Paediatric dermatological nursing

Paediatric dermatological nursing is a highly specialised field that involves working with newborns to teenagers with a variety of skin conditions. These may range from mild and common presentations through to potentially fatal or life-limiting genetic abnormalities. There are certain dermatological conditions that are only seen in children; some have minimal impact, while some are so life-limiting that the affected child may not reach adulthood.

Paediatric dermatology is progressively being recognised as a specialty in its own right, and the role of the specialist nurse in this field is both rewarding and challenging. Until recently, a major issue has been that such a specific area of nursing attracted limited interest or recognition. However, increased research and understanding of skin disease in children, combined with developments in treatment options, awareness of physical comorbidities and a greater understanding of the benefits of earlier intervention, mean that this highly specialised field has become an exciting area in which to develop an interest.

Nursing role

Paediatric dermatological nursing is a unique branch of dermatology that allows the nurse not only to develop their own particular area of interest and expertise but also to expand their role to include teaching, treatment planning, liaison and prescribing.

The nursing approach to a chronic skin condition that is initially identified in a newborn or child is very different from that required when an adult is diagnosed with the same disease. It is important to remember that children are not mini adults and that the nurse’s parental experience does not count as paediatric experience. The nurse working mainly or exclusively with children should have a qualification in paediatric nursing. It is crucial for all nurses working with children to appreciate the impact of early attachment and understand the importance of play and security, as well as physical issues such as developmental milestones, drug metabolism and nutritional needs. All nursing staff, even those with limited contact with children, must be able to identify, and know how to raise, any safeguarding concerns. They should have access to a qualified paediatric nurse, a paediatrician and a designated safeguarding lead who can provide support and supervision, as necessary.

When working in paediatric dermatology, it is crucial to see past the skin manifestation of the diagnosis. There have been times when long-term issues, such as global developmental delay, autistic spectrum disorder and degenerative disorders, have been identified in the dermatology clinic through observing and handling the child as part of a skin examination. The nurse may identify times when the skin manifestation is the least of the concerns, such as by recognising a rash or lesion as an indication of a more serious issue that may require prompt medical intervention. Paediatric dermatology nurses should also be aware that children can deteriorate very quickly, but equally can recover with remarkable resilience.

Training. Traditionally, nurses who work within dermatology have a mixed caseload of children and adults but, in the past, often only had qualifications in general nursing. In 2010, the Kennedy Report identified that healthcare professionals working with children should have appropriate training in the development and management of children and young people to ensure that their holistic and developmental needs are recognised.1,2 As nurse training evolves and the seminal recommendations of the Clothier Report are met,3 it is likely that an increasing number of nurses working in this field will have Paediatric Nursing as their primary qualification.

Training requirements will vary, depending on the caseload and level of contact with children. For example, the dermatology nurse working in phototherapy or patch testing primarily treats adults and will have limited contact with children and therefore does not require paediatric nurse training. However, those working in areas of dermatology where regular contact with children is likely should consider a relevant child development course as a minimum requirement. Certain universities offer modules that give an overview of paediatrics, including childhood surveillance, communication, and the physical and emotional development of children.

Scope of practice. Across the UK, there are significant banding variations depending on the responsibility of the nurse. There are several children’s hospitals with inpatient beds for paediatric dermatology that are primarily staffed with nurses working at bands 5 to 7. However, most nurses working in paediatric dermatology have

specialised roles: a band 6 nurse may advise and oversee treatment for a specific group of patients, such as teenagers with acne or children with eczema. Band 7 nurses work more independently and have a greater degree of autonomy, often prescribing medications, requesting and interpreting investigations, overseeing nurse-led clinics and undertaking skin biopsies. The band 7 nurse will also take responsibility for instigating and monitoring patient treatments while supervising junior colleagues, and will consult with the medical team as indicated. Band 8 nurses often have a more managerial role or a greater degree of autonomy, diagnosing and managing more complex skin conditions while still advising and supervising other healthcare professionals.

