlight the importance of real-world data in treatments for psoriasis and we are fortunate to have this data base in the UK. Through the BADBIR group we are working to lease with colleagues managing paediatric psoriasis patients (including European colleagues and PsoNET) to combine data sets. This work and engagement with international partners is a very encouraging collaboration. However, we are sure that there are many eligible paediatric patients in the UK who have not been registered with BADBIR and we would really like this to change.

There is recent evidence that, whereas previously children and young people may have been relatively undermanaged, there is a move to more effective control of psoriasis. Given the impact

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of living with psoriasis, this is a positive development. This is likely to be due to improved guidelines, monitoring and more licensed medications.

As use becomes more frequent, the need for pharmacovigilance for systemic medications in this cohort becomes even more urgent. BADBIR is a fantastic initiative, and few other countries have such good prospective data sets including children that allows for their seamless follow-up as they move into adulthood.

Please include your patients on the data base and encourage colleagues to do so to. This is a vital to our understanding of the risks and benefits of treatments in younger patients.

Thanks for your help recruiting and please inform your colleagues.

Any patient under 16 with moderate or severe psoriasis who is starting systemic treatments or biologic treatments is eligible – and, unlike in adults any biologic treatment is included in the paediatric cohort. Additionally, the DLQI does not need to be greater than 10.

Full details of the eligibility criteria for paediatric patients on BADBIR can be found at http://www.badbir.org/ Clinicians/Eligibility/

References: 1. Lam ML, Burden-Teh E, Taibjee SM, Taylor A, Webster S, Dolman S et al. A UK multicentre audit of the assessment and management of psoriasis in children. Br J Dermatol 2015. 172(3):789-92 2. Bronckers IMGJ et al. Psoriasis Investigator Group (PsIG) of the Pediatric Dermatology Research Alliance and the European Working Group on Pediatric Psoriasis (EWGPP).

Safety of Systemic Agents for the Treatment of Pediatric Psoriasis. JAMA Dermatol 2017.

153(11):1147-1157 3. Khan et al. World Congress of Paediatric Dermatology. Poster presentation.

If you require any assistance/advice, please contact BADBIR study team at badbir@manchester.ac.uk or call 0161 306 1896.

Coming soon The British Dermatological Nursing Group Clinical Handbook We’re delighted to announce that we will soon be publishing a new, digital, BDNG Clinical Handbook.

Clinical Handbook

Please keep your eyes peeled for further information on social media and in the BDNG newsletter, as well as December’s issue of Dermatological Nursing.

British Dermatological Nursing Group 2024-2025

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www.bdng.org.uk

BIMZELX®(BIMEKIZUMAB) LONG TERM DATA BIMZELX demonstrated a complete and sustained response with PASI 75, 90 and 100 responses through to Year 4 (Week 196) 1,2

Proportions of patients achieving PASI 90 and PASI 100 endpoints are reported from baseline through Year 4. PASI 90 and PASI 100 response rates were consistent in the subset of patients enrolled in the OLE who received BKZ 320 mg Q4W to Week 16 then Q8W thereafter.1 § N= modified non-responder imputation (mNRI), missing data were imputed with mNRI (patients with missing data following treatment discontinuation due to lack of efficacy or a treatment-related adverse event were counted as non-responders; multiple imputation methodology was used for other missing data). BE VIVID lasted 52 weeks and BE SURE and BE READY lasted 56 weeks; to pool data across studies, Week 56 data were not included. In this figure, the period after Week 52 corresponds to the BE BRIGHT OLE. BKZ, bimekizumab; MI, multiple imputation; mNRI, modified non-responder imputation; OLE, open-label extension; PASI 75/90/100, ≥75%/≥90%/100% improvement in Psoriasis Area and Severity Index; Q4W. Every 4 weeks; Q8W, every 8 weeks.

BIMZELX® (Bimekizumab) is indicated for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. Bimzelx, alone or in combination with methotrexate, is indicated for the treatment of active psoriatic arthritis in adults who have had an inadequate response or who have been intolerant to one or more disease-modifying 3 antirheumatic drugs (DMARDs). Please refer to the SmPC for further information.

PRESCRIBING INFORMATION FOR HCP’S in GREAT BRITAIN (Please consult the Summary of Product Characteristics (SmPC) before prescribing)

▼

Bimzelx® (Bimekizumab) Active Ingredient: Bimekizumab – solution for injection in pre-filled syringe or pre-filled pen: 160 mg of bimekizumab in 1 mL of solution (160 mg/mL).

Indications: Moderate to severe plaque psoriasis in adults who are candidates for systemic therapy. Alone or in combination with methotrexate, for active psoriatic arthritis in adults who have had an inadequate response or intolerant to one or more disease-modifying antirheumatic drugs (DMARDs). Adults with active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) who have responded inadequately or are intolerant to non-steroidal anti-inflammatory drugs (NSAIDs).

Adults with active ankylosing spondylitis who have responded inadequately or are intolerant to conventional therapy.

Dosage and Administration: Should be initiated and supervised by a physician experienced in the diagnosis and treatment of conditions for which Bimzelx is indicated. Recommended dose: Plaque Psoriasis: 320 mg (given astwo subcutaneous injections of 160 mg each) at week 0, 4, 8, 12, 16 and every 8 weeks thereafter.

Psoriatic arthritis:160 mg (given as 1 subcutaneous injection of 160 mg) every 4 weeks. For psoriatic arthritis patients with coexistent moderate to severe plaque psoriasis, the recommended dose is the same as for plaque psoriasis. After 16 weeks, regular assessment of efficacy is recommended and if a sufficient clinical response in joints cannot be maintained, a switch to 160 mg every 4 weeks can be considered. Axial spondyloarthritis (nr-axSpA and AS): 160 mg (given as 1 subcutaneous injection) every 4 weeks. For patients with plaque psoriasis (including psoriatic arthritis with coexistent moderate to severe psoriasis) and a body weight ≥ 120 kg who did not achieve complete skin clearance at week 16, 320 mg every 4 weeks after week 16 may further improve treatment response.

Consider discontinuing if no improvement by 16 weeks of treatment.

Renal or hepatic impairment: No dose adjustment needed. Elderly: No dose adjustment needed.

Administer by subcutaneous injection to thigh, abdomen or upper arm. Rotate injection sites and do not inject into psoriatic plaques or skin that is tender, bruised, erythematous or indurated.

Do not shake pre-filled syringe or pre-filled pen. Patients may be trained to self-inject.

Contraindications:Hypersensitivity to bimekizumab or any excipient; Clinically important active infections (e.g. active tuberculosis).

Warnings and Precautions: Record name and batch number of administered product.

Infection: Bimekizumab may increase the risk of infections e.g. upper respiratory tract infections, oral candidiasis. Caution when considering use in patients with a chronic infection or a history of recurrent infection. Must not be initiated if any clinically important active infection until infection resolves or is adequately treated.

Advise patients to seek medical advice if signs or symptoms suggestive of an infection occur. If a patient develops an infection, the patient should be carefully monitored. If the infection becomes serious or is not responding to standard therapy do not administer bimekizumab until infection resolves. TB: Evaluate for TB infection prior to initiating bimekizumab – do not give if active TB. While on bimekizumab, monitor for signs and symptoms of active TB. Consider anti-TB therapy prior to bimekizumab initiation if past history of latent or active TB in whom adequate treatment course cannot be confirmed. Inflammatory bowel disease: Bimekizumab is not recommended in patients with inflammatory bowel disease. Cases of new or exacerbations of inflammatory bowel disease have been reported. If inflammatory bowel disease signs/symptoms develop or patient experiences exacerbation of pre-existing inflammatory bowel disease, discontinue bimekizumab and initiate medical management.

