Practical skills

Holistic assessment is central to the safe and timely care of patients living with skin disease. They will have a range of physical and emotional needs, all of which must be considered in order to provide appropriate intervention and support. These needs are identified through a systematic process, which requires competence in a broad range of skills, some of which are unique to the specialty of dermatology.

There are many potential triggers and risk factors associated with the chronicity of skin disease, including infection, allergy, poor adherence to treatment, and psychological and social concerns. All these considerations are integral to the assessment process and serve to emphasise that holistic intervention goes far beyond the management of cutaneous manifestations.

Nursing role. Dermatology nurses who develop competence in the assessment process must ensure that therapeutic decisions and patient support are based on strong clinical evidence rather than first impressions and personal opinions of the patient’s need. It is therefore necessary to look beyond the presenting complaint and consider wider visual clues within the integumentary system, including the hair, nails and mucous membranes. Other factors associated with skin disease should also be considered, such as the patient’s race/ethnicity and skin colour. This is particularly important when assessing acute inflammation, which may be masked in darker skin leading to the risk of undermanagement and increased morbidity.

Fundamentally, the assessment process involves listening to the patient’s story to establish a strong therapeutic relationship and ensure all relevant supporting evidence relating to the patient’s overall health is elucidated. For many people, alterations in physical appearance can lead to reduced self-esteem, social anxiety, feelings of shame and depression. These emotions may compromise self-care, or lead to economic hardship or substance misuse. It is important to remember that patients’ experiences vary and that a high negative impact does not always correlate with the extent and severity of the skin disease.

Inexperienced nurses may find a patient assessment proforma (Appendix 1) helpful to structure the evaluation. However, as consultation skills develop, the dermatology nurse will be able to take

a more advanced approach to produce a confident accurate assessment with appropriate diagnosis. Other validated assessment tools are available to help grade severity and record the patient’s perceptions, emotions or patterns of behaviour (Table 2.1).

Clinical findings should be communicated and documented using accurate terminology. Similarly, patient information and support should take account of a diverse range of health literacy needs and regional variations in service provision.

Once the assessment process is complete a plan of care can be devised. It is important that this is shared with all members of the patient’s healthcare team for delivery of appropriate holistic care in a wide range of environments by all care givers, including non-specialist practitioners and informal carers.

As outlined in Table 2.2, the roles and responsibilities of dermatology nurses in the assessment process increase by band, with each band building on the skills outlined in the previous band.

TABLE 2.1

Itch and pain Visual analogue scale Impact on quality of life Dermatology Life Quality Index (DLQI) Depression Patient Health Questionnaire (PHQ-9) Hospital Anxiety Depression Scale (HADS)

Anxiety Generalised Anxiety Disorder (GAD-7) assessment Hospital Anxiety Depression Scale (HADS)

Excessive alcohol consumption

Alcohol Use Disorders Identification Test (AUDIT) Suicidal ideation Question the patient directly if evidence suggests this may be necessary. Ascertain whether they have considered suicide and if so whether they have made any plans to carry it out1,2

TABLE 2.2

5 • Uses a proforma to identify health needs • Plans nursing care for common skin diseases such as eczema, psoriasis, acne and infection • Uses validated assessment tools to establish disease severity, comorbidity and impact on quality of life (see Table 2.1) • Uses appropriate terminology to describe cutaneous features • Evaluates nursing care and escalates concerns to colleagues • Provides health promotion using standard literature and patient support • Refers patients for onward care (e.g. district nursing or IAPT) • Recognises the potential psychological concerns associated with skin disease • Promotes the use of patient support groups, self-help and mindfulness resources 6 • Identifies health needs, including mood • Plans nursing care for a wide range of skin diseases • Uses a wide range of assessment tools to establish disease severity, comorbidities and the impact of skin disease on quality of life and mental health wellbeing • Evaluates nursing care and communicates patient health needs to a wide range of care agencies • Actively promotes health to a defined patient cohort 7 • Autonomously assesses patient care and treatment needs • May diagnose skin disease for a defined patient cohort • Prescribes treatments as appropriate • Liaises with a wide range of agencies to meet ongoing care 8 • Autonomously assesses and diagnoses skin disease for a wide range of patients with complex health needs • Prescribes treatments for above patient cohort

*Each band builds on the skills outlined in the previous band. IAPT, improving access to psychological therapies.