Nevertheless, there are significant regional variations in banding, with anecdotal evidence of some band 7 posts requiring both an MSc and a qualification as an independent prescriber, while nurses with similar or fewer responsibilities and qualifications in different regions are awarded a band 8. Paediatric dermatology is an area in which the appropriately trained nurse can develop their interest and role, taking on increasing responsibility within their level of competence.

The BDNG role descriptors (see page 12) provide useful guidance in this respect,4 but in practice there does appear to be considerable variation, possibly because paediatric dermatological nursing is such an unusual and specialised field.

The patient care setting

Nurses who choose to work in paediatric dermatology can either specialise in more complex conditions, such as epidermolysis bullosa, vascular malformations or xeroderma pigmentosa, within a tertiary paediatric dermatology unit, or work with more common conditions, such as eczema, psoriasis and acne, often in the dermatology departments of district general hospitals. As there are very few hospitals with paediatric dermatology wards, most children requiring inpatient dermatological care are nursed on general paediatric wards. However, the aim is to manage paediatric dermatology on an outpatient basis as much as possible.

The clinical setting is important, particularly for face-to-face consultations. Children should be seen in clinic rooms where appropriate toys and play areas are available. Ideally, no painful

procedures, such as blood tests, should be undertaken in the ‘safe’ clinic room. Investigations that may cause distress should be carried out in a separate environment where play therapists are available to help with distraction techniques.

The nurse working with children must be aware that they are communicating not only with the child (patient) but also the parents and other family members. Cultural issues must also be acknowledged. In many societies, the father will bring the child to the appointment, but the mother may be the person administering treatment. Language may be a barrier and it is important to be sensitive to varying attitudes to gender, exposure of skin and the use of herbal or local treatments. At times it may be appropriate and beneficial for the nurse to visit the child in the home, school or nursery setting.

Benefits of independent nurse prescribing

Depending on the skin condition, the paediatric dermatology nurse may not only diagnose and provide counselling and education, but also prescribe short- and long-term medications. Awareness must be given to the complex and unique physical needs of children and how they respond to medications, whether systemic or topical. The nurse prescriber must feel safe and confident in recommending the required medications and only provide treatment within their realm of competence and expertise.2

Many nurses work alongside dermatologists and paediatricians to ensure that the holistic needs of the child are met. Extensive research has been conducted into the scope of independent prescribing, and dermatology has been shown to be an ideal area for such a qualification.5 Being an independent prescriber enables the development of ‘condition-based’ nurse-led clinics, such as those for acne and eczema, as well as more generalised paediatric dermatology nurse-led clinics.

The nurse prescriber can provide a holistic service by using their own clinical judgement on the medication required, prescribing it within the clinic, home or school setting, and then monitoring the efficacy of the treatment, thus improving the service offered for children and their families. Nurse-led clinics are cost-effective alternatives to the more traditional doctor-led appointments and

can free up valuable clinic slots for the more complex or unusual conditions that require medical expertise.

Nurse prescribing for children with atopic eczema. Many conditions in paediatric dermatology can be managed primarily by the dermatology nurse, eczema being a typical example.

There is much confusion and anxiety surrounding eczema treatments and so management can be both challenging and rewarding for the dermatology nurse. Although eczema management primarily involves regular application of emollients and appropriate use of topical steroids,6 parents are often exposed to conflicting and incorrect information. Topical steroids are among the most prescribed medications in dermatology, yet primary care providers are often reluctant to prescribe appropriate quantities, especially in children.7,8 This, coupled with sometimes confusing information on the internet, can increase parental anxiety and frustration regarding the management of the condition. As a result, parents are often found to be manipulating their child’s diet and purchasing alternative and expensive creams to avoid using steroids on their child’s skin.

The nurse prescriber overseeing the management of children with eczema can provide appropriate education and treatment (Figure 7.1), dispel confusion, provide realistic expectations of outcomes and protect the child from potentially harmful practices. Parents may feel more able to discuss their anxieties and opinions with a dermatology nurse, who in turn can offer sensible advice and reassurance, particularly regarding the use of topical steroids and allergy tests.