Hypersensitivity: Serious hypersensitivity reactions including anaphylactic reactions have been observed with IL-17 inhibitors.

If a serious hypersensitivity reaction occurs, discontinue immediately and treat. Vaccinations: Complete all age appropriate immunisations prior to bimekizumab initiation. Do not give live vaccines to bimekizumab patients. Patients may receive inactivated or non-live vaccinations.

Interactions: A clinically relevant effect on CYP450 substrates with a narrow therapeutic index in which the dose is individually adjusted e.g. warfarin, cannot be excluded. Therapeutic monitoring should be considered.

Fertility, pregnancy and lactation: Women of child-bearing potential should use an effective method of contraception during treatment and for at least 17 weeks after treatment. Avoid use of bimekizumab during pregnancy. It is unknown whether bimekizumab is excreted in human milk, hence a risk to the

References:1. Strober B, et al. AAD 2024; oral presentation; 2. UCB DOF. PS0008, PS0009, PS0013 and PS0014 Table 6.19.3.1G. 3. BIMZELX® (bimekizumab) Summary of Product Characteristics.

GB-BK-2400308 Date of Preparation April 2024 © UCB Biopharma SRL, 2024. All rights reserved.

BIMZELX® is a registered trademark of the UCB Group of Companies.

newborn/infant cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Bimzelx therapy. No data available on human fertility.

Driving and use of machines: No or negligible influence on ability to drive anduse machines.

Adverse Effects: Refer to SmPC for full information. Very Common (≥ 1/10): upper respiratory tract infection; Common (≥ 1/100 to <1/10): oral candidiasis, tinea infections, ear infections, herpes simplex infections, oropharyngeal candidiasis, gastroenteritis, folliculitis; headache, rash, dermatitis and eczema, acne, injection site reactions, fatigue; Uncommon (≥1/1,000 to <1/100): mucosal and cutaneous candidiasis (including oesophageal candidiasis), conjunctivitis, neutropenia, inflammatory bowel disease.

Storage precautions: Store in a refrigerator (2ºC – 8ºC), do not freeze. Keep in outer carton to protect from light. Bimzelx can be kept at up to 25ºC for a single period of maximum 25 days with protection from light. Product should be discarded after this period or by the expiry date, whichever occurs first.

Legal Category:POM MarketingAuthorisation Numbers: PLGB 00039/0802 (Prefilled Syringe), PLGB 00039/0803 (Pre-filled Pen).

UK NHS Costs: £2,443 per pack of 2 pre-filled syringes or pens of 160 mg each.

Marketing Authorisation Holder: UCB Pharma Ltd, 208 Bath Road, Slough,Berkshire, SL1 3WE, United Kingdom.

Further information is available from: UCBPharma Ltd, 208 Bath Road, Slough, Berkshire, SL1 3WE. Tel: 0800 2793177 Email: ucbcares.uk@ucb.com Date of Revision: August 2023 (GB-P-BK-AS-2300047) Bimzelx is a registered trademark.

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Adverse events should be reported. Reporting forms and information can be found at http://www.mhra.gov.uk/yellowcard. Adverse events should also be reported to UCB Pharma Ltd at ucbcares.uk@ucb.com or 0800 2793177

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Mind and Skin Workshop report Emma Button

A

s part of the Mind and Skin Day hosted by QV, workshops were held to give opportunity for delegates to use provided tools and consider the implementation of these in day-to-day practice. The tools used included: DLQI,1 PHQ-9,2 GAD-7,4 WHO-5,5 SWIFT, Brief Illness and Distress Thermometer.

Screening tools can help to identify potential concerns early on, with a view that early detection could support better health and social outcomes.

When considering the standardisation of tools now used across the UK and Ireland, one of the challenges discussed was how useful these are when patients are accessing multiple services, such as primary, intermediate and secondary care, particularly for monitoring purposes.

What did surface in conversation is the need for consideration of different tools, or a combination approach that is personalised to the patient.

The tools the clinicians were familiar with included the DLQI, PHQ-9 and GAD-7. It was felt that the last two tools – the PHQ-9 and GAD7 – were being utilised more since the introduction of the new NICE (2023) isotretinoin guidance.3 Tools clinicians were less familiar with but aware of were the WHO-5 and SWIFT. Those familiar with the Brief Illness Perception Questionnaire and the Distress Thermometer had been working in other settings, such as oncology.

From left: Rebecca Penzer-Hick, Karen Stephen and Emma Button.

Efficiency of assessment tools was taken into consideration, with debate around how the DLQI, EASI and PASI are often required to access high-cost drug funding and are at risk of being used in a ‘tick box’ manner. There is potential for this to occur from both the patient and the practitioner. With time constraints in consultations and pressured environments, the risk remains to look at the screening tools, but not necessarily discuss the answers in depth.

It is important to recognise that the outcome of these assessments can help you as a practitioner to support the enablement of a patient by listening to their concerns and worries and providing suggested resources, such as onward social prescribing referrals. When completing these tools, patients are often in noisy, busy waiting rooms, which left the group wondering how would you feel in that scenario. Would you feel comfortable answering question number nine on the PHQ-9?2

“The tools the clinicians were familiar with included the DLQI, PHQ-9 and GAD-7”

Summary: A short summary report of the recent Mind and Skin Workshop, which considered the psychological impact of dermatological conditions and challenged delegates to think about how they include psychological tools and interventions in their practice. www.bdng.org.uk

Reviewing previous scores, positive and negative changes and recurring patterns allows for opportunity to explore the skin and mind connection for that individual patient further. It was thought from several practitioners that there is risk for patients to ‘downplay’ how they are really feeling, with fear a change in scoring could risk access to high-cost drugs. Therefore, the need for a conversation may be pertinent, especially if the context in the consultation does not align with the scores you are reviewing.

Author info: Emma Button is an Advance Nurse Practitioner and Lead Clinical Nurse Specialist working in dermatology in a highly regarded NHS London Trust.

She is also the Events Education Lead for the British Dermatological Nursing Group.

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BDNG News

With the patient expressing some of their most vulnerable thoughts and fears through these screening tools, it is essential as practitioners that we sit and listen after they have taken the time to complete them. A discussion occurred around attendee’s trusts, who have digitalised screening tools, with patients being sent these in advance. This led to consideration, of how to address this in their trust with reference to utilising resources, such as NHS digital and programme managers.

What did become apparent through the workshops is the desire for many clinicians to want to ‘fix’ the concern or a negative impacting feature for

the patient. When discussed further, the majority agreed that this can be a challenge, as naturally nurses are incredibly empathetic. However, it is important to empower the patient so they are able to make informed decisions. Often, listening skills alone – without any further intervention in that scheduled appointment – can provide great relief for an individual and a successful consultation for both patient and practitioner.

The workshops provided a safe space for nurses to collaborate, consider best practice, learn how to utilise screening tools, and to reflect on previous implementation in consultations.