Core knowledge domains. Registered nurses are responsible for evaluating, planning and implementing healthcare for a diverse population with a wide spectrum of clinical needs. They must have an established core knowledge of therapeutic communication and the legalities of clinical documentation and professional accountability.3 They must embrace diversity, uphold dignity and observe standard operating procedures (SOP) and clinical guidelines that govern policies on patient care in specific clinical areas. In a dermatological context, knowledge is focused on understanding the underlying biological, social and psychological factors that affect patients with skin conditions and how these influence the individual’s experience.

A variety of investigations can be used in clinical settings to confirm a diagnosis or identify exacerbating factors (Table 2.3). Some of these investigations fall beyond the scope of this chapter and are considered in more detail within the context of the relevant sections later in the book. It is important to note that specialist investigations such as dermoscopy and minor surgery should not be undertaken without formal training or postgraduate qualifications. Table 2.4 outlines the roles and responsibilities of dermatology nurses (by band) in completing investigations.

Investigating infection. Swabs and scrapings should be obtained when bacterial, viral or fungal infections are suspected. A tool similar to a cotton bud is used for swabs. Viral swabs contain a liquid transport medium to preserve the specimen, while bacterial swabs often contain a charcoal gel. It is therefore important to use the correct swab for the specified laboratory test. To collect the specimen, the tip of the swab is rubbed and rotated over the suspect area. This should be completed in accordance with local policy.

Skin scrapings are obtained using the blunt edge of a scalpel to collect loose skin scales. Samples should be taken from the edge of the lesion where a higher yield of active microorganisms can be retrieved.

Nursing role. Investigations used to identify infection are frequently initiated by dermatology nurses. They must therefore be familiar with the clinical features of bacterial, viral and fungal dermatoses and the respective sample collection techniques (swabs

TABLE 2.3

Bacterial swab (MC & S) To confirm candida and bacterial infection and treatment sensitivities Viral swab (PCR) To confirm viral infections such as herpes simplex and varicella zoster Fungal scraping To confirm dermatophyte infection and treatment sensitivities Blood tests To identify inflammation, systemic disease and infection, and monitor the effects of systemic medication Wood’s light To confirm vitiligo and fungal infections Biopsy (punch or ellipse excision) For histological diagnosis Dermoscopy For diagnosis of lesions To identify scabies mites Patch testing To identify type 4 allergic contact sensitivity Prick testing To identify type 1 allergens

MC & S, microscopy, culture and sensitivity; PCR, polymerase chain reaction.

and scrapings) to ensure samples are collected and sent for testing in the appropriate manner. Samples should be obtained within optimal timeframes to ensure that organisms remain viable for culture. It is vital that the correct collection techniques are used to obtain sufficient sample size and quality, while vigilant documentation and labelling will avoid rejection of samples. Storage and despatch of samples must be completed in line with standard protocols.

Timely implementation can help direct swift therapeutic intervention to alleviate symptoms and distress. The benefit of gaining diagnostic evidence not only supports patient care but also serves to limit public health concerns about antimicrobial resistance and overprescribing of antibiotics. Results must be shared with relevant colleagues and the patient to ensure that therapeutic interventions are considered. Nurses with diagnostic and prescribing qualifications will have the skills to interpret the results of many investigations and initiate appropriate treatments.