Many cases of paediatric eczema can be managed primarily by the specialist nurse, particularly if the nurse is an independent prescriber. The nurse can ensure that correct quantities of treatment are prescribed and then modified as the condition evolves. Within the secondary care setting, it has been shown that a single consultation with a specialist nurse can result in greater understanding of the treatment regimens and fewer follow-up appointments with the dermatologist, freeing up valuable clinic slots.9

When a child has eczema, household expenses are likely to increase because of extra laundry, the cost of cotton clothing and transport to

Use the adult finger-tip unit as your guide

One adult finger-tip unit Finger-tip measurements 1 finger-tip length = 0.5 g 2 finger-tip lengths = 1 g

1 pump unit = 1 g

Topical steroids: single application requirements in a child aged 4 years

One arm 0.5 g 0.5 g Face and neck

Trunk (front and back) 2.0 g

One leg 1.0 g 1.0 g Hands and feet

Figure 7.1 A guide to applying the correct amount of topical steroid to a 4-year-old child. Reproduced with permission from Long CC and Finlay A, 1991.7

hospital appointments. There are also employment implications for parents who regularly have disturbed nights and need to spend extra time caring for their child’s skin. Dermatology nurses can demonstrate practical techniques and application of medications and bandages, which improves adherence. Providing appropriate intervention and treatment that results in the child sleeping through the night or

being prepared to wear shorts and summer tops, offers immense job satisfaction for the nurse.

Paediatric dermatology is an area in which the nurse can make a visible difference, improve the long-term prognosis, develop a sense of autonomy and steer or expand the service to meet the needs of hospital caseloads and the community.

Communicating with children

Communication must be appropriate to the age and development of the child and their ability to understand. Awareness of the different stages of development from infancy to young adulthood and how to communicate with children and families of varying backgrounds are as crucial to clinical practice as a knowledge of dermatology.

Children’s concept of illness and treatment varies significantly depending on age, and their perceptions may be completely different from those of their parents or carers. Obviously, infants and toddlers need their parents or carers to report changes and issues. Young children often express their concerns through play, while adolescents may communicate specific needs and anxieties about their skin. The nurse must also know how to communicate with children who have complex or developmental issues, including the non-verbal child.

Challenging topics. Certain skin conditions can be related to smoking, alcohol or obesity. These factors can be challenging to discuss with teenagers and sometimes younger children.

Isotretinoin, a retinoid used to treat severe acne, can cause developmental abnormalities in the foetus. Female patients of childbearing age who are being treated with isotretinoin must therefore comply with the pregnancy prevention programme. Discussing the importance of contraception and avoiding pregnancy with girls in their early teens can be challenging, as issues such as under-age sexual activity and confidentiality must be considered. Gillick competency and the Fraser guidelines are in place to help healthcare professionals balance the need to listen to the child’s wishes with the responsibility of keeping them safe (Box 7.1).10

BOX 7.1

Definitions

Gillick competency. A child under 16 can make their own decisions related to consent or refusal of medical treatment if they are deemed to understand the implications. Fraser guidelines. As above but specifically related to the young person’s decisions on contraception, sexual health and the right to confidentiality.

Recognising individual needs. When communicating with children it is important to consider not just their age and stage of development but also their specific needs. This may involve helping a young person with sensory issues to select an emollient of an acceptable texture, reassuring a child about phototherapy, offering treatment options for alopecia, or supporting a teenager who avoids socialising because of severe acne. At times it may be appropriate to directly discuss potential issues so that the child realises their concerns are not unusual or abnormal. However, at other times discretion may be required to avoid embarrassment.

In children presenting with unusual skin manifestations that indicate dermatitis artefacta (skin lesions produced by the patient’s own actions), the nurse should consider the possibility that the child is self-harming as a way of expressing an underlying stress or anxiety. Equally, what may have started as a classroom dare or social media challenge could have escalated out of the child’s control, and they need an ‘escape route’ to avoid being in trouble with their parents. Tact and sensitivity are required in recognising complex issues that teenagers may not wish to discuss with their parents or guardians present.