References 1. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clinical and Experimental Dermatology 1994. 3: 210–216 2. Kroenke K, Spitzer RL, Williams J. The PHQ-9. Journal of General Internal Medicine 2001. 16(9): 606-613 3. National Institute for Health and Care Excellence. Isotretinoin. NICE 2023. Available at: https://bnf.nice.org.uk/drugs/isotretinoin/ (last accessed July 2024) 4. Spitzer RL, Kronenke K, Williams J, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine 2006. 166 (10):1092-1097 5. World Health Organization. Wellbeing Measures in Primary Health Care / The Depcare Project. WHO Regional Office for Europe: Copenhagen 1998.

Podcast update Teena Mackenzie

T

he education team have had a busy three months producing podcasts and we now have the pleasure of welcoming Lynne Skrine as the new BDNG Member and International Liaison Lead. This does, of course, mean that we can record further podcasts in the future, and we look forward to hearing from and listening to our international colleagues. As a reminder, the podcasts are available to non-members via Apple and Spotify, and can also be accessed through the BDNG website for members. We try to vary the podcasts and have many interesting topics available for you to listen to. If a podcast is linked to a journal article, we will provide the QR code to make listening as straightforward as possible.

The topics range from managing emotional triggers in the workplace, the role of antioxidants in skin protection, information on the ‘What Matters To You’ initiative, an interview with representatives from Changing Faces, and a discussion about bedbugs. Mandy Aldwin- Easton, whom I’m sure many of you know from the Ichthyosis Support Group, has been working closely with me to produce a range of podcasts focusing on living with ichthyosis, and this will be available soon.

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The education team have many podcasts recorded and they will be going live soon. We have a few exciting topics lined up for future recordings and are always looking for more. If you, or a member of your team, have an idea for a podcast, please email me Teena Mackenzie (EDLead@bdng. org.uk). We record over Microsoft Teams and allocate an hour slot that suits you. We always provide support prior to the recording to discuss any questions you may have.

Happy Listening and we look forward to hearing from you.

Mandy Aldwin-Easton on recording a podcast In a first podcast about ichthyosis, we had an insightful discussion between myself, Teena and Gulzeab Ahmed, a member of the Ichthyosis Support Group (ISG). We were able to touch on some of the challenges faced by individuals and parent carers, emphasising the need to raise awareness and educate nurses about this often underdiagnosed and misunderstood genetic skin disease.

www.bdng.org.uk

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UK Dermatology Clinical Trials Network Update Carron Layfield

Please note all studies mentioned below are funded by a range of National Institute for Health and Social Care (NIHR) funding programmes. These are just a selection of studies developed with UK DCTN support – for a full list please see http://www.ukdctn.org/ourclinicaltrials/index.aspx.

Studies in set-up Acne-ID

Low dose isotretinoin study needs more sites Acne-ID is a two-arm, parallel-group, individually randomised, multicentre, non-inferiority trial with an internal pilot phase. The study will compare a low-dose isotretinoin strategy (the intervention 0.2-0.3 mg/kg/ day) with standard care (the comparator >0.5mg/kg/ day) and aims to recruit 800 people aged 12 to 24 years with acne over a 12-month period. The primary outcome for the study is acne clearance, defined by the Comprehensive Acne Severity Score, at the end of treatment course. Secondary outcomes include side effects and tolerability, change in mood, quality of life, treatment satisfaction and recurrence of acne along with costs to patients and the NHS. Further information is available at https://www.acne-id.ac.uk/.

The study is coming to the end of set-up phase and aims to start recruiting soon with 15 sites identified to take part. Due to the large numbers of participants required, more sites are needed, so please think about encouraging your department to take part.

If interested, you can email the study team at acne-id@nottingham.ac.uk or complete a site questionnaire https://app.onlinesurveys.jisc.ac.uk/s/nottingham/acne-idsite-selection-questionnaire.

Ongoing studies RAPID Eczema Trials

Bathing frequency study recruits to target in just over five months This five-year research programme is investigating new approaches to undertaking studies in mild to moderate eczema. This includes prioritising and co-producing trials with patients which are then delivered online.

We’re pleased to let you know that the first study (investigating whether it is better for people with eczema to bath/shower weekly or daily) has recruited 74

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440 participants in just over five months (against a target of 390).

Further details of the study can be found at https:// rapideczematrials.org/eczema-bathing-study/. Another important part of the research programme is looking at ways of getting research results out more quickly to people that need them, so please keep an eye out for these.

“Many thanks to Nicola Cottom, a dermatology nurse based in Wigan, who played a key role in the co‑production team” The next online trial will be on the theme of the ‘best way to keep control of eczema between flare-ups’. Coproduction work with patients is complete and the study aims to start recruiting early in the new year. Many thanks to Nicola Cottom, a dermatology nurse based in Wigan, who played a key role in the co-production team.

The final Rapid Eczema Trials study will focus on ‘Psychological interventions to influence how people respond to stress’ – please see https://rapideczematrials. org/ or contact the research team at eczema@nottingham. ac.uk if you’d like to get involved.

HEALS2

Dermatological surgery study seeking more sites This pragmatic randomised controlled trial, evaluating the clinical and cost effectiveness of compression therapy in the healing of surgical wounds (by secondary intention) following excision of lower limb keratinocyte cancers, www.bdng.org.uk

BDNGXXXX News

opened to recruitment in February 2024. It has randomised more than 20 patients to date, and aims to recruit 396 participants from secondary care skin cancer surgical centres across the UK, aiming to complete recruitment by December 2025.

The primary outcome is time to healing between standard care or standard care plus compression therapy with secondary objectives including an assessment of scar quality, antibiotic usage post-surgery and complications/hospitalisation until healed. Twelve sites have opened to recruitment and the study team are aiming to open another 10 centres – please do get in touch at HEALS2@ leeds.ac.uk if your site can help.

Further study information is available at https://ctru.leeds.ac.uk/heals2/.

BEACON

Systemic treatments for eczema study adding fourth arm The BEACON study aims to provide the first ever comprehensive evidence on the comparative effectiveness, tolerability and cost-effectiveness of ciclosporin, methotrexate and dupilumab in the treatment of moderate to severe adult eczema. The study has now recruited more than 50 of the required 402 participants, with five sites (out of a planned total of 29) opened to date.

Patients can self-refer to the study – currently more than 300 patients have self-referred – demonstrating an unmet need in the adult eczema patient population.

The study was set up as a multi-arm, multi-stage platform trial capable of adding new arms as novel treatments emerge (similar to the RECOVERY trial in COVID) and an additional fourth arm (abrocitinib, a Janus kinase inhibitor) is being added from November 2024.

For further information, please see the study website www.beacontrial.org/ or contact the Trial Manager at BEACON@ kcl.ac.uk.

www.bdng.org.uk

“UK DCTN Network Manager Carron Layfield will present an update on UK DCTN studies and other activities on Tuesday 17 September as part of the BDNG Annual Conference” Other UK DCTN news 2024 UK DCTN Fellowship Awards

The deadline for our 2024 UK DCTN Nurse/Pharmacist Fellowship Award is fast approaching – and applicants will need to get their submission in by Monday 7 October.

Full details of this two-year research education award and how to apply are on our website http://www.ukdctn.org/ fellowships/index.aspx. Please feel free to get in touch with us at ukdctn@ nottingham.ac.uk with any queries; we’re always happy to hear from prospective applicants.

2024 UK DCTN Themed Call

We’re pleased to let you know that we received a total of nine applications for this funding call to support projects that will inform the development of future clinical trials in areas identified by previous dermatology priority setting partnerships. We’re now shortlisting the applications and final funding decisions will be made at our Steering Committee meeting in October.