TABLE 2.4

5 • Recognises the clinical signs of cutaneous infections • Collects optimal samples (swabs, scrapings) when requested • Completes supporting documentation in line with policy • Identifies routine results and ensures that colleagues and patients are informed • Implements infection control precautions 6 • Recognises the clinical signs of a wide range of cutaneous infections • Requests and collects optimal samples (swabs, scrapings) • Interprets results of infection screens • Implements clinical decisions for the management of infection using a PGD • Identifies and communicates results to colleagues and patients 7 • Recognises the clinical signs of a range of systemic concerns • Requests a wide range of investigations (e.g. blood tests, radiology) • Interprets a wide range of results • Adjusts the patient’s management plan appropriately • Liaises with colleagues to request more complex investigations • Informs patients of results and provides appropriate counselling 8 • As above, with focus on more complex systemic concerns and investigations • Liaises with specialist MDT to request more complex/ specialist investigations

PGD, patient group direction.

Core knowledge domains. Dermatology nurses are responsible for completing standard clinical investigations that fall within their scope of competence and responding appropriately to results. To do this effectively, an understanding of the different infective processes should underpin knowledge of safe sample collection. Dermatology nurses should also have the appropriate level of knowledge within their banding to take relevant actions in accordance with the results of the investigations.

Patch testing. Allergy tests are used to evaluate type 1 (immediate) or type 4 (delayed) hypersensitivity reactions. Patch testing is used to evaluate allergic contact dermatitis (ACD), a delayed type 4 immune response triggered by a chemical penetrating the skin’s epidermis. Precipitating chemicals, which are formally described as ‘haptens’, may be found in a wide range of common household products, cosmetics, topical therapeutics, clothing and metals.

It is estimated that 27% of adults in Europe have a type 4 allergy to one or more of the most common sensitisers used in patch test clinics,4 and people with atopic dermatitis are more susceptible to this risk than the general population. The consequences of allergy can be devastating, limiting occupational opportunities and negatively affecting the individual’s physical and psychological wellbeing.5 Dermatology nurses must therefore be mindful of the potential for ACD, particularly in the event of persistent symptoms or treatment failure.

Identifying the precipitating trigger is not always straightforward and requires careful consideration of the patient’s lifestyle and occupation to establish the range of potential sensitising agents. Patch testing is carried out to establish the causative agent(s). Suspect chemicals are applied onto small discs that are secured to the patient’s back by strips of tape (Figure 2.1). These are left in place on unaffected clear skin for 48 hours to provoke a reaction, which reveals culprit allergens.

The outcomes of patch testing vary (Table 2.5). • No response: no changes in the skin. • An irritant response, demonstrating an irritant rather than allergic reaction. • An allergic response, which typically manifests as well-defined, itchy, eczematous patches.

Figure 2.1 Patch testing.

TABLE 2.5

?/+ Doubtful reaction, faint erythema only + Weak positive reaction, erythema, infiltration and/or papules ++ Strong positive reaction, erythema, infiltration, papules, vesicles +++ Extreme positive reaction, intense erythema, infiltration and vesicles

–

Negative reaction IR Irritant reaction NT Not tested

Nursing role. The inflammatory appearance of ACD is in many ways like other eczematous skin manifestations, including irritant contact dermatitis. There are, however, classical features and associated risk factors that should enable the dermatology nurse to differentiate between these conditions and identify patients with an increased propensity for allergy. This ensures that patch testing is requested appropriately.

Knowing the classical features of ACD and the common sensitising agents and how they can be avoided will enable the dermatology nurse to help patients manage their skin condition and prevent relapse of their symptoms. Nursing input within the patch test clinic will vary considerably from supportive practical involvement with the application of patches to the identification of relevant allergens and ongoing management through advice on avoidance, as well as counselling against risk (Table 2.6).

Core knowledge domains. All nurses working in a patch testing service should have an underlying knowledge of the immunology relating to cutaneous allergy to support their assessment and care of patients. Dermatology nurses working with greater levels of autonomy will develop competence to assess exposure to, and diagnose, allergens. They will be familiar with the range of available test batteries and understand the implications of positive results.