Safeguarding

Safeguarding responsibilities are paramount for all practitioners working with children. The dermatology nurse with children on their caseload should have regular safeguarding training to level 3. Within

paediatric dermatology, many skin conditions may look similar to physical abuse, and vice versa.11 Physical abuse in children over 2 years old usually manifests as skin lesions, be it bruising, lacerations, scalds, bites or burns. It is important that the nurse gains skills in recognising and differentiating these from dermatological conditions such as congenital dermal melanocytosis (Mongolian blue spots) (Figure 7.2), lichen sclerosus or vascular anomalies. Equally, the nurse has a responsibility to identify when presentations of conditions, such as untreated head lice or nappy rash, could indicate neglect or certainly non-adhererence with treatments.

Liaising with other practitioners, such as the school nurse or health visitor, is important. Serious case reviews have frequently recognised that voicing concerns to colleagues is crucial, and the Laming Report into safeguarding identified that the safety of the child should always override concerns about confidentiality.12 The nurse has a duty to voice and report concerns of suspected abuse or neglect to the relevant agencies, be it Social Services or the Trust’s safeguarding officers.

(a) (b)

Figure 7.2 Congenital dermal melanocytosis (Mongolian blue spots) predominantly affects children of African and Asian descent. The birthmarks (naevi) appear as pigmented patches of skin that can resemble bruising. Reproduced under Creative Commons licence CC BY 4.0.

Teamwork

Teamwork and interagency working are crucial elements of the dermatology nurse’s role, especially for children with chronic or lifelong conditions such as occulocutaneous albinism or epidermolysis bullosa. The dermatology nurse is an essential part of a team of professionals that include dermatologists, paediatricians, dieticians, psychologists, allergists, health visitors, school nurses and primary care providers, all focused on the best possible outcome, both physically and emotionally, for the child and their family.

The dermatology nurse plays an essential role in liaising with other professionals to ensure that the child’s developmental and educational needs are met. Part of the nurse’s role may include school visits to provide education and support to classroom staff, identify potential issues and advise on the management and adaptations that may be required for integration of a child with a complex skin disorder.

The dermatology nurse will also need to work closely with other agencies and services to ensure that the transition of adolescents to adult services is well supported.

Courses and training

Training and experience are essential, not only in dermatology but also in child development and paediatric issues. While some nurses may already have a qualification in paediatric nursing and choose to specialise in dermatology, many dermatology nurses who have a qualification in adult nursing find that their job evolves to include a paediatric caseload. Each nurse’s educational and training needs for the provision of appropriate and holistic paediatric care will therefore vary significantly.

An increasing number of courses that focus on paediatric development are now available. Standalone modules that can be utilised towards an undergraduate or postgraduate degree are also available. Useful information on paediatric-specific professional development and paediatric dermatology education can be found

from the following sources (see also Further reading and resources, page 119, for website addresses): • BDNG • elfh • patient support groups (for example,

DEBRA/National Eczema Society) • Royal College of Nursing • drug manufacturing companies. The above offer a variety of education on both general and paediatric dermatology. The elfh website has a range of topics from neonatal rashes and infantile haemangiomas through to lymphatic disorders and paediatric psoriasis.

Many hospitals run study days on paediatric dermatology that may be appropriate for nurses working at band 5 or 6, particularly with a mixed caseload of ages and conditions. However, more experienced or specialist nurses need to access training that is primarily aimed at medical practitioners or seek the support of other such nurses. In the highly specialised and unique field of paediatric dermatology it is often more challenging to find relevant courses and study days, as there may be limited demand.

The BDNG has a subgroup for paediatric dermatology nurses, offering contact, support and training. The importance of networking and peer support must not be underestimated, and many nurses initially gain experience and training in the field of paediatric dermatology from other nurses working in this area. There are so few nurses attracted to the specialty that advice, support and placements are often available on an informal basis from experienced nurses in this field who are usually more than happy to share their knowledge and skills.