Three awards of up to £10,000 each are available due to generous cofunding from the British Society for Dermatological Surgery (BSDS) and the British Society for Paediatric and Adolescent Dermatology (BSPAD).

2024 UK DCTN Lifetime Honorary Membership Awards

These awards are announced each year at our AGM in recognition of those who have made a sustained and significant contribution to the efforts of the UK DCTN and have championed dermatology research to improve patient care. Recipients of our 2024 awards were Amanda Roberts, for her dedication to public and patient

involvement in research, and Dr Debbie Shipley, for her work in helping to establish UK DCTN research capacity building initiatives such as our fellowship awards.

UK DCTN Activities at BDNG Meetings

UK DCTN Network Manager Carron Layfield will present an update on UK DCTN studies and other activities on Tuesday 17 September as part of the BDNG Annual Conference. Carron will also be delivering a session on Patient and Public Involvement (PPI) in dermatology research at the BDNG Research Education event taking place in London on Monday 14 October.

She will be joined in this session by experienced dermatology PPI representative Amanda Roberts.

How to get involved Membership of the UK DCTN is free and open to anyone with an interest in dermatology research.

You can join via the website www. ukdctn.org, and can keep up to date with what is happening at https://x.com/UK_DCTN.

Correspondence Carron Layfield (UK DCTN Network Manager) UK DCTN Co-ordinating Centre, Centre of Evidence Based Dermatology, Applied Health Research Building, Main University Campus, University of Nottingham, Nottingham NG7 2RD. Email carron.layfield@nottingham.ac.uk

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E, AE, adverse AE, adverse AE,AE, adverse adverse event; AE, adverse event; adverse HCP, event; event; HCP, event; healthcare event; HCP, HCP, healthcare HCP, healthcare HCP, healthcare healthcare professional; healthcare professional; professional; professional; professional; professional; IV, intravenous; IV, intravenous; IV,IV,intravenous; IV, intravenous; IV, intravenous; intravenous; LTE,LTE, long-term LTE, long-term LTE,LTE, long-term long-term LTE, extension; long-term long-term extension; extension; extension; extension; PASI, extension; PASI, Psoriasis PASI, PASI, Psoriasis PASI, Psoriasis PASI, Psoriasis Area Psoriasis Psoriasis Area and Area Area and Severity Area and Area Severity andand Severity Severity and Index; Severity Index; Severity Index; Index; Index; Index; sA,PsA, psoriatic PsA, psoriatic PsA, PsA, psoriatic PsA, psoriatic arthritis; psoriatic arthritis; psoriatic arthritis; arthritis; PsO, arthritis; PsO, arthritis; psoriasis; PsO, PsO, psoriasis; PsO, psoriasis; PsO, psoriasis; sPGA, psoriasis; psoriasis; sPGA, static sPGA, sPGA, static sPGA, Physician’s sPGA, static static Physician’s static static Physician’s Physician’s Physician’s Global Physician’s Global Assessment; Global Global Assessment; Global Global Assessment; Assessment; Assessment; Assessment; TYK2, TYK2, tyrokise TYK2, TYK2, tyrokise TYK2, TYK2, tyrokise tyrokise kinase tyrokise kinase tyrokise receptor kinase kinase receptor kinase kinase receptor receptor 2. receptor 2.receptor 2.2. 2. 2.

787-GB-2400156 1787-GB-2400156 1787-GB-2400156 1787-GB-2400156 1787-GB-2400156 1787-GB-2400156 | May | May |2024 |May May |2024 May | May 2024 2024 2024 2024

References: 1. SOTYKTU (deucravacitinib) Summary of Product Characteristics; 2. Armstrong A et al. J Am Acad Dermatol. 2023;88(1):29–39; 3. Strober B et al. J Am Acad Dermatol. 2023;88(1):40–51; 4. Lebwohl MG et al. Dermatol Ther (Heidelb). 2022;12(1): 61–78; 5. Piragine E et al. J Clin Med. 2022;11(6):1506; 6. Green W et al. Dermatology and Therapy. 2021;11:1635–1642; 7. Armstrong AW et al. Oral presentation at the EADV Annual Meeting; 11–14 October 2023; Berlin, Germany. Presentation FC.02.7; 8. SOTYKTU. European Product Assessment Report (EPAR). 26 January 2023. Available at: https://www.ema.europa.eu/en/documents/assessment-report/sotyktu-epar-public-assessment-report_en.pdf. Date accessed: May 2024.

SOTYKTU®

(deucravacitinib) PRESCRIBING INFORMATION

Great Britain

Consult Summary of Product Characteristics (SmPC) before prescribing. This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information.

PRESENTATION: Film-coated tablet containing 6 mg of deucravacitinib.

INDICATION: Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy.

DOSAGE AND ADMINISTRATION: Treatment should be initiated under the guidance and supervision of a physician experienced in the diagnosis and treatment of psoriasis. Posology: 6 mg orally once daily. If a patient shows no evidence of therapeutic benefit after 24 weeks, treatment discontinuation should be considered. The patient’s response to treatment should be evaluated on a regular basis. Special populations: Elderly: No dose adjustment is required in elderly patients aged 65 years and older. Clinical experience in patients  75 years is very limited and deucravacitinib should be used with caution in this group of patients. Renal Impairment: No dose adjustment is required in patients with renal impairment, including end stage renal disease (ESRD) patients on dialysis. Hepatic impairment: No dose adjustment is required in patients with mild or moderate hepatic impairment. Deucravacitinib is not recommended to be used in patients with severe hepatic impairment. Paediatric population: The safety and efficacy of deucravacitinib in children and adolescents below the age of 18 years have not yet been established. No data are available. Method of administration: For oral use. Tablets can be taken with or without food. Tablets should be swallowed whole and should not be crushed, cut, or chewed.

CONTRAINDICATIONS: Hypersensitivity to the active substance or to any of the excipients (see SmPC). Clinically important active infections (e.g. active tuberculosis).

WARNINGS AND PRECAUTIONS: Infections: Treatment should not be initiated in patients with any clinically important active infection until the infection resolves or is adequately treated.

Caution should be exercised when considering the use in patients with a chronic infection or a history of recurrent infection.

Patients treated with deucravacitinib should be instructed to seek medical advice if signs or symptoms suggestive of an infection occur. If a patient develops a clinically important infection or is not responding to standard therapy, monitor carefully and deucravacitinib should not be given until the infection resolves.

Pre-treatment evaluation for tuberculosis (TB): Prior to initiating treatment with deucravacitinib, patients should be evaluated

SOTYKTU®

for TB infection. Deucravacitinib should not be given to patients with active TB. Treatment of latent TB should be initiated prior to administering deucravacitinib. Anti-TB therapy should be considered prior to initiation of deucravacitinib in patients with a past history of latent or active TB in whom an adequate course of treatment cannot be confirmed. Patients receiving deucravacitinib should be monitored for signs and symptoms of active TB. Malignancies*: Malignancies, including lymphomas and nonmelanoma skin cancer (NMSC), were observed in clinical studies with deucravacitinib. Limited clinical data are available to assess the potential relationship of exposure to deucravacitinib and the development of malignancies. Long-term safety evaluations are ongoing. The risks and benefits of deucravacitinib treatment should be considered prior to initiating patients**. Major adverse cardiovascular events (MACE), deep venous thrombosis (DVT) and pulmonary embolism (PE)*: An increased risk was not observed in clinical trials with deucravacitinib. Long-term safety evaluations are ongoing. The risks and benefits of deucravacitinib treatment should be considered prior to initiating patients**. Immunisations: Consider completion of all age-appropriate immunisations according to current immunisation guidelines prior to initiating therapy. Use of live vaccines in patients being treated with deucravacitinib should be avoided. Excipients: Contains lactose.