TABLE 2.6

5 • Alerts senior staff to the possibility that a patient might need patch tests • Completes patch test application under supervision, and informs the patient what to expect • Uses standardised information to help patients avoid allergens • Uses PGD to support the management of adverse reactions within the clinic

CONTINUED

TABLE 2.6 CONTINUED

6 • Identifies and refers patients with suspected allergy for patch testing • Organises the running of the patch test clinic, adhering to best practice guidance • May support the assessment process using a proforma to identify potential sensitisers • Supports senior staff with the grading of patch test results • Counsels patients on measures to avoid common allergens • Uses PGD or, working as an independent prescriber, prescribes treatment to manage adverse reactions • Communicates results of investigations to other staff as required 7 • Oversees the organisation and running of the patch test clinic • Assesses patients to identify potential allergens • Grades results and diagnoses allergens • Counsels and supports patients to avoid a wide range of allergens • Prescribes treatment to manage adverse reactions and limit the effects of allergy • Communicates the results of investigations to the MDT 8 • May be the lead clinician in the patch test clinic • Assesses complex cases to identify potential allergens • Prescribes systemic treatment to limit the effects of allergy • Liaises with a wide range of MDT members to request further specialist interventions • Completes surveillance data to ensure emergence of new allergens is recorded

PGD, patient group direction.

Patients require practical guidance to help them avoid exposure to allergens. It is important to be aware that counselling patients on how best to avoid allergens may require lifestyle adjustments and may affect the patient’s employment choices. A best practice guide to patch testing is available from the BDNG to support individual nursing practice and provide a framework for competence.6

Prick testing is used to evaluate type 1 hypersensitivity reactions, which result in rapid development of symptoms such as rhinoconjunctivitis, asthma and urticaria. Allergens responsible may include food, drugs or pollens. Allergen extracts are dropped onto the surface of the skin, which is then gently broken using a small lancet. Positive reactions lead to the release of histamine and the development of a ‘wheal and flare’. Severe type 1 hypersensitivity reactions may result in anaphylaxis.

Despite the advent and rapidly increasing range of systemic therapies, topical agents are still the fundamental first-line treatment for chronic inflammatory skin disease.

Nursing role. All dermatology nurses, regardless of the level they work at, should be able to instruct patients in the correct application of topical therapies. Table 2.7 outlines the expectations of knowledge required at each band.

Core knowledge domains. Knowledge of anatomical structures and immunological pathways must underpin these skills to support the understanding of pharmacological mechanisms, including absorption, distribution and side-effect profiles. Novel treatments continue to be developed and nurses must keep up to date with extending formulary options.

Patients’ adherence to topical treatments is often suboptimal for a wide range of complex reasons. Dermatology nurses must be able to recognise these in order to target support and education appropriately.7 An appreciation of the significant lifestyle adjustments that are required to sustain effective topical treatment regimens is essential.

TABLE 2.7

5 • Applies topical medication effectively as directed/ prescribed • Promotes adherence through education and support • Identifies adverse events and safety concerns • Alerts colleagues to treatment failure • Supports the education of junior colleagues on topical therapeutics 6 • As above, plus: • Uses a wide range of strategies to promote adherence • Monitors treatment response • Supports the education of peers on topical therapeutics 7 • May prescribe topical therapeutics for a defined range of skin conditions • Provides patients with in-depth explanation of topical agents’ mode of action and potential adverse events • Reviews and develops the local formulary • Provides education to the wider MDT • Disseminates and implements MHRA safety guidance 8 • Prescribes a wide range of topical therapeutics for complex skin conditions • Leads the development of specialist formularies • Manages the prescribing budget • Leads research/audit into prescribing data • Develops medicines management policies (e.g. to promote adherence)

MHRA, Medicines and Healthcare products Regulatory Agency.

Specialist nurses can empower patients to optimise the management of their skin conditions by explaining effective application techniques, including frequency and quantities of topical products required for the affected area. General considerations that promote medicines’ optimisation are identified in national guidelines8 and quality statements within these guidelines should be explored.

Learning the practical skills that are so fundamental to dermatological nursing will often start in the workplace via demonstration and explanation by more senior staff. This clinical exposure is vital and should always be supported by a clearly articulated system of clinical governance with mentorship and support readily available. The development of new skills should be monitored by assessment processes to ensure competence and patient safety.