Key points – paediatric dermatological nursing

• As well as developing knowledge and experience in skin conditions that affect children and adolescents, paediatric dermatological nursing offers opportunities for teaching, treatment planning, liaison and prescribing. • Paediatric dermatology nurses can choose to specialise in complex conditions in tertiary paediatric dermatology units, or work with patients with more common conditions in dermatology departments of district general hospitals. • Although there are regional variations in banding for paediatric dermatology nurses, band 6 nurses are likely to advise on and oversee treatment, while band 7 nurses are likely to prescribe medication, request relevant investigations, take skin biopsies and run nurse-led clinics.

Band 8 nurses are likely to diagnose and manage a wide variety of skin conditions and supervise more junior colleagues. • Nurse-led clinics have an opportunity to provide a holistic service, including prescribing and monitoring treatment, demonstrating practical techniques such as the application of medications and bandages, and providing appropriate education and support for parents who may be anxious about their child’s treatment regimen. • Communication must be appropriate to the child’s age, stage of development and ability to understand, as well as their individual needs. • The paediatric dermatology nurse should be able to differentiate between dermatological conditions and manifestations of physical abuse, but also recognise signs of neglect, including non-adherence to treatments.

References and resources

1. Kennedy I. Getting It Right for Children and Young People.

Overcoming Cultural Barriers in the NHS so as to Meet Their

Needs. HMSO, 2010. www.gov. uk/government/publications/ getting-it-right-for-childrenand-young-people-overcomingcultural-barriers-in-the-nhs-soas-to-meet-their-needs 2. Nursing & Midwifery Council.

The Code. Professional Standards of Practice and Behaviour for

Nurses, Midwives and Nursing

Associates. Nursing & Midwifery

Council, 2018. www.nmc.org. uk/standards/code 3. Clothier C. Report of the

Independent Inquiry Relating to Deaths and Injuries on the

Children's Ward at Grantham and Kesteven Hospital during the period February to April 1991.

HMSO, 1994. 4. 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. www. bdng.org.uk/wp-content/ uploads/2020/08/BAD-BDNG-

RCN-NURSING-WORKSTREAM-

A4-LANDSCAPE-002.pdf, last accessed 1 February 2022. 5. Courtenay M, Carey N,

Stenner K et al. Patients’ views of nurse prescribing: effects on care, concordance and medicine taking. Br J Dermatol 2011;164:396–401. 6. National Eczema Society.

Topical Steroids Factsheet. www.eczema.org/wp-content/ uploads/Topical-steroids-

Sep-19-1.pdf, last accessed 1 February 2022. 7. Long CC, Finlay A. The fingertip unit – a new practical measure. Clin Exp Dermatol 1991;16:444–7. 8. National Eczema Society. What is Eczema? www.eczema.org/ information-and-advice, last accessed 1 February 2022. 9. Gradwell C, Thomas K,

English J, Williams H.

A randomized controlled trial of a single dermatology nurse consultation in primary care on the quality of life of children with atopic eczema.

Br J Dermatol 2002;147:513–17. 10. National Society for the

Prevention of Cruelty to

Children (NSPCC). Gillick

Competency and Fraser

Guidelines. https://learning. nspcc.org.uk/child-protectionsystem/gillick-competencefraser-guidelines, last accessed 1 February 2022. 11. Swerdin A, Berkowitz C,

Craft N. Cutaneous signs of child abuse. J Am Acad Dermatol 2007;57:371–92. 12. Laming H. The Protection of

Children in England: A Progress

Report. HMSO, 2009. www.gov. uk/government/publications/ the-protection-of-children-inengland-a-progress-report, last accessed 4 April 2022.

Further reading and resources

Kerr O, Benton E, Walker J et al. Dermatological workload: primary versus secondary care. Br J Dermatol 2007;157(Suppl 1):1–9. DEBRA. Charity supporting individuals and families affected by epidermolysis bullosa. www.debra.org.uk elearning for healthcare. www.e-lfh.org.uk National Eczema Society. www.eczema.org Royal College of Nursing. www.rcn.org.uk

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