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose galactose malabsorption should not take this medicinal product. Contains less than 1 mmol of sodium (23 mg) per tablet, essentially ‘sodium-free’. *serious. **It is not known whether tyrosine kinase 2 (TYK2) inhibition may be associated with the adverse reactions of Janus Kinase (JAK) inhibition. In a large randomised active-controlled study of a JAK inhibitor in rheumatoid arthritis (RA) patients 50 years and older with at least one additional cardiovascular risk factor, a higher rate of malignancies (particularly lung cancer, lymphoma and NMSC), a higher rate of MACE (defined as cardiovascular death, non-fatal myocardial infarction and non-fatal stroke), and a dose dependent higher rate of venous thromboembolism (including DVT and PE) were observed with a JAK inhibitor compared to TNF inhibitors.

INTERACTIONS: Deucravacitinib does not have any known clinically relevant drug interactions. Refer to SmPC for full details.

PREGNANCY AND LACTATION: Pregnancy: There is a limited amount of data on the use of deucravacitinib in pregnant women.

As a precautionary measure, it is preferable to avoid the use of deucravacitinib during pregnancy. Breast-feeding: It is unknown whether deucravacitinib/metabolites are excreted in human milk.

A risk to the newborns/infants by breast-feeding cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from deucravacitinib

therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman. Fertility: The effect of deucravacitinib on human fertility has not been evaluated.

UNDESIRABLE EFFECTS: The most commonly reported adverse reaction is upper respiratory infections (18.9%), most frequently nasopharyngitis. The longer-term safety profile of deucravacitinib was similar and consistent with previous experience. Very common ( 1/10): Upper respiratory infections*** (including nasopharyngitis, upper respiratory tract infection, viral upper respiratory tract infection, pharyngitis, sinusitis, acute sinusitis, rhinitis, tonsillitis, peritonsillar abscess, laryngitis, tracheitis, and rhinotracheitis). Common ( 1/100 to < 1/10): Herpes simplex infections*** (including oral herpes, herpes simplex, genital herpes, and herpes viral infection), Oral ulcers (including aphthous ulcer, mouth ulceration, tongue ulceration, and stomatitis), Acneiform rash (including acne, dermatitis acneiform, rash, rosacea, pustule, rash pustular, and papule), Folliculitis and Blood creatine phosphokinase increased. Uncommon ( 1/1,000 to < 1/100): Herpes zoster***. Refer to SmPC for full details on adverse reactions. ***serious adverse drug reaction LEGAL CATEGORY: POM MARKETING AUTHORISATION NUMBER and BASIC NHS PRICE: PLGB 15105/0179: Carton of 28 film-coated tablets 6 mg NHS price: £690.00; Carton of 84 film-coated tablets 6 mg NHS price: £2070.00.

MARKETING AUTHORISATION HOLDER: Bristol-Myers Squibb Pharma EEIG, Plaza 254, Blanchardstown Corporate Park 2, Dublin 15, D15 T867, Ireland.

FOR FURTHER INFORMATION CONTACT: medical.information@bms.com or 0800 731 1736 (Great Britain).

DATE OF PREPARATION: May 2023 ADDITIONAL INFORMATION AVAILABLE ON REQUEST Approval code: 1787-GB-2300080

Adverse events should be reported. Reporting forms and information can be found at: Great Britain – www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store; Adverse events should also be reported to Bristol-Myers Squibb via medical.information@bms.com or 0800 731 1736 (Great Britain).

(deucravacitinib) PRESCRIBING INFORMATION

Northern Ireland / Ireland

Consult Summary of Product Characteristics (SmPC) before prescribing. This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information.

PRESENTATION: Film-coated tablet containing 6 mg of deucravacitinib.

INDICATION: Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy.

DOSAGE AND ADMINISTRATION: Treatment should be initiated under the guidance and supervision of a physician experienced in the diagnosis and treatment of psoriasis. Posology: 6 mg orally once daily. If a patient shows no evidence of therapeutic benefit after 24 weeks, treatment discontinuation should be considered.

The patient’s response to treatment should be evaluated on a regular basis. Special populations: Elderly: No dose adjustment is required in elderly patients aged 65 years and older. Clinical experience in patients  75 years is very limited and deucravacitinib should be used with caution in this group of patients. Renal Impairment: No dose adjustment is required in patients with renal impairment, including end stage renal disease (ESRD) patients on dialysis. Hepatic impairment: No dose adjustment is required in patients with mild or moderate hepatic impairment.

Deucravacitinib is not recommended to be used in patients with severe hepatic impairment. Paediatric population: The safety and efficacy of deucravacitinib in children and adolescents below the age of 18 years have not yet been established. No data are available. Method of administration: For oral use. Tablets can be taken with or without food. Tablets should be swallowed whole and should not be crushed, cut, or chewed.

CONTRAINDICATIONS: Hypersensitivity to the active substance or to any of the excipients (see SmPC). Clinically important active infections (e.g. active tuberculosis).

WARNINGS AND PRECAUTIONS: Infections: Treatment should not be initiated in patients with any clinically important active infection until the infection resolves or is adequately treated.

Caution should be exercised when considering the use in patients with a chronic infection or a history of recurrent infection.

Patients treated with deucravacitinib should be instructed to seek medical advice if signs or symptoms suggestive of an infection occur. If a patient develops a clinically important infection or is not responding to standard therapy, monitor carefully and deucravacitinib should not be given until the infection resolves.

Pre-treatment evaluation for tuberculosis (TB): Prior to initiating treatment with deucravacitinib, patients should be evaluated for TB infection. Deucravacitinib should not be given to patients

with active TB. Treatment of latent TB should be initiated prior to administering deucravacitinib. Anti-TB therapy should be considered prior to initiation of deucravacitinib in patients with a past history of latent or active TB in whom an adequate course of treatment cannot be confirmed. Patients receiving deucravacitinib should be monitored for signs and symptoms of active TB. Malignancies*: Malignancies, including lymphomas and nonmelanoma skin cancer (NMSC), were observed in clinical studies with deucravacitinib. Limited clinical data are available to assess the potential relationship of exposure to deucravacitinib and the development of malignancies. Long-term safety evaluations are ongoing. The risks and benefits of deucravacitinib treatment should be considered prior to initiating patients**. Major adverse cardiovascular events (MACE), deep venous thrombosis (DVT) and pulmonary embolism (PE)*: An increased risk was not observed in clinical trials with deucravacitinib. Long-term safety evaluations are ongoing. The risks and benefits of deucravacitinib treatment should be considered prior to initiating patients**. Immunisations: Consider completion of all age-appropriate immunisations according to current immunisation guidelines prior to initiating therapy. Use of live vaccines in patients being treated with deucravacitinib should be avoided. Excipients: Contains lactose.

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose galactose malabsorption should not take this medicinal product. Contains less than 1 mmol of sodium (23 mg) per tablet, essentially ‘sodium-free’. *serious. **It is not known whether tyrosine kinase 2 (TYK2) inhibition may be associated with the adverse reactions of Janus Kinase (JAK) inhibition. In a large randomised active-controlled study of a JAK inhibitor in rheumatoid arthritis (RA) patients 50 years and older with at least one additional cardiovascular risk factor, a higher rate of malignancies (particularly lung cancer, lymphoma and NMSC), a higher rate of MACE (defined as cardiovascular death, non-fatal myocardial infarction and non-fatal stroke), and a dose dependent higher rate of venous thromboembolism (including DVT and PE) were observed with a JAK inhibitor compared to TNF inhibitors.