The learning of new skills can be consolidated with more formal learning. The most suitable type of formal learning will depend on the topic, job role, previous experience and level of competence. Those wanting to underpin practical experience with knowledge of specific skills or conditions will find the BDNG’s online resources, regional study days and annual conference helpful; other useful resources, for example on patch testing technique and interpretation, are provided by elearning for healthcare (elfh) and other providers (Table 2.8). Career pathways that involve studying at Masters level (for example, for bands 7 and 8) require academic university-based education.

Nurses with roles in subspecialist areas may not need to develop and maintain all the practical skills identified within this chapter. However, as outlined in Chapter 1, it is recommended that all dermatology nurses gain competence in a broad range of dermatological treatments to support patients at all stages of their journey through dermatology services.

When planning career development, it is important to find a mentor who will provide support in the workplace. External support can also be helpful: for example, by visiting other departments to gain insights into a variety of care and patient pathways.

TABLE 2.8

BDNG e-learning (members only): www.edu.bdng.org.uk/courses • Fundamentals: Skin anatomy and physiology; Skin assessment;

Terminology of skin disease • Dermatological conditions: Atopic eczema; Psoriasis • Practical skills: Collecting swabs; Emollients; Topical corticosteroids;

Paste bandaging • Advancing practice: Atopic dermatitis; Psoriasis; Photodynamic therapy • Webinars: The practical management of psoriasis • Other: Case studies; Infections and infestations; Skin surgery;

Understanding and interpreting blood test results – systemic drug monitoring; The patient perspective on treatment BDNG events: www.bdng.org.uk • Annual conference • In-person and on-demand meetings • Regional study days • Webinars Other online resources and study days • BMJ Learning: https://new-learning.bmj.com* – Various dermatology modules • elfh: https://portal.e-lfh.org.uk* – Modules on skin disease and less common cutaneous infections – Other examples: Communication skills; Patch testing technique and interpretation; Psychosocial assessment in dermatology practice; Topical corticosteroids and appropriate use in dermatology • St John’s Derm Academy: www.stjohnsdermacademy.com/upcomingevents – Various courses/study days including Clinical dermatology care course for nurses and allied health professionals

CONTINUED

TABLE 2.8 CONTINUED

Academic courses • University of Hertfordshire: www.herts.ac.uk/courses – MSc Clinical dermatology; MSc Skin lesions management; MSc Skin integrity and wound management • Other widely available university courses – Advanced history taking and assessment skills; Independent and supplementary prescribing – PGDip/MSc Advanced clinical practice

*Available via Open Athens.

As well as providing access to educational resources, the BDNG can help dermatology nurses to reach out to others for advice. The BDNG role descriptors provide guidance on the educational input needed to move through the different bands (see page 12).9

• Assessment skills take years to develop. Be systematic in your approach, do not jump to conclusions and consider all potential concerns. • To develop your practical assessment skills, arrange opportunities for clinical supervision from colleagues. • Listen and learn from your patients’ experiences. Their perceptions are central to your clinical development. • Share your knowledge by supporting clinical teaching for students, peers and the wider healthcare team. • Consider your professional goals and identify the steps you need to take to achieve them.

1. National Institute for Health and Care Excellence. Scenario:

Acute Management of a Person at Risk of Self-Harm. National

Institute for Health and Care

Excellence, 2020. https:// cks.nice.org.uk/topics/selfharm/management/acutemanagement-of-a-person-atrisk-of-self-harm, last accessed 1 June 2022. 2. Skin Support Psychodermatology.

The Psychosocial Aspects of Skin

Conditions. Skin Support. www.skinsupport.org.uk/ content/psychodermatology, last accessed 1 June 2022. 3. Nursing and Midwifery Council.

The Code. Professional Standards of Practice and Behaviour for

Nurses, Midwives and Nursing

Associates. Nursing and

Midwifery Council, 2018. www.nmc.org.uk/code, last accessed 6 January 2022. 4. Mortz CG, Lauritsen JM,

Bindslev-Jensen C et al.