INTERACTIONS: Deucravacitinib does not have any known clinically relevant drug interactions. Refer to SmPC for full details.

PREGNANCY AND LACTATION: Pregnancy: There is a limited amount of data on the use of deucravacitinib in pregnant women.

As a precautionary measure, it is preferable to avoid the use of deucravacitinib during pregnancy. Breast-feeding: It is unknown whether deucravacitinib/metabolites are excreted in human milk. A risk to the newborns/infants by breast-feeding cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from deucravacitinib therapy taking into account the benefit of breast feeding for the

child and the benefit of therapy for the woman. Fertility: The effect of deucravacitinib on human fertility has not been evaluated.

UNDESIRABLE EFFECTS: The most commonly reported adverse reaction is upper respiratory infections (18.9%), most frequently nasopharyngitis. The longer-term safety profile of deucravacitinib was similar and consistent with previous experience. Very common ( 1/10): Upper respiratory infections*** (including nasopharyngitis, upper respiratory tract infection, viral upper respiratory tract infection, pharyngitis, sinusitis, acute sinusitis, rhinitis, tonsillitis, peritonsillar abscess, laryngitis, tracheitis, and rhinotracheitis). Common ( 1/100 to < 1/10): Herpes simplex infections*** (including oral herpes, herpes simplex, genital herpes, and herpes viral infection), Oral ulcers (including aphthous ulcer, mouth ulceration, tongue ulceration, and stomatitis), Acneiform rash (including acne, dermatitis acneiform, rash, rosacea, pustule, rash pustular, and papule), Folliculitis and Blood creatine phosphokinase increased.

Uncommon ( 1/1,000 to < 1/100): Herpes zoster***. Refer to SmPC for full details on adverse reactions. ***serious adverse drug reaction LEGAL CATEGORY: POM MARKETING AUTHORISATION NUMBER and BASIC NHS PRICE: EU/1/23/1718/006: Carton of 28 film-coated tablets 6 mg NHS price: £690.00.

MARKETING AUTHORISATION HOLDER: Bristol-Myers Squibb Pharma EEIG, Plaza 254, Blanchardstown Corporate Park 2, Dublin 15, D15 T867, Ireland.

FOR FURTHER INFORMATION CONTACT: medical.information@bms.com or 0800 731 1736 (Northern Ireland) / 1 800 749 749 (Ireland).

DATE OF PREPARATION: June 2023 ADDITIONAL INFORMATION AVAILABLE ON REQUEST Approval code: 1787-IE-2300001

Adverse events should be reported. Reporting forms and information can be found at: Northern Ireland – www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store; Ireland – via HPRA Pharmacovigilance at www.hpra.ie Adverse events should also be reported to Bristol-Myers Squibb via medical.information@bms.com or 0800 731 1736 (Northern Ireland); 1 800 749 749 (Ireland).

Sponsored by

BDNG News

Diary dates Find out what events are coming up in the world of dermatology.

To get an event listed, please email rob.mair@pavpub.com BDNG Annual Conference

Birmingham Winter Meeting

2025

What: BDNG’s 33rd Annual Conference When: 17-19 September 2024 Where: Harrogate Convention Centre Description: For more information see the QR code

What: BDNG Winter Meeting When: 11-12 November 2024 Where: Leonardo Royal Hotel Birmingham, 245 Broad Street, Birmingham, B1 2HQ Description: l 11 November 2024: Metoject MEDAC l 11 & 12 November: Skin Surgery Course l 12 November: Aesthetics Meeting l 12 November: Inclusivity and Diversity Day l 12 November: Getting to know the BDNG team and how to be involved, and service and selfdevelopment support

What: HS day When: 25 March 2025 Where: IET Birmingham: Austin Court, 80 Cambridge Street, Birmingham, B1 2NP

Aesthetics Conference for Dermatology

What: BDNG Winter Meeting (Birmingham) When: 10-11 November Where: Leonardo Royal Hotel Birmingham, 245 Broad Street, Birmingham, B1 2HQ

Or use this QR code

BDNG London Regional Meeting What: BDNG Regional Meeting When: 14 October 2024 Where: ETC venue 133 Houndsditch, 3rd floor Description: l Research Meeting l Menopause Day l Patch Testing and Contact Dermatitis l Primary Care Day

What: Aesthetics Conference for Dermatology When: Saturday 23 November 2024 Where: Cavendish Venues 22 Duchess Mews, London, W1G 9DT

What: BDNG Spring Meeting 2025 (Manchester) When: 12-13 May 2025 Where: Mercure Manchester Hotel, Portland Street, M1 4PH What: BDNG’s 34th Annual Conference When: 30 September – 2 October 2025 Where: Harrogate

More details on future events will be published on the BDNG website, and on e-newsletters.

Advancing dermatology for every skin story

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Dermatological Nursing 2024, Vol 23, No 3

www.bdng.org.uk

Coal Tar Solution 12% w/w | Salicylic Acid 2% w/w Sulfur for External Use 4% w/w

Coconut Oil Compound

The Scaly Scalp Saviour Sebco, managing scaly scalp conditions such as: Psoriasis*, Eczema, Dandruff and Seborrheic Dermatitis... ...by softening and removing the scale as well as having mild antipruritic and antiseptic properties. *NICE recommend a topical treatment containing salicylic acid and oils as a second line treatment for patients with scalp psoriasis1

For more details, contact us: E: info@dermauk.co.uk T: 0191 375 9020

Scan to watch Sebco™ application video Abbreviated Prescribing Information for SebcoTM Please refer to the full Summary of Product Characteristics (SmPC) prior to prescribing.

Presentation: Ointment containing coal tar solution 12%, salicylic acid 2%, sulfur for external use 4%. Uses: Treatment of common scaly scalp disorders such as psoriasis, eczema, seborrheic dermatitis and dandruff. Dosage: Gently rub into scalp, leave in contact for approximately one hour. Wash out using warm water and mild shampoo. For severe scalp conditions, use daily for 3-7 days until improvement is obtained then intermittently as necessary. For less severe conditions such as dandruff use intermittently as necessary, e.g., once a week. If symptoms persist after 4 weeks consult your doctor. For children 6-12 years use under medical supervision only. Not recommended for use on children under six years.

Contraindications: Skin infections of the scalp or known sensitivity to any of the ingredients. Use in Pregnancy and Lactation: To be used at the discretion of the prescribing doctor. Warnings and Precautions: Instruct patients not to smoke or go near naked flames - risk of severe burns.

Fabric (clothing, bedding, dressings etc) that has been in contact with this product burns more easily and is a serious fire hazard. Washing clothing and bedding may reduce product build-up but not totally remove it. Avoid contact with eyes, and any areas of broken skin. Coal tar may stain clothes and jewellery. Remove or protect these items during treatment. Side Effects: May cause skin irritation, folliculitis and rarely photosensitivity.

In the event of such a reaction, discontinue use. Prescribers should consult the Summary of Product Characteristics in relation to other side effects.

Another trusted product from

dermauk.co.uk Pharmaceutical Precautions: Store below 25°C. Do not refrigerate. Replace the cap after use and return tube to carton. Discard tube no later than 4 weeks after opening. Package Quantities: 100g tube, 40g tube. Basic NHS Price: 40g £10.41, 100g £15.88. Legal Category: GSL. Marketing Authorisation Number: PL 19876/0001. Full prescribing information is available on request. Marketing Authorisation Holder: Derma UK Ltd, The Toffee Factory, Lower Steenbergs Yard, Ouseburn, Newcastle upon Tyne NE1 2DF, UK. “Sebco” and “Derma UK” are registered Trade Marks.

Date of Revision of Text: January 2024.

Adverse events should be reported. Information about adverse event reporting can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Derma UK Ltd, UK on 0191 375 9020.

References: 1. National Institute for Health and Care Excellence, Psoriasis, https://bnf.nice.org.uk/treatment-summaries/psoriasis/, last accessed 4th July 2024 SEB/99/0724

Date of Preparation: July 2024

Say hello to the BDNG’s new Member and International Liaison Lead Lynne Skrine

I

’m Lynne Skrine your new Member and International Liaison Lead for the BDNG.

I’ve been a Dermatology Nurse Manager working in both secondary and primary care for more than 20 years.

I have a passion for promoting dermatology nursing, and part of my role is to signpost my team to educational resources which will help them achieve their goals in their nursing career.

I operationally manage a small team of nurses and General Practitioners with Extended Roles (GPwER) alongside Val Anderson (Clinical Lead). Between us, we like to recruit nurses into the service with transferable skills so we can watch them grow into dermatology nurses. In our service we like to ensure that the patients are front and centre of their care in the community. I also support the team with service improvements and developments which are never‑ending.

I have been involved with the BDNG for many years, starting off as a regional representative for the Southwest of England, sitting on the committee and being the link between the Southwest and the rest of the UK and Ireland. Most recently I had the privilege to take on the role of President from 2016-2018, before handing over the role to Rebecca Penzer-Hick. Then, after a year, I returned to the committee as a Trustee where I was able to attend and speak at conferences both internationally and nationally, building up a network of contacts.

In June, I started working for the BDNG for two days a week (Mondays and Fridays), and I resigned from being a Trustee. The role I have taken on is new for the organisation. The purpose of this role is to provide communications and support for BDNG members both nationally and internationally, and to lead on the international development of the BDNG, forging partnerships and links with other countries.

Over the years I have built up a good network of dermatology nurses from around the world in places such as Singapore, Australia, New Zealand, Norway, America and Hong Kong, to name a few.

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Dermatological Nursing 2024, Vol 23, No 3

Making contacts at the World Congress During the World Congress, I was able to facilitate a nurse-led meeting with Brenda Lim, Chair of the Singapore Nurses Association Dermatology Chapter outside of the main congress and support the BDNG President with the nurse-led session in the World Congress, hosted by the BDNG. Both events were represented by nurses from several different countries, highlighting the dermatology nurse roles and the diverse, nurse-led clinics in each of the different countries.

We had two great days networking, which were valuable to the rising stars we had been fortunate to take over there with us. During this time, I was the main point of contact, ensuring that everyone was kept up to date with the programmes and ensuring we had the technology if they were unable to attend in person, not just for the the nurses who attended from the UK and Ireland, but for nurses from all the other countries too. This experience has helped me with my new role.

Over the past few months – which have been very busy – I have commenced building a dermatology service directory www.bdng.org.uk

BDNG News

of all the dermatology services within the UK, Ireland and the Channel Islands, and using social media and the BDNG newsletter to gather information regarding the lead nurses and their contact details. I’m not there yet, so please get in contact if you lead your service. We are doing this so we have a more comprehensive idea of where the services are situated. Over the next year I would love to have a complete database of all dermatology services within the UK and Ireland, with named leads and an idea of how many nurses work within the speciality of dermatology.

From this database, I am hoping to send out a more comprehensive questionnaire to gather further information, such as banding, nurse-led services and treatments. If you haven’t yet seen these posts on social media, or on the BDNG newsletter, please contact me at lynne@bdng.org. uk. This also leads quite nicely onto saying please can you ensure your details for the BDNG are up to date.You can do this by going to the login page and updating your profile.

Communicating with the membership You may have also noticed that there has been a lot of activity on the BDNG social media channels. I’ve had a great time putting these together, although I did at one point think I had broken Facebook (luckily, I didn’t!). The whole team actively take part in informing you about what is happening in the world of the BDNG, so follow us on Facebook, Instagram, X and LinkedIn AND help us share the good work we are doing.

I want to ensure that all new members of the BDNG are communicated with when they join, so they have all of the information about the benefits of what the organisation can offer them as a member. Alongside this, with the help of the education team, I’m keen to promote health and www.bdng.org.uk

wellbeing. Part of this will involve a dedicated webpage, which will show that we are thinking about your health.

This will be supported by podcasts, relaxation techniques and Apps you can download.

Part of my role will also see me promoting dermatology nursing within the wider community and internationally by liaising with all the different organisations nationally and internationally. I’ll be holding regular meetings and keeping in contact with partners via email. I’ll also be promoting conferences and study sessions, and taking an active part in building educational programmes with the support of the President, Trustees and the educational team.

There are a lot of international dermatology conferences taking place over the next few years, and the BDNG would like to play an active role, both within the events and by promoting the BDNG as a leader within the dermatology nursing community. Additionally, following the success of the rising stars and their attendance at the WCD 2023, I would like to be able to offer other rising stars the chance to attend the World Congress in 2027 – funding permitting.

But that’s enough from me about what I have planned.

What I would like to know is what you, as members, would like from me? Drop me a line and let me know.

I will keep you up to date with my progress with a regular update in the journal, and I look forward to hearing from you – especially new members with feedback about the welcome emails.

See you all soon, Lynne Dermatological Nursing 2024, Vol 23, No 3

81

BDNG News

Providing education opportunities nationwide, and preparing for the annual conference Jodie Newman

T

he education team has been busy planning for our upcoming seasonal study events and the annual conference, plus we have grown as a team now that Lynne Skrine has joined us. On behalf of the education team, we welcome Lynne and look forward to working closely with her on future projects, and you can read more about Lynne’s role and remit on page 80.

In June this year, Molly kindly invited Jodie to attend the Royal Infirmary Edinburgh to do a Pediatrics Eczema Workshop with community colleagues, including school nurses, health visitors and community children’s nurses.

We all had a great time doing our workshop activities, which included the application of emollients, wet wraps and an eczema-knowledge quiz.

Additionally, Richard from Skinnies Garments kindly came to show all the attendees the different garments and how they can be prescribed for children with skin conditions. We’d like to say a massive thank you to Richard for coming, and it was lovely to meet all the attendees and to be able to let them know how the BDNG can support them in their roles.

“In June this year, Molly kindly invited Jodie to attend the Royal Infirmary Edinburgh to do a Pediatrics Eczema Workshop with community colleagues” Molly is also looking forward to doing some group education about topical steroid use and emollients for district nurses based in Edinburgh, and will be doing some more group sessions later in the year. If your team is interested in doing any workshops or practical education on topical treatments and is based in Scotland, then get in touch with Molly (molly@bdng.org.uk) as she can help run these sessions with your team.

year, with the education team now expanded, we have listened to the feedback from members and decided that ‘Derm School’ will not only focus on adult patients but we are delighted to be welcoming some of our pediatric subgroup members to discuss hot topics in pediatric dermatology. For those of us who are not paediatric trained but offer a service to this patient cohort, this might be beneficial for clinical practice.