Prevalence of atopic dermatitis, asthma, allergic rhinitis, and hand and contact dermatitis in adolescents. The Odense

Adolescence Cohort Study on

Atopic Diseases and Dermatitis.

Br J Dermatol 2001;144:523–32. 5. Allergy UK. Not Just Skin Deep –

Getting Under the Skin of Eczema.

Allergy UK, Sanofi, 2021. www.allergyuk.org/wp-content/ uploads/2021/11/Not-Just-Skin-

Deep-min-compressed.pdf, last accessed 29 December 2021. 6. British Dermatological

Nursing Group. Patch Testing:

A Best Practice Guide. British

Dermatological Nursing Group, 2016. www.bdng.org.uk/ wp-content/uploads/2017/02/

FINAL130117.pdf, last accessed 20 June 2021. 7. National Institute for Health and Care Excellence. Medicines

Adherence. Involving Patients in Decisions about Prescribed

Medicines and Supporting

Adherence. National Institute for Health and Care Excellence, 2009. www.nice.org.uk/ guidance/cg76/chapter/ 1-Guidance, last accessed 5 January 2022. 8. National Institute for Health and Care Excellence. Medicines

Optimisation. National Institute for Health and Care Excellence, 2016. www.nice.org.uk/ guidance/qs120, last accessed 5 January 2022. 9. British Association of

Dermatologists Education

Board. Clinical Dermatology

Nursing Role Descriptors:

Guidance on Scope of Practice.

British Dermatological Nursing

Group, British Association of Dermatologists and Royal

College of Nursing, 2020. bdng.org.uk/wp-content/ uploads/2020/08/BAD-

BDNG-RCN-NURSING-

WORKSTREAM-A4-

LANDSCAPE-002.pdf, last accessed 20 June 2021.

All Party Parliamentary Group On Skin. Mental Health and Skin Disease. All Party Parliamentary Group on Skin, 2020. www.appgs.co.uk/ publication/mental-health-andskin-disease-2020, last accessed 12 July 2022. British Association of Dermatologists. Service Guidance and Standards for Cutaneous Allergy Investigations. British Association of Dermatologists, 2019. https://cdn.bad.org.uk/uploads/ 2021/12/29200202/CutaneousAllergy-Service-Guidance-andStandards-20192-1.pdf, last accessed 12 July 2022. British Association of Dermatologists. Specialty Training Curriculum for Post-CCT Fellowship in Cutaneous Allergy V2. British Association of Dermatologists, 2022. https://cdn.bad.org.uk/uploads/ 2022/05/06105020/CutaneousAllergy-Curriculum-Apr-2022.pdf, last accessed 12 July 2022. DermNet NZ. Principles of Dermatological Practice. Examination of the Skin. DermNet NZ, 2008. www.dermnetnz.org/cme/principles/ examination-of-the-skin, last accessed 6 January 2022. DermNet NZ. The Mind and the Skin. DermNetNZ. www.dermnetnz.org/ topics/the-mind-and-the-skin, last accessed 6 January 2022. Oakley A. Principles of Dermatological Practice [Course]. DermNet NZ, 2008. www.dermnetnz.org/cme/principles, last accessed 11 April 2022. Primary Care Commissioning. Quality Standards for Teledermatology using ‘Store and Forward’ Images. Primary Care Commissioning, 2021. https://sad.org.ar/wp-content/ uploads/2020/12/TeledermatologyQuality-Standards.pdf, last accessed 12 July 2022. Royal Pharmaceutical Society. The Competency Framework for all Prescribers. Royal Pharmaceutical Society, 2021. www.rpharms. com/resources/frameworks/ prescribing-competency-framework/ competency-framework#assess, last accessed 6 January 2022. Schofield J, Grindlay D, Williams H. Skin Conditions in the UK: A Health Care Needs Assessment. Centre of Evidence Based Dermatology, University of Nottingham, 2009. www.nottingham.ac.uk/ research/groups/cebd/documents/ hcnaskinconditionsuk2009.pdf, last accessed 11 April 2022.