Teena and Jodie were also involved in the Guardian’s Health Awareness campaign back in June, where they produced an article on vitiligo to help raise awareness of the condition and to help reduce the stigma of living with vitiligo.

We also plan to have a designated space for our education team. The rationale for wanting to do this is so we can meet you all! We would love for you to engage with us, and we will be free to answer any questions relating to education or if you are interested in becoming more involved with the BDNG. Molly will be releasing a timetable of activities and some more information about this very soon.

The BDNG’s 33rd annual conference is on the horizon, and we’re planning to be bigger and better than ever. This

Join us at BritDermNurse/ 82

Dermatological Nursing 2024, Vol 23, No 3

@_BDNG

@b_d_n_g www.bdng.org.uk

The British Dermatological Nursing Group Corporate Sponsors

The BDNG would like to thank all our corporate sponsors for their support and continued investment with the BDNG

What’s that Wynzora feeling?

Choose the first and only CAL/BDP cream that treats psoriasis on the body and scalp1,2 PRESCRIBING INFORMATION Please consult the Summary of Product Characteristics (SmPC) before prescribing Name: Wynzora, 50 micrograms/g + 0.5 mg/g cream Active Ingredient: One gram of Wynzora Cream contains 50 micrograms of calcipotriol and betamethasone dipropionate equivalent to 0.5 mg betamethasone. Excipients with known effect: Butylated hydroxyanisole (E 320) 1.0 micrograms/g cream Macrogolglycerol hydroxystearate 3.4 micrograms/g cream Indication: Wynzora is indicated for topical treatment of mild to moderate psoriasis vulgaris, including scalp psoriasis, in adults.

Dosage and Administration: Rub a thin layer of Wynzora Cream to affected areas once daily for up to 8 weeks. Discontinue when control is achieved. Treatment should be continued only after medical review and under regular medical supervision. For calcipotriol containing medicinal products, do not exceed the maximum daily dose of 15 g; the body surface area treated should not exceed 30%. Wynzora Cream should not be applied directly to the face or eyes. Allow 8 hours between the application and showering or bathing. Hands must be washed after use. Consult SmPC and package leaflet for full method of administration.

Contraindications, Precautions and Warnings: Contraindications: Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 of SmPC. Wynzora Cream is contraindicated in erythrodermic, exfoliative and pustular psoriasis; in patients with known disorders of calcium metabolism; viral (e.g. herpes or varicella) lesions of the skin, fungal or bacterial skin infections, parasitic infections, skin manifestations in relation to tuberculosis, perioral dermatitis, atrophic skin, striae atrophicae, fragility of skin veins, ichthyosis, acne vulgaris, acne rosacea, rosacea, ulcers and wounds. Precautions: Avoid application under occlusive dressings, large areas of damaged skin or on mucous membranes or in skin folds due to increased corticosteroids systemic absorption and potential adrenocortical suppression or impact on the metabolic control of diabetes mellitus. Hypothalamic–pituitary–adrenal axis suppression was evaluated in adult subjects (N=27) with extensive psoriasis (including scalp). Adrenal suppression was seen in 1 out of 27 subjects (3.7%) after 4 weeks of treatment, and in one additional patient after 8 weeks of treatment. Visual disturbance may be reported with systemic and topical corticosteroid use. Patients presenting with blurred vision or other visual disturbances should be considered for a referral to an ophthalmologist. Hypercalcaemia may occur however the risk is minimal if maximum daily dose (15 g) is not exceeded. Serum calcium is normalised upon discontinuation. Avoid concurrent treatment with other steroids on the same treatment area. Do not use on the face and genital areas. Patients should wash hands after each application. Treat secondarily infected lesions with antimicrobiological therapy. Stop treatment with corticosteroids if the infection worsens. Continue medical supervision in the post-treatment period in case of rebound effects or development of generalised pustular psoriasis. Discontinue treatment in case of adverse reactions related to long-term use of corticosteroid. Limit or avoid excessive exposure to either natural or artificial sunlight during treatment. Consider risk/benefits balance of the use of topical calcipotriol with ultra-violet radiation. Butylhydroxyanisole (E320) contained in Wynzora Cream may cause local skin reactions (e.g. contact dermatitis) or irritation to the eyes and mucous membranes. Macrogolglycerol hydroxystearate contained in Wynzora Cream may cause skin reactions. Do not smoke or go near naked flames due to the risk of severe burns. Fabric (clothing, bedding, dressings etc) that has been in contact with this product burns more easily and is a serious fire hazard. Washing clothing and bedding may reduce product build-up but not totally remove it. Consult SmPC and package leaflet for more information.

Fertility, pregnancy and lactation: Fertility: No impairment of male and female fertility (animal studies). Pregnancy: No adequate data available. The potential risk for humans is uncertain. Carefully consider benefit/risk balance during pregnancy. Lactation: Exercise caution in breast-feeding women. Do not use Wynzora Cream on the breast when breast-feeding. Consult SmPC and package leaflet for more information.

Adverse Reactions: All reported adverse reactions were seen at a frequency below 1%. Uncommon: Application site reactions including application site irritation, pain, pruritus, eczema, exfoliation, telangiectasia and folliculitis. Rash, urticaria and pruritus. Insomnia. Not known (cannot be estimated from available data):Vision, blurred. Adverse reactions considered to be related to the pharmacological classes of calcipotriol and betamethasone. Calcipotriol: application site reactions, pruritus, skin irritation, burning and stinging sensation, dry skin, erythema, rash, dermatitis, eczema, psoriasis aggravated, photosensitivity and hypersensitivity reactions including very rare cases of angioedema and facial oedema. Very rarely cases of hypercalcaemia or hypercalciuria. Betamethasone (as dipropionate): Skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation and colloid milia. Generalised pustular psoriasis. Systemic reactions are rare in adults, but can be severe. Long-term treatment may cause adrenocortical suppression, cataract, infections, impact on the metabolic control of diabetes mellitus and increase of intraocular pressure. Systemic reaction may occur when applied under occlusion (plastic, skinfolds), on large areas and during long-term treatment. Consult SmPC and package leaflet for further information.

Legal Category: Ireland: POM Subject to prescription which may not be renewed (A). United Kingdom: POM Price: Ireland: Price to wholesaler United Kingdom: UK NHS Cost: £35.66 (excluding VAT). Marketing Authorisation Numbers: Ireland: PA 0968/006/001; United Kingdom: PL 16973/0044 Marketing Authorisation Holder: Almirall, S.A., Ronda General Mitre, 151 08022 Barcelona, Spain Further information available from: Almirall Limited, Harman House, 1 George Street, Uxbridge, Middlesex, UB8 1QQ, UK. Date of First Issue: March 2022 Item code: IE-WYN-2200007

UK-Adverse events should be reported.

Reporting forms and information can be found at MHRA https://yellowcard.mhra.gov.uk Adverse events should also be reported to Almirall Ltd. Tel. 0800 0087 399

IE-Adverse events should be reported.

Reporting forms and information can be found at HPRA Pharmacovigilance, Website: www.hpra.ie. Adverse events should also be reported to Almirall Ltd. Tel. +353 (0) 1431 9836

BDP, betamethasone dipropionate; CAL, calcipotriol.

References: 1. Præstegaard M, et al. SKIN 2020;4(5):s62; 2. WYNZORA® SmPC. Almirall.

Almirallmed.co.uk

IE-WYN-2400007 DOP: March 2024